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Based on interview and record review, the facility failed:

To develop a nursing plan of care for four newborns identified with risk factors in developing hyperbilirubinemia (high bilirubin levels in the blood), resulting in the potential to result in delay in identifying early signs of hyperbilirubinemia, subsequently delay in treatment and intervention (Patients 11, 25, 26, and 27).

To develop a nursing plan of care for an antepartum patient (period before child birth) identified positive of ESBL (a multi-drug resistant organism) in the urine, resulting in the potential to result in the spread of the MDR organism to other patients (mothers and babies).

Findings:

1. The facility policy titled, "Management of Hyperbilibinemia (Hyperbilirubinemia) and Phototherapy," effective June 2010, was reviewed and indicated the following:

"Scope: RN Staff in Pediatrics, Mother/baby, NICU, or Nursery for infants requiring Phototherapy and assessment for jaundice and or hyperbilirubinenia (hyperbilirubinemia)..."

"Assessment: The nurse will review history for possible risk factors: Major Risk Factors: TSB or TcB in the high risk zone (95% or greater), Jandice (Jaundice) observed in the first 24 hours, blood group incompatibility with positive direct antigloblin (antiglobulin) test (DAT) or other known hemolytic disease, Coombs Positive (mothers with Rh- or O+), gestational age 35-36 weeks, Previous sibling received phototherapy or was jaundiced, cephalohematoma or significant bruising, exclusive breastfeeding particularly if breastfeeding is not going well or weight loss is experienced, and East Asian race..."

During the visits on November 14 through 17, 2011, Patients 11, 25, 26, and 27's records were reviewed.

a. Patient 11's record indicated the patient was born on November 10, 2011. The patient had a major risk factor of 35 6/7 weeks age of gestation.

Patient 11's record included a plan of care titled, "Increase in bilirubin levels as related to prematurity, infection, or disease process." The plan of care was not developed and left blank.

b. Patient 25's record indicated the patient was born on November 16, 2011. The patient had a major risk factor of 35 5/7 weeks age of gestation. Patient 25's record did not provide documented evidence that a plan of care was developed for the management of the risk for developing hyperbilirubinemia.

c. Patient 26's record indicated the patient was born on November 16, 2011. The patient had a major risk factor of 35 5/7 weeks age of gestation. Patient 26's record did not provide documented evidence that a plan of care was developed for the management of the risk for developing hyperbilirubinemia.

d. Patient 27's record indicated the patient was born on September 18, 2011. The patient had a major risk factor of 35 1/7 weeks age of gestation. Patient 27's record did not provide documented evidence that a plan of care was developed for the management of the risk for developing hyperbilirubinemia.

The facility policy titled, "Interdisciplinary Plan of care, Pediatrics," effective March 2009, was reviewed. The policy indicated the following:

"Scope: Inpatients 14 years of age and younger...Purpose: to ensure that care, treatment and developmental needs are planned and are appropriate to the individual child. To identify individualized patient care goals and interventions that will be achieved in collaborative, interdisciplinary manner."

"Policy: The RN initiates the interdisciplinary plan of care after completion of the admission assessment...The patient care plan is individualized based on actual or potential problems...assessed needs, age specific, policies, patient care standards..."

On November 15, 2011, at 2:20 p.m., the CNO stated plan of care should have been developed according to facility policy for patients at risk for developing hyperbilirubinemia.

2. On November 14, 2011, Patient 12's record was reviewed. The patient was admitted to the Mother-Baby Unit on November 11, 2011, with diagnosis of hyperemesis gravida (excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids).

The record indicated a urinalysis with culture and sensitivity (urine test for infections and what antibiotics the bacteria were sensitive and resistive to) was ordered and collected on November 11, 2011. The results indicated the patient was positive for ESBL and was called to RN 13 on November 13, 2011, at 10:36 a.m., by the laboratory department.

There was no documented evidence that a plan of care for the positive ESBL urine infection was developed in Patient 12's record.

On November 14, 2011, at 12:10 p.m., the WSM was interviewed and stated staff should have developed a plan of care for the positive ESBL urine infection for Patient 12.

On November 15, 2011, the facility policy titled, "Interdisciplinary of Care, Completion Of," effective January 2003, was reviewed and indicated the following:

"Purpose: To ensure that care, treatment and rehabilitation are planned and appropriate to the patient's needs and severity of illness. To identify individualized patient care goals and interventions to achieve those goals in a collaborative, interdisciplinary manner."

"Policy: The Patient Care Plan is individualized and based upon actual or potential problems...policies, patient care standard..."

Based on observation, record reviews and staff interviews, the hospital failed to ensure the dietary staff, responsible for safe food handling, was competent in their duties to ensure safe and sanitary food handling practices in the dietary department of a hospital with a licensed bed capacity of 145.

Findings:

1. During a document review of the hospital's "Food Cooling Log" dated November 2011, the form instructed that staff that the standard was to cool cooked potentially hazardous foods to 70? F within 2 hours and from 70? F to 41? F and below within an additional 4 hours.

According to the 2009 Food Code, excessive time for cool of potentially hazardous foods has been consistently identified as one of the leading contributing factors to food borne illness. If food is not cooled in accordance with the code requirement, pathogens may grow to sufficient numbers to cause food borne illness. The Food Code provision for cooling provides for cooling from 135?F to 41?F in 6 hours, with cooling from 135?F to 70?F in 2 hours. The initial 2-hour cool is a critical element of this cooling process.

Further review of the "Food Cooling Log" for November 2011 revealed an entry for roast beef that was cooked and then cooled on November 10, 2011. The roast beef had an initial temperature of 179? (Fahrenheit -F) at 1:00 p.m.. The next temperature was recorded at 3:00 p.m., two hours later, and was 72? F. The final temperature was recorded at 5:00 p.m., total of four hours cooling, and was 39? F.

During an interview with Cook 1 on November 14, 2011 at 11:50 a.m., he stated that if the potentially hazardous food being cooled does not reach 70? F within the 2 hour timeframe, it would then have to be reheated to 165? F. Then the cooling process would have to start over again to ensure it was safe.

During an interview with Cook 2 on November 14, 2011 at 12:00 p.m., he stated that he was the staff who monitored and recorded the temperature of the roast beef on November 10, 2011. He stated that when the temperature was 72? F instead of 70? F at two hours, he placed the roast beef in the freezer. He stated that he should have discarded the roast beef.

During a follow-up review of the hospital's Food Cooling Logs for July, August and September 2011, it was noted for 13 of 82 entries, the potentially hazardous food was not properly cooled to 70? F within two hours. For those foods that were not cooled to 70? F within two hours, the range of temperatures at two hours was 72? F to 87? F. Only one of the 13 entries indicated that the potentially hazardous food was discarded. One item on the logs did not have a final temperature recorded to indicate that it reached 41?F or below within the safe timeframe.

During an interview with the Director of Food and Nutrition Services (DFNS) on November 14, 2011 at 1:00 p.m., she was unable to explain why the staff was not following the instructions on the Food Cooling Logs to ensure that potentially hazardous foods were properly cooled. She also was unable to explain why the unsafe practice continued to occur without remediation from July 2011 to the present. She further stated that she was ultimately responsible to ensure her staff followed safe food handling practices when cooling cooked potentially hazardous food.

The employee files for the dietary cook staff responsible for the monitoring of the safe cooling of cooked potentially hazardous foods were reviewed on November 15, 2011. The competency evaluations for Cook 2 and Cook 3, responsible for all the errant entries on the cooling logs, did not included an evaluation of their competency with regard to safe cooling practices. There was no documented training for these cooks specifically on the safe cooling of cooked potentially hazardous foods.

2. During the initial tour of the kitchen on November 14, 2011 at 10:00 a.m., the dishwashing area was observed. While demonstrating the use of the dishmachine, FSW 2 loaded the machine with dirty dishes then unloaded the clean dishes without washing his hands between tasks.

During a concurrent interview with FSW 2, he stated that he usually works in the evenings and often washed dishes by himself. He stated that he sometimes changed gloves between dirty and clean dishes but didn't wash his hands.

A review of the hospital's policy titled, "Hand Hygiene" dated November 2009, revealed that in the Food & Nutrition Services Department: all employees associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: after handling soiled silverware, after removing gloves and after any other activity that may contaminate the hands.

According to the 2009 Food Code, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with clean equipment and utensils. It further states that employees must wash their hands after any activity which may result in contamination of the hands.

The employee file for FSW 2 was reviewed on November 15, 2011 at 11:30 a.m.. The Competency Validation Checklist for FSW 2 dated October 24, 2011 indicated that he was competent regarding safety and sanitation. It stated that he met the "competent" rating related to following company sanitation policy and unit programs. It further stated that he adhered to company guidelines on food handling.

During a concurrent interview with the DFNS, she was unable to explain why FSW 2 did not wash his hands between handling dirty dishes and clean dishes and why he understood that it was acceptable to not wash them. She stated that it was her responsibility to ensure her staff was knowledgeable and practiced safe food handling.

3. During the initial tour of the kitchen on November 14, 2011 at 10:15 a.m., FSW 3 was observed filling a red bucket with one half tap water and one half sanitizer solution. She then placed the bucket in her work area in the cafeteria.

The standard of practice in food service was to use red buckets to contain a sanitizer solutions to sanitize food contact surfaces as needed.

During a concurrent interview with FSW 3, she stated that the solution in the red bucket was used to sanitize the food prep areas in the cafeteria. When asked to demonstrate how she was able to ensure that the sanitizing solution in the bucket was the appropriate concentration for effectively sanitizing the food contact surfaces, she stated that she didn't know how.

The employee file for FSW 3 was reviewed on November 15, 2011 at 11:35 a.m.. The Job Specific Competencies for FSW 3 dated October 12, 2011 was reviewed. With regard to the chemical competency, she was marked as requiring "minimal assistance" in order to verbalize the purpose of the sanitizer solution and the correct concentration of the test strip and how to refill containers. The competency further indicated that the items scored as requiring "minimal assistance" were all reviewed with the employee.

During a concurrent interview with the DFNS, she was unable to explain why FSW 3 was competent in her duties as a food prep assistant if she did not know how to properly fill the sanitizer buckets and check the concentration of the solution to ensure proper sanitation and prevent cross contamination.

The Food Service Supervisor (FSS) was then asked to check the concentration of the solutions. He did this by dipping a test strip into the solution for 10 seconds. The test strip did not change color. The FSS stated that when the strip does not change color, that was an indication that the solution was not the proper concentration to effectively sanitize food contact surfaces. He further stated that the proper procedure for filling the red buckets was to not add additional water to the sanitizer solution. He stated that adding extra water diluted the solution so that is was not effective. He further could not explain why FSW 3 did not know how to fill the sanitizer bucket and test the solution. He stated that the dishwasher usually fills the buckets every two hours throughout the day.

Based on interview and record review, the facility failed to implement the infection control policy and procedure. The facility did not place Patient 12 (an antepartum mother - period before child birth) on contact isolation upon receiving the positive ESBL (a MDRO infection) urine infection result. This had the potential to result in the spread of the MDRO to other patients (mothers and babies).

Findings:

On November 14, 2011, Patient 12's record was reviewed. The patient was admitted to the Mother-Baby Unit on November 11, 2011, with diagnosis of hyperemesis gravida (excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids).

The record indicated a urinalysis with culture and sensitivity (urine test for infections and what antibiotics the bacteria were sensitive and resistive to) was ordered and collected on November 11, 2011. The results indicated the patient was positive for ESBL and was called to RN 13 on November 13, 2011, at 10:36 a.m., by the laboratory department.

The "Physician Orders" dated November 14, 2011, at 9 a.m., was reviewed and indicated, "Contact Isolation for ESBL in urine [iso (isolation) started 11/13/11 @ 1200 (12 p.m.)]...per protocol..."

On November 14, 2011, at 12 p.m., RN 14 was interviewed and stated she wrote the "Physician Order" indicating the need to isolate Patient 12 because of the positive ESBL in the urine result. She stated the Infection Control nurse told her the patient needed to be placed on isolation. RN 14 stated she started her shift at 7 a.m., did not get any report the patient was positive for ESBL in urine, or the patient required any kind of isolation. She stated the patient was not on contact isolation when she started her shift.

On November 14, 2011, at 12:10 p.m., Patient 12's record was reviewed with the WSM. The WSM was unable to find documented evidence Patient 12 was placed on contact isolation until November 14, 2011, at 9 a.m. The WSM stated there should be documentation the patient should have been placed on contact isolation.

On November 15, 2011, at 10:40 a.m., the DA and OCE were interviewed and stated Patient 12 should have been placed on contact isolation, according to facility policy. Both stated a physician's order was not required to place the patient on contact isolation.

The records titled, "Mother Baby Daily Staffing Log" were reviewed and indicated:

a. On November 13, 2011, day shift (7 a.m. to 7 p.m.) - RN 13 was assigned to care for Patient 12, two couplet care (mother and baby; total of four patients), and one mother (patient);

b. On November 13, 2011, night shift (7 p.m. to 7 a.m.) - RN 15 was assigned to care for Patient 12, one couplet care, and one mother (patient); and

c. On November 14, 2011, day shift - RN 14 was assigned to care for Patient 12, one couplet care, and one mother (patient).

On November 14, 2011, the facility policy titled, "Contact Precautions," effective August 2010, was reviewed and indicated, "In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment...MDRO's= Multiple Drug Resistant Organisms (ESBL Extended Spectrum Beata (Beta) Lactamase)..."

According to CDC guidelines, it included ESBL in the MDRO list. The guidelines also indicated, "...application of Contact Precautions for patients infected or colonized with MDROs..."