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Based on medical record review and facility policy review, it was determined the facility failed to ensure a physician's order for restraints was obtained when restraints were utilized for 2 of 5 (Patients #6 and 26) sampled patients with restraints.

The findings included:

1. Review of the facility's "Restraints--Clinical Restraint-Medical Interference Protocol" policy revealed the following : "...The use of restraint must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint by hospital policy. If restraints have been initiated by nursing staff, a physician order must be obtained as soon as possible..."

2. Closed medical record review for Patient #6 revealed verbal physician's orders dated 10/15/10 at 8:50 AM, included "Restraints per medical protocol" and ventilator settings.
An "Order for Clinical Restraint/Medical Interference Protocol" dated 10/15/10 at 11:15 AM documented, "Protocol criteria for application of restraints: Patient is intubated and may extubate if sedation level decreases or level of cognizance changes." The type of restraint was documented as soft, and location of restraint was documented as LUE and RUE. Documentation for "Alternatives tried: Change in environment, assess level of consciousness and presence of pain evaluated and relief measures instituted."
This form documented the patient's family was notified of the application of restraints and the patient/family educated.

Telephone physician's orders, dated 10/19/10 at 10:12 PM included, "Haldol 2 mg IV Q 4 PRN agitation. OK to leave on soft restraints."

An "Order for Clinical Restraint/Medical Interference Protocol" dated 10/24/10 at 4:00 PM documented, "Protocol criteria for application of restraints: Patient is confused and is high risk for falling, wandering or interference with medical treatment." Type of restraint applied was marked as soft; location of restraint was marked as LUE and RUE. Alternatives tried were documented as "Invasive site covered, Change in environment, Asses Level of Consciousness, Presence of pain evaluated and relief measures instituted, and Utilize bed alarm monitors."
There was no physician's signature on this order.

A Physical Therapy Evaluation dated 10/22/10 at 11:44 AM documented, "Pt with vest restraint on 2nd to fall in past several days... Comment: x 2. secured vest restraint B to bed... pt having previous fall per RN and now in vest restraint so pt not left up in bedside chair..."
Nurse's Notes dated 10/22/10 at 8:00 AM documented, "Torso Restraint Activity: initiated vest restraint."
Nurse's notes documented torso vest restraint was released and reapplied every 2 hours 10/22/10 at 8:00 AM through 10/24/10 at 2:00 AM.
Nurse's notes dated 10/24/10 at 2:00 AM documented, "Behavior Requiring Medical Restraint Pt confused/high risk interfering with medical tx, Pt has arterial/venous lines and may pull out, Behavior interfering with medical care, devices, tubes/drain."

There was no further documentation of restraints until 10/24/10 at 4:00 PM; nurse's notes at that time documented soft restraints LUE and RUE, and "No evidence of injury related to restraint, Restraints properly applied."
The Behavior Requiring Medical Restraint was documented as "Pt confused/high risk for falling/wandering, Pt confused/high risk interfering with medical tx."

3. Medical record review for Patient #26 revealed a verbal order dated 1/18/11 at 5:20 AM that documented "4 Point soft restraints PRN [when needed], Per Protocol."
An "ORDER FOR CLINICAL RESTRAINT/ MEDICAL INTERFERENCE PROTOCOL" dated 1/18/11 at 7:00 AM documented, "...Type of restraint applied: ... Soft... Location of restraint: was marked LUE, RUE, LLE, and RLE..." There was no physician's signature on the verbal order written by the nurse.

Review of the Nurses Notes dated 1/18/11 from 12:00 PM until 1/19/11 at 2:00 AM documented "Torso Restraint Type Vest." There was no physician order for Vest restraint.

Based on policy review and medical record review, it was determined the facility failed to ensure no PRN orders were written for restraint use for 1 of 5 (Patient #26) sampled patients with restraints in accordance with this regulation.

The findings included:

1. Review of the facility's "Restraints--Clinical Restraint-Medical Interference Protocol" policy revealed the following : "...The use of restraint must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraint by hospital policy. If restraints have been initiated by nursing staff, a physician order must be obtained as soon as possible..."

2. Medical record review for Patient #26 revealed a verbal order dated 1/18/11 at 5:20 AM that documented "4 Point soft restraints PRN, Per Protocol."

Based on facility policy review, medical record review, observation and interview, it was determined the facility failed to ensure the nursing staff provided ongoing assessment and monitoring of Clinical Restraints in accordance with the facility's policy for for 1 of 5 (Patient #8) sampled patients with restraints.

The findings included:

1. Review of the facility's "Restraints--Clinical Restraint-Medical Interference Protocol" revealed the following: "Patient will be reassessed at least every two (2) hours to determine if they still meet protocol criteria." and "...reassessments by a qualified RN will include, at a minimum, the following: 1. The actual behavior observed. 2. The reason (cause) for the behavior as assessed by the RN. 3. Determination that the patient's behavior is potentially injurious to themselves or others. 4. Alternative methods employed to avoid restraints and the effectiveness of those methods. 5. Criteria used for determining the need for restraint. 6. Discussion with the patient and/or family concerning the use of restraints. I. Documentation of the nursing observations and care provided while the patient is restrained are made by or under the direction of a qualified RN and will include, at a minimum, the following: 1. Fluids are offered every two (2) hours. 2. Mental status of the patient addressed every two (2) hours. 3. Toileting needs addressed every two (2) hours. 4. Circulation of restrained limb observed every two (2) hours. 5. Nutritional needs addressed every two (2) hours. 6. Personal hygiene is addressed at least every eight (8) hours. 7. Vital signs are obtained at least once per shift ..."

2. Medical record review for Patient #8 documented the patient was placed in bilateral wrist restraints on 1/28/11 at 1900.
Review of the "Hemodialysis Flowsheet " form dated 1/31/11 revealed no documentation of the patient's behavior, alternative methods attempted, criteria used to determine the need for restraints, discussion with the patient or family concerning the use of the restraint, level of consciousness, mental status, circulation checks, or nutritional needs of the patient.
There was no documentation of current restraint orders.

Observations on 1/31/11 at 9:35 AM revealed bilateral wrist restraints intact on Patient #8.

During an interview in the dialysis unit on 1/31/11 at 0945, when asked if (nurse) would be doing anything (releasing the restraints per facility policy, doing circulation checks or checking for orders) with the restraints, while patient received dialysis from 0915 until the treatment was stopped at 1300, Nurse #2 stated "No."

During an interview in the conference room on 2/1/11 at 11:15 AM the Medical Record Supervisor confirmed dialysis patients, in restraints, would need an assessment performed during the treatment.

Based on review of the hospital's policies, ED Committee Minutes and interview, it was determined the hospital failed to ensure the QAPI committee developed, implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program in order to maximize quality health outcomes.

The findings included:

1. The hospital failed to ensure all pts who presented to the ED with post-surgical site MRSA infections were tracked and trended to identify the root cause.
Refer to A 267

2. The hospital failed to ensure the QAPI program utilized collected data to monitor the effectiveness and safety of services and quality of care.
Refer to A 268

3. The hospital failed to ensure the QAPI program identified opportunities for improvement and implemented changes that would lead to improvement.
Refer to A 276

Based on hospital policy, ED Committee Minutes, and interview, it was determined the facility failed to provide QAPI documents that measured, analyzed, and tracked quality indicators.

The findings included:

1. The hospital's policy, "Quality+ Plan for Improving Organizational Performance," documented as an objective on page 2, "...to use appropriate statistical tools and techniques to organize and analyze data to identify trends, variations, patterns, and performance levels that suggests opportunities for improvement (OFI)..."

2. ED Committee Minutes for 9/7/10 on page 2 documented a medical director's concern regarding "...a few cases of patients who have come back with surgical site infections," and sent home with antibiotics which, "may or may not work due to the MRSA situation."

3. During an interview in the conference room on 2/2/11 at 3:25 PM the Infection Control (IC) Nurse stated she had knowledge of 5 MRSA cases related to post-op infections presenting to the ED. The IC Nurse would not directly answer any of the questions posed by the surveyors regarding MRSA readmissions to the hospital or if these surgeries were in-house or performed at another facility. The IC Nurse was unable to provide QAPI documents that measured, analyzed, and tracked quality indicators related to MRSA infections in the facility.

During an interview in the conference room on 2/2/11 at 3:30 PM, the IC Nurse was asked about the "MRSA situation" in the ED. The Infection Control Nurse stated she did not recognize this as a "situation."
Refer to A 750

Based on review of hospital policy, ED Committee Minutes review and interview, the facility failed to provide QAPI documents that used collected data to monitor the effectiveness and safety of services and quality of care.

The findings include:

1. Facility policy "Quality+ Plan for Improving Organizational Performance," documented as objectives on page 2, "...fostering an organizational-wide commitment to Quality +, Performance Improvement and improving patient safety...establishing quality improvement priorities and principles."

2. ED Committee Minutes for 9/7/10 on page 2 documented a medical director's concern for "...a few cases of patients who have come back with surgical site infections," and sent home with antibiotics which, "may or may not work due to the MRSA situation."

3. During an interview in the conference room on 2/2/11 at 3:25 PM the IC Nurse stated she had knowledge of 5 MRSA cases related to post-op infections presenting to the ED but was unable to verify if these surgeries were performed in-house or performed at another facility.
The IC Nurse was unable to provide QAPI documents that measured, analyzed, and tracked quality indicators related to MRSA infections in the facility.

Based on review of policy, ED Committee Minutes and interview, it was determined the facility failed to provide QAPI documents that used data collected to identify opportunities for improvement and changes that would lead to improvement.

The findings include:

1. The facility policy "Quality+ Plan for Improving Organizational Performance," documented as objectives on page 2, "...establishing quality improvement priorities and principles...analyzing their own processes and effectiveness...".

2. ED Committee Minutes for 9/7/10 on page 2 documented a medical director's concern for "...a few cases of patients who have come back with surgical site infections," and sent home with antibiotics which, "may or may not work due to the MRSA situation."

2. During an interview in the conference room on 2/2/11 at 3:25 PM the IC Nurse stated she had knowledge of 5 MRSA cases related to post-op infections presenting to the ED but was unable to provide QAPI documents used to identify opportunities for improvement and changes related to MRSA infections in the facility.

Based on medical record review and interview, it was determined the hospital failed to ensure a care plan was developed for 1 (Patient #15) of 44 sampled patients reviewed.

The findings included:

1. Medical record review for Patient #15 documented an admission date of 1/24/11 with a PEG tube in place on admission.
Review of the care plan documented the care plan was developed on 1/24/11 with no documentation of the PEG tube until 1/31/11.

2. During an interview with Nurse #4, in the classroom of floor B3 on 1/31/11 at 11:30 AM, Nurse #4 confirmed Patient #15 did have a PEG tube on admission and the Peg Tube was not included in the care plan on admission.

Based on medical record review, Medical staff Rules and Regulations review and interview, it was determined the facility failed to ensure all orders for medications were written and signed by practitioners authorized by hospital policy for 2 of 44 (Patients #4 and 24) sampled patients.

The findings included:

1. Medical record review for Patient #4 revealed:
Medication order dated 1/18/11 documented, "0815, Decrease Vancomycin to 1.25 g IV q 12 hrs. Next dose @ 1800 today." This order was signed with Physician's name/Pharm D #1.
Medication order dated 1/21/11 documented, "0845, (1) hold vancomycin...(3) if level results < 20.0, start Vancomycin 1250 mg IVPB Q 24." This order was signed with Physician's name/Pharm D #2.
Medication order dated 1/22/11 documented, "1235, Go ahead and start Vanc 1250 mg IV Q 24 start now please." This order was signed with Physician's name/Pharm D #3.
A medication order dated 1/26/11 documented, "1245, Change Vancomycin ^ 1.5 g IV Q 24 c next dose due at 1300 1/27/11." This order was signed with Physician's name/Pharm D #4.

2. Medical record review for Patient #24 revealed:
A medication order dated 1/28/11 documented, "0930, Change IV Protonix to Prevacid 30 mg Solutab PT daily @ next dose. Per P & T Protocol/Pharm D #1."

3. Medical staff "Rules and Regulations, Approved on 7/27/10...Diagnostic and Therapeutic Orders" documented, "Persons Authorized to Give Orders: Orders are to be given for patients...by those individuals who have been granted practice privileges, including physician/oral surgeon members of the medical staff, licensed independent affiliates, as defined in the Medical Staff Bylaws, CRNA, CNM, or Neonatal-ICU Nurse Practitioners (Authorized Persons)."

4. In an interview on 1/31/11 at 3:05 PM at the nurse's desk in the SICU, the Director of SICU stated, "The physicians tag the PharmD to dose Vancomycin and Gentamycin. It's a protocol and I've never seen a physician co-sign their orders."

In an interview on 1/31/11 at 5:25 PM, the facility's Director of Nursing stated, "They (PharmDs) can sign orders. If they write v.o., the orders have to be authenticated."

5. There was no documentation available for review to document the Medical Staff had granted privileges for Doctors of Pharmacy to write medication orders, therefore any orders written by the PharmDs, according to the P&T protocols, were not legal orders authorized by the Medical staff.

Based on medical record review, it was determined the facility failed to ensure all verbal and telephone orders were authenticated within 48 hours for 3 of 44 (Patients #4, #15 and 26) sampled patients.

The findings included:

1. Medical record review for Patient #4 revealed the following verbal and telephone orders documented by a nurse and not authenticated:
A telephone order, dated 1/15/11, 10:45 AM, "Place central line s consent."
A verbal order, dated 1/18/11, 11:40 AM, "[Change] Tylenol to liquid per PEG."
A verbal order, dated 1/20/11 at 1:35 PM, "PCXR @ 1735, s/p attempted left thoracentesis."
A verbal order, dated 1/21/11 at 9:10 AM, "CT chest without."
A telephone order, dated 1/25/11 at 7:45 AM, "Portable chest X-ray stat/ non rebreather, ABGs STAT, Unit bed."
A verbal order, dated 1/25/11 at 1:45 PM, "Case management consult: Assist with obtaining vibratory vest from HillRom RE: Recurrent mucous plugging."
A verbal order, dated 1/28/11 at 11:05 AM, "Please continue aggressive chest PT Q 4 by RT by hand / Attn: left lower / Portable chest Xray in the am x 3 days."

2. Medical record review for Patient #15 revealed the following verbal and telephone orders documented by a nurse and not authenticated:
A telephone order dated 1/24/11 at 1933, "Tag Dr.,,,[MD's name], Baclofen 20 mg per PEG tid prn spasms, Lasix 40 mg IV daily."
A verbal order on 1/24/11 at 2235, "If SBP < 80 may start Dopamine drip keep sys >90 NS @ 100 now."
A telephone order on 1/25/11 at 0000, "May convert Depakote to Valporic Acid per peg."
A verbal order on 1/26/11 at 1400, "RT to manage Bipap."
A telephone order on 1/26/11 at 1220, "Contact Isolation for resistance E Coli urine."
A verbal order on 1/27/11 at 1020 "DC hep gtt, Plavix 75 mg po daily."
A telephone order on 1/27/11 at 1145 "LFT in AM."
A verbal order on 1/29/11 at 1045, "WOCN consult re: possible deep tissue injury L sacrum/buttocks...Comfort measures only."
A telephone order on 1/30/11 at 0700, "KCl 40 meq IV over 4 hours x 2 doses K+ level in AM."
A telephone order on 2/1/11 at 8:15, "Vanc trough c tomorrow's dose."
A telephone order, "DC all lines, DC to morgue."

3. Medical record review for Patient #26 revealed the following verbal and telephone orders documented by a nurse and not authenticated:
A telephone order, dated 1/13/11, "Steroid eye gtt 1/1 drop left eye q 6 hours prn."
A verbal order, dated 1/14/11 at 8:30 AM, "PT eval & tx-strenghthening."
A verbal order, dated 1/18/11 at 5:20 AM, "5 mg haldol IV Q 4 PRN."
A verbal order, dated 1/18/11 at 5:20 AM, "4 Point soft restraints PRN, Per Protocol."

Based on record review and interview, it was determined the facility failed to ensure pharmacy services were provided, in accordance with these regulations and with pharmacy records documented in sufficient detail to verify the flow of controlled pharmaceuticals through dispensation.

The findings included:

1. Observations during tour of the Pharmacy on 1/31/11 at 2:15 PM revealed a stack of papers titled, "Delivery Signature For Location" on a desk.

2. Review of the papers documented Vicodin, Ambien, Xanax, Lunesta, Demerol, Morphine, MS Contin, Valium, Lortab, Duragesic, Tussionex, Roxicodone, Dilaudid, Stadol, Restoril, Ativan, Percocet, Lyrica, Tylox, Dilaudid PCA, Versed and Fentanyl had been delivered to various locations within the hospital from 6:16 AM - 1:22 PM on 1/31/11. There was no documentation of a signature of who delivered, verified and received the dispensed medications.

3. During an interview on 1/31/11, at 2:28 PM in the Pharmacy by the desk, the Pharmacy Tech verified he/she had prepared and delivered the medications to various locations within the hospital.

During an interview on 1/31/11, at 2:45 PM in the Pharmacy by the desk, the Director of Pharmacy verified the Pharmacist had not signed each of the papers that each medication dispensed had been inspected.

Based on record review and interview, it was determined the pharmacy failed to ensure records documenting the dispensation of medications were not altered and that all medications were appropriately dispensed as ordered.

The findings included:

1. Review of the medication dispensation book revealed entries for the quantities of Fish Oil, Theravite, Tussinex, Levaquin, Norvir, Diphenoxylate/Atropine, Leperamide HCL, Augmentin, Children's Ibuprofen, Sulfamethoxazole, Vibramycin, Promethazine syrup and Epivir solution were scribbled through and altered. There was no documentation who altered the quantities.

2. During an interview on 1/31/11, at 2:55 PM by the desk where the medication dispensation book was located, the Pharmacy Director verified the medications in the book had been delivered to different areas of the hospital. The Pharmacy Director verified the entries had been written over and altered. The Pharmacy Director could not verify who had altered the entries.

Based on observations, it was determined the facility failed to have a full-time employee who demonstrated, through daily management, the implementing of a training program for dietary staff and ensured established policies and procedures were followed as evidenced by the poor sanitation practices observed in the various kitchens under the hospital's control.

The findings included:

During tours of the various kitchens, on 1/31/11 from 9:30 AM to 3:00 PM, unsafe practices for food handling were observed. The dietary manager failed to ensure "Food Service" codes were followed. The following deficient practices were observed:
The staff failed to properly label foods containers/food products as they were opened and then stored in the refrigerators.
The staff fail to ensure all foods were labeled especially those prepared by staff as to the date prepared or the date expired.
The staff fail to maintain a clean and sanitary environment by routine cleaning of floors, tops of storage bins, microwaves, deep fat fryers, food chopper, fan vents and refrigerator fans.

Refer to A 749

Based on observation and interview, it was determined the facility failed to arrange and maintain the hospital to ensure the safety of all patients.

The findings included:

1. The facility failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner to ensure the safety and well being of the patients.
Refer to A 701

2. The facility failed to ensure the life safety requirements for the hospital were met.
Refer to A 709

Based on observation and interviews, the facility failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner to ensure the safety and well being of patients.

The findings included:

1. The means of egress were not continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits.
Refer to K 072

2. The piped in medical gas systems did not comply with NFPA 99, Chapter 3.
Refer to K 077

3. The electrical wiring and equipment was not in accordance with NFPA 70, National Electrical Code.
Refer to K 147

Based on observation, it was determined the hospital failed to meet all fire safety requirements for the entire building.

The findings included:

1. All required smoke detectors, including those activating door hold-open devices, were not maintained and inspected in accordance with the manufacturer's specifications.
Refer to K 054

2. The required automatic sprinkler systems were not continuously maintained in reliable operating condition and inspected periodically.
Refer to K 062

3. The cooking facilities were not protected in accordance with 9.2.3.
Refer to K 069

4. Penetrations of smoke barriers by ducts were not protected in accordance with 8.3.6.
Refer to K 104

Based on review of facility policy, observation and interviews, it was determined the hospital failed to ensure measures to prevent the potential spread of infection were in place as evidenced by the lack of sanitation in the dietary department, not adopting accepted standards of practice or adhering to facility policy for cleaning/disinfecting glucometers and failure to wear PPE during hemodialysis treatments. The facility also failed to ensure the QAPI program identified all infection control problems.

The findings included:

1. The hospital failed to maintain a clean and sanitary dietary department by dating and labeling all food containers placed in refrigerators and maintaining equipment and environment in a clean sanitary condition.

Failure to disinfect the glucometers in accordance with an acceptable standards of practice or the facility ' s policy.

Failure to ensure PPE was worn by dialysis staff while providing patient care.
Refer to A 749

2. The hospital's infection control officer was unable to provide a log to demonstrate the hospital was maintaining information on incidents related to infections throughout the hospital.
Refer to A 750

3. The hospital failed to ensure the hospital-wide quality assurance program addressed problems identified by the infection control officer or officers and to be responsible for the implementation of successful corrective action plans in affected problem areas.
Refer to A 756

Based on review of Flexx Meter Operator's Guide, facility policy, observation and interviews, it was determined the facility failed to ensure measures to prevent the potential spread of infection were in place as evidenced by poor sanitation of the dietary department, not adopting accepted standards of practice or adhering to facility policy for cleaning and disinfecting blood glucose meters (glucometers) and failure to wear PPE during hemodialysis treatments.

The findings included:

KITCHEN SANITATION
1. Observation during the tour of the dietary department on 1/31/11 at 9:30 AM revealed in the catering area 3 door refrigerator there were 3 - 1 gallon containers of salad dressing. Documented on the tops of 2 of the containers was "10/29" and documented on the top of the third container "12/23/10."
One 4 pound 8 ounce container of maraschino cherries was dated 12/7. Also in the refrigerator were 2 - 12 quart containers of chicken salad, each was labeled "use by 2/10/11." There was 1- 12 quart container of tuna salad that was labeled "use by 2/4/11." Also observed was an open package of cheese (containing 160 slices). These items were not labeled with the dates they were opened.

During an interview at the time of the observations, the PM stated the dates on the tops of the salad dressing containers was the date they were received by the facility and stated "the shelf life on all dressing is 90 days once it has been opened." The PM verified the containers were not labeled with the date they had been opened, therefore, it could not be determined when the shelf life would end.

During an interview, at the time of the observations, two staff members working in the catering area stated they had made the containers of chicken salad and tuna salad earlier that day and that both salads were good for 3 days after they had been made. The two staff members and the PM verified the dates documented on both salads was more than the stated 3 days. The PM also verified the opened cheese was not labeled with the date it had been opened and confirmed it should be labeled.

2. Observation in the hospital bake shop on 1/31/11 at 9:45 AM revealed crumbs and food particles on the floor.

During an interview at the time of the observation, the PM stated the floors were cleaned by a hired company 4 times a year. After confirming the floors were not clean, he stated the bake shop employees should maintain clean floors at all times.

3. Observation in the hospital production/cook area on 1/31/11 at 9:50 AM revealed there was a large build up of grease on the side of the deep fat fryer.
Also observed in this area were the tops of bins for rice, bread crumbs, corn meal, flour and sugar that were dirty.
The stored food chopper was observed to be greasy and contained food particles.
The microwave used to heat food for hospital patients was noted to have splattered food particles on the outside of the door as well as inside the microwave.
Observed in #8 walk-in refrigerator in the production/cook area was a build up of a black substance around the refrigerator fan and on the fan vent.
Observed in produce cooler #4 was a box containing 4 heads of cabbage, all of which were yellowed and had brown/black edges.

During an interview at the time of the observations, when questioned about when the side of the deep fat fryer had last been cleaned, the EC stated he had worked there 1 and ½ years and had never seen it cleaned. The EC verified the microwave was dirty. The DDS also present at the time of the observations, stated he did not know what the black substance around the refrigerator fan was and removed the heads of cabbage from the refrigerator.

4. Observation in Vendor #3 on 1/31/11 at 10:25 AM revealed the scoop stored inside the sugar bin.
Observation in the walk in cooler revealed there was a black substance around the refrigerator fan and on the fan vent. Debris such as flour, crumbs and 2 chicken pieces were noted on the floor.

During an interview at the time of the observations, the DDS stated the scoop should not be stored inside the sugar bin and stated the floors had not been cleaned because they had just finished serving the breakfast rush.

5. Observation during the tour of Vendor #1 shop on 1/31/11 at 2:00 PM revealed, in the refrigerator, one opened package of banana loaf not labeled when it had been opened.

During an interview at the time of the observation, the coffee shop employee stated she had opened the banana loaf earlier in the day. The DDS also present at the time of the observation, verified the banana loaf was not labeled when it had been opened, therefore, it could not be determined how long the banana loaf had been opened.

6. Observation during the tour of Vendor #2, on 1/31/11 at 2:10 PM, revealed in the stack refrigerator the following items were not labeled when opened or placed in the refrigerator:
1 metal pan of uncooked chicken, 1 container mixed carrots and green peas, and 1 container raw onions.
Also observed in the refrigerator were 1 container uncooked green peppers labeled use by 1/20/11, 1 container cauliflower labeled use by 1/20/11 and 1 pan of chicken dated 1/27/11. There was 1 partial head purple cabbage with brown edges, that was not dated when it had been placed in the refrigerator.

Observation in the preparation table refrigerator revealed the following items:
1 container carrots, 1 opened dirty container of oyster sauce, 1 opened container Hoisting sauce, 2 opened bottles of hot sauce and 1 opened bottle Meson sauce. None of these listed items were labeled when they had been opened.
Also observed in the refrigerator was 1 metal container of uncooked imitation crab meat and 2 large containers of uncooked chicken, none of the three containers were labeled to show how long they had been in the refrigerator.

Observed in a display case were 8 containers of prepared, packaged sushi for sale. These had been prepared by the staff in Vendor #2 and none of the 8 containers were labeled as to when they were prepared or the date they would expire.

BLOOD GLUCOSE MONITORING EQUIPMENT
1 Review of SureStepFlexx Meter's operator's guide documented:
"When to Clean the Meter: If dirt, blood, or lint is present..As defined by your institution's infection control policies. " Directions for cleaning were " Cleaning the Outside of the Meter: Clean the outside of the meter with a cloth dampened with a 10% bleach solution. Follow with a cloth moistened with water to remove residual bleach. Dry thoroughly. Wipe the test strip holder cover and base with a cotton swab dampened with a 10% bleach solution. Follow with a swab dampened with water to remove residual bleach. "

2. Review of the facility's NURSING POLICY AND PROCEDURE TITLE: Bedside Blood Glucose Testing with the Flexx revealed, "... unit should be cleaned as needed, but at least once a week ...Clorox wipes, 70% Isopropyl alcohol, or water can be used to clean the meter..."

3. Observations In the Dialysis Unit Hall on 1/31/11 at 9:35 AM, revealed Nurse # 2 placed the glucometer machine on the bedside table, obtained a blood specimen, then placed the glucometer back in the glucometer box. Nurse #2 failed to clean the meter before or after use.

During an interview in the Peri-operative Unit Hall at 9:00 AM, Nurse #12 stated, "Glucometers cleaned with alcohol ...holders cleaned weekly."

During an interview in the Dialysis Unit on 1/31/11 at 9:35 AM, Nurse #2 stated,"...clean glucometers 1 time a week and as needed."

During an interview in the Nursery Unit on 1/31/11 at 10:00 AM, Nurse # 3 stated, "glucometers cleaned weekly."

During an interview in the Emergency Department on 1/31/11 at 1:50 PM, Nurse # 5 confirmed glucometers are cleaned 1 time a week.

During an interview in the In-Patient Hospice Hall at 3:30 PM, Nurse # 7 confirmed glucometers are cleaned weekly.

During an interview in the Cardiovascular Intensive Care Unit on 1/31/11 at 3:43 PM, Nurse # 8 stated, "glucometers cleaned at the first of every shift."

During an interview in the Cardiac Telemetry Hall A-7 on 2/1/11 at 10:30 AM, Nurse # 9 stated, "glucometers cleaned daily."

The facility failed to follow manufacturer's recommendation for cleaning glucometers.
The facility failed to develop standards of practice based on current FDA recommendations that documented on a report titled " Medical Devices ...updated November 29, 2010 " stating " ...point of care (POC) blood testing devices can be reused safely by a single patient in the home ...However ...POC blood testing devices can be a source of bloodborne infections if used on multiple patients ...whenever possible use POC blood testing devices, such as blood glucose meter ...for one patient only ...if not possible, the devices should be properly cleaned and disinfected after every use ... "

PPE
1. Observation on the dialysis unit on 1/31/11 at 10:20 AM, revealed a technician wearing a thigh length gown, open in the front, standing next to a random dialysis patient #1 connected to the dialysis machine.

2. Observation on the dialysis unit on 1/31/11 at 10:35 AM, revealed a nurse seated, pulling needles from random dialysis patient #2's arm. The nurse wore a waist length gown that was not buttoned or closed at the front.

During an interview on 1/31/11 at 10:45 AM, the unit manager verified the nurse should have her PPE closed in the front when removing the patient's needles.

Based on interview, it was determined the facility's infection control nurse was unable to provide a log to demonstrate the hospital was maintaining information on incidents related to infections throughout the hospital.

The findings included:

During an interview on 2/2/11 the IC nurse would not specifically respond to questions, posed by the surveyors, regarding MRSA readmissions to the ED. When asked how she (IC nurse) tracked/trended MRSA readmissions on surgical patients, she avoided responding directly to the questions and stated others tracked/trended for her and she would need more information to be more specific. Finally when asked "How many patients with potentially infected surgical wounds were admitted to the ED in the past 6 months?" The IC nurse replied "...only interested in positive results"
After a lengthy discussion the IC nurse was unable to show the type of information the facility was tracking for healthcare-associated infections identified by the hospital, including surgical site infections following either inpatient or outpatient procedures. The nurse was asked several times to explain the type of tracking being done by the hospital to identify multi drug-resistant organisms as defined by the hospital's Infection Control Program.

Based on observations, QAPI documents, and interviews, it was determined the facility failed to ensure the hospital-wide QAPI program addressed problems identified by the infection control officer or officers and was responsible for the implementation of successful corrective action plans in affected problem areas.

The findings included:

1. The facility failed to ensure kitchen sanitation was maintained and food service codes followed in all areas of food preparation for use by patients or public

The facility ensure the staff was educated on the principle and practices for preventing transmission of infectious agents within the hospital and through proper use of equipment.
Refer to A 749

2. Review of QAPI documents failed to demonstrate the QAPI program and staff in-service training programs addressed staff education based on results from tools used to track and trend infection control issues.
Refer to A 749 and A 276