HospitalInspections.org

Cross refer to:

A0057

Based on interviews and a review of documentation, the facility failed to appoint a chief executive officer, responsible for managing the hospital. Failure to manage the hospital can compromise patient safety.

Findings were:

During a review of 4 surgical records (patients #9 - #12), one of four patients (patient #11) had not received the necessary update or addendum to the history and physical prior to the patient's surgery on 5-11-15. A history and physical exam was performed on 4-24-15, within 30 days prior to the surgery, but contained no addendum by the physician (staff #37) clarifying the patient's current condition. The patient had surgery performed on 5-11-15 and was discharged from the facility on 5-12-15. In an interview with staff #5 on 7-1-15, staff #5 verified that no History and Physical (performed more recently than 4-24-15) nor an addendum was present in the patient's electronic record. Failure to update the History and Physical prior to surgery places the patient at risk, as neither the surgeon nor the anesthesiologist are able to take into consideration any possible changes in the patient's physical condition that may increase the risk to the patient's health or safety.

Facility policy 6a.017 titled "History and Physical" states, in part:
"POLICY
1. A history and physical exam shall be completed on patients within the following parameters:
a. The history and physical exam shall be completed prior to the patient having any procedure or surgery. NOTE: An H&P must be on the chart prior to the patient receiving any medication for sedation/narcotics.
b. Patients having outpatient procedures must have a history and physical that has been completed within 30 days of admission with an addendum by the physician stating either that no changes have occurred, or describe the patient's current condition."

During a review of documentation, staff #37 was found to have 5 chart delinquencies (pertaining to patients #23, #24 and #25). The patient's discharge dates ranged from 1-28-15 to 3-19-15. During an interview with staff #2 on 7-1-15, staff #2 confirmed that staff #37's privileges were still current and that staff #37 had surgical procedures scheduled for the week of 7-6-15.

Facility "Rules and Regulations of the Medical Staff" page 7 states, in part:
"F. All records must be completed within 30 days of discharge;
4.15 Suspension Due to Delinquent Charts: any physician, who has records delinquent past 30 days from discharge, will be given notification with 15 days to complete the records. In the event that the records are not completed, suspension of privileges will occur. A Physician may continue the care of patients currently in the hospital when he/she has been notified of suspension but may not admit any additional patients or schedule any procedures, including surgery and catheterizations."

Facility policy 6a.005 titled "Content of the Record of Admission" states, in part:
"PROCEDURE:
.....
3. ...The attending physician shall be held responsible for preparation of a complete medical record for each patient within thirty (30) days of discharge."

Facility policy 6a.007 titled "Delinquent Records & Suspension Policy" states, in part:
"PROCEDURE:
1. The physicians must understand and adhere to these guidelines:
a) On the 30th day post discharge, an incomplete record is delinquent. The Health Information Management Manager notifies the physician that his or her admitting, consultative and surgical privileges have been suspended until his or her medical records have been completed."

During a tour of the facility kitchen on 7-1-15, the following observations were made:
- 5 large baking trays, lined in parchment-type paper and filled with raw bacon slices, were stacked on top of each other in the walk-in cooler. Although the cooking surface of the baking tray is expected to be clean in anticipation of food preparation, the bottom surface of the baking tray does not. Stacking trays in a manner that puts the food item in contact with the outside of a baking tray can introduce bacteria (picked up from the surface where the baking tray was previously sitting) onto the food being prepared.
- Inside the dry goods pantry/storage area, 1 of 2 5-gallon buckets of soy sauce contained sticky residue around the pour spout, which can serve as a food source for disease-carrying vermin.
- An open, 20-lb box of dry, pinto beans was found on a shelf, and was approximately 1/3 full of beans. Storing beans in an open box can serve as a food source for disease-carrying vermin.
- The food storage area contained 32 external shipping boxes, which transport outside dirt and bacteria onto other food products.
- An examination of the floor area underneath the shelving units revealed many items, such as crackers, jelly condiment packets, bottled water, several pieces of dry pasta, a single-unit serving of breakfast cereal and packets of peanut butter, which can all serve as a food source and to attract disease-carrying vermin.
- A large, personal radio and a fan with dusty vents were located on a food preparation table, inches away from containers of fruit cobbler and refried beans. Outside, personal items carry and transmit disease-causing bacteria.
- 2 large metal pans full of meat, each weighing approximately 15 to 20 pounds, were covered in foil, hot to the touch and sitting on a metal food-preparation counter. When asked if they were to be served immediately, staff #17 stated that the trays contained just-cooked turkey and pork to be served the next day, but were being allowed to "cool down" before being placed in the walk-in cooler. Allowing hot foods to cool down before refrigeration encourages bacterial growth, leading to illness for patients and staff.
- Spilled, burned food was located on the inside of the convection oven, serving as a food source for disease-carrying vermin. In an interview with staff #15, staff #15 stated that the oven was not scheduled to be cleaned until Saturday, allowing the food to sit for 3 additional days.
- An inspection of all dish-drying racks revealed wet cooking/baking pans stacked on top of each other. Moisture encourages bacterial growth, increasing the chances of illness among patients and staff.

Facility policy 2e.068 titled "Sanitation Program" states, in part:
"PURPOSE
To maintain a clean, safe and effective environment of care and to prevent the transmission of disease-carrying organisms.
POLICY
The Food & Nutrition Services Department maintains a sanitation program.
PROCEDURES
1. The Foodservice (sic) Manager develops and monitors sanitizing schedules and procedures with frequencies identified.
2. Equipment, walls, floors and storage areas are cleaned with the appropriate Ecolab products per departmental cleaning schedules."

The above findings were confirmed with the facility Chief Executive Officer, Director of Quality, Chief Financial Officer, Director of CCCU/ER, Northstar Administrator, Chief Nursing Officer and Director of Acute Care on the evening of 7-1-15.

Based on observation, the facility failed to ensure that all drugs and biologicals were must be kept in a secure area, and locked when appropriate. Unsecured medication could be accessed by unauthorized personnel, diverted by staff, or compromised; placing patients at risk.

Findings included:

During a tour of the North Star Surgical campus on 07/01/15, the following observation were made:
* A cart was observed unattended in the pre-operative area. A drawer was found unlocked containing vials of : Marcaine, Xylocaine,Lydocaine, and Depo Medrol.
* A medication cabinet in the pre-operative was observed unlocked and unattended. The cabinet contained medications such as, Toradol and Decadron.

The above unsecured medications were confirmed with staff member #23 on 07/01/15.

Cross refer to:

A0621

Based on observation, interviews and a tour of the facility, the facility failed to employ a qualified dietitian that observed and adhered to professional standards of practice regarding food storage and sanitation. Failure to adhere to these professional standards compromises patient safety and increases the likelihood of infections caused by improper sanitation and improper food storage.

Findings were:
During a tour of the facility kitchen on 7-1-15, the following observations were made:
- 5 large baking trays, lined in parchment-type paper and filled with raw bacon slices, were stacked on top of each other in the walk-in cooler. Although the cooking surface of the baking tray is expected to be clean in anticipation of food preparation, the bottom surface of the baking tray does not. Stacking trays in a manner that puts the food item in contact with the outside of a baking tray can introduce bacteria (picked up from the surface where the baking tray was previously sitting) onto the food being prepared.
- Inside the dry goods pantry/storage area, 1 of 2 5-gallon buckets of soy sauce contained sticky residue around the pour spout, which can serve as a food source for disease-carrying vermin.
- An open, 20-lb box of dry, pinto beans was found on a shelf, and was approximately 1/3 full of beans. Storing beans in an open box can serve as a food source for disease-carrying vermin.
- The food storage area contained 32 external shipping boxes, which transport outside dirt and bacteria onto other food products.
- An examination of the floor area underneath the shelving units revealed many items, such as crackers, jelly condiment packets, bottled water, several pieces of dry pasta, a single-unit serving of breakfast cereal and packets of peanut butter, which can all serve as a food source and to attract disease-carrying vermin.
- A large, personal radio and a fan with dusty vents were located on a food preparation table, inches away from containers of fruit cobbler and refried beans. Outside, personal items carry and transmit disease-causing bacteria.
- 2 large metal pans full of meat, each weighing approximately 15 to 20 pounds, were covered in foil, hot to the touch and sitting on a metal food-preparation counter. When asked if they were to be served immediately, staff #17 stated that the trays contained just-cooked turkey and pork to be served the next day, but were being allowed to "cool down" before being placed in the walk-in cooler. Allowing hot foods to cool down before refrigeration encourages bacterial growth, leading to illness for patients and staff.
- Spilled, burned food was located on the inside of the convection oven, serving as a food source for disease-carrying vermin. In an interview with staff #15, staff #15 stated that the oven was not scheduled to be cleaned until Saturday, allowing the food to sit for 3 additional days.
- An inspection of all dish-drying racks revealed wet cooking/baking pans stacked on top of each other. Moisture encourages bacterial growth, increasing the chances of illness among patients and staff.

Facility policy 2e.068 titled "Sanitation Program" states, in part:
"PURPOSE
To maintain a clean, safe and effective environment of care and to prevent the transmission of disease-carrying organisms.
POLICY
The Food & Nutrition Services Department maintains a sanitation program.
PROCEDURES
1. The Foodservice (sic) Manager develops and monitors sanitizing schedules and procedures with frequencies identified.
2. Equipment, walls, floors and storage areas are cleaned with the appropriate Ecolab products per departmental cleaning schedules."

The above findings were confirmed with the facility Chief Executive Officer, Director of Quality, Chief Financial Officer, Director of CCCU/ER, Northstar Administrator, Chief Nursing Officer and Director of Acute Care on the evening of 7-1-15.

Cross refer to:

A0748

Based on observation, interviews, a review of documentation and a tour of the facility, the infection control officer failed to develop and implement adequate policies governing control of infections and communicable diseases. Failure to develop and implement adequate policies increases the likelihood of disease and illness within the facility.

Findings were:

During a tour of the facility kitchen on 7-1-15, the following observations were made:
- 5 large baking trays, lined in parchment-type paper and filled with raw bacon slices, were stacked on top of each other in the walk-in cooler. Although the cooking surface of the baking tray is expected to be clean in anticipation of food preparation, the bottom surface of the baking tray does not. Stacking trays in a manner that puts the food item in contact with the outside of a baking tray can introduce bacteria (picked up from the surface where the baking tray was previously sitting) onto the food being prepared.
- Inside the dry goods pantry/storage area, 1 of 2 5-gallon buckets of soy sauce contained sticky residue around the pour spout, which can serve as a food source for disease-carrying vermin.
- An open, 20-lb box of dry, pinto beans was found on a shelf, and was approximately 1/3 full of beans. Storing beans in an open box can serve as a food source for disease-carrying vermin.
- The food storage area contained 32 external shipping boxes, which transport outside dirt and bacteria onto other food products.
- An examination of the floor area underneath the shelving units revealed many items, such as crackers, jelly condiment packets, bottled water, several pieces of dry pasta, a single-unit serving of breakfast cereal and packets of peanut butter, which can all serve as a food source and to attract disease-carrying vermin.
- A large, personal radio and a fan with dusty vents were located on a food preparation table, inches away from containers of fruit cobbler and refried beans. Outside, personal items carry and transmit disease-causing bacteria.
- 2 large metal pans full of meat, each weighing approximately 15 to 20 pounds, were covered in foil, hot to the touch and sitting on a metal food-preparation counter. When asked if they were to be served immediately, staff #17 stated that the trays contained just-cooked turkey and pork to be served the next day, but were being allowed to "cool down" before being placed in the walk-in cooler. Allowing hot foods to cool down before refrigeration encourages bacterial growth, leading to illness for patients and staff.
- Spilled, burned food was located on the inside of the convection oven, serving as a food source for disease-carrying vermin. In an interview with staff #15, staff #15 stated that the oven was not scheduled to be cleaned until Saturday, allowing the food to sit for 3 additional days.
- An inspection of all dish-drying racks revealed wet cooking/baking pans stacked on top of each other. Moisture encourages bacterial growth, increasing the chances of illness among patients and staff.

Facility policy 2e.068 titled "Sanitation Program" states, in part:
"PURPOSE
To maintain a clean, safe and effective environment of care and to prevent the transmission of disease-carrying organisms.
POLICY
The Food & Nutrition Services Department maintains a sanitation program.
PROCEDURES
1. The Foodservice (sic) Manager develops and monitors sanitizing schedules and procedures with frequencies identified.
2. Equipment, walls, floors and storage areas are cleaned with the appropriate Ecolab products per departmental cleaning schedules."

During a tour of the Radiology area on 7-1-15, the following observation was made:
- Personal jackets and clothing belonging to radiology employees was hanging on pegs adjacent to and touching lead aprons and other protective coverings worn by patients during radiology procedures. Personal items transport bacteria from outside the facility and increase the risk of illness to facility patients and other staff.

The above findings were confirmed with the facility Chief Executive Officer, Director of Quality, Chief Financial Officer, Director of CCCU/ER, Northstar Administrator, Chief Nursing Officer and Director of Acute Care on the evening of 7-1-15.





30250

Based on observation and interview the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The infection control officer failed to implement policies governing control of infections and communicable diseases.


Findings included:

The following infection control issues were noted while touring the North Star Surgical campus on 07/01/15:
* Throughout the facility water damaged tiles were observed, presenting a risk for bacterial growth and contamination.
* In the nourishment area, dust was observed on top of the patient ice machine, indicating ineffective cleaning.
* In both Operating Room # 2 and 6, a cloth covered rolling chair was observed. The cloth fabric cannot effectively be cleaned and provides an environment for potential bacterial growth.
* Outside Operating Room # 5 a water stain was observed in a light fixture. Paint was also observed peeling from the wall above a sterilizer in this hall.
* The sterile supply area for the Operating Rooms, 4 scissors that had been sterilized and stored in the closed or partially closed position. It could not be determined that these surfaces were appropriately cleaned. When instruments are closed, the sterilizing agent cannot penetrate all surfaces to ensure complete sterilization of all surfaces of the instruments. The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that close should be opened during the process of sterilization.

The above findings were confirmed with staff members # 4, 21, and 22 on 07/01/15.