HospitalInspections.org

C-1208
485.64(a)(3)

Based on dietary staff interviews, facility policy and procedure review, job description review, and review of manufacturers recommendations of sanitizer the facility failed to ensure cooking utensils were properly sanitized in the three (3) compartment sink due to the misrepresentation of the "Sanitation Log" by staff for three (3) calendar days and eight (8) meals.

Findings Include:

An interview on 09/29/22 at 1:30 PM, with Dietary Worker #1 confirmed she pre- fill documentation of sanitizer checks on the "Sanitation Log" for the three (3) compartment sink for breakfast and lunch on 09/27/2022, 09/28/2022, and 09/30/2022.

Review of facility policy entitled "Testing of Sanitizing Solutions in the Three Compartment Sink", no date, revealed; " ...the cook or the person washing pots and pans will check for adequacy of the disinfectant agent in the three compartments three times daily or more if necessary" ... (6) the concentration should be recorded on sanitation log for three compartment sink ...".

Review of "Sanitation Log" for the three (3) compartment sink on 09/26/22 at approximately 2:00 P.M. revealed the "Sanitation Log" had been pre-filled for 09/27/2022, 09/28/2022, and 09/30/2022 for breakfast and lunch.

Review of the "Sanitation Log Sheet Instructions" revealed " ...1. Concentration of the Sanitizer of the three-compartment sink must be checked three times daily. 2. Concentration of sanitizer should match with the 200 ppm. 3. If concentration is not at proper concentration, notify the dietary manager."

Review of job description for Dietary Employee #1 revealed job summary " ...complies with established sanitary standards and personal hygiene and health standards of personnel...".

Survey findings were discussed at Exit Conference on 09/28/2022 at 2:15 P.M. and no further documentation was submitted for review.

Based on staff interview, contact review, dashboard review, and policy and procedure review, the facility failed to notify the organ procurement organization of deaths for four (4) of 46 deaths in 2021 and four (4) of 32 deaths for the months of January 2022 through August 2022 in a timely manner.

Findings Include:

During an interview on 09/28/2022 at 1:16 p.m. the Director of Nursing confirmed the facility was not compliant with timely notification to the Organ Procurement Organization.

Review of contract with Organ Procurement Agency and the facility, effective date December 13, 2018, " ... A timely referral is one that is made as soon as possible (within one (1) hour) and ... "Timely notification of tissue donation ... individuals who have died a cardiac death notification is timely if the referral is made soon as possible, within one (1) hour ...".

Review of the Mora Donation Dashboard for 2021 and 2022 reveals the months of March, July, and September 2021 each has one (1) referral between 61 minutes and two (2) hours, and the month of August 2021 has one (1) referral between two (2) and four (4) hours. In January 2022 two (2) referrals between 61 minutes and two (2) hours; January 2022 and July 2022 each has one (1) referral between two (2) hours and four (4) hours.

Facility policy, "Donor Referral Procedure," dated January 2009 revealed, " ...Donor Referral Procedure: MORA should be notified ideally within one hour of cardiac death ...".

Survey findings discussed at Exit Conference on 09/28/2022 at 2:15 P.M. and no further documentation was submitted for review.