HospitalInspections.org

Based on staff interview, record review and review of the hospital's QAPI (Quality Assurance Performance Improvement) Program, it was determined that the facility failed to accurately report medication administrative errors to its hospital wide QAPI program.

The findings include:

A review of the hospital wide QAPI program on 01/13/14 and 01/15/15 revealed that the hospital was not accurately reporting medication administration errors to its hospital wide QAPI program. This was evidenced by comparing the QAPI report to the EMR (Electronic Medical Records), and medication incident reports during the time periods from April 2014 through November 2014. Review of these reports revealed discrepancies in the reporting of medication errors.

Based on observation, staff interview and review of hospital documentation, the hospital's Director of Food and Nutrition failed to ensure that food was stored and prepared in a manner to assure patient safety.

The findings include:

On 1/12/2015 at 10:40 AM during a tour of the Dietary Department with the Director of Food and Nutrition, the following was observed:

Walk-in refrigerator
Bag of Mozzarella cheese with an expiration date of 1/11. A bag of pepper cheese was open and undated.

Dishwashing area
6 serving pans stored with standing water inside.

Food Preparation area
6 loaves of bread, no expiration date.
3 packages of English Muffins, no expiration date.
2 packages of Pita bread, no expiration date.

Clean Storage Area
Dirty Ice cream scoop.

On 1/14/2015 at 11:30 AM, the staff was observed taking food temperatures prior to the food being served to patients, the following was observed. The staff member failed to take temperatures of cold foods being served.

A review of the food temperature logs for November 2014 and December 2014 revealed the following:
November 2014-48 of 90 meals lacked having food temperatures recorded.
December 2014-44 of 93 meals lacked having food temperatures recorded.

On 1/16/2015 at 8:50 AM, a review of the hospital policy "Infection Control-Food Preparation, Storage Service reviewed 11/20/2014, revealed the following; Purpose/Rationale; To identify how food is prepared, stored and served in accordance with infection control standards."

The policy lacks temperatures required for storage and serving of foods.

A review of Hospital policy reviewed 11/20/2014, "Cutting Boards", revealed ; "#5 All foods should be stored at the appropriate temperature, covered, dated and labeled."

A review of Hospital policy "Ware Washing," reviewed on 11/20/2014, "#3 The final rinse sink is tested with PH paper to ensure the proper level of sanitizing agent is present. The test paper is attached to the Temperature Control Log that is maintained by the Food Service Supervisors."

A review of the Temperature Control Log lacked any indication of how often the pot sink was used or test papers were and saved.

In an interview with the Director of Food and Nutrition on 1/12/2015 at 11:00 AM it was acknowledged that refrigerated foods should be discarded after the use by date, Items should be dated when opened and not exposed to air. He was again re-interviewed on 1/16/2015 at 10:15 AM. He acknowledged that the food temperatures had not been consistently recorded in November and December. He also said he was unaware that the baked good being sent to the hospital lacked an expiration date. He also said that pans should not be stored with standing water and that items stored should be clean. In regards to the hospital policies and he stated that there were no parameters in the policies documenting the required temperatures for storage of foods and admitted non adherence to the pot washing issue regarding the test strips. The Director also acknowledged that temperatures on cold foods were not taken on 1/14/2015 at 11:30 AM during surveyor observation.

Based on observations and staff interviews, it was determined that the facility failed to ensure that the hospital environment was maintained in a manner to assure the safety and well-being of all patients as evidenced by a dirty floor sink, dusty ceiling air vents, trash on floors, kitchen wall behind ice machine crumbling, missing light bulb in housekeeping closet, missing ceiling tile,missing escutcheon, ice machines lacking air-gaps or backflow preventers, stained ceiling tiles, outer wall of loading dock damaged, trash stored in loading dock area in trashbags and in an open trailer and the door to trash compactor open with trash bags partially falling out.

The findings include:

On 1/16/2015 at 1:00 PM during a tour of the physical environment with the Maintenance Director, the following was observed.

Loading Dock area
Numerous plastic trashbags stored in an open trailer with a bird using it's beak to open a plastic bag.
Trash compactor with door open and trash bags partially falling out.
Wall of building damages and concrete crumbling exposing the inner studs of support.

Dietary Department
The ice machine lacking air-gap or backflow preventer,
The wall behind ice machine crumbling near floor.
Ceiling vents were dusty.
A missing ceiling tile in chemical closet

Receiving Room
Three (3) Empty boxes stored on floor
Two (2) Trashbags stored on floor with six (6) empty boxes outside Receiving Room.

Communication Room
A stained ceiling tile outside room.

Fourth Floor Soiled Utility Room
The ceiling sprinkler head lacked an escutcheon

Maternity Unit
The ice machine lacking air-gap or backflow preventer.

Telemetry Unit
A housekeeping closet- dirty floor sink
The ice machine no air-gap or backflow preventer.

Operating Room Suite
Ice machine lacking air-gap or backflow preventer.

Post Anesthesia Care Unit
Ice machine lacking air-gap or backflow preventer.

Emergency Department
Ice machine lacking air-gap or backflow preventer.

Cafeteria
Ice machine lacking air-gap or backflow preventer.
Stained ceiling tile in trayline area.
Stained ceiling tile in seating area.

In an interview with the Maintenance Manager on 1/15/2014 at 3:00 PM, it was acknowledged that the items discovered during the environmental tour had to be corrected.

The Housekeeping Supervisor was interviewed at 3: 30 PM on 1/15/2015. He acknowledged that there was numerous trashbags stored in and around the area of the loading dock. Work orders were requested relative to the broken trash compactor by the survey team. However, no work orders were produced that were dated prior to the exit date of the survey.

Based on observation and staff interview, it was determined that the facility failed to ensure that the hospital's equipment was maintained in a manner to assure the safety and well-being of all patients as evidenced by not disposing of expired Cidex test strips, empty oxygen tanks stored with full canisters, exposed wire in an overhead light, light cover in a clean utility room partially ajar, exposed wiring in the walk-in freezer, expired Cidex OPA and Prolystica enzymatic cleaner.

The findings include:

On 1/13/2015 at 2:35 PM during an observation of the Operating Suite in an Anesthesia workroom, the following was observed: Oxygen storage caddy's containing 3 empty oxygen tanks co-mingled with full tanks.

The observation was confirmed by the unit's Transporter who acknowledged that he had co-mingled the oxygen tanks.

On 1/15/2015 at 1:00 PM during an environmental tour of the facility, the following was observed:

Dietary
Exposed wires in an electrical box located in the walk-in freezer

Intensive Care Unit
Housekeeping closet-exposed wires hanging from overhead light.

Operating Suite
Utility Room-overhead light cover partially dislodged.

Radiology/Nuclear Medicine
Cidex room-gallon container of Polystica (caustic cleaner) enzymatic cleaner expired 10/1/2014

Cidex Room
Cidex Test strips, do not use after 6/28/14
Cidex OPA (caustic cleaner), expired 7/6/14

In an interview with the Maintenance Manager on 1/15/2014 at 3:00 PM, it was acknowledged that the items discovered during the environmental tour had to be corrected.