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Based on observation, interview, and record review, the Governing Body failed to:
A. ensure expired items were removed from patient care areas.
Refer to tag A0724

B. ensure the infection control officer had an adequate system in place to prevent the following unsanitary conditions. 2 of 2 kitchens were found to be unsanitary. Patient equipment was not maintained to avoid contamination. Soiled plastic biohazard bins were found in patient rooms.

Refer to tag A0749

Based on observation, interview, and document review, the facility failed to provide policies for the safe storage, transportation and distribution of linen.

On 2/11/2013 at 1:00 PM, during a tour of the central supply linen storage area, a tall steel linen cart was observed. Staff #16 was questioned about the cart. He indicated the linen cart was being loaded for delivery to the nursing unit. The cart had a plastic drape over three sides. The front of the cart had the plastic drape flipped up over the top. The cart was unattended. Staff #16 indicated the staff member who was working on loading the cart was on break.

On 2/11/2013 at 1:00 PM in the central supply area, staff #16 was interviewed and confirmed that the responsible staff member should have placed the front drape down to cover the clean linen before she went on break. When questioned about policies for staff to review, staff #16 reported there were no polices he was aware of for the storage of the clean linen in the central supply area. He also reported he had no knowledge of polices for the safe transport of clean linen to the nursing units, nor policies for the safe distribution of the clean linen by staff for patient use.

On 2/12/2013 in the conference room, multiple requests were made for linen and laundry services polices. Facility staff provided no policies.

On 2/12/2013 at 2:30 PM in the conference room, the linen/laundry services contract was reviewed. The contracted linen service did not provide policies for linen/laundry services for the facility.

Based on record review and interviews, the facility failed to follow physician orders in a timely manner. 2 (#2, #3) of 5 (#2, #3, #51, #52, #53) patient charts had a greater than two hour delay in medication administration.

Findings include:
1.)Review of medical records on 02/13/2013 at 2:10 PM revealed patient #3 had a physician order for Adult Hyperalimentation (IVH) written on 2/1/2013 at 1:00 PM. The order was noted by nursing on 2/1/2013 at 3:00 PM. Patient #3 received the IVH the next day, 2/2/2013 at 12:20 AM. No further documentation was noted to explain the eleven hour and twenty minute delay.
During an interview on 02/14/2013 at 10:00 AM, staff #24 and #58 confirmed the delay in IVH administration.
During an interview on 2/14/2013 at 10:00 AM, staff #24 reported that orders for IVH are scanned to the pharmacy, where the IVH is mixed and sent to the floor. The nurse electronically scans the bag and administers the medication. When the bag is scanned, the electronic medical record (EMR) documents the time scanned as the time administered on the MAR. Review of the medication administration record (MAR) revealed the IVH medication for patient #3 was administered on 2/2/2013 at 12:20 AM. According to the EMR, the pharmacy received the order for this IVH on 2/2/2013 at 1:00 PM. Therefore, according to the EMR, patient #3 was administered the medication forty minutes before it was filled by the pharmacy. Staff #24 and #58 confirmed that the EMR MAR was not accurate.

2.) Review of medical records on 02/13/2013 at 2:10 PM revealed patient #2 had a physician order for Adult Hyperalimentation (IVH) written on 2/8/2013 at 12:00 PM. The order was noted by nursing on 2/8/2013 at 7:30 PM. The MAR revealed patient #2 received the IVH on 2/8/2013 at 8:30 PM. No further documentation was noted to explain the eight hour and thirty minute delay.
During an interview on 02/14/2013 at 10:00 AM, staff #24 and #58 confirmed the delay in IVH administration.

Based on record review, observation, and interview, the facility failed to ensure expired medications were removed from patient care areas. The facility also failed to require necessary documentation of the date multidose vials were opened and accessed. This lack of dating makes it impossible to determine if the medication is beyond the safe use date, as defined by the United States Pharmacopeia.


Findings include:

The US Pharmacopeia (USP 2008), General Chapter 797, Pharmaceutical Compounding/ Sterile Preparations, requires multidose vials to be discarded 28 days after initial stopper penetration unless the manufacturer specifies otherwise. The vial should be labeled to reflect the penetration date or the beyond-use date (United States Pharmacopeia (USP) 797: Guidebook to Pharmaceutical Compounding - Sterile Preparations. Second Edition, June 1, 2008).

During a tour of the Emergency Department (ED) on 2/12/12 at 9:00am, the following expired drugs/biologicals were found:
-expired bottle of Iodine was opened on 8/1/2012;
-2 bottles of normal saline opened, with no date opened or beyond-use date;
-lidocaine bottle opened, with not date opened or beyond-use date.

During the tour, staff #44 confirmed these findings.

During an observation on 02/12/13 at 9:15am, a bag of Dobutamine that expired 02/01/13 and 14 intravenous infusion sets that expired 04/2011 were found stored in the pharmacy.

During an interview on 02/12/12 at 9:15 am, Staff #43 confirmed the expired items.

Based on observation and interview, the facility failed to assure expired items were removed from patient care areas.

Findings include:

During a tour of the Emergency Department (ED) on 2/12/12 at 9:00am, the following expired items were found on the pediatric crash cart in Trauma Room 4:
-Braslow Pediatric Emergency System Kits x 1- expired 3/12;
-Braslow Pediatric Emergency System Kits x 1- expired 4/12;
-Braslow Pediatric Emergency System Kits x 1- expired 9/12;
-Braslow Pediatric Emergency System Kits x5- expired 10/12;
-Braslow Pediatric Emergency System Kits x 1- expired 12/12;
-Bard Temperature Sensing Urinary Catheters x1- expired 8/12;
-Bard Temperature Sensing Urinary Catheters x3- expired 4/11;
-Bardex Urinary Catheter x2- expired 10/12;
-Nasopharyngeal airway x1- expired 01/12;
-Gastric tube x1- expired 12/08;
-Laryngeal Mask Airway x1- expired 4/11;
-Laryngeal Mask Airway x1- expired 10/12.

During the tour, staff #45 confirmed these findings.

During an observation on 02/13/13 at 11:15 am, the following were found stored in the Physical Therapy wound care treatment cart:
-Two Sensa Trac dressing pads- one expired 7/2010 and another expired 12/2010;
-One packet of skin staple extractors expired 11/2010;
-Eight tongue blades expired on 02/1/2012.

During an interview on 02/13/13 at 11:15 am, Staff #42 confirmed the expired items in the treatment cart.

Based on observation, interview, and record review, the facility failed to:
A. ensure expired items were removed from patient care areas.
Refer to tag A0724

B. ensure the infection control officer had an adequate system in place to prevent the following unsanitary conditions. 2 of 2 kitchens were found to be unsanitary. Patient equipment was not maintained to avoid contamination. Soiled plastic biohazard bins were found in patient rooms.

Refer to tag A0749

Based on observation, interview, and record review the facility failed to ensure the infection control officer had an adequate system in place to prevent the following unsanitary conditions. 2 of 2 kitchens were found to be unsanitary. Patient equipment was not maintained to avoid contamination. Soiled plastic biohazard bins were found in patient rooms.

Findings include:
1.) Review of the "Nutrition and Food Service Policy and Procedure Manual," dated 09/2011 revealed the following:
*After each use, all production and serving areas, kitchenware and food contact surfaces, utensils, and equipment, exclusive of cooking surfaces, used in preparation, serving, display and storage of food shall be thoroughly washed and sanitized.
*Surfaces of equipment will be kept free of encrusted grease deposits and other accumulated soil by daily cleaning.
*All refrigerators (shelves and flooring) storage bins and carts should be washed and sanitized daily.
*Insure perishables are utilized prior to product expiration date. Moreover, items stored in the refrigerator will be held no longer than 40 Fahrenheit for up to 48 hours.
*Staples items such as sugar, rice, flour, etc., must be stored in clean and sanitized portable bins which are located in the dry storage room in order to eliminate the possibility of infestation.
*Non-perishables will be dated and stored in areas designated by Nutrition and Food Service staff. The dry goods storeroom should be segregated into areas used exclusively for food. Paper goods and/or disposables should be stored in an area separate from food and chemicals.
*Gloves must also be cleaned/changed between each change or task or anytime they might be contaminated while performing daily tasks.
*Hairnets and/or caps are required.

During an observation on 02/11/2013, the following was found in the kitchen:
2.) Starting at 11:00 a.m.
* A kitchen worker was observed to be walking around with a full mustache, which was uncovered.
* The baseboards behind the main dishwasher had a buildup of dirt and debris.
*Outside the dishwasher area were uncovered plastic containers of spatulas and scoops stored on a stainless steel shelf in the hallway. Some of the utensils were soiled with food. The inside of the plastic containers were soiled.
* Six large plastic lids were stored wet and had traces of food particles.
* Five plastic containers were stored wet and had traces of food particles.
*Three plastic containers used for salad dressing were stored wet.
*Two stainless steel shelves, used for storing clean dishes, had a buildup of dust.

3.) At 11:25 a.m., the inside of a plastic bin which held the saucers was found soiled. The saucers were stored upright in the uncovered bin.

4.) At 11:27 a.m., the 3-compartment sink room had the following:
*Above the 3-compartment sink was a plastic strip which had separated from the tile backsplash. A buildup of black substance was observed on the tile and on top of the sink.
* Six clean steam table pans were stored on a rolling cart and were stacked wet. They were drying on a soiled towel. Five more clean steam table pans were stored and stacked wet on the counter.

5.) At 11:32 a.m., four coffee pots were stored upright underneath a shelf and had standing water in them.

6.) At 11:42 a.m., the lower stainless steel grill on the dessert/salad refrigerator had a buildup of dried spills and dust. The upright cooler, used to store salads and fruit, was observed with the front lower metal grill covered with a buildup of brown substance. Staff #37 assisted with preparing trays and left the door to the dessert/salad refrigerator open during lunch tray prep time. While preparing trays, the front of her hair was not completely covered with a hairnet. Staff #37 was observed to open the soda refrigerator, pick up menus, and, with the same gloves on, continued to prepare patient food trays.
The conveyor belt, on which patient food trays were placed, was missing sections and contained a buildup of food spills.

7.) At 11:52 a.m., the following was found in a 3-compartment refrigerator in the room with the steam table:
*The plastic gasket on the sides and bottoms of the doors had a buildup of dirt and food particles. The bottom floor of one refrigerator had dried spills. The vent in the top of one of the refrigerators had a buildup of dust. The plastic coverings over the door handles were broken and/or missing, making them unsanitizable.
*Inside the refrigerator was a pan of jello with a prep date of 02/02/13 and a discard date of 02/05/13.
A bag of lettuce, which was turning brown, had a prep date of 02/07/13 and no discard date written on it. During an interview on 02/11/13 at 12:04 p.m., the Food Service Director (FSD) reported the lettuce should have been discarded yesterday (02/10/13).

8.) At 12:05 p.m., the following was found in the food prep area:
*A knife rack, mounted on the wall, was soiled with food particles and contained clean knives.
*Three white plastic bins stored in a corner were covered with stains. One bin contained rice and the other flour. Both bins had metal scoop containers lying directly on top of the rice and flour.
*A toaster, stored underneath a shelf, was soiled with a buildup of crumbs.
*A mixer, stored underneath a shelf, had dry spills.
* A scale, stored underneath a shelf, was covered with food particles and dried spills.
*Three stainless steel mixing bowels, stored underneath a shelf, were wet and soiled with food particles.
*The Robo mixer had a buildup of dried food spills and was rusted.
*Stainless steel bowls, steam table pans, pots, and lids were stored uncovered on a shelf in a high traffic hallway. They were soiled with food particles, dust, and some were stacked wet.

9.) At 12:15 p.m. the following food was found in the refrigerators in the food prep area:
*Three pans of jello had prep dates of 02/02/13 and were to be used by 02/5/13.
*One pan of jello had a prep date of 02/05/13 and was to be used by 02/08/13
* One pan of olives had a prep date of 02/06/13 and was to be used by 02/09/13.
* One pan of red peppers had a prep date of 02/04/13 and was to be used by 02/07/13.
* One pan of sweet relish had a prep date of 02/06/13 and was to be used by 02/09/13.
The inside of the door hinges and the gaskets on the refrigerators were soiled with a buildup of food particles and spills.

10.) At 12:19 p.m., the walk-in freezer, which held the baking supplies, vegetables and breakfast foods had a build-up of ice on the door, the floor at the entrance, and on the walls. The plastic flaps at the entrance were covered with a sheet of ice. Part of the gasket (down one side) was missing. Boxes of food were stored on the shelves, still in packing boxes. An electrical box on one wall in the freezer had a buildup of ice, which protruded about 5 inches. On one side of the freezer was a shelf with food items which was directly underneath a dusty ceiling fan, motor, and rusted pipes. Underneath the pipes were two white containers which were identified as being pickles. The white tops of the containers were soiled with brown particles.

11.) At 12:27 p.m., the walk-in meat freezer had the following:
*Plastic flaps covering the front entrance were frozen with a sheet of ice. Three of the flaps were missing.
*Boxes of meat were stored on the shelves in packing boxes.
*Two containers of Gumbo base were stored on a cart. One was completely uncovered and the other had a lid which was not completely over the top of it.

12.) At 12:37 p.m., the following was found in the dry storage area:
*Baseboards behind shelves had a buildup or dirt and debris. The off-white floor tile had turned brown around the baseboards.
*Two bags of peanuts, one bag of sesame seeds, one bag of pasta, and two bags of noodles were not labeled nor contained in a manner to prevent rodent infestation.
* Paper goods and disposables were stored on a shelf in the room. Bags of laundered mop heads were stored on the floor near some of the disposables.

13.) At 4:00 p.m., Staff #38 performed the final prep on the supper trays. Staff #38 opened a refrigerator, touched the sleeves on her jacket, and used the bottom of her jacket to wipe her face. With the same gloves, she touched the patients' napkins, placed condiments on trays, and touched patients' silverware. With the same gloves, she placed salads on trays, with her thumb making direct contact with the salads. During an interview, Staff #39 (FSM) confirmed all observations.
During an interview on 02/11/13 at 2:55 p.m., Staff #39 (FSD) reported the cleaning schedule was not clearly defined, and could occur daily, weekly, or monthly. There was no documentation of the cleaning schedules.



28659


On 2/13/2013 at 8:30 AM, during a tour of the kitchen, the industrial oven, cooking and baking pots/pans, and carts used in the oven were observed with heavy baked-on grease and carbon buildup. This observation was confirmed by the Food Service Supervisor (FSS) and Lead Chef. This practice has the potential to harbor bacteria in the buildup, resulting in unsafe food preparation.

During the same tour of the kitchen, the plastic curtain, used to maintain the temperature of the freezer when the freezer door is open, was observed to have 10-12 inches of missing plastic allowing warm air to enter into the freezer. This presented the potential for reduced food temperatures, leading to food born pathogens. The FSS confirmed the plastic curtain was missing and reported he had been attempting to purchase a new one.

Also, during this tour of the kitchen, food stocks stored in the cooler were not observed with a "use by" date. Foods were stored in the walk-in cooler in the shipping boxes they were shipped in. The boxes were not dated with "date received" or "use by date." Once the boxes were opened, the content, if removed from the box, was not dated with a "Use by" date. A brown, 12 in square package was observed in the cooler with no identification as to what the content was or when it should be used. Both the FSS and Lead Chef confirmed these findings. This practice leads to the use of expired or possibly damaged/spoiled food items.

During the same tour, a custard in a 8 by 13 inch pan was observed on a shelf in the walk-in refrigerator without a cover to protect it from room air. The custard was not dated with a "use by date." The Lead Chef indicated the custard had been discontinued and should have been discarded.

On 2/13/2013 and 11:00 AM in the conference room, the policies for the dietary department were reviewed. No policy was identified addressing the cleaning of baked-on grease and carbon buildup on the oven, pans or carts. There was no policy identified addressing the storage of food stocks in the cooler. There was no policy addressing the dating or labeling of food once it was placed in the cooler or removed from the box it was shipped in. There was no available policy guidance for the staff regarding these issues.



29763

During a tour of the emergency department (ED) on 2/12/13 at 9:00am, the following was observed:
-there were multiple tears in the covers of exam tables in fast-track rooms 2 & 3;
-there was a dark reddish-brown substance on the exam table under the mattress in RMA room 4;
-a bear hugger (patient warming blanket) was found on the floor and soiled;
-two stretchers had a dark reddish-brown substance on the mattresses in trauma room #4;
-there were soiled needle caps at the base of the stretchers in trauma room #4.

During the tour, staff #44 confirmed these findings.


During a tour of the pharmacy on 2/12/13, the backsplash of the laminar vent hood (used to prepare intravenous fluids and medications for patients) was found to be soiled with a brownish-gray substance. The interior of the hood should have been free of any soiling or debris.

During a tour of the pharmacy on 2/12/13, the interior of the vertical vent hood (used to prepare intravenous fluids and medications for patients) was found to be soiled with a brownish-gray substance. The interior of the hood should have been free of any soiling or debris.

During the tour, staff #48 confirmed these findings.

During an observation on 02/12/2013 at 12:27 p.m., two bundles of sterile supplies were stored on a bottom closet shelf in the ultrasound room. The shelf was lined with a piece of carpet and was approximately 4 inches from the floor. The floor underneath the shelf was soiled with dirt and debris.
A cushion, used to prop patients, had a torn plastic covering with the foam interior exposed.

During an interview on 02/12/13 at 12:27 p.m., Staff #41 confirmed the location of the supplies and the cushion.

During a facility tour on 2/11/12 at 9:20am, the following observations were made:
-the facility used plastic reusable bins to store and transport biohazard waste within and outside the facility;
-these bins were delivered "clean" to the facility by the biohazard waste company and stored outside on a loading dock, exposed to the weather and possibly local animals and insects;
-the "clean" bins were then moved as needed into each patient care department's soiled utility room;
-when a patient was placed in isolation, a bin would be moved from the soiled utility room into the patient's room, where it would be used for biohazard waste disposal.

During the tour, staff #46 and #47 confirmed the following:
-these "clean" biohazard bins were stored in soiled utility rooms throughout the facility;
-the bins were taken from the soiled utility rooms and placed in patient rooms and used to collect biohazard waste;
-this was standard practice throughout the facility.