HospitalInspections.org

Based on staff interview and document review, the facility failed to incorporate the telemedicine program into the Medical Staff bylaws. This had the potential to prevent oversight of telemedicine services.

Findings:

During an interview and concurrent review of the medical staff bylaws on 5/16/19 at 3 p.m., Management Staff D acknowledged the medical staff bylaws, dated July 7, 2017, did not address the telemedicine program.

Based on observation, interview, and record review, the facility failed to maintain the building in a manner that ensured patient safety when:
1) Staff did not routinely test/monitor two alarmed doors, located on the Women's Unit to ensure proper functioning and 1.b) Visitors were not monitored on the Women's unit, which was an open, non-secure and unlocked unit (the Women's unit included the newborn nursery, labor and delivery rooms, and postpartum rooms), and
2) The entrance door between the Emergency Department (ED) and the main hospital was unlocked (using a push-panel on the wall).
These failures created potential for infant abduction and for unauthorized access of individuals from the ED into the main hospital.

Findings:

1) During a facility tour with Administrator B on 5/13/19 at 3:45 p.m., the Women's Unit was open and unlocked. The main hospital hall branched into a left-sided hall (medical/surgical unit) and right-sided hall (Women's unit). There was no locked door leading to the Women's unit and there was no security staff located at the Women's unit entrance. Two alarmed doors were located on the Women's unit. One alarmed door was outside the Newborn Nursery and the other was outside postpartum room 308.

During a tour (with Administrator C) and concurrent interview of the Women's unit on 5/14/19 at 3:50 p.m., RN E and RN F were asked if the door outside the Nursery was alarmed (the alarm would sound if the door was opened). RN E and RN F both stated they were unsure if the door was alarmed. Facility Staff N stated the door's alarm had been checked (for proper functioning) a few weeks earlier (during another facility survey). Facility Staff N was asked for the logs (that documented alarm monitoring). He stated he would have to ask Management Staff E for the logs.

During an interview on 5/16/19 at 9:45 a.m., Security Supervisor O (Supervisor O) was asked about infant security at the facility. Supervisor O stated the area (Women's unit with nursery) was, "supposed to be" secure but was, "not secure." He stated infants wore color-coded wrist bands (for identification) and security staff provided hourly patrols (of the unit). Supervisor O stated the doors leading to the medical/surgical and Women's unit were closed, but not locked at night. When asked about visitors to the Women's unit, Supervisor O confirmed security staff did not check visitors into the unit or provide them with a visitor sticker (to identify them).

During the same interview, Supervisor O stated the facility had recently had a Code Pink drill (infant abduction drill, where staff take a baby doll and try to exit the building). Supervisor O stated the staff and baby doll had gotten out the door (indicating the baby had been abducted in the drill). He stated the door in the same-day surgery unit was not alarmed and the staff member was able to get to the door undetected. When asked about the two doors on the Women's unit, Supervisor O stated the alarm on the door next to room 308 was checked but not documented and stated nobody checked (the alarm) the door outside the Newborn Nursery.

During an interview on 5/17/19 at 11:40 a.m., Administrative Staff A stated infant security was her biggest concern. She stated the facility had had architects assess the Women's unit but issues were identified related to fire code (unable to lock hall doors due to fire code). When asked what actions the facility took to address infant security, Admin Staff A stated staff in the Women's unit wore burgundy colored scrubs, nurses wore name badges with baby footprints on them, staff educated family, and babies were mostly kept in their mother's room. When asked if the facility had considered having visitors sign-in with security and wear a visitor sticker/badge to identify them, Admin Staff A stated she had not thought of that.

During an interview on 5/17/19 at 1 p.m., Management Staff E confirmed the facility had a Code Pink Drill where the baby "almost got out." Management Staff E stated the staff member and baby doll got to the exit without detection. Management Staff E was asked about monitoring (checking) the alarms on the two doors located on the Women's unit. He stated the facility had checked them during a recent survey (a few weeks earlier) and when asked when the alarms had been checked prior to the survey, he stated, "I couldn't tell you."
He stated the facility had no formal process for alarm monitoring/checking, but they planned to check them quarterly going forward.

Review of facility policy titled, "Visitor and Traffic control," subtitled, "Compliance - Key elements" (Revised 10/5/17) indicated, "A. Access and Egress... 2. Sensitive areas such as....Emergency Department, and Obstetrics (Women's unit) will be provided additional security measures that may include limited access/egress, security cameras, alarm system, key pad entry, or increased visitor control and security rounds..."

Review of facility policy titled, "Infant Security" (Reviewed 9/6/18) revealed it did not contain information on visitor monitoring (such as security sign-in and visitor badges) and did not address monitoring/checking the alarms on the two doors located on the Women's unit.

2) During an interview on 5/16/19 at 9:45 a.m., Supervisor O was asked about hospital security. Supervisor O stated within the past year, a man with a gun was on campus. Supervisor O stated a shooting had occurred offsite and the shooter had followed the victim to the ED. He stated the shooter did not enter the hospital but drove away when he saw hospital security.

During an observation and concurrent interview on 5/17/19 at 10:45 a.m., the door between the ED lobby and the main hospital had a badge lock (staff swiped their badge to open the door). The door also had a push-panel (that opened the door when pushed) and was located to the left of the door. Admin Staff C confirmed non-staff persons could enter the hospital through this door by pushing the push-panel.

Review of facility policy titled, "Operational Plan- Emergency Department," subtitled, "Key Elements," further subtitled,"G. Key Functions Affecting the Department," (Revised 8/13/18) indicated the ED had, "7. ...secured entrances and access points to the department....The department is kept locked 24 hours/day and entry is allowed only via key or bag (badge) access..."

Based on observations, interviews, and document reviews the hospital 1) Failed to store "protect from light" medications appropriately when Metoclopramide (anti-emetic), Iopamidol (used to improve imaging), Bupivacaine with Epinephrine (medication used for local anesthesia) were stored under direct light. This failure increased the potential for administering compromised medications, and 2) Failed to secure one medication (Dexamethasone, a steriod) per facility policy. This failure caused potential for unauthorized access to medication.

Findings:

1) A review on 5/13/19 of an undated hospital policy entitled MEDICATION AREA INSPECTIONS-HOSPITAL indicated "The pharmacist ensures that all drugs stored in the hospital are under the proper conditions of...light ...Drugs requiring special storage conditions are properly stored."

A review on 05/13/19 of the manufacturer insert indicated protect from light for Metoclopramide, Iopamidol, Bupivacaine with Epinephrine. According to the manufacturer these medications were to be stored away from light.

During an observation on 05/13/19 at 1:12 PM multiple vials of Metoclopramide 2 ml and Iopamidol 10 ml were found in the Pharmacy and was stored under direct light. During an observation on 05/13/19 at 3:13 PM a few vials of Bupivacaine with Epinephrine 20 ml was found in the nursing medication room and was stored under direct light.

The above mentioned medications were found under direct light, were uncovered, and inappropriately stored. Medication that require protect from light deteriorate under direct light. The labels of each of these medications indicated "protect from light".

During an interview on 05/13/19 at 3:13 PM the Pharmacist In Charge stated he did not know the Metoclopramide, Iopamidol, Bupivacaine with Epinephrine needed to be protected from direct light. He said he would cover these medications and keep them away from light.

2) During an observation and concurrent interview at the off-campus Occupational and Physical Therapy building on 5/16/19 at 5:15 p.m., a small box of Dexamethasone was located in a locked box, inside an unlocked drawer. Physical Therapist (PT) Q was asked who had the key to the box. PT Q located the key inside the (unlocked) drawer (staff, visitors etc. could open the unlocked drawer and use the key to open the locked box).

Review of facility policy titled, "Medication Standards," subtitled, "Compliance - Key Elements," further subtitled, "Key Points" (Reviewed on 12/26/18) indicated, "3. Storage and Handling of Medications....c. All medications will be kept in a locked cabinet or room..."

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for §485.635 Provision of Services was met when:

1) Staff stored contaminated instruments and dirty equipment in the newborn nursery and washed their dirty hands (after using a bathroom located in the nursery) on the "clean" side of the nursery, in close proximity to the newborn warmer [bassinet-style bed] (Cross reference C-278);

This failure caused potential for cross-contamination (spread of disease-causing microorganisms) from a dirty area (bathroom and contaminated instrument area) to the clean area where the newborn warmer was located, thereby increasing the risk of infection to 3 of 3 newborn babies.

An IMMEDIATE JEOPARDY (IJ) was identified on 5/15/19 at 2:05 p.m. under Provision of Services at C278. Administrative Staff B and Administrative Staff C were notified of the IJ on 5/15/19 at 3:10 p.m. The IMMEDIATE JEOPARDY was abated on 5/15/19 at 6:05 p.m.

2) Licensed Staff rinsed contaminated instruments in patient bathroom sinks (Cross reference C-278);
3) Licensed Staff stored belongings in the newborn nursery (Cross reference C-278 );
4. a) Expired food was located and available for consumption in the Emergency Department and ICU patient's refrigerators, 4.) A container of ice with scoop was located in the ICU pantry, and 4.c) the ICU pantry was located in a room with a covered Hopper (toilet-like device used to ...) and contaminated equipment (Cross reference C-278);
5) The floor in the kitchen was dirty (Cross reference C-278).
6) The Registered Dietitian did not provide supervision in the kitchen (Cross reference C-279);
7) The Dietary Manager did not possess required job qualifications (Cross reference C-279);
8) Dietary staff did not maintain cool down logs (documentation to monitor cooling times of food) for tuna salad (Cross reference C-279);
9) The facility did not verify dietary staff competencies (skills required to perform job function) prior to allowing them to perform tasks (Cross reference C-279); and
10) Dietary Manual and Disaster Feeding Plan were not current. (Cross reference C-279)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on observations, interviews, and document reviews, the hospital failed to develop and implement the hospital policies to ensure medications are administered in accordance to professional standards of practice as evidence by:

1. The hospital failed to accurately account for multiple missing medications in the night locker. The night locker medication record did not reconcile with the medications found in the locker. This failure increases the potential or is an indication of medication errors such as administering the wrong dose or wrong drug.

2. The hospital failed to administer medications in accordance to professional standards of practice when the hospital nurses did not rotate the site for injection for 2 of 2 patients (Patient 31, Patient 32) on subcutaneous (SC-injection given under the skin) injections. These failures increase the risk for an adverse reaction.

3. The hospital failed to fully administer intravenous (IV) antibiotics when Vancomycin and Piperacillin/Tazobactam which were attached to the mini-bag plus container system, IV solution connected to a drug vial which needs to be activated and mixed prior to administration, where not correctly activated. This failure caused a medication error in which nurses did not fully administer IV antibiotics.

Findings:

1. A review on 5/13/19 of an undated hospital policy entitled AFTER HOURS MEDICATION PROCUREMENT AND USE OF THE NIGHT LOCKER indicated " Access to the Night Pharmacy Locker (NPL) shall be limited...Record of drugs taken from the NPL shall be maintained and the registered pharmacist will be notified of such use. The records will include name of patient, the name and strength of the drug, the amount taken, the date, and the initials of the house supervisor removing the medication...The supervisor will unlock the night locker complete the "Sign Out Log" in the NPL, filling in the required information...The pharmacy department is responsible for...Check quantities of medications used and replace all items used...Check night locker medications to see that quantities are correct..."

During an observation on 5/13/19 at 3:40 PM in the Night Pharmacy Locker the following medications were found in each individual bin:
*#2 tablets Metolazone 2.5 mg-Par level (amount expected if there was no use) 10 tablets
*#5 capsules of Pantoprazole 40 mg-Par level 10 tablets

The above indicated a difference between the actual inventory and the expected inventory. There were 8 tablets of Metolazone missing and 5 capsules of Pantoprazole.

During an interview and record review on 5/13/19 at 3:40 PM the Pharmacist in Charge stated that he did not have the documentation that any Metolazone and Pantoprazole were recently used. He also said he was not sure why there were missing doses of these medications.

During an observation on 5/14/19 at 1:38 PM in the Night Pharmacy Locker the following medications were found in each individual bin:
*#7 Amiodarone 200 mg Tab-Par level 10
*#0 Ipratropium Bromide HFA-Par level 1

The above indicated a difference between the actual inventory and the expected inventory. There were 7 tablets of Amiodarone missing and one missing Ipratropium Bromide HFA.

During an interview and record review on 5/14/19 at 1:38 PM the Pharmacist in Charge stated that he did not have the documentation that any Amiodarone and Ipratropium were recently used. He also said he was not sure why there were missing doses of these medications. He acknowledged that the missing doses could indicate that there were medication errors and he said that he would better control the use and distribution of medications from the NPL.

2. A review on 5/14/19 of the Lippincott Online, a nationally recognized nursing information resource, for subcutaneous injections indicated "Subcutaneous injections...For subcutaneous injections administered repeatedly...rotate sites. Choose one injection site in one area, move to a corresponding injection site in the next area, and so on. When returning to an area, choose a new site in that area..."

A review on 05/14/19 of the Enoxaparin manufacture's insert indicated "Patients should be lying down and Lovenox [Enoxaparin] administered by deep SC injection...Administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall... "

A review on 05/14/19 of Patient 31's clinical record indicated that Patient 31 had physician's orders on 05/13/17 for Enoxaparin 40 mg once daily to prevent venous thromboembolism (blood clot). The Medication Administration Record (MAR) indicated that Registered Nurse 1 (RN1) had documented that the Enoxaparin was administered in the abdomen.

During an interview on 5/14/19 at 1:29 PM RN H stated that she had administered the Enoxaparin and documented that she administered it in the abdomen. She acknowledged that the documented injection site was not specific enough and other nurses would not know where subsequent SC injections should be administered. She said she should have been more specific when documenting the injection site (i.e. right lower quadrant -RLQ, right upper quadrant -RUQ, left lower quadrant -LLQ, and left upper quadrant-LUQ).

A review on 5/14/19 of the Lippincott Online, a nationally recognized nursing information resource, for subcutaneous injections indicated "For heparin injections...The preferred site for heparin injections is the lower abdominal fat pad, 2'(5 cm) beneath the umbilicus, between the right and left iliac crests. Injecting heparin into this, which isn't involved in muscle activity, reduces the risk of local capillary bleeding. Always rotate the site from one side to the other..."

A review on 05/14/19 of the Heparin manufacture's insert indicated "Subcutaneous injection Use a different site for each injection..."

A review on 05/14/19 of Patient 32's clinical record indicated that Patient 32 had physician's orders on 01/06/17 for Heparin 5000 units twice daily to prevent venous thromboembolism (blood clot). The Medication Administration Record (MAR) indicated the previous Heparin injections were documented as followed:
*5/14/19 8:55 AM injection site-abdomen
*5/13/19 9:49 PM injection site-abdomen
*5/13/19 8:38 AM injection site-abdomen
*5/12/19 8:28 PM injection site-abdomen

During an interview on 5/14/19 at 1:33 PM RN I stated that she had administered the Heparin and documented that she administered it in the abdomen. She acknowledged that the documented injection site was not specific enough and other nurses would not know where subsequent SC injections should be administered. She said she would be documenting right RLQ, RUQ, LLQ, and LUQ in the future.

3. A review on 5/14/19 of the manufacturer guidelines on the use of the Mini-Bag Plus Container system in the entitled document Mini-Bag Plus Container System indicated "Squeeze bag and check vial...Bend up then down to break seal...Squeeze solution into vial until half full...Shake to suspend drug in solution...repeat...until vial is empty of drug and solution is thoroughly mixed...Hang container on I.V. pole...Ensure that vial is empty of drug and solution..."

During an observation on 05/14/19 at 2:15 PM in Patient 34's room there was an IV bag labeled Piperacillin/Tazobactam (antibiotic) that was attached to a Mini-Bag Plus Container System. The Piperacillin/Tazobactam vial was partially full, the size of the vial was about 15 ml and approximately 1-2 ml of solution was still in the vial. The 1-2 ml left in the vial was concentrated solution. This IV bag was previously administered in the morning. The vial's concentrated solution was not mixed into the IV bag solution which would have been administered to Patient 34.

During an observation on 5/14/19 at 2:20 PM in Patient 34's room RN J began to prepare the next Piperacillin/Tazobactam IV administration. RN J used about 10 ml to reconstitute the Piperacillin/Tazobactam she did not wait until the Piperacillin/Tazobactam vial was empty. There was 1-2 ml (10-20%) of the concentrated solution that was left in the vial that did not go into the IV bag solution which was then infused into Patient 34. Patient 34 did not receive the full dose of the Piperacillin/Tazobactam.

During an interview on 5/14/19 at 2:35 AM RN J stated she thought the Piperacillin/Tazobactam vial was empty. She then walked back to Patient 34's room and emptied the vial into the IV bag solution so that the full dose was administered. She acknowledged that she needed to check that the vial was completely empty before infusing the Piperacillin/Tazobactam.

During an observation on 05/14/19 at 2:15 PM in Patient 33's room there was an IV bag labeled Piperacillin/Tazobactam that was attached to a Mini-Bag Plus Container System. The Piperacillin/Tazobactam vial was partially full, the size of the vial was about 15 ml and approximately 1-2 ml of solution was still in the vial. The 1-2 ml left in the vial was concentrated solution. There was also a IV Vancomycin (antibiotic) that was attached to a Mini-Bag Plus Container System. The Vancomycin vial was partially full, the size of the vial was about 10 ml and approximately 2 ml of solution was still in the vial. The 1-2 ml left in the Vancomycin vial was concentrated solution.

The full dose of the concentrated solution that was left the vials, Piperacillin/Tazobactam and Vancomycin, were not infused into Patient 33.

During an interview on 5/15/19 at 9:00 AM the Pharmacist in Charge stated that he was not aware that the nurses were not fully emptying the concentrated antibiotics into the IV bag solution. He said that he would educate the nurses of the appropriate technique of activating the Mini-Bag Plus Container System.

Based on observation, interview, and record review, the facility failed to ensure an effective infection control program, and infection control practices were not implemented in accordance with hospital policy and nationally recognized standards when:

1) Staff stored contaminated instruments and dirty equipment in the newborn nursery and washed their dirty hands (after using a bathroom/toilet located in the nursery) on the "clean" side of the nursery, in close proximity to the newborn warmer (bed warmer).

This failure caused potential for cross-contamination (spread of disease-causing microorganisms) from a dirty area (bathroom and contaminated instrument area) to the clean area where the newborn warmer was located, thereby increasing the risk of infection to 5 of 5 newborn babies (Patient 9, 10, 40, 41, and 42).

An IMMEDIATE JEOPARDY (IJ) was identified on 5/15/19 at 2:05 p.m. under Provision of Services §485.635, C-278. Administrative Staff B and Administrative Staff C were notified of the IJ on 5/15/19 at 3:10 p.m. The IMMEDIATE JEOPARDY was abated on 5/15/19 at 6:05 p.m.

2) Licensed Staff rinsed contaminated instruments in patient bathrooms;

3) Licensed Staff stored belongings in the newborn nursery;

4. a) Expired food was located and available for consumption in the Emergency Department and ICU patient's refrigerators, 4.b) A container of ice with scoop was located in the ICU pantry, and 4.c) the ICU pantry was located in a room with a covered Hopper (toilet-like plumbing fixture used to flush/dispose of liquid waste) and contaminated equipment; and

5) The floor in the kitchen was dirty.

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality healthcare in a safe environment.

Findings:

1) During a tour of the newborn nursery and concurrent interview on 5/14/19 at 3:20 p.m., a bathroom (that contained a toilet, but no sink) was located inside the nursery. Registered Nurse (RN) E stated nursing staff used the bathroom (toilet). A sink was located immediately outside the bathroom. A plastic container was located on top of the sink and had a sticker that indicated, " Biohazard." RN E stated the container was used to store dirty instruments from a baby's delivery. A plastic splash-guard was located to the right of the sink to keep water from splashing on the counter. A sign over the sink indicated, "Dirty Area."

During a tour of the newborn nursery and concurrent interview on 5/15/19 at 12 p.m., a plastic container (that had a "Biohazard" sticker) and a piece of medical equipment was located on top of the sink outside the bathroom. RN F stated the equipment was a breast pump and stated the pump had been used (by a nursing mother) the night before. RN F was asked about newborn babies use of the nursery. RN F stated compromised (sick) babies came to the nursery prior to being transferred (via helicopter) to another facility and babies came to the nursery within the first twenty-four hours of birth to be weighed, have their hearing tested and have their blood drawn. RN F stated it was rare for a baby to stay alone in the nursery (they usually stayed with their mother's in their rooms).

During the same interview, RN F was asked how instruments got from the delivery room into the plastic "Biohazard" container in the nursery. RN F stated she rinsed the instruments in the patient's (mother) bathroom, placed them in a HumiPak (moist pouch that held the instruments prior being cleaned and sanitized), and then took the HumiPak to the nursery (and placed it into the plastic container). When asked where staff washed their hands after touching the Humipak and after using the bathroom, she stated they used the sink across from the baby bed warmer (a sign over that sink indicated, "Clean Area.") When asked if this process necessitated staff crossing from the dirty area into the clean area in order to wash their hands, RN F stated, "yes." (Photographs were taken of the nursery).

According to the NCBI (National Center for Biotechnology Information), virulent (severe of harmful) microorganisms can overwhelm the immature immunity of a newborn infant. Effective infection control in the nursery attempts to reduce the exposure of the neonate (newborn) to harmful microorganisms. Important measures include hand washing before and after contact with a patient, good hygiene among personnel, and use of use of aseptic technique (procedures designed to reduce the risk of transmission of disease-causing microorganisms to patients). [https://www.ncbi.nlm.nih.gov/pubmed/6906027].

Online review of AORN (Association of periOperative Registered Nurses) Facility Reference Center Guidelines for Perioperative Practice: Instrument Cleaning (Copyright © 2012-2019) indicated cross-contamination can result when soiled items are placed in close proximity to clean items or are placed on surfaces upon which clean items are later placed.
(https://aornguidelines.org/guidelines/content?sectionid=173736661&view=book#180197698)

An IMMEDIATE JEOPARDY (IJ) was identified on 5/15/19 at 2:05 p.m. Administrative Staff B and Administrative Staff C were notified of the IJ on 5/15/19 at 3:10 p.m.

The facility's Plan of Action to abate the IJ was accepted on 5/15/19 at 5 p.m. The Plan of Action indicated: 1) The Infection Preventionist immediately removed the containers that held the contaminated instruments and ordered a terminal clean of the entire nursery, 2) The Dirty Utility sign was removed and the room was terminally cleaned, including the bathroom and the area previously designated as the dirty area. Nurses would now wash hands at the sink directly outside the bathroom. Dirty instruments or dirty equipment would no longer be allowed to be brought into the nursery. A sign was posted in the nursery indicating no dirty instruments/equipment would be allowed, 3) Nursing staff on duty were re-educated to take dirty instruments to the dirty utility room on the medical/surgical unit. The remaining nursing staff would be educated prior to their next shift, including the night shift of 5/15/19. A sign was placed on the nursery room door that informed nursing staff of this information. Nurses would continue to decontaminate instruments at the bedside and place them in HumiPak's prior to transport from bedside to the dirty utility. Central Sterile processing was notified of the change in location of the dirty instruments.

The IMMEDIATE JEOPARDY was abated on 5/15/19 at 6:05 p.m. in the presence of Administrative Staff B and Administrative Staff C.

2) During an interview on 5/17/19 at 9:40 a.m., Certified Technician K (CT K) was asked how nurses should prepare contaminated delivery instruments prior to placing them in a Humipak. CT K stated staff should wipe off the instruments with a cloth or a four-by-four (4x4 sterile gauze) to remove bioburden (the number of microorganisms living on a surface that has not been sterilized), prior to placing them in the Humipak. CT K was informed nursing staff had reported rinsing dirty instruments in patient bathrooms (sinks). The CT K stated he had educated nursing staff in the past not to rinse instruments in patient bathrooms, but instead wipe them down and place in the Humipak. When asked if rinsing the instruments in a patient bathroom was an infection control issue, the CT K stated, "absolutely."

Review of facility document (provided by CT K on 5/17/19) titled, "Safe Handling of Dirty Instruments" (undated) indicated, "4. Put on gloves, wet 4x4 with water, wipe gross bioburden from each instrument. 5) Place dirty instruments into the HUMIPAK and seal HUMIPAK."

Online review of AORN (Association of periOperative Registered Nurses) Facility Reference Center Guidelines for Perioperative Practice: Instrument Cleaning (Copyright © 2012-2019) indicated, "V.b. Instruments should not be cleaned or decontaminated in... hand sinks." Cleaning soiled instruments in a hand sink can contaminate the sink and faucet, which are intended to be used for clean activities (eg, hand washing...). The guidelines indicated droplets
and aerosols (containing microorganisms) created during cleaning of soiled instruments can cause cross-contamination of any nearby clean items or surfaces.
(https://aornguidelines.org/guidelines/content?sectionid=173736661&view=book#180197698)

3) During an observation and concurrent interview on 5/14/19 at 5:25 p.m., the newborn nursery had lockers and clothing hanging by the lockers. Admin Staff C stated nursing staff used the area for storage of their belongings.

Requested policy and procedure for storage of staff belonging in the nursery. None was provided.

4) During observation of the Emergency Department (ED) on 5/14/19 at 10 a.m., a box lunch containing a turkey sandwich was located in the ED patient refrigerator. The box indicated, "Enjoy by 5/13/19." Manager G confirmed the sandwich lunch had expired.

During a tour of the ICU and concurrent interviews on 5/14/19 at 10:45 a.m., the ICU food pantry had a hopper that was covered by plastic. Manager L stated the pantry had recently been relocated to the dirty utility room (its current location) and the hopper had been covered. A cupboard contained an empty syringe box and a storage box that had the word, "Biohazard" on its exterior. Administrative Staff C stated the "Biohazard" box had been used previously and, "it was an oversight" that it was located in the pantry. The patient refrigerator located in the pantry contained nine expired containers of pudding, one expired container of custard, and one expired container of milk. Administrator C counted and confirmed the expired food containers. A container of ice with ice scoop was located next to the pantry refrigerator. Administrator C stated the scoop should have been in its holder, next to the ice.

During an interview on 5/15/19 at 8:40 a.m., Administrative Staff B (Director of infection prevention) stated the ice in the ICU was not stored per facility policy. She stated ice should come directly from an ice machine (not stored in a container) and the ice in the ICU had been removed. Admin. Staff B stated the food stored in the ICU (with the covered hopper) was not stored per facility policy and all the food had been removed.

5) During an initial observation of the kitchen on 5/14/19, at 10:00 a.m., the kitchen floor appeared to have a dark film over the tile and in-between grout, food particles were observed underneath the ovens and food preparation counters. The mats in the dishwashing area were grungy with food particles. The walls under the dishwashing sink showed a white film, food particles and debris were observed in the kitchen floor sink. Head Chef T was asked how often the kitchen floors were cleaned, he stated, the floors are cleaned every night by EVS. Cleaning schedules for the kitchen were requested but not provided.

During additional observations of the kitchen on 5/16/19 at 08:35 a.m. and 2:35p.m., and 5/17/19, at 3:00 p.m., the kitchen floors were observed to have the same dark film over tile and in-between grout, and a grungy white film on the walls under the dishwashing areas. Food particles and debris were observed under the kitchen prep areas and under the refrigerators. Current copies of weekly sanitation checklists were requested but not provided. Weekly sanitation check-lists dated, 9/12/18 and 4/6/18, completed by previous RDs were provided and showed (at the time), the kitchen floor was not clean, floor drains were not clean, and sinks were not clean.

During an interview with Administrative Staff B (Director of infection prevention) on 4/17/19, at 4:00 p.m., she stated, infection control rounds are conducted bi-weekly to the kitchen and all hospital areas. The information is collected and reviewed at the infection control meetings. Current copies of the infection control rounds for the kitchen along with meeting minutes from team reviews were requested. One meeting review dated 4/17/19, not signed or initialed by a team member indicates, cleaning of the kitchen floors and equipment, "Needs Improvement, floor has to be clean."

Review of the facility policy titled, "Sanitation of Work Areas and Equipment," dated 10/21/18, indicates,
C. Cleaning Hard Surfaces: a. floors shall be cleaned frequently using hospital-approved cleaners ...; b. Mats shall be easily cleanable, removable and cleaned regularly to keep free of visible.; d. Floor drains - shall be kept free of food and debris and cleaned regularly.
E. Documentation of Cleaning and Sanitation: 1. Established cleaning logs shall be maintained for daily, weekly, monthly cleaning completion of tasks. Logs shall be reviewed by department management.

Based on observations, dietary staff interviews, and dietary document reviews, the facility failed to ensure safe dietary practices and recognized dietary food services were met in accordance with professional standards when:

1) The Registered Dietitian did not provide supervision in the kitchen
2) The Dietary Manager did not possess required job qualifications
3) Dietary staff did not maintain a cool down log for potentially hazardous foods (e.g., tuna salad)
4) The facility did not verify department staff competencies (skills required to perform job function) prior to allowing dietary staff to perform tasks
5) Dietary Manual and Disaster Feeding Plan were not current

Failure to ensure safe and professional food practices may put patients at nutritional risk and compromise patients health.

Findings:

1) During an observation and concurrent interview in the kitchen on 5/14/17, at 10:00 a.m., the Registered Dietician (RD) was asked how he supervises the kitchen. The RD was new to the position and had only been at the facility for one month, he stated, Head Chef T has oversight of the kitchen staff and all food production. The RD stated, he performs all nutritional assessments for patients, creates and monitors care plans, attends clinical meetings with the medical team, and develops patient menus in (CBORD).

Review of the RD's job description dated 4/16/19, does not list the RD's responsibilities of the kitchen.

Review of the Chef's job description (no date), stated, "Under the supervision of the Manager of Nutritional Services, prepares, seasons, and cooks food needed for cafeteria, catering, and patients following proper food handling and preparation principles to insure food safety. Manages the kitchen operations during the absence of the Nutritional Services Manager."

2) During an interview on 5/16/19, at 2:00 p.m., the nutritional service manager (NSM) was asked how she supervises the kitchen. The NSM stated, Head Chef T has oversight of kitchen operations and kitchen staff. My job is primarily administrative and staff scheduling. I am currently in school finishing my certification for dietary manager.

Review of the NSM job description (no date), indicates, "Directs and coordinates the activities of the Nutritional Services Department to provide dietetic service for patients, hospital employees, and community." License or Certification for this position requires a "Certified Dietary Manager."

3) During an interview in the kitchen with Head Chef T on 5/15/19, at 9:30 a.m., Head Chef T stated, he has oversight of the kitchen operations and kitchen staff. Head Chef T stated, he reports to the nutritional manager. When asked how he conducts kitchen supervision, Head Chef T stated, he helps the kitchen staff when they have questions (e.g. how to cut a melon) and provides in-services on various topics during weekly staff huddles. When questioning Head Chef T about the department competencies for the kitchen staff, he stated, "we do not have competencies."

During an observation and concurrent interview of the kitchen on 5/15/19 at 10:00 a.m., Refrigerator #2 had prepared box lunches with tuna salad. When asked to review the cool down logs, Head Chef T stated, we do not have cool down logs and do not use cool down methods. The food in the kitchen is prepared daily and is tempted prior to serving; any left over food is discarded. When asked how temperatures of the prepared salads (e.g. tuna and chicken salad) are monitored, he stated, salads are prepared from ingredients at room temperature, a cool down is "not done." Food is tempted prior to serving. A recipe for Tuna salad was requested but did not contain measurements with ingredients for preparation or temperatures.

During a second interview with Head Chef T on 5/16/19, at 12:15 p.m., he stated that his previous experiences as a Chef were in a restaurant; this was his first Chef position in a health care facility. When questioning how he ensured the tuna salad was at 41 degrees after preparing the tuna salad, Head Chef T stated, the "temperature was not checked." Head Chef T also stated, he is still learning the kitchen processes for working in a health care facility, "I am learning as I go along."

Review of the facility policy and procedure titled, "Quality Standards of Food Preparation," dated, 10/21/18, indicates, Cooking: "Temperatures are to be carefully regulated and monitored." and "All cold meat salads, poultry salads, potato salads... and other potentially hazardous foods shall be prepared from chilled products and refrigerated below 41 degrees F immediately after preparation.

Review of the Federal Food Code, dated, 2017, section 3-501.14, Cooling, indicates: (B)TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. Section 2-103.11, indicates, The PERSON IN CHARGE shall ensure that: H) EMPLOYEES are using proper methods to rapidly cool TIME/TEMPERATURE CONTROL FOR SAFETY FOODS that are not held hot or are not for consumption within 4 hours, through daily oversight of the EMPLOYEES' routine monitoring of FOOD temperatures during cooling.

4) Review of six of six dietary staff employee files (Head Chef T, Cook U, Dietary Staff V, Registered Dietician R, Chef W, and Dietary Manager S) did not contain verification of staff competencies prior to working in the kitchen. Department competencies and orientation assessments for kitchen staff were requested but not provided.
During a concurrent interview with the HR director on 5/17/19, she confirmed competencies were not located in the employees files.

5) Review of the facility Clinical Diet Manual (not dated) did not show diet manual approval forms. The diet manual approval forms signed by the dietician and medical staff with dates of the last dietary manual review were requested from Administrative Staff B but not provided. The approval forms and previous diet manual reviews were not located.

Review of the facility policy, titled, "Diet Manual," revised 10/4/2018, indicated, 1. the site-specific diet manual shall be approved by the dietitian and medical staff to be used as the basis for diet orders and for planning modified diets. 3. The diet manual shall be reviewed and revised as needed, at least every five (5) years.

Based on observation, interview, and record review, the facility did not ensure nursing services met the the needs of the patient when Certified Nursing Aides (CNA's) and Telemetry Technicians performed bedside blood glucose testing. This contributed to licensed nursing care being delivered by unlicensed staff.

Findings:

During an observation on 5/15/19 at 11:35 a.m., CNA M checked the blood sugar (level of glucose in a patient's blood) of the patient in room 317. CNA M pricked the patient's finger, squeezed a drop of blood onto the test strip and put the strip into the glucometer (hand-held machine that calculated blood sugar levels). CNA M stated the patient's blood sugar was 256.

During an interview on 5/15/19 at 11:40 a.m., CNA M was asked how she was trained to perform blood sugar checks at the facility. CNA M stated she had watched a video and practiced with a Registered Nurse.

Review of CNA M's employee file revealed documentation of glucometer competency (verification of skill needed by staff to perform a task), titled, "Stat Strip," subtitled, "Competency Exam" (dated 9/11/18). The competency documentation did not indicate CNA M had performed supervised testing on a patient (prior to independently performing the test). Nurse Educator P (NuEd P) indicated CNA M had passed the competency and NuEd P signed the document.

During an interview and document review on 5/17/19 at 9 a.m., Administrative Staff B reviewed the facility's CNA job description titled, "Job Description," subtitled, "Cert Nurse Aide" (dated 2/5/17). Admin Staff B confirmed the CNA job description did not list performance of blood sugar testing as a job function. When asked how long this practice had occurred at the facility, Admin Staff B stated the practice (of CNA's performing blood sugar checks) had occurred as long as she had been there. When asked about the Stat Strip competency, Admin Staff B stated they were simulated, and not performed on a live patients.

During an interview and document review on 5/17/19 at 10:30 a.m., Administrative Staff B and Staff C reviewed the CNA job description titled, "Job Description," subtitled, "Cert Nurse Aide" (dated 2/5/17) and the policy and procedure titled, "Facility Policy and Procedure: POCT - Glucose Testing - With NOVA Glucometer" (review date 8/17/18). Administrative Staff B confirmed that neither the job description nor the policy and procedure indicated facility CNA's were allowed to perform patient blood sugar testing using a glucometer.

During an interview on 5/17/19 at 11:40 a.m., Administrative Staff A was asked about the facility practice of allowing CNA's to perform blood sugar testing. Admin Staff A stated it was her understanding the practice was acceptable and the facility had trained the CNA's. Admin Staff A stated she was unaware the CNA job description and the policy and procedure (for glucose testing) did not address CNA's performing the testing.

During an interview on 5/17/19 at 12:30 p.m., Administrative Staff B stated Nurse Educator P had the CNA's practice glucose testing on each other (staff), not on patients. Admin Staff B stated Telemetry technicians (who read the heart monitors in the Intensive Care Unit) also performed blood sugar testing at the facility.

Review of facility job description for Telemetry technicians titled, "Monitor Tech Unit Se" (dated 2/5/17) revealed the facility did not list the performance of blood sugar testing as a job function.

Review of the California Nursing Practice Act, dated 11/2010, (a copy of which was provided by Administrative Staff B on 5/17/19) indicated, "2725.3. Functions performed by unlicensed personnel (a) A health facility...shall not assign unlicensed personnel to perform nursing functions in lieu of a registered nurse and may not allow unlicensed personnel to perform functions under the direct clinical supervision of a registered nurse that require a substantial amount of scientific knowledge and technical skills, including...(7) Moderate complexity laboratory tests."