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Based on observation, interview and record review, the facility failed to ensure qualified, competent staff were in place to perform their duties according to professional standards of practice when:

1. The facility had no Registered Dietitian (RD) since 2/6/22 (more than a year) to provide comprehensive nutrition assessment, nutrition care planning or nutrition consultation for patients, or consultation and oversight of the Food and Nutrition Services kitchen.

2. Staff training and competency was inadequate, ineffective, or inadequately monitored when kitchen staff did not perform hand hygiene, glove use, cleaning fixed equipment, or labeling and dating according to policy and professional standards of practice.

3. Staff did not puree food according to the diet manual or professional standards of practice.

These failures had the potential to result in patients receiving inadequate nutrition care resulting in diminished health outcomes, the potential for foodborne illness for patients consuming food from the facility, and the potential to cause patients requiring pureed food to choke and have decreased meal intakes.

Findings:

1. Review of a document titled, "Consultant Dietitian, Dietary," expiration date 5/27/22, showed the Consulting Dietitian (RD) was responsible to provide nutrition assessments, charting, in-service trainings, quality assurance reviews, food safety and sanitation checks, and staff meetings. It further indicated the Consulting Dietitian was available seven days per week for nutrition assessments and nutrition or food service consultations, and the RD would follow patients with a moderate to high Nutrition Risk Screening score of two or greater.

Review of an untitled closed medical records report provided by the Health Information Lead (HIL) showed in the past year the facility had 21 different inpatient and swing bed patients with high nutrition risk admitting diagnoses including adult failure to thrive, weight loss or low BMI (Body Mass Index, an indicator of weight status) or malnutrition that would have been flagged to a Registered Dietitian if one had been employed at the facility.

During an interview on 5/15/23 at 10:15 a.m. the Dietary Manager (DM) stated they currently had no RD but they were looking for one and they were hard to find. She stated, "We're trying to do the best we can."

During an interview with the DM on 5/15/23 at 11:50 a.m. she stated there had been no RD for more than a year.

During an interview with the Infection Prevention Nurse (IPN) on 5/16/23 at 8:45 a.m., she stated the IPN and the DM had recently been doing the monthly sanitation rounds in the kitchen (except for when she was on vacation) because there had been no RD at the facility to do that for about a year. (Cross Reference C-1208).

During an interview with the DM on 5/16/23 10 a.m., she stated she had been a Certified Dietary Manager (CDM) since 2004.

During an interview on the Med/Surg unit on 5/16/23 at 9:50 a.m., Registered Nurse 6 (RN) 6 stated if a nurse had nutrition care concerns for a patient, they would talk with the doctor about it, and he would write nutrition intervention-related orders. Also, a lady from the kitchen talked with patients about food preferences. When asked if it was a concern the facility did not have an RD, RN 6 stated "I think it would be really helpful to have an RD here, especially if there were patients on TPN or tube feeding, to ensure their nutritional needs were being met."

During an interview with the DM on 5/16/23 at 10 a.m. regarding staff handwashing and glove use, the DM stated the IPN had been "working really, really hard with us in the kitchen since we don't have an RD and especially since COVID."

During further interview with the DM on 5/16/23 at 10 a.m. she was asked, since there was no RD at the facility, what happened if there were patients with nutrition concerns? The DM replied she did a "nutrition assessment" and did what she was allowed to do, including participation in patient care conferences. When asked what she did in her Nutrition Assessment, the DM stated she looked at the medical record for labs, meal intakes, and body weight. When asked what labs she looked at she stated, "I don't know anything about them. It's on the sheet so I just write them down." She stated she looked to see if they had teeth or dentures, "I do what I can do," tried to cater to patient preferences, to talk with them, and she wrote "a little blurb."

During an interview with the Chief Executive Officer (CEO) on 5/16/23 at 3:30 p.m. he was asked what they were doing to recruit a dietitian. He stated they've "flown the position" to schools and would accept a new grad. They had two dietitians' express interest, and two interviews with one applicant, but she did not accept the position. Their previous RD posted the job at her hospital in Redding and sent it to where she went to school. The CEO stated they offered the job in multiple ways including to work as an employee, as contracted staff, or as remote staff, and they were "not low balling the wage."

During an interview with the Human Resources Director (HRD) on 5/16/23 at 3:55 p.m., she stated they had been without an RD for one year and she would provide evidence of their recruitment efforts.

During a review of closed medical records with the HIL on 5/17/23 at 8:40 a.m., Patient 21's inpatient admission dated 6/15/22 - 10/25/22 showed an order for Nutrition Consultation. HIL stated that MD didn't work there very often and maybe didn't know they didn't have an RD.

During an interview with the Chief Nursing Officer (CNO) on 5/17/23 at 2:20 p.m. she was asked what the facility did regarding nutrition interventions and monitoring when there was no RD. The CNO replied, the doctor and nurse collaborated about what interventions to use. Interventions were individualized to the patient and were addressed in the patient care conference for swing bed patients (less ill, longer length of stay, hospitalized patients). The RN monitored weight changes, and the DM did periodic rounds if a patient wasn't eating much.

When asked how the RD responsibilities were being covered in the facility, the CNO stated the IPN did EOC (Environment of Care) rounds in the kitchen for infection control. Nurses did what they could through nutrition screening and nutrition care with the help of the provider and DM. She stated they were "not able to meet the responsibilities of the RD because we don't have one." The CNO stated Nutrition Care Plans were not created for each inpatient, but the provider, DM and nursing collaborated to develop them for swing bed patients.

Review of documents provided by the HRD showed the facility's dietitian-related recruitment efforts prior to the survey. They included:
*A resignation email from the previous RD to the CEO dated 1/7/23 stating her last day would be 2/6/22.
*An email thread dated 2/3/22 among the CEO, DM and HRD regarding the RD position's wage, hours, and a revised flyer about the position.
*A (what appears to be) Facebook job posting dated 2/8/22, with heading Mountain Communities Healthcare District.
*An undated job posting titled, "Mountain Communities Healthcare District - Registered Dietitian Opportunity - Trinity Hospital"
*An undated list of 14 open positions at Trinity Hospital including Registered Dietitian.
*An email thread among the HRD, DM and CEO, dated 4/14/22 - 4/28/22 regarding efforts to get the previous RD to return to the facility.
An email thread among the HRD, DM, CEO and an applicant, dated 5/17/23 through 6/1/22 regarding an applicant visit to the facility, and with a second dietitian who asked for more information, dated 6/24/22 - 6/27/22. (Both dietitians declined the position).
Dates on the evidence provided suggested the last effort to recruit a Registered Dietitian was 6/27/22.

2. Review of a policy titled, "In-service Education, Continuing Education," expiration date 10/31/2024 showed it's purpose was "To define the current processes used at Trinity Hospital to provide personnel with educational opportunities that enable them to 1) maintain competencies, 2) create new competencies, or 3) correct deficiencies identified in CQI findings." It did not describe general orientation, training or competency processes or requirements. It did describe in-service education as activities that assisted personnel to fulfill their assigned responsibilities.

During an interview with the DM on 5/16/23 at 10 a.m., she stated her best staff trained new staff. She liked the training to be for about two weeks, but sometimes it was less if someone called off or got hurt or something. To show competency they did a dietary checklist where the new staff signed off that the trainer showed them everything, and the trainer signed off that the new staff did everything. The DM stated staff would not be competent after just two weeks of training, and she told them to just ask questions, especially with special diets. Through scheduling she ensured trusted staff were always there to watch and answer questions. The DM stated staff did not do any demonstration competencies to show how they completed tasks properly. When asked about staff competency in preparing texture modified diets, the DM stated the diet manual explained diets and textures, or staff could ask someone else who was there.

2A. Hand Hygiene and Glove Use - During multiple observations in the kitchen beginning 5/15/23 at 10:15 a.m., kitchen staff did not perform hand hygiene or change their gloves per policy and professional standards of practice. Multiple kitchen staff did not wash their hands or change their gloves between tasks, when moving from one work area to another, or after touching their nose, mouth, skin or hair (Cross Reference C-1208).

Review of a policy titled, "Personnel Guidelines, Dietary," expiration date 3/3/22 showed "Annual in-service education will include personal hygiene, sanitation, and hand washing techniques. Periodic educational programs on infection control practices must be presented and documented."

During an interview with the DM on 5/16/23 at 10 a.m., she stated staff needed to wash their hands every time they went in and out of the kitchen. They needed to wear gloves when handling ready to eat foods, and to change their gloves with each food they prepared.

Review of a policy titled Hand Hygiene, Infection Control showed hand washing was required before and after eating, drinking, applying makeup; before and after each shift; after using the restroom; after covering a sneeze, cough or blowing your nose ...after removing gloves."

Review of the 2022 FDA Food Code 3-304.15(A) showed single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation."

Review of documents titled, "Competency Checklist Diet Aide/All Shifts," were provided by the HRD for DC 1 (6/26/21), DA 2 (2/21/19), DA 3 (9/28/22), DA 4 (10/5/21), and DA 5 (5/3/23). They listed 21 skills and skill descriptions the staff knew how to perform and were signed off by the staff, preceptor (trainer) and DM. The skill list included, "Knows how to clean equipment in the production area" but did not include hand hygiene, glove use, hair restraints, apron use, or food labeling and dating.

In-services provided by the IPN in 3/24/22 (DC 1, DA 4), 12/22 (DC 1, DA 2), 4/14/23 (DC 1) titled, "Bug of the Month, Hand Hygiene." No curriculum or post-tests were provided. An additional in-service provided 7/26/21 (DC 1, DA 2) was titled, "Gastroenteritis, Norovirus, and C. Diff" and included a quiz that spoke to the need to change gloves and wash hands to prevent spread of the infections. A post-test included the True/False question "Gloves should always be worn in a patient's room when a patient has diarrhea." It focused on nursing practices and did not connect the importance of hand hygiene and glove use practices to kitchen staff and food safety.

2B. During observations in the kitchen beginning 5/15/23 at 10:15 a.m., equipment was not sanitary including the oven, can opener, can opener mount, cutting boards, hood and fans, and kitchen staff did not clean and sanitize fixed equipment according to manufacturer's instructions or professional standards of practice. Staff did not consistently clean equipment before sanitizing it, did not allow adequate wet time for sanitizer to be effective, and left soiled rags unattended on counters and other food preparation or clean surfaces throughout the survey (Cross Reference C-1208).

Review of untitled cleaning assignment logs dated 4/1/23 - 4/30/23 showed the can opener was to be cleaned daily and was signed off 15 out of 30 days. The can opener mount was not included in the cleaning assignments. The hood and the convection oven were to be cleaned monthly and were not signed off in April. Fans were not included on the list for cleaning.

Review of the 2022 FDA Food Code 4-602.11 showed, "Equipment food contact surfaces and utensils shall be clean to sight and touch ...Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris." 3-304.14(B) showed, "Cloths in-use for wiping counters and other equipment surfaces shall be (1) held between uses in a chemical sanitizer solution."

2C. During multiple observations in the kitchen beginning 5/15/23 at 10:15 a.m., kitchen staff did not perform labeling and dating according to policies and professional standards of practice when staff personal food was comingled with patient food, products were not dated consistently per policy and the meaning of dates was not easily decipherable, staff were not aware of the fine print on many food items that shortened the use-by date when food was opened (pasteurized eggs, almond milk), and expired items were found in the refrigerator (Cross Reference C-1208).

Review of a policy provided by the DM titled, "Labeling, Dating Covering Food, Dietary," expiration date 4/14/22, showed, "To provide a standardized procedure for labeling, dating and covering specific food items to ensure that maximum storage times are maintained." "All refrigerated food will contain a cover, label, prep date, and expiration date with the exception of food items to be used on a tray for upcoming meal services (e.g., individual salads, desserts, etc.). The US Food & Drug Administration chart will be utilized for guidance, a copy to be provided to kitchen staff."

3. During a concurrent observation and interview on 5/16/23 at 12:25 p.m., DC 1 stated all pureed foods get served to patients in bowls. "It's easier for them to eat that way."

During an interview on 5/17/23 at 10:55 a.m., the DM stated pureed food should be like baby food, with no chunks, and with the consistency of smooth applesauce. She stated nursing wanted patient's pureed food put into bowls because it was easier to feed them that way. She stated if the patient was feeding themselves, the kitchen put it in a divided plate, so it didn't all run together and was easier for them to scoop up.

During an observation on 5/17/23 at 11:41 a.m., DC 1 pureed food for the lunch meal. He measured the portions, slowly added hot flavorful liquids to hot foods (cold to cold foods), blended, added more liquid as needed, and blended until done. He stated a skilled nursing resident required nectar thick pureed food, so applesauce was too thin for him, and his food needed to be thick, smooth, even, with no lumps, no chunks. After portioning out that resident's food, DC 1 added more fluid to the pureed food for other patients. He stated "When a doctor orders a pureed diet it needs to be thin, pureed, smooth like applesauce. It's a lot thinner."

During an observation and concurrent interview on 5/17/23 at 12:24 p.m. test trays with regular and pureed diet trays were conducted with the DM and DC 3. DC 3 stated the pureed garlic bread was gummy. When asked what the consistency of pureed food should be, DC 3 stated unless the diet order was for "thin pureed," the pureed foods should mound on the plate like pudding. DC 3 agreed all the pureed foods on the test tray spread across the divided plate and did not mound.

Review of an undated policy titled, "Preparing Modified Consistency Diets, Dietary," showed "4. Puree: Thick, smooth, homogenous, semi-liquid texture. Should be "spoon thick" or "pudding-like" consistency, without lumps."

Review of a document titled, "Diet Manual for Long Term Care and Residential Facilities 2015" showed a Regular Pureed Diet was for patients who had difficulty chewing and/or swallowing. 'The texture of the food should be of a smooth and moist consistency and able to hold its shape."

Review of a document titled, "Competency Checklist Cook & Diet Aide/ All Shifts" for DC 1, dated 6/26/21, did not include texture modification of food, how to puree food, or how to look up diet information in the facility's diet manual.

Based on observation, interview and record review the facility failed to maintain the facility's kitchen when:

1. The kitchen ceiling had a long history of a leak with drywall removed, water marks, and a large hole into the attic.

2. The floor had curling and broken linoleum, was pitted in a manner likely to attract and retain grime, and baseboards were in disrepair.

3. Kitchen cabinets had chipped paint creating an uncleanable surface.

These failures had the potential to put employee safety at risk, and to negatively impact food safety and sanitation resulting if foodborne illness for patients consuming food from the facility.

Findings:

During the initial tour of the kitchen beginning on 5/15/23 at 10:15 a.m., there were multiple areas where the linoleum was curling or broken and the baseboards along the walls were in disrepair. The floors had black pitting throughout the kitchen that would likely attract and retain grime. Metal cabinets used for food storage had chipped paint, creating an uncleanable surface.

In further observation of the dish room on 5/15/23 at 11:10 a.m., there was a large hole in the ceiling, approximately four feet long by two feet wide. The drywall was removed and there were water marks on wall. In a concurrent interview with the Dietary Manager (DM) stated they had a roof leak and needed a new roof. She stated they had tried to fix it multiple times, couldn't seem to find the leak, and that it had been leaking for about 10 years.

During an interview with the Infection Prevention Nurse (IPN) on 5/16/23 at 8:45 a.m., she was asked about her role in food services. She stated she and the DM had been doing monthly rounds in the kitchen. The concerns they had identified were the floors and the roof. The floors were supposed to get a new epoxy floor covering. The roof leaked and there were holes in the ceiling. She added a third concern that a beam in the dry storage area needed paint.

During an interview with the Director of Plant Operations (DPO) in the maintenance office on 5/16/23 at 2:05 p.m., he stated he and the IPN did Environment of Care (EOC) rounds quarterly. He stated a current concern in the kitchen was the ceiling leak, but they had identified where it was leaking, and today they received the goop to fix it. They expected to get it fixed the next week. The DPO stated the roof had been patched several times, but they didn't get it quite right. When asked if it was going to be right this time, he stated they were going to find out by setting a sprinkler up on the roof and letting it run. He stated they would call in a roofer if this attempt to repair the roof failed.

In further interview the DPO stated they also needed to replace the kitchen floor. They already started removal of the linoleum, but it had to be done after hours when the kitchen was closed. He explained they would get the floor degreased, hose it down, and then would coat it with an epoxy paint. The DPO was asked to provide copies of the last two EOC rounds that included the kitchen.

During an observation of the kitchen floors on 5/17/23 at 10:55 a.m., it was uneven and pitted throughout the kitchen, making it likely to collect grime. In a concurrent interview the DM stated that to repair the floor, they (Plant Ops) needed to finish removing the curling linoleum around the edges of the kitchen. She stated they had already put the epoxy paint on the center areas of the kitchen floor a couple of years ago.

During an interview with the DM and Dietary Cook 3 (DC)3 on 5/17/23 at 12:10 p.m., they stated Plant Ops had already done the floors in the kitchen except for the edges where they still needed to pull up the old curling linoleum. Regarding the condition of the kitchen floor they explained, "They (Plant Ops) only had one bucket of the paint, it wasn't enough, and they spread it as far as they could."

During an interview with the DM on 5/18/23 at 8:20 a.m., she stated "The roof (kitchen ceiling) has fallen down on some of my employees doing dishes during the rain."

Review of the EOC rounds documentation provided by the DPO, and conducted by the DPO and IPN showed:

6/7/22 - "Paint over leak areas in storage room ceiling. Paint over leaked area in washer room (dish room) ceiling. Clean floor - Kitchen floor coming up needs replaced, repaired, or covered over. Staff tripping on buckled floor." "Dietary Storage Room - paint leaked area ceiling."

1/10/23 - "Paint over leak areas in dry storage room ceiling-chipping and stained paint. Paint over leaked area in washer room (dish room) ceiling/ ceiling needs repaired/exposed. Clean floor - kitchen floor coming up needs replaced, repaired, or covered over. Wall base needs replaced with laminate not wood base in dry storage room. Fix roof leak in dry storage room."

Review of the 2022 FDA Food Code §6-101.11 showed, "Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be (1) Smooth, durable, and easily cleanable for areas where food establishment operations are conducted." The FDA Food Code defined "Smooth" as "3) a floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean." §6-201.11 showed, "floors, floor coverings, walls, wall coverings and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable."

Review of a policy provided by the DPO titled, "Preventative Maintenance, Maintenance," with expiration date 1/30/26, showed the purpose of the policy was to provide preventative maintenance for the facility. It included a list of daily, weekly, monthly, and every three months, six months, and yearly tasks to be monitored or completed but it did not include attention to critical maintenance activities such as roof repair or floor repair that would be basic in ensuring patient and staff safety, and food safety and sanitation in the kitchen.

Based on observation, interview and record review, the facility failed to ensure that patient-care equipment was inspected and maintained in safe operating condition when:

1. A Force Triad Bovie (FTB, an electrocautery device used to cut through human tissue or control bleeding during surgery) located in operating room (OR) 1 did not have the required routine inspections to test for performance or safety.

2. An incubator (device that allows for temperature and humidity control) for newborns located in the emergency department (ED) did not have the required routine inspections to test for performance or safety.

3. The kitchen ice machine was in disrepair.

4. A fan that drew air from the exterior of the building into the kitchen had an accumulation of a gray substance resembling dust on its blades, wire cover, and the white closing slats as it blew air over food preparation and clean dish areas.

5. The handwashing sink faucet did not work properly.

These failures had the potential to compromise patient safety and increase the risk of patient illness or injury.

Findings:

1. A review of the facility's policy titled, "Electrical Equipment Safety, Maintenance" ,Version 7, undated, indicated the policy's purpose was to ensure all facility equipment is safe for patient care and staff use. All electrical equipment must be tested atleast annually and the results must be documented.

A review of the facility's document titled, "Mountain Communities Healthcare District Critical Access Hospital, Annual Hospital Evaluation for Calendar Year 2022," dated 2023, indicated that safety checks are completed on all facility equipment, annually or biannually, depending on the equipment requirements.

A review of the facility's document titled, "Trinity Hospital: Inventory by Department," dated 5/2023, indicated that all equipment requiring routine safety and performance inspections are compiled on a spreadsheet that includes: the device name, the area in the hospital where the device is located, the device manufacturer, the device's last inspection date, and the device's next inspection due date. The document did not have the FTB located in OR 1 included on the list.

During a concurrent observation and interview on 5/16/23, at 8:59 am, surgical technician (ST) reported that she was responsible for ensuring that all operating room equipment have biomedical (Biomed) stickers affixed to them that indicated the equipment passed a routine safety and performance inspection. The Biomed stickers were marked with the equipment's next inspection due date. ST stated the Director of Plant Operations (DPO) was responsible for managing the facility's equipment inspections and ensuring they were conducted prior to the due date. If ST noticed that a device's inspection due date was approaching, she would notify DPO and confirm that the equipment was scheduled for inspection and maintenance prior to the due date.

During a concurrent observation and interview on 5/17/23, at 11am, ST, DPO, and registered nurse (RN) 1 verified that the FTB located in OR 1 did not have a Biomed sticker applied to track if the device was inspected for performance or safety. ST, DPO, and RN 1 reported they were not aware the device was missing a Biomed sticker and stated the FTB was required to have safety and performance testing every 6 months because it comes into contact with patients' bodies. DPO advised he would check the hospital inventory by Department Spreadsheet to verify when the FTB was last inspected and confirm the next inspection due date.

During a concurrent interview and record review on 5/17/23, at 11:42 am, DPO confirmed he was responsible for tracking the Biomed sticker dates on the facility's equipment and arranging for Biomed to inspect, calibrate, and service facility equipment. DPO reported he utilized the hospital inventory by Department Spreadsheet to ensure all equipment was inspected within the required due dates. The FTB in OR 1 was not listed on the spreadsheet and DPO could not confirm when the device was last inspected for safety or performance. DPO stated he would notify Biomed that the FTB needed to be serviced as soon as possible.

During an interview on 5/17/23, at 1:30 pm, Chief Nursing Officer (CNO) CNO confirmed that DPO was responsible for ensuring that all facility equipment was inspected by the equipment due dates. CNO reported she was not aware that the FTB in OR 1 was not being monitored for routine inspection or maintenance. CNO stated this was a safety issue that she would work with the DPO and ST to resolve immediately.




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2. During a concurrent observation and interview on 5/15/23 at 12:20 pm, the CNO pointed out an incubator, for newborns with airway equipment, located in the radiology area next to the ED. During a follow up interview on 5/18/23 at 8:43 am, CNO confirmed there was a birth in the ED last year and the incubator functioned without any problems.

During an interview on at 5/18/23 at 8:25 am, the DPO reviewed their Biomed (company that services, repairs and maintains equipment) list and said the incubator for newborns was not on the list. During a concurrent inspection of the incubator, a sticker was observed, with the next due date, of 4/2019, for electrical services. DPO said their old Biomed company had been doing the maintenance and service for this equipment. He said he did not know when it had last been checked, but he would notify their current Biomed company and get it on the list for routine service and maintenance.


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3. During three days of observations of lunch tray line beginning on 5/15/23 at 12:07 p.m., Dietary Aide 5 stocked the cold side of tray line with a tub of drinks covered with ice to keep it cold.

During an interview on 5/16/23 at 11 am, the Dietary Manager (DM) stated it was a standard for staff to cover cold drinks with ice during tray line to keep them cold.

During an observation of the ice machine on 5/16/23 at 11:52 am, the ice machine's lower cover to the ice machine had been left removed and there was debris and a gray substance resembling dust around the edges where it would have attached to the machine.

During an observation of the kitchen ice machine and concurrent interview with Maintenance Technician 2 (MT) 2 on 5/16/23 at 2:05 pm, MT 2 stated he cleaned the ice machines, described the process, and showed the chemicals he used to do it. He stated he didn't notice before that the ice machine cover was off. He commented that every time he touched of fixed the ice machine something else in it broke. He picked the lid up from where it was stored on the floor against the wall, stated it was broken, and he would have to order a new one. He stated the ice machine was always breaking.

During an interview with the DM on 5/17/23 at 10:55 am, she stated Food and Nutrition Services staff removed the ice and sanitize the ice bin and exterior of the ice machine weekly, and Plant Ops did the deep clean monthly with chemicals. She stated the front cover of the ice machine had been broken for four months. "They are supposedly waiting for a new one to come in." She confirmed the ice machine kept breaking down. She stated she was trying to find the right one to replace it but due to COVID it was hard to get equipment. The DM stated she ordered one ice machine about a year ago and it never came in. She stated she had no record of that order, and that in the past she had gone in to try to find it but couldn't, and she hadn't gotten back to it.

Review of a document titled Refrigerators-Freezer-Ice Machines with "Year 23" date showed the Kitchen "Cold Chest" had been cleaned monthly in 2023, January through April. No dates were included on the form.

4. During an observation on 5/15/23 at 2:33 a.m. a kitchen fan that drew air from the exterior of the building into the kitchen had an accumulation of a gray substance resembling dust on its blades, wire cover, and the white closing slats as it blew air over food preparation and clean dish areas.

During interview with MT 2 on 5/16/23 at 2:05 p.m. Jonathan stated other things he did in the kitchen included he cleaning the fan that pulled air from the exterior of the building. In a concurrent observation and interview MT 2 agreed the fan had dust accumulation on the wires around the fan, blades and on the white rectangular cover/closures to the outside.
Review of an undated document provided by Plant Ops titled "Trinity Hospital Exhaust Fan Service" had check boxes indicating the kitchen fans were to be cleaned quarterly in February, May, August and November. The February box had a check mark but there were no dates. The remaining boxes were blank. Further review of the form showed "Fans are to be cleaned and serviced monthly," yet the kitchen fans were only scheduled to be cleaned quarterly, they were not sanitary, and they had the potential to cross contaminate food and clean equipment.

Review of a policy titled Preventative Maintenance, Maintenance, expiration date 1/30/26 showed ice machines were to be "checked" every three months. Ice machine filters were to be checked yearly, but fans were not identified on the tracking list.

Review of the Environment of Care (EOC) Rounds minutes for the past year in the kitchen, dated 6/7/22 and 1/10/23 did not note any concerns with the ice machine or the fans.

5. During multiple observations of the kitchen handwashing sink beginning 5/15/23 at 10:15 a.m., there was a sign posted above the sink warning "Caution - Water temp exceeds 125°F (degrees Fahrenheit)." When cold water was needed to cool hot water to prevent burns, the cold-water handle could only be moved a very short radius before it hit the back wall of the sink and could not be turned further. This created the potential for staff to be burned by the hot water as they washed their hands many times throughout their workday.

During an observation on 5/17/23 at 10:55 a.m., Dietary Cook 1 (DC 1), Dietary Aide 4 (DA 4) and DA 5 stood in line at the handwashing sink to wash their hands. In a concurrent interview they were asked if it was a problem the cold-water handle on the handwashing sink could not be turned very far. DC 4 stated the cold-water handle would only turn about an inch before hitting the back of the sink. DC 1 stated "Maintenance installed it backwards." When asked if they ever got burned by the hot water since they couldn't control adding cold water very well, DC 1 stated the hot water turned his hands red. DC 4 stated the water got hotter the longer it ran so when multiple staff lined up to wash their hands it got really hot.

Based on interview and record review, the facility failed to implement its emergency services policies and procedures relating to Obstetrical (OB, care of the pregnant patient) care policy for one of two pregnant patients (Patient 6), its patient assessment policy for one of eight patients (Patient 6) and its triage (the process of deciding which patients should be treated first) policy for two of eight patients (Patients 6 and 7) seen in the emergency department (ED).

1. The well-being of the fetus (unborn baby) was not adequately assessed for one of two pregnant ED patients (Patient 6), using an available, external fetal monitor (device attached to the pregnant patient's abdomen, provides a continuous fetal heart rate, detects if there are contractions, and is commonly used to assess fetal well-being), and repeat blood pressure (BP), and triage level were not done in accordance with the facility's policies.

2. The triage assessment and triage level was not recorded for Patient 7 in accordance with the facility's policy.

These failures resulted in the inability to assess how Patient 6's medical condition affected the fetus and put all patients at risk for poor outcomes.

Findings:

The facility's policy titled, "Obstetrical Care, Emergency Room," expiration date 3/30/22, indicated as its policy statement, "To ensure safe quality care to the obstetrical patient by conforming with hospital policy." "1. Patient is registered and received a medical screening exam (MSE) by the physician on duty, including if possible, a fetal heart monitor strip."

The facility's policy titled, "Triage, Emergency Room," expiration date 10/31/24, indicated as its policy statement, "The purpose of this policy is to establish criteria for triage procedure and classification for all patients presenting to the Emergency Department (ED) for treatment." "Triage will be performed by a qualified Registered Nurse (RN) of all patients presenting to the Emergency Department for care. The Registered Nurse will document triage time, and evaluate and categorize each patient by triage level (1-5 - see below) and document in the patient's EHR (electronic health record) Triage Assessment in Evident, or on appropriate paper charting if during a disaster or downtime. 1. Resuscitation 2. Emergent 3. Urgent 4. Semi-urgent 5. Non-urgent."

The facility's policy titled, "Patient Assessment, Emergency Room," expiration 6/2/24, indicated as its policy statement, "Establish criteria for all Emergency Department patients." "Vital signs: Initial vital signs including temperature, heart rate, BP, respiratory rate, oxygen saturation, . . . and pain level (0-10 scale). . . All patient will have discharge vital signs taken and documented in the patient's chart: including heart rate, respiratory rate, BP, oxygen saturation, and pain level re-evaluation. Immediately before discharge to home, unless they quality as non-urgent condition and have been in the ED less than one hour at time of discharge."

1. A review of Patient 6's record indicated she presented to the ED on 4/4/23 at 7:38 pm. The triage assessment indicated the patients was 26 weeks gestation with complaints of a headache and dark urine and with a pain level of 5. The triage note did not include the triage level. The ED physician's (MD 2) note indicated Patient 5 had a headache for the past five days and dark urine despite drinking water, denied vaginal bleeding and vision changes, and was feeling the baby move. The patient had recently moved to this area and had no OB physician, but had previously seen a OB physician. At 7:51 pm, Patient 6's initial vital signs indicated a BP of 148/90 (normal BP in pregnancy is 110-139/70-89). A urinalysis (urine test) was normal and showed no protein and no bacteria in Patient 6's urine. No fetal heart tones or fetal monitoring strip could be located in the record. No repeat vital signs or pain level could be located in the record. Patient 6 was discharged at 8:11 pm and instructed to follow up with an OB physician as soon as possible and return to ED if symptoms persist or worsen.

During a concurrent observation and interview on 5/15/23 at 10:30 am, RN 8 pointed out the external fetal monitor machine. He said it was for use with pregnant patients and all ED nurses should now how to use.

During an interview on 5/15/23 at 12:20 pm, the Chief Nursing Officer (CNO) said any pregnant patient who is 20 weeks gestation or greater should have a fetal monitor strip. She said that was something she monitors and she audits all charts of pregnant patients who come to the ED.

During a concurrent interview and record review on 5/16/23 at 8:45 am the CNO confirmed there was a triage note but it did not include a triage level. She confirmed the only BP taken was at 7:51 pm and it was not repeated and the pain level of 5 was not repeated. She confirmed there were no fetal monitor strips in the record and no documentation for fetal heart tones. She said RN 7 was the ED nurse and knew how and when to put the fetal monitor on a patient. In a follow up interview on 5/17/23 at 3:50 pm, the CNO said even for level 5 patients (non-urgent) if vital signs were out of range they should be repeated prior to the patient's discharge.

During a concurrent interview and record review on 5/16/23 at 2 pm, MD 2 said the nurses ordinarily get the fetal heart tones and put pregnant patients on the fetal monitor if over 20 weeks gestation. He said often patients are put on an automatic BP machine but at times the BPs may not get added to the chart. He said the BP fetal heart tones should have been done and even with the absence of protein in the urine, Patient 6 should have had repeat a BP prior to discharge. MD 2 said he should asked about a repeat BP before signing his note.

2. A review of Patient 7's record indicated he arrived to the ED on 3/17/23 at 7:07 pm with a complaint of chest pain and statements that he had been without his usual home oxygen for two days. He was seen by the ED physician, a chest x-ray was completed, and staff arranged for home oxygen to be delivered to Patient 7 after discharge. The triage assessment and triage level could not be found in the record. This was requested from the Health Information Management Lead (HIL) on 5/15/23 at 3 pm.

During a concurrent interview and record review on 5/16/23 at 3:20 pm, the CNO said a physical assessment was completed by the nurse but the triage note and triage level was not completed. She said a suicide screening, homelessness screening, and triage level are included in the triage note so those items were missing.

Based on observation, interview and document review, the hospital failed to administer pharmaceutical services in accordance to accepted professional practices as evidenced by:

1. The hospital nurses did not rotate the site for injection for 2 of 2 patients on subcutaneous (SC-injection given under the skin) Enoxaparin (blood thinner that helps prevent the formation of blood clots) in accordance to manufacturer's specifications. This failure increases the risk for an adverse reaction to Enoxaparin.

2. The hospital failed to meet the professional standard of practice when the hospital pharmacy did not have an up-to-date narcotic (controlled substance) count for three out of four randomly selected narcotics.

3. The hospital pharmacy failed to ensure safe storage of medications when emergency medications and dispensed medications were stored in an unorganized and crowded manner in an unused sterile compounding room.

4. The hospital staff did not store "protect from light" medications appropriately when Verapamil (heart medicine) and Phenylephrine (nasal decongestant) were stored on shelves in direct light.

5. The hospital failed to store contrast dyes (medication used for imaging studies) appropriately when contrast dyes were found in the warmer without accurate expiration dates.

6. The hospital failed to have the content list on the outside cover of all their emergency medication crash carts.

7. The hospital failed to have easily accessible refrigerated emergency medications for use in case of an emergency.

8. The hospital failed to have an emergency malignant hyperthermia drug supply stored in a container with a break away seal for quick and easy access.

9. The hospital failed to remove expired medications when two bottles of outdated Esmolol (heart medicine) were stored in operating room # 1's anesthesia cart (an operating room device used to store anesthesia supplies, equipment, and medication) for patient use.

These failures had the potential to compromise patient safety and increase the risk of patient illness or injury.

Findings:

1. A review on 05/17/23 of the online Lippincott Procedures 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 05/17/23 of the Enoxaparin manufacturer's insert indicated, "Administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall...."

A review on 05/17/23 of Patient 17's clinical record indicated that Patient 17 had physician's orders for Enoxaparin 40 milligrams (mg) daily to prevent venous thromboembolism (blood clot). The record also indicated no specific area (left or right or upper or lower abdominal wall) as to where the nurses had injected the Enoxaparin on following dates:
05/09/23 Abdomen
05/11/23 Abdomen
05/12/23 Abdomen
05/13/23 Abdomen
05/14/23 Abdomen
05/15/23 Abdomen
05/16/23 Abdomen

The above indicated that the Enoxaparin SC injections were not rotated.

A review on 05/17/23 of Patient 16's clinical record indicated that Patient 16 had physician's orders for Enoxaparin 40 mg daily to prevent venous thromboembolism (blood clot). The record also indicated no specific area (left or right or upper or lower abdominal wall) as to where the nurses had injected the Enoxaparin on following dates:
05/13/23 Abdomen
05/14/23 Abdomen
05/15/23 Abdomen

The above indicated that the Enoxaparin SC injections were not rotated.

During an interview on 05/17/23 11 AM, Registered Nurse (RN) 4 stated after reviewing Patient 17 and Patient 16's clinical record for the Enoxaparin injections, he did not know why the rotation of the injections were not documented. He acknowledged that without documenting the site it would be difficult to know where to rotate the injection site to prevent an adverse medication reaction (i.e., Hematoma).

During an interview on 05/17/23 11:10 AM RN 2 stated after reviewing Patient 17 and Patient 16's clinical record for the Enoxaparin injections stated that without documenting the site it would be difficult to know where to rotate the injection site to prevent an adverse medication reaction (i.e., Hematoma-swelling).

2. During an observation on 5/16/23 at 9:40 AM, it was observed that eighteen Fentanyl 12.5 mcg/hr patches, a strong opioid used for pain, were stored in the locked narcotic cabinet. The narcotic cabinet was where all the narcotics were stored. It was also observed that the Director of Pharmacy (DOP) was checking what was observed against a computer spreadsheet which documented the quantity of what was expected. In other words, the computer spreadsheet was used to verify the amount of narcotic stored by the pharmacy. The spreadsheet indicated that there was supposed to be sixteen patches, however eighteen patches were in stock.

During an interview on 5/16/23 at 9:45 AM the DOP stated that he had not updated the computer spreadsheet. He also stated that the spreadsheet should have been updated last month on 4/21/23. He said that he would make sure that the spreadsheet count was equal what was stocked in the pharmacy.

During an observation on 5/16/23 at 9:55 AM, it was observed that 56 syringes of Hydromorphone 0.5 mg syringes, a strong opioid used for pain, were stored in the locked narcotic cabinet. It was also observed that the Director of Pharmacy (DOP) was checking what was in stock against a computer spreadsheet which documented the quantity of what was expected. The spreadsheet indicated that there was supposed to be 65 syringes, however 56 syringes were in stock.

During an observation on 5/16/23 at 10:20 AM, it was observed that 160 tablets of Hydrocodone Acetaminophen 10mg/325 mg tablets, an opioid used for pain, were stored in the locked narcotic cabinet. It was also observed that the Director of Pharmacy (DOP) was checking what was in stock against a computer spreadsheet which documented the quantity of what was expected. The spreadsheet indicated that there was supposed to be 180 tablets, however 160 tablets were in stock.

During an interview on 5/16/23 at 10:30 AM, the DOP stated that he had not updated the computer spreadsheet for the Hydromorphone, and the Hydrocodone Acetaminophen. He also stated that the spreadsheet should have been updated last month. He said that he would make sure the spreadsheet count was equal to what was stocked in the pharmacy. He acknowledged the importance of accurate narcotic counts to help prevent narcotic diversion and early detection of medication errors.

3. A review on 5/17/23 of an undated hospital policy entitled, "Pharmaceutical Storage and Preparation," indicated "Drugs shall be stored in an orderly manner in... shelves, drawers or carts of sufficient size to prevent crowding"

During an observation on 5/16/23 at 10:32 AM, in the pharmacy there were shelves with multiple different types of medications. Some of these medications were emergency medications, in addition to oral suspensions, injectable medications, topical medications, and oral medications. The medications were very difficult to access because there were multiple towers of boxes stacked on top of each other that ranged from 4-6 feet high. The boxes covered some of the medications.

During an interview on 5/16/23 at 10:40 AM the Director of Pharmacy (DOP) stated that the boxes contained medications and documents. He also stated it made it difficult to dispense the medications because the boxes were in the way. The DOP said that the boxes increased the risk of dispensing errors because it was more difficult to see what medications were available and when you grabbed the medications you would be more likely to grab the wrong the medication.

During an interview on 5/17/23 at 8:58 AM, the DOP stated that he was aware of the overcrowding of the medications and was working on having the boxes moved and the pharmacy reorganized.

4. A review on 5/17/23 of the undated hospital policy entitled, indicated "Drugs must be stored under proper conditions..."

A review on 5/17/23 of the manufacturer's insert indicated to protect from light for the Phenylephrine 10mg/ml 1ml vial and Verapamil 5mg/2ml. Phenylephrine may be used in the treatment of low blood pressure, shock, or supraventricular tachycardia. Verapamil can be used to restore normal heartbeats rapidly or temporarily in people with certain heart rhythm disorders. The Phenylephrine and Verapamil was to be stored away from light.

During an observation on 5/17/23 at 9 AM, the Phenylephrine 10mg/ml 1ml vial was found under direct light in the hospital pharmacy. There were five-1 milliliter (ml) vials of the Phenylephrine that was under direct light.

During an observation on 5/17/23 at 9:04 AM, the Verapamil 5mg/2ml 2ml vial was found under direct light in the hospital pharmacy. There were four-2 milliliter (ml) vials of Verapamil that was under direct light.

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

During an interview on 5/17/23 at 9:05 AM, the DOP stated that he did not know that the Phenylephrine 10mg/ml 1ml vial and Verapamil 5mg/2ml were to be stored away from direct light. He also stated that he would ensure that the medications were stored away from light.

5. A review of the Optiray package insert, which included Optiray 320 and Optiray 350, indicated "Storage ...Store at 25C (77F) ...Store up to 40 C (104 F) for up to one month in a contrast media warmer utilizing circulating warm air." Optiray was a contrast dye are used to allow blood vessels, organs, and other non-bony tissues to be seen more clearly on a computerized tomography (CT) scan or other radiologic (x-ray) examination.

During an observation on 5/17/23 at 11:13 AM, it was observed in the CT warmer and there was a thermometer inside the warmer that indicated a temperature 33 degrees Centigrade. There was no indicating of an updated expiration date (30 days) since it was in the warmer. There were five boxes of Optiray 320 125 ml syringes and one vial of Optiray 350 inside the warmer.

During an interview on 5/17/23 at 11:15 AM, RT stated that there should be daily documented temperatures of the warmers. RT also stated it was the standard of practice to document and monitor daily temperatures. There were no daily documented temperatures of the warmer

6. During an observation on 5/16/23 at 11:23 AM, it was observed in the Medical Surgical floor an emergency crash cart that was used for patients in an emergency. There were medications in the first two drawers of the cart, however there was no contest list on the outside cover of the cart.

During an observation on 5/16/23 at 11:55 AM, it was observed in the Emergency Room an emergency crash cart that was used for patients in an emergency. There were medications in the first two drawers of the cart, however there was no contest list on the outside cover of the cart.

During an observation on 5/16/23 at 11:57 AM, it was observed in the Emergency Room floor an emergency pediatric crash cart that was used for pediatric patients in an emergency. There were medications in the first two drawers of the cart, however there was no content list on the outside cover of the cart.

During an interview on 5/16/23 at 2:57 PM, the DOP stated that there was no listed content list on the outside cover of any of their emergency carts. The DOP also stated that he was not aware that there had to be a content list on the outside cover of all the emergency carts.

7. During an observation on 5/16/23 at 11:20 AM, it was observed in the Emergency Department a pediatric emergency crash cart that was used for patients in an emergency. There was a note that the emergency medications Fosphenytoin (medication to manage seizure) 50mg/ml 10 ml vial was in the refrigerator.

During an observation on 5/16/23 at 11:25 AM, it was observed in the Medical Surgical floor an emergency crash cart that was used for patients in an emergency. There was a note that the emergency medications Diltiazem (medication to treat high blood pressure) 5mg/1ml 5 ml vial and Vasopressin (medication used to manage anti-diuretic hormone deficiency) 20 units/l 1 ml vial were in the refrigerator.

During an interview on 5/16/23 at 11:25 AM, Licensed Vocational Nurse (LVN) 1 stated that, when in an emergency occurs, if a patient needed the Fosphenytoin, Diltiazem and Vasopressin then nurses would get medications from the emergency room refrigerator.

During an observation on 5/16/23 at 3:27 PM, Registered Nure (RN) 4 was observed, in a demonstration he was asked to find the emergency refrigerated medications mentioned above (Diltiazem, Vasopressin, and Fosphenytoin), that the locked refrigerator was opened by RN 4. The refrigerator was filled with medications. There were emergency medications and mostly non-emergency medications. The RN 4 took several minutes to find the medications. RN 4 did not find the Vasopressin and Fosphenytoin.

During an interview on 5/16/23 at 3:27 AM, RN 4 stated that it was difficult to find the refrigerated emergency medications in a fully packed refrigerator. RN 4 also stated if there was an emergency it would be a problem obtaining the emergency medications in the refrigerator.

8. Malignant hyperthermia (MH) is a type of severe reaction that occurs in response to medications used during general anesthesia, among those who are susceptible. Symptoms include muscle rigidity, fever, and a fast heart rate. Complications can include muscle breakdown, high blood potassium and death.

During an observation on 5/16/23 at 11:30 AM, it was observed that the Malignant Hyperthermia cart was locked. There was no outside breakaway seal, and the cart could not be opened unless you had a key. When asked to open the cart it took 15 minutes before Certified Registered Nurse Anesthesist (CRNA) 1 was available to open the cart.

During an interview on 5/16/23 at 11:45 AM, CRNA 1 stated that in case of an emergency it would be best that keyless entry to the emergency medication supply would be most beneficial to patients because of quick and easy access. He acknowledged that minutes could make a difference when treating someone with Malignant Hyperthermia.


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9. A review of the facility's policy titled, "Disposal of Medications, Pharmacy", undated, indicated that all unused and outdated medication should be removed from patient care areas and taken to the pharmacy for disposal.

During a concurrent observation and interview with the facility's Chief Nursing Officer (CNO) on 5/15/23, at 10:34 am, it was observed that operating room (OR) 1's anesthesia cart was a locked device that opened with keys only accessible to the facility's CRNAs. CNO stated that CRNA 1 agreed to assist with the oversite of specific operating room procedures that included conducting monthly audits of OR 1's anesthesia cart to ensure stocked medications were not outdated.

During a concurrent observation and interview on 5/16/23, at 9:42 am, CRNA 1, Infection Prevention Nurse (IPN), and surgical technician (ST) verified that OR 1's anesthesia cart had two bottles of outdated Esmolol, with expiration dates of 4/30/23, available for patient use. CRNA 1 removed the two bottles from the cart and reported he would send them to the facility's pharmacy for proper disposal. CRNA 1 stated since the facility did not have a formal monthly audit form, he opted to create a list of the anesthesia cart's medications and their respective expiration dates in his personal cell phone. CRNA 1 verified that his personal notes indicated Esmolol expired on 4/30/23 and stated he accidentally overlooked the expiration date.

Based on interview and record review, the facility failed to ensure nursing staff were adequately qualified, trained, and oriented to meet the patients' nursing care needs develop nursing policies and procedures when:

1. The operating room nurse (RN 1) was not provided with initial orientation or ongoing training to meet the surgical patients' needs.

2. The Chief Nursing Officer (CNO), acting as the operating room manager (ORM), did not possess the experience, qualifications, or training to meet the surgical patients' needs.

3. A Medication Administration Policy was not developed to provide nursing staff with a safe and effective process for administering medications to patients.

This failure had the potential to increase the risk of patient needs not being met and compromise patient safety.

Findings:

1. A review of the facility's policy titled, "In-service Education, Continuing Education", Version 6, undated, indicated that the policy's purpose was to provide personnel with opportunities to maintain competencies, create new competencies, or correct deficiencies. The policy's procedure included providing personnel with unit-specific in-service education to maintain or create new competencies.

A review of the facility's document titled, "Registered Nurse, Operating Room Job Description", dated 2016, indicated that the operating room nurse must demonstrate competency in performing all procedures necessary to the operating room department. The operating room nurse's immediate supervisor is the the operating room manager, who reports to the CNO.

A concurrent interview and review of RN 1's employee file was conducted on 5/15/23, at 3:30 pm. After review, the Human Resource Director (HRD) stated that RN 1 was hired as an operating room (OR) nurse on 10/06/21, with no prior OR experience. HRD stated RN 1's personnel file indicated that she had no specialized training or certification in the provision of surgical services and that there was no documentation that RN 1 received a formal OR nurse orientation at the time of hire. HRD reported that newly hired RN's are typically given a unit-specific orientation packet specific that outlines the education and training required for new hires to work independently. HRD was unsure if an actual orientation packet existed for the OR nurse job role,

During an interview on 5/17/23, at 11:00 am, RN 1 reported she received her Registered Nursing License in 2010 and worked as a correction's nurse prior to being hired at the facility on 10/06/21. RN 1 stated she had no prior operating room experience and did not receive any formal orientation or training from the facility at the time of hire. RN 1 reported she developed her OR nursing skills from "on the job training" at the facility and from a "self-initiative to research" the Association of PeriOperative Registered Nurses's (AORN, an organization that that defines the standard of nursing care for surgical patients) standards. RN 1 utilized the facility's electronic employee competency platform, RELIAS, to complete annual training's that were assigned to her by the CNO or HRD.

RN 1's RELIAS Transcript, dated 12/09/21 - 3/09/23, was reviewed on 5/17/23, at 2 pm. The document indicated that RN 1 was not assigned, and did not complete, RELIAS courses that were specific to surgical services or OR nursing.

During an interview on 5/17/23, at 1:30 pm, CNO confirmed that RN 1 was hired without any OR experience and did not receive the OR nursing new hire orientation or specialized training at the time of hire. CNO relied on the lead Certified Registered Nurse Anesthetist (CRNA, a nurse that administers and provides anesthesia to patients before, during, and after surgery) and facility surgeon to guide and instruct RN 1 on OR nursing processes and procedures. The CNO stated she called a nearby general acute care hospital, and requested copies of their OR nurses' orientation process and on-going OR nurse competencies to review for possible implementation at the facility.

2. A concurrent interview and record review of the employee for operating room manager (ORM) /CNO was conducted on 5/15/23, at 3:30 pm. After review of the employee file, HRD confirmed that the CNO/ORM did not have experience, certification, or specialized training in the provision of surgical services/ management of surgical service operations. HRD reported that CRNA 1 assisted the CNO with ORM duties, since the CNO was not proficient in OR nursing.

During a telephone interview on 5/17/23, at 11:46 am, CRNA 1 stated he has been the Director of Anesthesia and contract servicer for the facility's CRNA services since 9/2022. CRNA 1 reported he helped the facility evaluate policies and procedures related to OR guidelines, but he did not operate or function as the ORM. CRNA 1 was based out of central California and was assigned to work in the facility's OR every six weeks, for one week. CRNA 1's stated he was not scheduled frequently enough at the facility to effectively evaluate the OR nursing services and provide nursing support. CRNA 1 believed the CNO was responsible for these duties.

During an interview on 5/17/23, at 1:30 pm, CNO stated when she was appointed the role of CNO she was "grandfathered in" as the acting ORM, despite having no OR experience or education. The CNO reported since she lacked experience in surgical services, she collaborated with the lead CRNA, CRNA 1, on OR management. CNO's main involvement with the facility's surgical services was generating the OR staff and patient schedule. Otherwise she relied on CRNA 1 to have oversite of surgical services and provide training and guidance to the OR nursing staff.


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3. In an interview on 5/15/23 at 2:20 pm, the CNO was asked for the facility policy on medication administration by the nursing staff, and she affirmed she would supply it. The CNO was unable to find such a policy. The CNO created a policy that day and presented it, stated she would include it in the plan of correction and that it was a preliminary policy that needed to go through the review process.

A review of a preliminary facility policy, undated, titled, "Administration of Medications," indicated that the purpose of the policy is to provide guidelines for the safe administration of medications to patients receiving care in all departments of nursing.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan based on nursing initial intake and assessments for Patient 18. This failure had the potential for the patient's needs not being identified and managed by the nursing staff.

Findings:

A review of a facility policy titled, "Care Plan Standards, Med/Surg, Swing," with an expiration date of 10/21/23, indicated that "care plans are devised from Registered Nurse (RN) analysis of assessment data to determine actual or potential diagnosis, problems, and issues," that the RN develops, implements and evaluates progress towards the attainment of planned goals and outcomes. Care plans should be evaluated by nursing staff each shift.

A review of a facility policy titled," Weighing Patients, Emergency, Med/Surg, SNF," with an expiration date of 9/28/22, indicated that patient weights will be done safely and accurately upon admission and as ordered by physician, or by nursing judgment.

A review of the 'History and Physical," dated 5/13/23, Medical Doctor (MD) 1 documented that Patient 18 was admitted through the emergency room with diagnoses of failure to thrive (a state of decline), enterocolitis (inflammation of the intestines), multiple sclerosis (a disorder wherein the body's immune system attacks the protective covering of nerve cells), incontinence (inability to control the bowels), and perineal chemical burns (burns to the area between the anus and vulva) due to frequent watery diarrhea. She was described as thin, frail, and cachectic (loss of body weight and muscle mass) with a BMI of 17.7 (body mass index, a calculation that screens for weight categories). In the physical examination, MD 1 documented that Patient 18 was weak, appeared dehydrated, and had paraplegia (the inability to voluntarily move the lower extremities). Her past medical history also included unintentional weight loss, nausea, and diabetes type 2 (a blood sugar disorder).

According to the Centers for Disease Control and Prevention, a BMI under 18.5 is considered underweight.

In an initial nursing interview with Patient 18 (wherein nursing staff interview new patients) dated 5/13/23, RN 7 documented a request for a dietary consult due to a poor appetite for more than 2 weeks, and an admission weight of 116 pounds, 6.4 ounces.

In an initial physical assessment of Patient 18 dated 5/13/23, RN 7 documented incontinence of bowels and diarrhea, paresis of both lower extremities, and that Patient 18 was unable to bear weight.

In a review of physician's orders for Patient 18 dated 5/13/23, MD 1 ordered weights to be taken once a week, and an ADA mechanical soft diet (ADA = American Diabetic Association diet of low-starch and low-sugar foods to control diabetes; mechanical soft = foods processed to be easier to chew).

A review of a document titled, "Graphic and I&O (intake and output)," with a date ranging from admission on the evening of 5/13/23 through the morning of 5/16/23. Patient 18's food consumption and fluid intake, vital signs, weight, and urinary and stool output were entered into the document. The admission weight of 116 pounds, 6.4 ounces, was documented on 5/13/23, with another weight of 111pounds, no ounces on 5/14/23. Patient 18 was documented as passing four stools on 5/13/23, five on 5/14/23, and four on 5/15/23.
Food intake was documented as follows:
5/13/23 dinner, 10% consumed
5/14/23 breakfast 10%, lunch 5%, dinner 0%
5/15/23 breakfast 25%, lunch 25%, dinner 25%
5/16/23 breakfast 50%

A review of Patient 18's care plan dated 5/13/23, RN 7 entered a care plan for impairment of skin integrity with a goal of regaining skin integrity. On 5/14/23, 5/15/23, 5/16/23, the care plan for impaired skin integrity was addressed; no other care plans were added.

On 5/17/23 11:59 am, during an interview RN 2 stated she had looked over the care plan (as developed on 5/13/23) earlier and thought it didn't address the patient's needs adequately and added to the care plan.

A follow-up review of Patient 18's care plan dated 5/17/23, RN 2 added body elimination, diarrhea.

On 5/17/23 2:15 pm, an interview was done with the Chief Nursing Officer (CNO) about Patient 18's nutrition, weights and care planning. CNO stated a nutritional intake below 50-75% would be concerning. She stated diet orders can be altered based on a patient's needs. When asked if the patient's needs go into the care plan she replied, "They do and they should," for example, she would expect a patient with documented malnourishment to have a care plan addressing this, it's her expectation that any patient at risk should be care planned, including nutritional deficiency and that there would be interventions to stimulate appetite or improve nutrition. She added that if there was no care plan addressing these concerns, she would like to see an explanation in the notes as to why not. She reviewed patient 18's weight and height and stated, "She is underweight."

Based on interview and record review, the facility failed to properly execute consents when four of six patients (Patient 9, Patient 10, Patient 11, and Patient 12) surgical and anesthesia consents were not documented with the date and time. This failure resulted in missing documentation that verified when patient consent was obtained.

Findings:

A review of the facility's policy titled, "Surgical Consents, Operating Room" Version 4, undated, indicated the facility follows the procedures set forth in the California Association of Hospitals and Health Systems Manual (CAHHS).

A review of the CAHHS Manual, undated, indicated that surgical, procedural, and anesthesia consents must document the date and time that consent was obtained.

A review of the facility's policy titled, "Preoperative Management, Operating Room," Version 3, indicated the policy's purpose is to outline care and management of patients prior to planned outpatient surgery. The facility's preoperative and circulating nurses are responsible for verifying that patients' consents are correct and complete prior to the patient entering the surgical unit.

During a concurrent interview and record review on 5/17 /23, at 11 am, Registered Nurse (RN) 1 reported she has worked as an operating room nurse at the facility for 1.5 years and had no prior operating room nursing experience. RN 1 stated the facility's preoperative nurses were responsible for obtaining the patient's signature on the consent forms, co-signing as a witness to patient consent, and recording the date and time when consent was obtained. The facility's operating room nurses were responsible for confirming with the patient that the signed consents list the correct procedures, but they do not review consent forms to ensure they have a documented date and time.

During a concurrent interview and record review on 5/17 /23, at 11:30 am, RN 3 reported she has worked as a pre and post-operative nurse at the facility for two years. RN 3 stated that preoperative nurses were responsible for verifying with the patients that the written consents were accurate and obtain the patient's signature. Once a patient signs a consent, the preoperative nurses were responsible for co-signing as a witness and documenting the date and time that patient consent was obtained. RN 3 confirmed that Patient 9, Patient 10, Patient 11, and Patient 12's consents were not completed correctly because they were missing the date or time when patient consent was witnessed and obtained.

During a concurrent interview and record review on 5/17/23, at 3 pm, the Chief Nursing Office (CNO) stated it was the preoperative nurse's responsibility to obtain a patient's signature, and document the date and time that consent was obtained, the operating room nurses were responsible for reviewing consent forms to ensure they were filled out completely prior to transporting a patient to the operating room. CNO confirmed that Patient 9, Patient 10, Patient 11, and Patient 12's surgical and anesthesia consents were missing the date or time that patient consent was obtained. CNO reported she intended to develop a chart audit system to identify nursing documentation errors.

Based on observation, interview and record review, the facility failed to ensure provision of an effective infection control program, and implement infection control practices in accordance with hospital policy and nationally recognized standards when:

1. The anesthesia cart in operating room 1 had expired intravenous (IV, a small, plastic tubing placed into a vein to deliver medicines or fluids) extension tubing sets (IV tubing that is connected to an IV to extend the length of the tubing) and damaged, sterile nasogratic tubes (NG, a plastic tube placed through the nose, esophagus, and into the stomach to deliver medicine, nutrition, or remove fluid) available for patient use.

2. The supply cabinets in operating room (OR) had expired 1000 milliliter (ml) bottles of sterile water available for patient use.

3. OR 1's left overhead light (a surgical light that is positioned over a patient to illuminate an area of the body) was contaminated with a brown, thickened substance around the inner light drum, where a missing rubber rim use to be.

4. Environmental services (EVS) staff failed to conduct routine, nightly cleanings in the OR, recovery room (RR), and scrub area (an area with surgical sinks where the operating room staff scrub their hands and arms before surgery) from 5/13/23 - 5/15/23.

5. EVS and the Infection Control Nurse (ICN) failed to survey the OR, RR, and scrub area while conducting quarterly environmental rounds on 6/07/22, 9/28/22, and 1/10/23.

6. The Emergency Department (ED) had expired isopropyl alcohol and an opened bottle of Normal Saline (NS) for patient use, used water bottles stored on emergency patient care equipment, and a hopper (large toileting device for emptying bedpans and other items) without a proper splashgaurd located near a patient gurney.

7. The kitchen was not adequately maintained to promote food safety and sanitation.

8. Staff did not follow professional standards of practice to prevent cross contamination.

9. Equipment was not sanitary, and staff did not follow manufacturer's instructions for cleaning and sanitizing equipment.

10. Labeling and dating was not performed per policy and there were expired foods in the refrigerator.

These failures had the potential to increase patient exposure to infectious contaminants, compromising patient health and safety.

Findings:

1. A review of the facility's policy titled, "Sterile Storage Shelf-Life Event Related, Infection Control," undated, indicated that the policy's purpose was to assure the integrity of sterile patient care items. Patient care items that had broken seals, holes, or torn wrappers were considered damaged and to be removed from patient care areas.

A review of the facility document titled, "Infection Control Program, Infection Control," Version 7, undated, indicated that the Chief Nursing Officer (CNO) was responsible for ensuring that patient care practices and product safety is maintained in all patient care areas and departments.

During a concurrent observation and interview with the facility's CNO on 5/15/23, at 10:34 am, it was observed that OR 1's anesthesia cart was a locked device that opened with keys only accessible to the facility's CRNAs. CNO stated that Certified the Registered Nurse Anesthetist (CRNA, a nurse that administers and provides anesthesia to patients before, during, and after surgery), CRNA 1, was responsible for conducting monthly audits of OR 1's anesthesia cart to ensure stocked supplies were not outdated or contaminated.

During a concurrent observation and interview on 5/16/23, at 8:59 am, CRNA 1, Infection Prevention Nurse (IPN), and surgical technician (ST) verified that OR 1's anesthesia cart had two outdated, 5" IV extension tubes sets, with expiration dates of 3/01/22 and 11/01/22, that were available for patient use. The anesthesia cart's fourth drawer had two sterile packages of 18 French NG tubes, with broken sterile seals and torn packaging, exposing the NG tubes to contamination. CRNA 1 reported he performed a monthly anesthesia cart audit in the beginning of May 2023, but he overlooked the outdated and damaged supplies. CRNA 1 and IPN confirmed that the supplies were no longer safe or sterile for patient use and removed them from the cart to discard.

2. During a concurrent observation and interview on 5/16/23, at 9:42, IPN and ST reported that the operating room nurse (RN) 1 was responsible for performing monthly audits to ensure that OR 1's supplies were not outdated. IPN and ST verified that OR 1's supply cabinets had three bottles of outdated 1000 ml sterile water with an expiration date of 3/22, that was available for patient use. ST removed the sterile water from OR 1's cabinets to discard.

During an interview on 5/17/23, at 11 am, RN 1 reported she is responsible for conducting monthly audits of OR 1's stored surgical supplies. RN 1 performed a monthly audit in the beginning of May 2023, but she overlooked the sterile waters' expiration dates. RN 1 stated the sterile water was stored in an OR cabinet with supplies that were rarely used, which made it easier to overlook.

During an interview on 5/18/23, at 1:30 pm, CNO stated she was not aware that outdated or damaged supplies were being stored in OR 1. CNO reported she delegates OR audits to specific OR staff, but she does not perform a quality control check to ensure these tasks are being conducted or completed correctly.

3. A review of the facility document titled, "Infectious Disease Control Plan, Infection Control", Version 7, undated, indicated that all equipment will be clean/sterile and maintained to provide a safe patient care environment.

During a concurrent observation and interview on 5/16/23, at 9:42 am, IPN and ST verified that OR 1's left overhead light had a ring of a brown, thickened substance around the inner light drum, where a missing rubber rim use to be located. IPN and ST confirmed that during surgery the overhead OR lights are moved and repositioned frequently to illuminate the patient's body. IPN stated she wasn't aware the light was broken and confirmed that the brown substance could be a median for bacteria in the OR, or pose a patient safety risk if the debris became dislodged over the sterile field (an area around the patient's surgical site that is free of bacteria or other substances that may cause infection) during surgery.

During a concurrent observation and interview on 5/16/23, at 11 am, RN 1 verified that OR 1's left overhead light had a thick, brown, ring of debris in the inner drum where the rubber rim used to be secured. RN 1 stated the overhead light was in this condition since her time of hire, approximately 1.5 years ago. RN 1 stated she had not made a work order to the Director of Plant Operations and Environmental Services (DPO), because this was the condition of the OR equipment when she was hired.

During a concurrent observation and interview on 5/16/23, at 11:43 am, DPO verified that OR 1's left overhead light was missing a rubber rim that lined the edge of the light drum. There was a thick, brown, ring of debris in the inner drum where the rubber rim was once secured. DPO reported he didn't recognize that the light was broken during environmental rounds (quarterly inspections of the facility that are conducted by the DPO and IPN, nor had he received a work order from the OR staff requesting the light to be repaired.

During an interview on 5/18/23, at 1:30 pm, CNO stated she was not aware that OR 1's left overhead light was damaged and had an exposed brown substance with debris. CNO reported she relies on the OR staff, IPN and DPO to identify damaged equipment and generate work orders for equipment repair. The CNO was copied on all electronic work orders, but she did not have a formal process of verifying that the work order was completed and the patient equipment no longer posed an infection control risk.

4. A review of the facility document titled, "TITLE: NIGHTLY CLEANING OF OR/RR (ROUTINE)", dated 6/13, indicated that environmental services staff (EVS) are to clean the surgical suite (OR 1, RR, and Surgical Scrub station) nightly. A germicide (a substance that destroys harmful germs) will be used on all walls, ceilings, light fixtures, floors, vents, and surgical scrub sinks.

A review of the facility document titled, "Environmental Services Nightly Cleaning Schedule List," dated May 2023, indicated that EVS staff did not document a staff signature or staff finials confirming that the surgical suite was cleaned on 5/13/23 and 5/14/23.

During a concurrent observation and interview on 5/16/23, at 10:56 am, IPN verified that the EVS nightly cleaning sign-off sheet for May 2023, indicated that staff did not conduct cleaning of the surgical suite on 5/13/23 and 5/14/23. IPN did not perform daily audits of the surgical suite cleaning and was unaware cleaning did not occur for two consecutive nights. IPN stated that the DPO was responsible for the oversite of the surgical suite cleaning.

During a concurrent observation and interview on 5/15/23, at 11:43 am, DPO reported that nightly cleaning of the surgical suite did not occur on 5/13/23 and 5/14/23 because the housekeeping staff assigned to clean the surgical suite called out sick and the duty was never reassigned. DPO stated he was responsible for rearranging workloads when staffing issues arise, however this occurred over the weekend when the DPO was not on site. DPO reported he wasn't notified by the facility that a staff member had called in sick, so he did not reassign the nightly cleaning duty. The facility staffs three housekeepers each night, so other housekeepers were available to perform the nightly surgical suite cleaning.

5. A review of the facility document titled, "Infectious Disease Control Plan, Infection Control," Version 7, undated, indicated that the DOP and IPN were involved in infection prevention risk assessment and were responsible for conducting environmental rounds periodically.

During a concurrent interview and record review on 5/18/23, at 8:13 am, DPO stated he attended quarterly environmental rounds with the ICN to identify building and patient care equipment maintenance or repair needs that have may affect infection prevention and patient safety. DPO stated surveillance of the surgical suite was not always conducted during the quarterly environmental rounds and verified that the Facility's Environmental Rounds Summaries dated 6/07/22, 9/28/22, and 1/10/23 did not include documentation on the surgical suite.



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6. During a concurrent interview and observation of the ED on 5/15/23 at 1030 am, the Pediatric crash cart (contains emergency supplies) had IV pole attached with oxygen tubing in a bag, and had a plastic bag with empty plastic bottles. RN 8 admitted there was probably a better place to hang the bag full of plastic bottles. Room 2 had two patient beds. Close to one of the beds, was a hopper that flushes, which RN 8 confirmed was used. The hopper had a splash guard only on the front but the splashguard had a gap of several inches (approximately 8 to 10) at the bottom, with the patient's bed being only about two feet away. In the cabinet in room 2 there was an opened bottle of 1000 ml Normal Saline (NS) for irrigation with about 1/3 left in the bottle with no open date on the bottle. RN 8 said the NS can be used to clean patient wounds and it should be labeled when opened or discarded after one patient use. At 11 am in Room 1, an unopened 16 ounce bottle of isopropyl alcohol was observed, with an expiration date of 4/2022. RN 8 confirmed the bottle had expired.

During a concurrent interview and observation in the ED on 5/15/23 at 12:20 pm, the CNO viewed the hopper with splashguard that had a large gap at the bottom. She confirmed this and said they have ordered other splash guards which extend from the bottom to the top of the hopper without any gaps. Also discussed other issues found during prior ED tour regarding opened bottles of NS, expired alcohol. She said the ED nurses should check for expired items.



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7. During the initial tour of the kitchen beginning on 5/15/23 at 10:15 am, there were multiple areas where the linoleum was curling or broken and the baseboards along the walls were in disrepair. The floors had black pitting throughout the kitchen that would likely attract and retain grime. Metal cabinets used for food storage had chipped paint, creating an uncleanable surface. These areas in disrepair created the potential for a lack of sanitation, cross contamination of food and equipment, access for vermin, and employee safety risks (Cross Reference C-0912).

Review of the 2022 FDA Food Code §6-101.11 showed "Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be (1) Smooth, durable, and easily cleanable for areas where food establishment operations are conducted." The FDA Food Code defined "Smooth" as "3) a floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean." §6-201.11 showed "floors, floor coverings, walls, wall coverings and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable."

8. Staff did not follow professional standards of practice to prevent cross contamination when they did not appropriately perform hand hygiene and glove use, did not adequately restrain hair, and did not protect their clothing from potential splash and soil.

Review of a policy provided by the IPN titled "Infection Control, Dietary," expiration date 2/5/22 showed the purpose of the policy was "to ensure that services are provided in a manner that minimizes the risk of hospital acquired infection to patients, staff, and visitors ...1. A clean uniform with sleeves an apron should be worn each day ...2. All food employees preparing, serving or handling food or utensils shall wear hair restraints such as hats, hair coverings or nets which are designed and worn to effectively keep their hair from contacting ...food, clean equipment, utensils ...9. Keep hands and fingers away from the hair, face, nose and mouth where food poisoning organisms can be picked up and transmitted to food ...15. Observe safe practices in storing, preparing and serving foods ...16. Employees are required to wash their hands and change their aprons after handling dirty dishes or leaving the department and before handling clean and sanitized dishes."

8A. Hand Hygiene and Glove Use

Review of a policy titled Hand Hygiene, Infection Control showed hand washing was required before and after eating, drinking, applying makeup; before and after each shift; after using the restroom; after covering a sneeze, cough or blowing your nose ...after removing gloves."

Review of the 2022 FDA Food Code 3-304.15(A) showed single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation."

During multiple observations in the kitchen beginning 5/15/23 at 10:15 am, the paper towel dispenser by the hand washing sink auto-dispensed towels to a length that caused the towel to land on the edge of the sink. This created the potential for cross contamination for anyone using the long, auto-dispensed paper towels after hand washing.

During an observation in the kitchen during lunch tray line (patient meal assembly process) on 5/15/23 at 12:07 pm Dietary Aide 5 (DA 5) wore his gloves and touched the refrigerator door handle to obtain a tub of drinks, then returned to working tray line without changing his gloves or washing his hands.

During an observation on 5/15/23 at 2:30 pm, DA 3 wore gloves while making pizza for dinner. She wore her same gloves as she touched and went in and out of the walk-in refrigerator, then went back to making pizza with the same gloves on. She did not wash her hands or change her gloves.

During an interview with the Infection Prevention Nurse (IPN) on 5/16/23 at 8:45 am, she stated kitchen staff should change their gloves when moving to different work areas and when serving (food). "They have to be changing gloves after touching a dirty area, for example refrigerator handles."

During an observation on 5/16/23 at 8:58 am, DA 2 washed her hands, dried them with a paper towel, then wiped her mouth with that paper towel and kept it in her hand as she walked through the kitchen and back to the dish room. She did not put the paper towel in the trash and did not rewash her hands.

During an observation on 5/16/23 at 9:05 am, DA 5 dished a dessert with gloves on. He wore his gloves and touched the walk-in refrigerator door as he entered and exited it multiple times. He wore the same contaminated gloves as he put lids on patient dessert bowls and used a pen to write on the lids. DA 5 continued to wear the same gloves as he touched the clean food prep counter, got a sheet pan, got parchment paper, used a pen to write on the parchment paper, grasped clean small black bowls by their rims to place them on the parchment paper on the sheet pan. He used a same-gloved hand to level a portion of gelatin dessert in the scoop before pouring it into a patient bowl.

During an observation on 5/16/23 at 9:15 am, DA 2 carried a white wadded up paper towel in her bare hand, wiped her nose with it, then used the paper towel to wipe food from the counter. She set the paper towel down on an adjacent counter next to the knife rack and can opener mount. Then she sprayed the first food prep counter with sanitizer and walked away to the dish room, taking the soiled paper towel with her. No hand washing was observed. She returned and placed the clean can opener back in its mount. She used a rag to wipe the sanitizer previously sprayed on the counter. Then sprayed more sanitizer and immediately wiped it off again. No hand washing was observed.

During further continued observation, DA 2 dumped a container of fruit into the 3-compartment sink garbage disposal, again carrying a soiled paper towel in her bare hand. She entered the walk-in refrigerator still carrying the paper towel in her hand and began pulling previously opened and prepared food items from the refrigerator and placing them on the food prep counter. She stated she was checking the dates. Then she returned the items to the refrigerator. No hand washing or glove use took place.

During an observation on 5/16/23 at 9:36 am, DA 3 wore gloves as she opened cabinets to obtain food ingredients, then returned to food prep to make dessert wearing the same gloves and with no handwashing. During further observation, DA 3 continued to wear her gloves as she touched the kitchen's exit door, walked across the hall, touched and entered the dry storage room door, then carried ingredients in her same-gloved hands back through both doors and returned to food preparation wearing the same gloves. There was no hand washing and no glove change.

During an interview with the DM on 5/16/23 at 10 am, she stated staff needed to wash their hands every time they went in and out of the kitchen. They needed to wear gloves when handling ready to eat foods, and to change their gloves with each food they prepared. She stated she told DC 1 that morning that if he touched a pen or answered the phone he had to change his gloves. "They are supposed to wash their hands when they change their gloves. The Infection Control nurse (IC) is always telling them that." "Infection Control has been working really, really hard with us in the kitchen since we don't have a Registered Dietitian and especially since COVID."

8B. Staff hair was not adequately restrained

During multiple observations in the kitchen beginning on 5/15/23 at 10:15 am, three (Dietary Cook 1, Dietary Aide 2, and Dietary Aide 4) out of nine staff did not wear hair nets and their hats did not fully cover their hair. Dietary Aide 4 (DA 4) also had facial hair and did not wear a beard net to protect food and equipment from possible cross contamination. In addition, there was hair consistently straggling out the sides and back of DA 3's hair net.

During an interview with the Dietary Manager (DM) on 5/16/23 at 10 am, she stated staff should wear hairnets, or they could wear hats as long as their hair was contained.

Review of the 2022 FDA Food Code 2-402.11 showed "Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils ...and unwrapped single service and single-use articles."

8C. Staff did not protect their clothing from potential cross contamination

Review of the 2022 FDA Food Code 2-304.11 showed "Food employees shall wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-service and single-use articles." Review of the FDA Food Code 2022, Annex 3, 2-304.11 explained "Dirty clothing may harbor diseases that are transmissible through food. Food employees who inadvertently touch their dirty clothing may contaminate their hands. This could result in contamination of the food being prepared. Food may also be contaminated through direct contact with dirty clothing."

During multiple observations in the kitchen throughout the survey beginning on 5/15/23 at 10:15 am, zero out of eight staff (DC1, DC2, DC3, DA1, DA2, DA3, DA4, DA5) wore aprons to protect their clothing from splash or other cross contamination during food preparation, food stocking, dish washing, or cleaning.

During an observation on 5/16/23 at 9:30 am, DC 1 was on his knees on floor cleaning the bottom shelves that were his weekly cleaning assignment prior to returning to his cook responsibilities.

During an interview with the DM on 5/16/23 at 10 am, she stated for dress code the staff usually wore scrubs. They had disposable aprons "if they want to wear them." When asked what if staff chose not to wear them? She stated, "They'll just get all wet and messy running the dish machine."

9. During observations in the kitchen beginning 5/15/23 at 10:15 am, the oven had a buildup of dust and food debris on the exterior, and a buildup of brown grime on the interior. The cutting boards along tray line had deep black cuts and cracks that could harbor microbial growth. There was a gray substance resembling dust on the kitchen's hood.

During an observation in the kitchen on 5/15/23 at 10:15 am, two wet towels were left unattended on the food preparation counter next to the knife rack and can opener, and below where clean utensils were hung. DC 1 stated the two towels were for wiping equipment down with sanitizer, and their sanitizer was in spray bottles. There were two spray bottles of Surface Cleaner Sanitizer RTU (ready to use) on the counter with the towels. Additional unattended towels were noted on counters and cutting boards in food preparation areas, and in the dish room throughout the survey. Unattended soiled towels can function as a source of cross contamination.

Review of the 2022 FDA Food Code 3-304.14(B) showed "Cloths in-use for wiping counters and other equipment surfaces shall be (1) held between uses in a chemical sanitizer solution."

During an observation on 5/15/23 at 11:10 am, DC 1 cleaned the cook's prep counter. He sprayed sanitizer into the air over counter instead of down onto the counter, and a fan blew the sanitizer droplets through the air. DC 1 stated the cleaning rags went into the dirty bin after use.

During an observation on 5/15/23 at 2:30 pm, three out of three fans in the dish room area had buildup of dust on the blades and wire covers.

During an interview on 5/15/23 at 2:30 pm, DA 1 was asked how they cleaned equipment. He stated they sprayed it with orange degreaser first, wiped it with a damp rag, then sprayed it down with sanitizer and wiped it with a clean cloth. "There's one that you leave on for three minutes and wipe it, and one you can spray and let dry." He looked up information on the sanitizer label. Then DA 1 stated they cleaned equipment off with orange degreaser spray, wiped it with a damp rag, then sprayed the equipment with sanitizer, and wiped it with a dry or damp rag. DA 1 added that if the counter looked clean, he would just sanitize it.

During an observation on 5/16/23 at 9:05 am, the can opener blade had a buildup of food debris, and the can opener mount had a buildup of grime. The finish was worn off the mount and there was rust around the screws, creating uncleanable surfaces. DC 1 agreed the can opener was not clean. He stated the mount was never removed from the counter, and staff cleaned it by spraying sanitizer on it and wiping with a cloth.

During an observation on 5/16/23 at 9:15 am, DA 2 used a soiled paper towel to wipe food debris from a food prep counter. She sprayed the food prep counter with sanitizer and walked away to the dish room. She returned and used a rag to wipe the sanitizer previously sprayed on the counter. Then sprayed more sanitizer and immediately wiped it off again.

Review of the manufacturer's instructions for Monogram Clean Force Surface Cleaner Sanitizer RTU showed Directions for Use:
"To sanitize hard, non-porous food contact surfaces" and "For cleaning and sanitizing stationary equipment and food processing equipment" "surfaces must be pre-cleaned with this product prior to sanitizing. No rinse is required prior to sanitizing. To sanitize, spray this product 6-8 inches from hard non-porous surface. Allow surface to remain visibly wet for not less than 1 minute. Allow to air dry. No water rinse required. If desired, wipe with a lint free cloth or paper towel after 1 minute contact time." Staff did not allow one-minute wet contact time when cleaning and sanitizing fixed equipment.

10. Review of a policy provided by the DM titled "Food Receiving and Storage, Dietary," expiration date 5/27/22 showed "All items are received free from damage and contamination and are stored in a way that protects them against cross contamination."

Review of a policy provided by the DM titled, "Labeling, Dating Covering Food, Dietary," expiration date 4/14/22, showed "To provide a standardized procedure for labeling, dating and covering specific food items to ensure that maximum storage times are maintained." "All refrigerated food will contain a cover, label, prep date, and expiration date with the exception of food items to be used on a tray for upcoming meal services (e.g., individual salads, desserts, etc.). The US Food & Drug Administration chart will be utilizes for guidance, a copy to be provided to kitchen staff."

During an observation of the three-door reach-in refrigerator a quart carton of coffee creamer had a manufacturer's use-by date 6/28/23 but had no opened-on date or other label. The manufacturer's instructions on the label showed "Keep refrigerated, use within 14 days of open." DC 1 stated the product was an employee's personal creamer, it belonged to him and another staff. He stated it was not ok for the employee personal food to be comingled with patient food. There is increased risk for cross contamination when employee food is comingled with patient food, and when it is not labeled or dated.

During an observation in the walk-in refrigerator on 5/15/23 at 10:45 am, the following products were found with these labels and dates:

Vegetable Broth Opened 3/27, Use By Date (UBD) 5/14/23. Label stated, "Refrigerate after opening and use within 7-10 days."

Buns in green crate. Crate labeled 5/9/23. Condensation inside plastic bags.

Tapito Sauce in bin dated 5/2/23

Sugar Free Chocolate Pudding dated 4/4/23, Expires 5/13/23, Manufacturer's UBD 6/7/23 (potential for wasted product).

Rewrapped sliced Pepper Jack Cheese dated 4/26 (space) 5/6 on a tray of cheeses. The tray of cheeses was dated 11/5/22.

Pasteurized Egg Product - Dated 5/2/23. Hard to read writing showed "open" 5/15/23. Manufacturer's label "Storage When kept refrigerated at 33 - 40 F product has a shelf-life as indicated on the package. Used opened cartons within 3 days.

Almond milk carton dated opened 5/2/23 on side of carton, and also dated opened 4/20/23 on the lid. Manufacturer's instructions stated "Must be refrigerated. Stays fresh 7-10 days after opening." According to both opened-on dates, the product was expired.

In a concurrent interview DA was shown the products listed above and was asked about the dating system. He stated vegetable broth 3/27 - "it's probably the date it was delivered." They are supposed to write the received date on products. Pasteurized egg product - he asked if it had the 14 days after opening expiration rule again. Buns dated 5/9 - "That was probably the received-on date."

The meaning of dates on foods was not clear, the food items did not meet all labeling and dating requirements of their policy, and staff were not aware of the manufacturer's instructions on many food items that shortened the use-by date when food was opened (pasteurized eggs, almond milk).

Based on interview, and record or document review, the hospital failed to ensure that all departments and patient care services affecting the health and safety of patients were evaluated, when there were no quality indicators (measures of performance or outcome of healthcare delivery, commonly chosen to correlate with greater patient safety and decreased mortality) for the outpatient surgical department and inadequate quality indicators for the dietary department.

This resulted in the facility's failure to identify quality issues and had the potential for problems to persist and compromise patient care outcomes.

Findings:

A review of the Quality Assessment Performance Improvement (QAPI) and Quality Core Group meeting minutes from 8/2022 through 4/2023 did not include any quality indicators for the outpatient surgical department. The 1/2023 minutes included tracking of the following quality indicators for the dietary department: refrigerator temperatures and infection disease prevention. Monitoring of the cleaning log was added.

During an interview on 5/17/23 at 3:50 pm, the Chief Nursing Officer (CNO) confirmed there were no quality indicators for their outpatient surgery which is included on their facility license. During a subsequent interview on 5/18/23 at 8:43 am, issues found during the survey regarding surgical services, including lack of a qualified supervisor and infection control issues, were discussed with the CNO. She said it was her understanding that humidity and temperature logs were being tracked as well as proper sterilization of hinged instruments (an issue from the prior survey of 6/2017) but didn't seem to be included in the QAPI information.

During an interview on 5/18/23 at 8:55 am, the Human Resources Director (HRD) said she attends all QAPI and governing board meetings. She said no one from the governing board meeting questioned the lack of information relating to surgical services.

During an interview on 5/18/23 at 10:25 am, the Quality Manager (QM) and HRD both confirmed the facility had no Registered Dietitian (RD) to provide oversight since 6/2022. QM said the dietary manager had been looking at infection prevention which included wiping down surfaces and added a new quality indicator for cleaning log completion starting the first quarter of this year, 1/2023. The issues found during the survey which included staff handwashing, glove use, expired food, label/dating of food, staff using a cloth to wipe face then counter, hair/beard covering, aprons, unclean equipment, employee food stored with patient food, most of which involved infection control were discussed. They said their infection control nurse gave hand hygiene classes and was involved in infection control in the kitchen, but they were not aware that she spent a lot of time in the kitchen, as a supervisor would. They were asked if any one from the QAPI or governing board committees questioned what they were doing as part of quality in the kitchen, given the long period of time they have been without a RD for oversight. HRD said she wasn't aware of anyone on the QAPI committee who questioned it.

Based on observation, interview and record review, the facility failed to ensure that Patient 18 maintained acceptable nutritional status when they did not obtain daily weights, evaluate the adequacy of her nutritional intake, provide additional nutritional interventions to maintain or improve her nutritional status, and did not provide comprehensive nutrition assessment and oversight when the position of Registered Dietitian was vacant from 2/6/22 until current.

This failure had the potential to a decline in the resident's general health.

Findings:

A review of a facility policy titled, "Weighing Patients, Emergency, Med/Surg, SNF," with an expiration date of 9/28/22, indicated that patient weights will be done safely and accurately upon admission and as ordered by physician, or by nursing judgment.

A review of History and Physical dated 5/13/23, Medical Doctor 1 (MD 1) indicated Patient 18 was admitted with diagnoses of failure to thrive (a state of decline), enterocolitis (inflammation of the intestines), multiple sclerosis (a disorder wherein the body's immune system attacks the protective covering of nerve cells), incontinence (inability to control the bowels), and perineal chemical burns (burns to the area between the anus and vulva) due to frequent watery diarrhea. She was described as thin, frail, and cachectic (loss of body weight and muscle mass) with a BMI of 17.7 (body mass index, a calculation that screens for weight categories). In the physical examination, MD 1 documented that Patient 18 was weak, appeared dehydrated, and had paraplegia (the inability to voluntarily move the lower extremities). Her past medical history also included unintentional weight loss, nausea, and diabetes type 2 (a blood sugar disorder).

According to the Centers for Disease Control and Prevention, a BMI under 18.5 is considered underweight.

In an initial nursing interview with Patient 18 (wherein nursing staff interview new patients) dated 5/13/23, Registered Nurse (RN) 7 documented a request for a dietary consult due to a poor appetite for more than 2 weeks, and an admission weight of 116 pounds, 6.4 ounces.

A review of physician's orders for Patient 18 dated 5/13/23, MD 1 ordered weights to be taken once a week, and an ADA mechanical soft diet (ADA = American Diabetic Association diet of low-starch and low-sugar foods to control diabetes; mechanical soft = foods processed to be easier to chew).

A review of a document titled, "Graphic and I&O (intake and output)," with a date ranging from admission on the evening of 5/13/23 through the morning of 5/16/23. Patient 18's food consumption and fluid intake, vital signs, weight, and urinary and stool output were entered into the document. The admission weight of 116 pounds, 6.4 ounces, was documented on 5/13/23, with another weight of 111pounds, no ounces on 5/14/23. Patient 18 was documented as passing four stools on 5/13/23, five on 5/14/23, and four on 5/15/23.
Food intake was documented as follows:
5/13/23 dinner, 10% consumed
5/14/23 breakfast 10%, lunch 5%, dinner 0%
5/15/23 breakfast 25%, lunch 25%, dinner 25%
5/16/23 breakfast 50%

On 5/17/23 2:15 pm, during an interview with the Chief Nursing Officer (CNO) who stated it's the facility process on admission to get a weight, then use same scale and equipment and clothing for repeat weights and enter the weight into the electronic health record (EHR). She stated that a physician's order was needed for daily weights and the nurses will suggest a daily weight to the physician if they feel it was needed. She further stated that nurses can get daily weights, but that a daily weight order was preferred for continuity. She expected that significant weight changes will be reported to the provider. When asked who monitored if the interventions were effective or not, she stated, "the nurses," that the staff did rounds and visit patients and ask after their food preferences, especially if the patient has a low dietary intake. She stated an intake below 50-75% would be concerning, and that it's her expectation that nursing will call dietary and asked them to alter meals or flavors. When asked how the responsibilities of the Registered Dietitian (RD) position were being covered the CNO stated, "We're piecing it together," and stated that nursing were doing what they can to provide individualized care and they were not able to meet the same level of oversight as the RD. When asked who created nutritional care plans and how they were communicated across the disciplines she answered, "I don't know that we have nutritional care plans for everybody," that the infection control nurse does rounds, "we involve everybody," the dietary manager and the provider, to come up with a plan and work off of that based on the patients' restrictions and needs. She stated that the provider determined what the patients' needs were, that they ordered the diets. CNO stated that nurses evaluated whether it worked for the patient or not and can be altered based on need. CNO stated that expectation would be that any patient at risk for nutritional deficiency should be care planned and uinterventions to include to stimulate appetite or improved nutrition. She added that if there was no care plan addressing these concerns, she would like to see an explanation in the notes as to why not. She reviewed patient 18's weight and height and stated, "She is underweight."

Based on observation, interview and record review, the facility failed to ensure its hospital-wide disaster plan was firmly in place when the hospital's emergency food plan was not fully integrated into the hospital-wide disaster plan, and the facility's emergency food plan was not approved by the Administrator, Medical Director, Chief Nursing Officer, Registered Dietitian (RD) or Dietary Manager.

These failures had the potential to result in lack of foresight and preparedness to respond to an emergency and implement the Emergency Operations Plan.

Findings:

During an observation in the dry storage room on 5/15/23 at 3 pm there were labeled boxes of emergency food, and an instruction binder. The signature approval page inside the emergency food instruction manual had not been filled out. There were blank signature locations for the CEO, Medical Director, Director of Nurses, Registered Dietitian, and Food Service Manager/Supervisor.

During an interview with the Chief Executive Officer (CEO) on 5/16/23 at 3 pm, he stated he didn't know how the food plan was integrated into the facility's disaster plan. He was unaware the disaster food plan was not reviewed and signed off by administrator, medical director, etc. He stated the HR director acted as the Incident Commander during a recent wildfire, when the highway out of the community was blocked for some time. The CEO stated that when their facility went into disaster mode last year due to wildfire and road closures, the Human Resources Director (HRD) functioned as the Incident Commander and managed all the pieces of it.

Review of a document provided by the CEO titled, "Emergency Operations Plan, Fire-Safety-Disaster," with Expiration Date 07/27/2021 showed "Mountain Communities Healthcare District (MCHD) Emergency Operations Plan (EOP) shall describe response procedures to follow when emergencies occur ...The District's Emergency Operations Plan ensures that effective mitigation, preparedness, response and recovery to emergencies affecting the environment of care are performed." It lists resources and assets, staffing, and patient management and support among the six critical areas to be addressed in the plan. "Response procedures include ...1. Maintaining services."

Further review of the Emergency Operations Plan (EOP) showed "The Safety Chairperson, hospital leadership and medical staff, in conjunction with the Safety Committee, are responsible for developing, implementing and monitoring all aspects of the Emergency Operations Plan ...The District's Emergency Operations Plan identifies who is in charge of specific activities and when they are to assume oversight responsibilities."

Under Resources and Assets, the EOP showed "Essential supplies, pharmaceuticals, medical supplies, equipment, food, water, linen and utilities shall be provided to meet shelter requirements for up to 96 hours when this hospital cannot be supported by the local community ...Vendors will be contracted for emergency acquisitions of ...food ...water." The policy did not direct staff regarding existing supplies/resources, their location, or how to access their instructions.

During an interview with the Human Resources Director (HRD) on 5/16/23 at 3:30 pm, she agreed it was a problem none of the facility leaders had reviewed and signed off on the disaster food plan. She was not aware if any education had been provided to facility staff regarding the disaster food plan. She agreed it was a problem that facility staff had no awareness of the facility's disaster food plan in the event a disaster if Food and Nutrition Services staff were unable to get to the facility and other staff had to implement it.

Based on observation, interview and record review, the facility failed to ensure its hospital-wide disaster plan was firmly in place when:

1. Only two out of ten existing Food and Nutrition Services staff had evidence they had received some training regarding the emergency food plan on date unknown.

2. No evidence was provided to show there was a system in place to ensure facility-wide staff training and competency for current and future staff regarding the disaster plan, including the emergency food plan.

These failues had the potential to result in poor and untimely implementation of the facility's Emergency Preparedness Plan, and waste of the facility's emergency preparedness resources.

Findings:

1. During an observation in the dry storage room on 5/15/23 at 3 pm, there were labeled boxes of emergency food, and an instruction binder. The signature approval page inside the emergency food instruction manual had not been filled out. There were blank signature locations for the CEO, Medical Director, Director of Nurses, Registered Dietitian, and Food Service Manager/Supervisor.

During an interview with the Dietary Manager (DM) in her office on 5/16/23 at 10 am, she stated they had Emergency Food for 75 people for 7 days, including vegetarians. She stated they calculated their numbers of people to feed from when they had to feed everyone during the region's wildfires and road closures last year, when they were unable to travel in or out of their town because the highway was blocked. She stated they had 500 each #10 cans of water in the basement.

During an observation of the dry storage room and concurrent record review and interview with the Dietary Manager (DM) on 5/17/23 at 10:40 a.m., the Emergency Food boxes and it's instruction binder, "Food & Nutrition Services Emergency & Disaster Management Policy & Procedure Manual," dated 2017, were discussed:

The binder contained a document titled, "In-Service Topic Outline and Attendance Record "Meals for All" Emergency Menu and Food Services, dated 9/6/18. The curriculum showed "Nutrition Department will provide meals and snacks to residents/patients as well as the designated staff working during an emergency. Trained nutrition staff may not be available during an emergency, so plan must be known by other departments." The document was signed solely by the DM. An additional undated sign-in sheet titled, "Emergency Foods" showed the signatures of five staff. The DM stated only two of those five staff still worked there. The DM was asked for evidence of current staff training on the emergency food plan. She stated, "Well they know about it," but she did not have any evidence of training.

In an additional concurrent interview on 5/17/23 at 10:40 am, Diet Clerk (DC) 2 stated she worked there 7 years. When she was asked when they were last in-serviced on the emergency food plan she replied, "It's been awhile, actually I can't even remember when."

2. During an interview at the Medical/Surgical nursing station on 5/16/23 at 1:45 pm, the following staff were asked Registered Nurse (RN) 4, Nursing Assistant (NA), Executive Assistant (EA), Certified Nursing Assistant (CNA) and Ward Clerk (WC) 2, if they received any training regarding their facility's disaster food plan, and would they know what to do if the food services staff was not there during an emergency. Five out of five staff interviewed stated they never received training about that "in at least the last 4 years." EA stated if that happened, she would pull the policy. She knew there was some emergency food in the stock room and some in the basement, but which door to pick would take some effort. She would follow the policy.

During an interview with the Chief Executive Officer (CEO) on 5/16/23 at 3 pm, he stated they educated staff about where information could be found if there was a disaster. He stated he didn't know how the food plan was integrated into the facility's disaster plan.

During an interview with the Human Resources Director (HRD) on 5/16/23 at 3:30 pm, she stated she was not aware if any education provided to facility staff regarding the disaster food plan. She agreed it was a problem that facility staff had no awareness of the facility's disaster food plan in the event a disaster if Food and Nutrition Services staff were unable to get to the facility and other staff had to implement it.

During a follow-up interview with the HRD on 5/17/23 at 2 pm, she stated she found no emergency preparedness training or competency for any staff in the facility.

A review of the policy titled, "Under Resources and Assets, the Emergency Operations Plan (EOP)," showed "Essential supplies, pharmaceuticals, medical supplies, equipment, food, water, linen and utilities shall be provided to meet shelter requirements for up to 96 hours when this hospital cannot be supported by the local community ...Vendors will be contracted for emergency acquisitions of ...food ...water." The policy did not direct staff regarding existing supplies/resources, their location, or how to access their instructions. The facility did not have a system in place or provide evidence staff had been trained and were competent to respond during an emergency, including the provision of food services.