HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure patient safety in the patient security room bathroom. In addition, patient care equipment was not maintained in proper working condition. The findings were:

1. Periodic observations from 7/22/13 through 7/25/13 revealed the two metal end panels (approximately 6" by 24") were missing from the baseboard heater in the patient security room bathroom. As a result, several sharp metal support attachments were exposed. Interview with the maintenance manager on 7/24/13 at 1:23 PM confirmed the observation.

2. Observation on 7/24/13 at 1:48 PM revealed the back panel from the blanket warming oven had been removed exposing the interior mechanical workings of the unit. The maintenance manager stated at the time of the observation that he was unaware the back had been removed

Based on observation and staff interview, the facility failed to ensure a clean and safe environment in the kitchen. The findings were:

Observation on 7/24/13 at 2:11 PM revealed the several pieces of linoleum were missing on the floor in the kitchen exposing black, dirty concrete. The maintenance manager stated at the time of the observation that the missing linoleum was an infection control problem as well as a trip hazard to kitchen staff. In addition, at the same time, observation revealed a piece of corner molding in the kitchen was displaced revealing sharp metal edges underneath. The maintenance manager stated at the time of the observation the exposed metal represented a safety hazard to kitchen staff.

Based on observation, staff interview and manufacturing labeling, the facility failed to ensure liquid nutritional supplements were labeled with the thaw date in the walk-in kitchen refrigerator. The findings were:

Periodic observations from 7/22/13 through 7/25/13 at various times revealed an unopened box of nutritional supplements in the walk-in freezer. Also noted was an opened box in the walk-in refrigerator. The opened box contained approximately 10 individual serving cartons. Both boxes were labeled "5/30". Interview with the kitchen manager on 7/25/13 at 9:48 AM revealed 5/30 was the date the boxes were delivered to the facility and placed in the freezer. She was unaware of when the one box was removed from the freezer and placed in the refrigerator. Each individual carton stated "Store frozen. Thaw at or below 40 degrees. Use thawed product within 14 days. Keep refrigerated".

Based on review of policies and procedures and staff interview, the facility failed to ensure all health care policies were reviewed annually. The findings were:

Review of the policies and procedures from dietary and medical records revealed the following concerns:
1. Review of the policies and procedures log for the medical records department (HIM) revealed the Department Manager, the Chief Executive Officer (CEO) and the Chief of Staff reviewed the department policies in January 2012. Further review of the log revealed only the Board Chair reviewed them in January 2013. Neither the Department Manager nor the CEO indicated on the review log they had reviewed them. Interview with the Medical Records Department Manager on 7/25/13 at 9:13 AM revealed she was new to her job and was not aware the policies and procedures needed to be reviewed annually.

2. Review of the policies and procedures log for the dietary department revealed the Department Manager reviewed the department policies in October 2011 while the CEO and the chief of Staff then reviewed them one month later in November 2011. Further review revealed they were not reviewed since 2011. Interview with the Dietary Manager on 7/25/13 at 10:31 AM revealed she was new to her job and was not aware the policies and procedures needed to be reviewed annually.

Based on medical record review, staff interview and review of policies and procedures, the facility failed to include advanced directives in the medical records for 2 of 20 (#7, #16) sample patients. The findings were:

According to the facility's policy and procedure "Advanced Directives", last reviewed January 2012, "All advanced directives including Living Will, Power of Attorney, Durable Power of Attorney will be filed in the patient's medical record when received by the hospital".
The following concerns were identified:

Review of the medical record for patient #16 revealed the advanced directives section to be completely blank. Review of medical record for patient #7 revealed the advanced directives section to be completely blank except the word "unknown" was written across the section.

Interview with the Director of Nursing on 7/25/13 at 8:48 AM revealed she was not aware why the advanced directives section had not been completed. She also stated "I don't know what that means" when asked about the documentation of "unknown" for patient #7.

Based on review of quality assurance meeting minutes and staff interview, the facility failed to ensure the medical director or designee participated in the quality assurance process. The findings were:

Review of the minutes of all quality assurance meetings for 2013 showed the Medical Director or designee never attended those meetings. During an interview with the administrator and DON on 7/25/13 at 7:40 AM, both confirmed the Medical Director or designee was not involved in the facility quality assurance process.