HospitalInspections.org

Based on policy and procedure review, observation, and interview, the dietary manager failed to ensure that expired patient food items were removed from service on the nursing unit.

Findings:
1. at 12:30 PM on 8/15/12, review of the policy and procedure titled: "Maintenance of Inpatient Nourishment Rooms", with a last revised date of 9/11, indicated:
a. under "Purpose:", it reads: "To delineate responsibility for sanitation/quality control of all inpatient unit's nourishment rooms"
b. under "Action Steps:", it reads: "...2. Sanitation: a. Nursing...b. Diet Office: 1. Delivers daily floor stock as per par levels 2. Rotates stock and discards outdated items. 3. Assures items delivered, rotated and are labeled to include a "use by" date: Jello: 3 days...**All other floor stock items have a manufacturer's printed date on package"

2. on 8/15/12 at 11:10 AM, while on tour of the 3 East general medical/surgical nursing unit in the company of staff members NN (quality program staff member) and NR (med/surg nurse manager), it was observed that:
a. the pantry patient food refrigerator had one jello that had expired on 8/14/12 and one pint of chocolate milk that had expired on 8/14/12
b. the pantry cupboard had 7 cups of pre packaged nectar thickened apple juice that had expired March 2012 and >3 cups of pudding thickened water without expiration dates

3. interview with dietary staff member NQ at 11:12 AM on 8/15/12 indicated:
a. dietary staff has been unclear if they should remove expiring products on the day they expire, or wait until the next day for removal
b. dietary staff check par levels and for out dated items once per day
c. if expired items aren't removed on the date of expiration, there is a possibility that the food item could be served to a patient the day after expiration, prior to the arrival of dietary staff and the checking of supplies/food items for expiration dates
d. the pre packaged/purchased nectar and pudding thickened products are the responsibility of SPD staff
e. SPD staff failed to follow the policy related to removal of expired nectar thickened apple juice drink cups in the 3 East pantry

4. at 12:40 PM on 8/15/12, interview with SPD staff member NP indicated:
a. it has been found that the pudding thickened water products/cups are not date stamped with an expiration date, but the case they come in is stamped with an expiration date
b. it will be necessary to dispose of the products currently in nursing unit pantry areas as it is unknown what the expiration date was on those cartons/cases
c. SPD staff will need to attach a label with an expiration date for the individual cups in the future as the manufacturere only puts the expiration date on the case itself

Based on observation and interview, the facility failed to ensure that environmental safety was maintained for the well-being of patients in three areas toured.

Findings:
1. at 2:05 PM on 8/13/12, while on tour of the healthy hearts and anti coag clinic, in the company of staff member NH, (quality staff member), it was observed that in the patient restroom, the call light cord was wrapped around the grab bar mounted on the wall making it impossible for a patient to call for help if the cord was pulled

2. at 10:15 AM on 8/14/12, while on tour of the hospital's surgery recovery room in the company of staff members NM, (operating room nursing manager/director), and NN, (quality staff member), it was observed that the bio hazard room door was propped open

3. interview with staff members NM and NN at 10:16 AM on 8/14/12, indicated the bio hazard room door was not to be propped open

4. at 11:10 AM on 8/14/12, while on tour of the obstetrics nursing unit in the company of staff members NJ, (nursing manager/director of obstetrics) and NN, (quality staff member), indicated in LDRPN (labor, delivery, recovery, post partum, nursery) room #10, the call light cord was wrapped around the grab bar mounted on the wall, making it impossible for a patient to call for help if the cord was pulled

5. interview with staff member NN at 11:12 AM on 8/14/12, indicated call light cords were not to be wrapped around the wall mounted grab bars

Based on review of the infection control program, policy and procedure review, personnel health file reviewand staff interview, the infection control practitioner failed to follow the infection control committee policies related to annual and triennial review of the program and its policies and failed to ensure that staff receiving TB (tuberculosis) tests and immunization status out side the facility are meeting facility policies for 2 of 2 contracted Dialysis nurses (P1 and P2) and 1 paramedic file (P8).

Findings:
1. at 11:40 AM on 8/13/12, review of the "Infection Control Program" document indicated:
a. the last review/revised date was "06/11"
b. under "TEXT", in item 1. a., it reads: "Infection Control Policies will be reviewed every three years or more often as necessary..."
c. under "TEXT", in item #14., it reads: "Evaluate and revise, at least annually and whenever risks significantly change, the goals and program (or parts of the program)."

2. interview with the infection control practitioner, staff member NE, at 12:15 PM on 8/13/12, indicated:
a. the infection control program document states that it is to be reviewed annually (see 1. c. above) and has not been reviewed, yet, in 2012--this should have been done in June of 2012, but is late

3. at 12:00 PM on 8/13/12, review of the policy and procedure "Infection Control Policy for Endoscopy", with a policy number "Endoscopy - ICP - 34", indicated it had a last date of reviewed or revised of "06/09"

4. interview with the infection control practitioner, staff member NE, 2:35 PM on 8/15/12, indicated:
a. this staff member is "working on" this policy and procedure in preparation of a review/revise process by the infection control committee
b. the endoscopy, and all infection control policies, are to be reviewed at least every three years (see 1. b. above)
c. the endoscopy policy should have been reviewed/revised by June of 2012, and is late

5. at 2:25 PM on 8/15/12, review of the policy and procedure "Standing Order of Purified Protein Derivative Tuberculosis Skin Testing by CHA (Community Hospital Anderson) EOHS (Employee Occupational Health Services) RN (registered nurse) and CHA Staff Certified in Tuberculosis Skin Testing" with a policy number of HR 42, and a last revised date of 4/10/12, indicated:
a. under "Action Steps:", it reads in section 4., "Performance Phase - Occupational Clinical Health Coordinator...f. Document in appropriate areas: date, time, site, lot number, expiration date of antigen." and in section 5., "Reading and Recording Results a. The Mantoux skin test is read at 48 and 72 hours..." (per the director of HR [human resources], item a. should read that the Mantoux skin test is read "between 48 and 72 hours")

6. at 2:30 PM on 8/15/12, review of the policy and procedure "Standing Order for Hepatitis B Vaccine Administration" with a policy number of HR44, and a last date revised of 3/20/12, indicated:
a. under "Clinical Assessment and Intervention", it reads: "...4. For all new employees who previously have received Hepatitis B vaccination series, testing for antibody response to Hepatitis B vaccination is mandatory unless they have documentation of immunity. An adequate antibody response to HBV surface antigen is defined as serum anti-Hbs (Hepatitis B surface antibody) titer greater than or equal to 10 mlU/ml...8. If antibody testing is completed and the results demonstrate an inadequate immune response, the employee will be revaccinated with a three-dose series and retested for the antibody titer. Employees who do no respond to the second vaccination series will be considered susceptible to Hepatitis B infection,...and informed of the need for Hepatitis B immune globulin prophylaxis and/or vaccine in response to any known or probable potential exposure to HbsAg-positive blood, per Dr. Ikerd's orders. 9. Employees who decline vaccination must have a signed declination form..."

7. at 11:45 AM and 1:00 PM on 8/15/12, review of personnel health files indicated:
a. staff member P1, a contracted dialysis RN (registered nurse) was hired 6/14/12 and had an Anti-Hbs "reported date" of 8/23/11, a result of "<10", and a reference range on the lab form indicating this was "Non-Immune"
b. staff member P2, another contracted dialysis RN, was hired 6/5/12 and lacked the documentation of a time the TB test was administered and the time the TB test was read, making it impossible to determine if the reading was within the 48 to 72 hours required per facility policy
c. staff member P8, a paramedic, was hired 6/11/12 and lacked the documentation of the time the TB test was read, making it impossible to determine if the reading was within the 48 to 72 hours required per facility policy

8. at 2:25 PM and 3:00 PM on 8/15/12, interview with human resources staff member NF, indicated:
a. staff members P2 and P8 had their TB tests performed outside this facility
b. the employee health staff at this facility should have seen that the TB tests given outside were not documented as per the policy here, and that they lacked times given and/or read
c. the non-immune titer result dated 8/23/11 for staff member P1, should have been noted by the employee health staff and either the nurse was to have received the series again, or signed a Hepatitis B declination form
d. the current TB and Hepatitis B facility policies were not implemented for these 3 staff persons