HospitalInspections.org

A043
Governing Body:
The Condition is not met as evidenced by:
Based on Observation Interview and Record review the Governing Body failed to:
1. Oversee and evaluate contracted services to assure contracted services were delivered in a safe and effective manner including:
a. "assuring Radiology Contracting Services were current and QAPI recommendations were implemented. (A084)
b. "assure the facility Ice Machine and Dishwasher machine contracted services were monitored and delivered in a safe, effective and sanitary manner. (A084)

2. Assure patients receive care in a safe setting. Including assuring contraband items are removed from patient rooms and patients do not walk barefoot in the hospital. Patients are monitored and prevented from self-injury, shoulder and hip fractures. (A144)

3. Have an ongoing Quality Assessment Performance Improvement (QAPI) program that included assuring:
a. "The Facility Ice machine was cleaned and maintained in a sanitary environment. There was no QAPI studies evaluating the Ice machine Preventative maintenance and cleaning of the ice machine. (A283)
b. "There was no ongoing studies monitoring and evaluating of Preventative maintenance or how effectively the dishwasher sanitized the kitchen utensils. The dishwasher machine was not reaching recommended temperatures required to sanitize pots and pans. The Facility did not have a system in place to validate the accuracy of the temperature gauge on the dish washer Machine. (A283)

4. The Governing Body failed to oversee and Implement an infection control program that was hospital wide and followed acceptable standards of practice. The Governing Body failed to maintain a sanitary environment for patient care, to avoid sources and transmission of infections and communicable disease. (A749)

The Governing Body failed to:
a. "assure the facility Ice machine was maintained in a sanitary manner to prevent the growth of microorganism resembling mold. (749)
b. "assure the facility dishwasher was reaching recommended temperatures required to sanitize pots and pans. The Facility did not have a system in place to validate the accuracy of the temperature gauge on the dish washer. There was no documentation of Preventative maintenance or cleaning logs for the ice machine and that the recommended temperature at dish surface is 160 degrees Fahrenheit was maintained. The hospital did not have a system in place to validate the accuracy of the temperature gauge or explanation as why a repair service was not requested for the gauge. The hospital was not aware that the machine may not have been adequately sanitizing the dishes prior to being tested by the surveyor. (A749)
c. "remove corrugated cardboard boxes from storage areas. (A749)
d. "ensure personnel health files were maintained with current health requirements for three of eleven employees and current infection control training for one of eleven employees. (A749)
e. "ensure that all employees (LVN 1) received required immunizations, skin tests, titers, or signed declination of the aforementioned requirements were documented in personnel files in order to safeguard against hospital acquired infection(749).
f. "confirm that biohazardous material was stored properly so as to limit the spread of possibly contagious pathogens. (A749)
g. "maintain cleanliness of a nursing staff hand washing station faucet. (A749)
h. "assure the grab rail in a patient's rest room was clean so that possibly harmful agents are not passed to his/her hands. (749)

The cumulative effects of these systemic problems resulted in the Facility's inability to ensure the provision of quality health care in a safe and sanitary environment

A 084

The Standard is not met:
Based on, observation, Interview and Record review, the Governing Body failed to provide contracted services in a safe and effective manner by:

1. Assuring Radiology Contracting Services were current and that Quality Assessment Performance Improvement (QAPI) recommendations were implemented.

2. Assuring the facility ice machine and dishwasher contracted maintenance services were monitored and delivered in a safe and sanitary manner.

These deficient practices had the potential of patients being exposed to excess radiation from equipment not maintained. Also, the potential for patients, staff and visitors being exposed to potential pathogenic organisms from improperly maintained, cleaned and operated kitchen equipment.

Finding: #1

During a review of the Facility contract list titled "Clinical Contracts Master Eval/Review Tracking Log 2018", and a second facility Contract list titled "non-Clinical Contracts Master Eval/Review Tracking Log 2018", the Radiology Contract provided for review was not on the Facility contract list.

A review of the facility radiology contract documented that the Certificate of Liability had expired on 5/25/16, and Certificate of registration with California Department of Public Health (CDPH), had expired on 6/30/16. A review of the Quality Assessment, Performance Improvement (QAPI), for the Radiology Services contract review dated 7/27/2018, documented quality indicators were not met. The categories on the Radiology contract that were not met included; expired Certificate of Liability, current Quality improvement reports, Utilization review, Risk management quality indicators, and evidence of standards of agency compliance.

The Facility failed to assure the Radiology Certificate and Liability insurance were current. The Facility failed to implement the QAPI contract review recommendations. The Governing Body failed to oversee and assure radiology contracted services were delivered in a safe and effective manner.

Finding#2

During a review of the Facility contract list titled "Clinical Contracts Master Eval/Review Tracking Log 2018", and a second facility contract list titled "Non-Clinical Contracts Master Eval/Review Tracking Log 2018", the contracts for the ice machine (Westco, a service company) and for the dishwasher machine (ECOLAB, a service company) were not listed. There was no documentation of an evaluation of the contracted services for the ice machine or the dishwasher by the Quality Assurance Risk management committee.

During an interview with the Director of Food and Nutrition (Dir FN), on 9/27/18 at 4:10pm, when asked for a contract for the ice machine the Dir FN indicated the facility did not have a contract. The Dir FN indicated that when the ice machine needed repairs, they contacted Westco (a service company), for repairs. When the Dir FN was asked for preventative maintenance (PM), and cleaning logs, for the ice machine for the last year, the Dir FN indicated the facility had no logs addressing preventative maintenance or cleaning of the ice machine.

A review of the outside company (Westco), service invoice for the ice machine dated 7/16/18, indicated that the ice machine service company was in the hospital to provide repair service. The invoice did not indicate the that ice machine was cleaned. the Food Director did not know when the ice machine had been cleaned. The facility had no log documenting the cleaning of the ice machine. The facility had no records of preventative maintenance (PM) for the ice machine.

The facilities ice machine was not maintained in a sanitary manner and proper sanitation practice not followed to prevent the growth of microorganism resembling mold. This deficient practice had the potential to cross-contaminate food and place 86 patients, staff and visitors at risk for food borne illness.

During an interview with the Dir FN on 9/27/18 at 4:10pm when asked for a contract for the dishwasher machine the Dir FN indicated the facility had no service contract for the dishwasher. The Dir FN indicated that Ecolab (a service and supply company), services the dishwasher machine monthly. The Dir FN indicated the facility had no documentation of monthly preventative maintenance (PM), that had been completed by Ecolab. The facility did not document PM, cleaning, or any contractual agreement with ECOLAB for the dishwasher.

During a review of an invoice for a repair of the dishwasher from the dishwasher ECOLAB, dated 9/26/18, the documented repair was done for the dishwasher not reaching the recommended water/rinse temperature of 160 degrees Fahrenheit for sanitizing the kitchen and culinary utensils. During an interview with the Dir FN on 9/27/18 at 4:10pm, the Dir FN stated that he could not provide documentation of how long the dishwasher temperature had been out of the recommended temperature range.

The facility had no document or log addressing how long the dishwasher was functioning outside of the recommended temperature for sanitary cleaning of kitchen utensils.

The facilities dishwasher machine was operational in a manner that had the potential to affect food quality and increase the potential of growth of microorganism. The hospital failed to verify the machine was reaching temperatures to sanitize pots and pans and did not have a system in place to validate the accuracy of the temperature gauge on the dish machine. Heat in the high temperature dish machine is used to sanitize food contact surfaces to prevent food borne illness.

The recommended temperature at dish surface is 160 degrees Fahrenheit. The hospital did not have a system in place to validate the accuracy of the temperature gauge or explanation as why a repair service was not requested for the gauge. The hospital was not aware that the machine may not have been adequately sanitizing the dishes used in patient care prior to being tested by the surveyor.

Based on Observation, Interview and Record review The Standard is not met.
The Governing Body failed to provide patient care in a safe setting by having:

1. Four silica gel packages were observed on a counter in a Patient restroom on the First Floor.
2. A bottle of Shampoo and one bottle of skin lotion were observed on a patient desk in a patient room .
3. A patient was observed walking bare foot in a hospital hallway and dining room On 2 South.
4. A hair straightening device was observed in the restroom of the chemical dependency unit.
5. A Patient repeatedly injuring himself .
6. A Patient sustaining a shoulder fracture.
7. A patient sustaining a Hip fracture.

These deficient practices had the potential of the facility not providing care in a safe environment.

Findings:

During tour of the Facility with Mental Health Worker 1 (MHW1), and MSD on 9/26/18 at 10:00 am, four (4), packets of silica gel (used as a preservative to store to maintain freshness during packaging items) were observed on the patient restroom countertop on 1 floor. The MHW1 was asked if the four (4), packets of silica gel should be here. MHW 1 stated that the silica gel packets should not be in the patients room.

On 9/26/18 at 10:20 am during a tour of the second floor, Inpatient 2 South ward with RN 8 and MSD, a two (2), ounce bottle of Shampoo and a two (2) ounce bottle of skin lotion were observed on a desk in a Patient room. RN 8 stated that the bottles of shampoo and skin lotion should not be kept in the patient room. RN 8 stated that Patients should check out what they need for personal grooming then return the items to the staff office. RN 8 stated that patient safety rounds are done every 15 minutes.

During an observation On 9/26/18 at 11:15 am on 2 South, Patient 17 was observed leaving her room with bare feet, walking down the hallway to the nurses station, getting her tray of food and walking to the dining room, sitting down and eating.
During an interview with RN 7 on 9/26/18 at11:30 am, RN 7 indicated that walking barefoot was not safe or sanitary and Patient 17 should not walk around without shoes. A policy for walking bare foot in the hospital was requested but not provided.

On 9/25/18 at 12:50 PM, during tour of the chemical dependency residential unit,
an electronic hair straightening device was observed in the restroom cabinet of room 341. Concurrently, the chief operating officer (COO) stated the hair straightener should be in a controlled area.

A review of the facility Policy and Procedure titled "Las Encinas Recovery Center Provisions for valuables" dated 7/31/18 indicated" Items which are not allowed to be kept with residents ... may be checked out from the staff office" the items included colognes.

The facility's policy and procedure titled, "Las Encinas Recovery Center Provision for Valuables," revised 7/31/18, indicated items which are not allowed to be kept with residents (i.e. shaving razors, cologne, blow dryers, curling irons, electric tooth brushes, etc.) may only be checked out from the staff's office during shower/grooming times.

During a review of Closed Medical for Patient 33, the medical record indicated that Patient 33 was admitted to the Facility on 6/20/18. A review of a Nurse note titled "Progress Note", dated 6/21/18 at 3:00 am indicated that, "During Q15's the patient was found was on floor on all fours then proceeded to let her head drop to the floor" and Patient 33's "right arm appeared discolored and limp". The Plan of care included to monitor patients' vital signs. A review of a Physician Progress note dated 6/21/18 documented at 7 am indicated that Patient 33 "seemed obtunded and confused and the patient's right arm was somewhat ecchymotic(bruised).. flaccid and not reflexive", and that a possible fracture of right Shoulder was indicated. A review of the facility discharge summary note indicated that Patient 33 was diagnosed at the Acute Care Hospital with a Right Shoulder fracture.

During an interview with the ADON and QAPI Director on 9/27/18 at 4:30 pm, The ADON stated that patient safety rounds take place, hospital wide, every15 minutes.

During a review of Closed Medical records for Patient 32, the medical record indicated that Patient 32 was admitted to the facility on 12/23/17. A review of a Nursing progress note dated 12/31/18 at 1:15 pm, indicated that Patient 32 "has been lying in bed reporting 'my leg is broken'. Patient complains of pain in his left leg. Patient 33 was not getting out of bed or walking". A review of a Physician Progress note dated 01/01/2018 at 10:20 am, indicated, "The patient complains of pain to the Left hip and pelvis and left lower extremity. He states he is unable to ambulate. He denies any history of falls". A review of a Nursing Progress note dated 01/01/18 at12pm, indicated that Patient 32 was unable to move their left leg.

During an interview with ADON on 9/27/18 at 4:30 pm, the ADON stated that the fall of Patient 32 was not witnessed. The ADON stated that Patient 32 was transferred to an Acute Care Hospital and was diagnosed with a left hip fracture.

During a review of Patient 31's closed medical record, the record indicated that Patient 31 was admitted to the Facility on 4/23/2018. A review of a facility document titled "Patient Send to the ED tracking sheet", dated 4/24/18, indicated that Patient 31 was sent to the ED, the document indicated that Patient 31 had, "self-inflicted injury to genital area and the patient was unable to urinate", and "the patient admitted to sticking a straw in his penis". At the acute care hospital, a Medical Doctor removed the straw and Patient 31 was returned to the facility .
A review of Nursing notes dated 4/26/18 at 7:45 pm, indicated that "the Patient broke their glasses and reported inserting the earpiece into his penis. The patient reported pain of 10/10. Patient 31 was sent to an acute care hospital". A review of a document titled, "Patient Send to the ED tracking sheet", dated 4/26/18, indicated that the acute care hospital, "removed the glasses piece and Patient 31 was able to urinate". Patient 31 returned to the Facility on 4/26/18 at 11:38 pm. A review of a Physician Orders dated 4/27/18 at 8 am, indicated that 1:1 observation was ordered for Patient 31 for Safety.
A review of a Nursing progress note for Patient 31, dated 5/1/18 at 1:30 pm, indicated that, "While the patient was using the restroom, he stuck a pencil down his penis". A nursing progress note entry dated 5/1/18 at 1:50 pm, indicated that, "the patient is urinating blood. States he took a pencil off the table and stuck it inside his penis". A facility nursing progress note dated 5/1/18 at 7:45 pm indicated that Patient 31 had "surgery for genital trauma".

During an interview with ADON, the ADON was asked for documentation that the Shoulder fracture for Patient 33, the Hip Fracture for Patient 32, and the self-injuries of Patient 31 were reported to the California Department of Public (CDPH). The ADON stated that the incidents were not reported to the CDPH.

A review of a facility policy titled, "Reporting of Unusual Occurrences to California Department of Public Health (CDPH)" dated 8/28/18, indicated that reportable occurrences included, "self-inflicted injuries resulting in significant deterioration in a patient condition" and "serious physical injury including injuries sustained during seclusion and restraint".

A facility policy and procedure titled, "Contraband and Restricted Articles" revised 3/29/2018, indicated that, "Items considered a danger or potential danger to patients will be locked ..."

A review of the Facility Policy and Procedure titled, "Performance Improvement" dated 8/10/2018, indicated, "The Governing Body is responsible to establish, maintain and support the Risk management program as an ongoing process" and "ensure patient safety through ...risk management program.." and "..Will promote the delivery of safe, quality patient care".

The Standard is not met:
Based on Observation, Interview and Record review the facility failed to impliment an ongoing Quality Assessment Performance Improvement (QAPI) program that:

1. Evaluated and monitored the cleaning and preventative maintance (PM) of the facilities ice machine, and assure the facility ice machine was maintained in a sanitary manner to prevent the growth of a microorganism resembling mold. There was no documentation of preventative maintenance or cleaning logs for the ice machine.

2. Assured that the facility dishwasher was operating at the recommended temperatures required to sanitize pots and pans. The Facility did not have a system in place to validate the accuracy of the temperature gauge on the dish washer, and that the recommended temperature at dish washer surface is 160 degrees Fahrenheit. The hospital did not have a system in place to validate the accuracy of the temperature gauge or explanation as why a repair service not requested for the gauge. The hospital was not aware that the machine may not have been adequately sanitizing the dishes prior to being tested by the surveyor.

There were no QAPI studies evaluating the safety, sanitary condition, and maintenance of the ice machine. As a result ice machine and dishwasher were not maintained in a sanitary manner and proper sanitation practice was not followed to prevent the growth of microorganisms. These deficient practices had the potential to cross-contaminate food and ice and put 86 patients, staff and visitors at risk for food borne illness.

Findings:

During an interview with the Director of Food and Nutrition (Dir FN) on 9/27/18 at 4:10 pm, when asked for a maintenance contract for the ice machine and the dishwasher, the Dir FN stated that there was none. When asked for documentation of preventative maintenance (PMs) for the last year, for the ice machine and the dishwasher, theDir FN stated that there were none. The Dir FN stated that Ecolab (an equipment service and supply company), completed monthly service maintenance of the dishwasher. The Dir FN stated that he had no documentation of monthly PM for the dishwasher or the ice machine. The DirFN stated that there was no periodic outside service company for the ice machine. The Dir FN indicated Westco (an equipment service and supply company) did repairs for the ice machine. A review of the outside company (Westco) service invoice for the ice machine dated 7/16/18, indicated that Westco was in the hospital to provide a repair service. The invoice did not indicate that the ice machine was cleaned. The Dir FN did not know when the ice machine had been cleaned. No cleaning log for the ice machine was provided .

During a review of A facility document titled "Aurora Las Encinas Hospital Kitchen Equipment" dated 5/7/2018 documented " the interior of the ice dispenser shall be cleaned and preventative maintenance will be performed"

A review of an invoice for a repair of the dishwasher from ECOLAB (an equipment repair/maintence and supply company), dated 9/26/18 indicated a repair was done for the facility dishwasher not reaching the recommended temperature necessary for sanitation.

The recommended temperature at dish surface is 160 degrees Fahrenheit. The hospital did not have a system in place to validate the accuracy of the temperature gauge or explanation as why a repair service not requested for the gauge. The hospital was not aware that the machine may not have been adequately sanitizing the dishes prior to being tested by the surveyor. Food service staff were actively washing dishes prior to the check of the machine

During an interview with the Infection Control Director on 9/26/18 at 2:30 pm, the Infection Control Director stated there were there were no QAPI studies or evaluation of the environmental. On 9/27/18 at 4:15 pm, during an interview with Director of QAPI, the Infection Control Director reviewed the studies implemented by the facility and stated that there were no ongoing studies monitoring environmental rounds, cleaning and maintenance of the ice machine or monitoring of the dishwater temperatures and maintenance. A review of the QAPI studies indicated that there were no studies monitoring cleaning, or PM contracts for the ice machine. The ice machine was not maintained in a sanitary manner and proper sanitation practice not followed to prevent the growth of a microorganism resembling mold.

A review of the Facility Policy and Procedure titled, "Performance improvement", dated 8/10/2018, indicated ,"The Governing Body is responsible to establish, maintain and support the Risk management program as an ongoing process" and "ensure patient safety through ...risk management program.." and "..will promote the delivery of safe, quality patient care".

Based on observation, interview and record review the facility failed to:

1. Ensure nursing staff documented pain reassessments in accordance with the facility's policies and procedures, for one of thirty sampled patients (Patient 6).

2. Ensure the nursing staff returned patient's personal medications upon discharge for three of thirty sampled patients (Patients 11, 12 and 13).

This deficient practice had the potential for not reassessing the patient's pain and not meeting the needs of the patients and patient's personal medications not being returned to patients.

Findings:

On 9/25/18 at 9:30 AM, during the initial tour of the unit in 2 West, Patient 6 was observed ambulating, with the use of a walker, in the hallway. Patient 6's left leg was slightly elevated above the floor. Patient 6 wore a sock on the left foot and a shoe on the right foot.

Concurrently, the Mental Health Worker (MHW 1) stated Patient 6 was not wearing any shoes because her left foot was swollen.

On 9/26/18 at 10:55 AM, in the 2 West unit, Patient 6 was observed on a wheelchair, the left leg was elevated and with a splint in place.

Patient 6 was admitted to the facility 9/23/18 for major depressive disorder. Patient 6 had a history of osteoporosis and complained of leg pain upon admission. Patient 6 was diagnosed with a left 5th metatarsal shaft fracture on 9/25/18. The fracture occurred just prior to being admitted to the facility while either entering or exiting the ambulance.

On 9/26/18 at 9:45 AM, a review of Patient 6's medication record with the licensed vocational nurse (LVN 2) indicted the following. Patient 6 had an order to give Tylenol (acetaminophen, an over the counter pain reliever) 650 milligrams (mg) by mouth, every six hours for mild pain.

a. On 9/24/18 at 2:14 PM, Tylenol 650 mg was given for pain rated at 5/10, the results were documented as "helpful" after one hour, the time of reassessment and the initials of the person who administered the medication were not documented.

b. On 9/25/18 at 9:45 AM, Tylenol 650 mg was given for pain rated at 5/10. There was no documentation of a pain reassessment or the initial of the person who administered the medication.

c. On 9/26/18 at 4:26 AM, Tylenol 650 mg was given for pain rated at 7/10, the reassessment or results were documented as "helpful" after one hour.

Concurrently, LVN 2 stated she forgot to document the pain reassessment on 9/25/18. LVN 2 stated the numerical scale should be used to assess pain.

On 9/26/18 at 10 AM, the registered nurse (RN 2) stated pain intensity should be documented using the numerical scale.

On 9/26/2018 at 10:48 a.m. during an inspection of the med storage area in the nursing station on the 1st floor with a licensed psychiatric technician (LPT), there was a locked two-level cabinet marked "POM" (Patients' Own Medications, brought to the facility with the patient on admission). Inside the cabinet, there were three sealed, bulging envelopes, marked with patient names with dates of admission that were at least 2 weeks old: Patient 11's enveloped was dated 8/4/2018; Patient 12's and 13's envelopes were dated 9/10/2018.

Review of Patient 11's admission record indicated Patient 11 was admitted on 8/4/2018 and was discharged on 8/6/2018.

Review of Patient 12's admission record indicated Patient 12 was admitted on 9/10/2018 and was discharged on 9/17/2018.

Review of Patient 13's admission record indicated Patient 13 was admitted on 9/10/2018 and was discharged on 9/17/2018.

On 9/27/2018 at 10:10 a.m. during an interview with the Assistant Chief Nursing Officer (ACNO), and a concurrent review of the contents in those POM envelopes, the ACNO indicated patients' own medications should have been returned to the patient when discharged from the hospital.

The facility's policy and procedure titled, "Pain Assessment, Reassessment and Management," effective 3/15/17, indicated the patient will undergo reassessment of pain at lease once per shift and after every pain control mechanism employed by patient care providers. Pain control mechanisms include medications administered for the control or relief of pain and during the post-procedure period. Any patient care provider, from any department, that has implemented a pain control mechanism will reassess the patient within one (1) hour to determine amount of pain control or relief achieved.

The facility's policy and procedure titled, "Pain Assessment and Management," effective 3/7/17, indicated pain scales are used to evaluate each patient's level of pain, including the description of the subjective experience of pain on admission and to evaluate pain history. The Numeric Pain Scale of 0-10 is used for adolescents and adults.

Based on observation, interviews, and record reviews, the hospital failed to ensure nursing staff properly and accurately documented medication administration for two of thirty sampled patients. This deficient practice had the potential for medication errors and/or diversion that may or may not affect patient safety or health.

Findings:

On 9/25/2018 at 8:40 a.m. during an interview, the Director of Pharmacy (DOP) stated the hospital utilized Omnicell (a type of automated drug dispensing machines) at the nursing units to distribute medications.

A review of Patient 14's Facesheet (admission record) indicated Patient 14 was admitted to 1st floor unit on 9/20/2018, and then transferred to another unit on 9/25/2018.

Review of Patient 14's physician's orders dated, 9/20/2018 at 11:55 p.m., indicated that Patient 14 was to receive Keflex (an antibiotic to treat certain infections) 500 milligram (mg) one (1) capsule by mouth, four times a day for seven (7) days.

On 9/27/2018 at approximatley 9:25 a.m., during an interview, and concurrent review of Patient 14's medication administration record, the DOP confirmed there were nineteen doses of Keflex documented as administered to Patient 14 during the stay in the 1st floor unit. A concurrent review of the Omnicell transaction report and medications taken from Patient 14's home medications indicated eighteen doses were taken from the Omnicell Medication Distributation device. Hence, one dose of Keflex was not accounted for.

A further review of the Omnicell transaction report of Patient 14's medications indicated the nurses had removed two capsules of Keflex 500 mg, on 9/26/18, one capsule each at 10 a.m. and 2:29 p.m..

On 9/27/2018 at around 10 a.m. during a concurrent interview and review of Patient 14's medication administration record (MAR), the DOP and the Assistant Chief Nursing Officer (ACNO) both confirmed the MAR indicated that nurses had documented the administrations of two doses of Keflex to Patient 14, one at 9 a.m. and one at 1:30 p.m. on 9/26/2018, an hour before the timed retrievals from the Omnicell. Both DOP and ADON acknowledged the inaccuracy and/or discrepancies in nursing documentation of medication administration.

A review of Patient 24's clinical record indicated the patient was admitted to the faciity on 9/16/18, with diagnoses that included Psychotic Disorder (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). A review of a physician order, dated 9/19/18, indicated to administer Seroquel (an antipsychotic medication) 100 milligrams (mg) orally every two hours, PRN (as necessary) for agitation, not to exceed six doses in 24 hours.

On 9/26/18 at 9:20 a.m., during an observation of Patient 24's medication pass with Licensed Vocational Nurse (LVN) 1, the patient informed LVN 1 that he wanted medication because he was anxious. LVN 1 then stated to the patient, "What's your anxiety level, seven, eight?"before the patient had a chance to respond. The patient replied, "Seven." LVN 1 then administered Seroquel 100 mg to the patient.

During an interview with LVN 1 immediately following, he stated he should have allowed the patient to verbalized his anxiety level without any prompting.

Review of the hospital policy, The Role of Nursing in Medication Administration, dated 8/2018, indicated " ...Time of administration & record-keeping: nursing will record the exact time of each medication administered ..."

Based on interviews, and record review, the hospital failed to ensure staff documented the proper reasons for overriding (bypassing the pharmacist review process) Omnicell (a type of automated drug dispensing cabinet) during pharmacy hours, per policy.
This deficient practice had the potential of medication errors and/or accountability issues that may affect patient safety or health.

Findings:

On 9/25/2018 at 8:40 a.m., during an interview, the Director of Pharmacy (DOP) stated the hospital utilized Omnicell cabinets at all the nursing units to distribute medications. The DOP stated that the main pharmacy had a pharmacist on duty from 7 am to 3:30 p.m., seven days a week, at minimum. The DOP also indicated the pharmacist on duty would review the override report, daily.

On 9/26/2018 at approximately 11:15 a.m., during an interview, and concurrent review of the Omnicell medication order override report for transactions occurred between 9/21/2018 at 12 midnight to 9/24/2018 11:59 p.m., the DOP confirmed that there were many override reasons chosen by the staff were not appropriate. There were at least fifty overridden transactions for non-emergency psychiatric medications (such as chapstick, vitamins, minerals, Tums, and others) with override reason "EMERGENCY PSYCH MED NEEDED".

On 9/26/2018 at 2 p.m. during an interview, the Regional Director of Pharmacy acknowledged there were override activities during pharmacy hours.

Review of the hospital policy and procedure, New Order Handling, dated 8/2018, indicated "All medications are reviewed for appropriateness prior to dispensing by a pharmacist ... After a prescriber writes an order, the nurse notes it and the order is sent to pharmacy services for verification ... Once the Pharmacist has verified that the order is correct, the medication will cross over to the automated drug cabinet ... During the absence of a pharmacist, a nurse may over-ride the automated drug cabinet and remove one dose of an emergent medication .... Pharmacy services will monitor and reconcile over-rides the next business day to ensure a valid physician order exists and the correct medication was removed from machine ..."

Based on interviews, and record reviews, the hospital failed to ensure staff followed the facility policy for new medication orders and the override function of the Omnicell (a type of automated drug dispensing cabinet).
This deficient practice had the potential for patients to receive incorrect medications and/or not receive needed medications.

Findings:

Review of the Omnicell medication order override report for transactions that occurred between 9/21/2018, 12 midnight and 9/24/2018, 11:59 p.m., indicated there were many override transactions with repeated medications for the same patients listed with reason, "NEW ORDER". Patient 14 was admitted on 9/20/2018 according to the admission record, however, there were multiple repeated medications with override reasons as "NEW PATIENT" from 9/21/2018 to 9/24/2018. These transactions occurred both during and after pharmacy hours.

On 9/26/2018 at 2 p.m. during an interview, the Regional Director of Pharmacy stated that unless it was after-hour or emergency, nursing staff should not use the Omnicell override function.

A review of the hospital policy and procedure titled, "After-hour Medication-Stock with or without Pharmacy Review", dated 8/2018, indicated " ... the facility recognizes the importance of pharmacist review prior to initiation of new drug therapy ... Exceptions to this policy would be an urgent situation (including sudden changes in a patient's medical status) ... New orders: When the pharmacy is on duty, drug orders are forwarded to the pharmacy for review. The nurse shall wait for the pharmacy approval to be received. The nurse knows when an order has been reviewed/approved by the pharmacy when the drug order is faxed back to the unit with approval OR when the medication order appears on the [Omnicell] machine's computer monitor ... First dose or emergency medication: The hospital allows for an exception to pharmacist review of the medication order for certain situations when time does not permit pharmacist review ... If a first dose is ordered (e.g. give now, give stat, or give first dose now), the medication can be administered without pharmacist approval ... the order to be sent to the pharmacy will be reviewed by the pharmacist before the next dose is administered ..."

Based on observation, interviews and record reviews, the hospital Food and Nutrition Services failed to ensure staff was competent and verified that rinse water temperature for the dish machine was adequate to ensure it was effective in sanitizing pots and pans per hospital policy. This deficient practice was evident when Dietetic Staff documented rinse temperatures that was less than the recommended manufactures guideline and hospital policy of 180 degrees Fahrenheit, for the high temperature mechanical dish machine to effectively sanitize pots and pans. Rinse water temperature of a minimum of 180 degrees Fahrenheit is required to ensure that surfaces of kitchenware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning.
This deficient practice had the potential to result in pots and pans not sanitized and cause food borne illness in 86 medically vulnerable patient populations, in addition to staff and visitors who eat food prepared in the kitchen.

Findings:

During an observation in the dish (washing) machine area on September 25, 2018, at 1:15 PM, Dietary Staff 1, (DS1), was asked to demonstrate dish machine operation. A check of the wash and rinse water temperature gauge indicated a wash temperature of 140 degrees Fahrenheit and a rinse temperature of 120 degrees Fahrenheit. When the wash cycle was completed the temperature display did not move and stayed on 140 (wash) and 120 (rinse) respectively. The recommended rinse water temperature for a high temperature dish machine is a minimum of 180 degrees Fahrenheit at the manifold.

During a concurrent interview, (DS1) stated that he checks the water temperature and it's adequate because the gauge is stuck on wash at 140 degrees Fahrenheit and rinse at 120 degrees Fahrenheit. (DS1) did not know what the dish surface temperature should be to ensure affective sanitization. (DS1) was not sure if the dish machine was high temperature or a low temperature dish machine. (DS1) was asked to verify the accuracy of the temperature gauge and dish surface temperature. (DS1) stated he does not know how to do that. He also stated that "we document temperatures on the log".

A review of Hospital's dish washing machine temperature log titled "Daily Dish machine temperature log", dated September 2018, indicated out of 49 rinse water temperatures documented, all were less than 180 degrees Fahrenheit.

According to the 2017 U.S. Food and Drug Administration Food Code, The temperature of hot water delivered from a ware washer sanitizing rinse manifold must be maintained according to the equipment manufactures specifications and temperature to ensure surfaces of kitchenware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. It further indicates the surface temperature of dishes must reach at least 160 Degrees Fahrenheit. The sanitizing rinse temperature at the manifold of 180 degrees Fahrenheit are based on the sanitizing rinse contact time required to achieve the 160 degrees surface temperature

A review of service request invoice dated 9/26/18 for the dish machine, showed that Ecolab (an equipment maintenance and supply company), service was requested for dish machine rinse temperature not reaching 180 degrees Fahrenheit. The gauge was replaced and issue resolved.

A review of hospital policy titled "Dishwasher Compliance - Nutritional Services", Policy No. 1300.19 (revised 3/15/17) indicated, "The final rinse cycle will operate with a water temperature of 180 degrees Fahrenheit."

Based on observation and staff interviews and record reviews, the facility failed to maintain its food service equipment per manufacture's guidance. The ice machine and dish machine were operational in a manner that had the potential of growth of microorganism that could cause food borne illness. The facility also failed to maintain a clean and sanitary environment. This deficient practice had the potential for cross contamination and spread of infection causing harm to 86 patients in addition to staff and visitors in the hospital.

Findings:

During a tour of the kitchen on September 25, 2018, at 8:35 a.m., the ice machine stored in the kitchen was inspected. A clean paper towel swipe of the ice storage bin ceiling and sides produced a significant amount of brown substance. The front panel was removed to reveal the water tubing and internal ice machine system. The water tubing were stained with black substance resembling mold.

During a concurrent interview with Director of Food and Nutrition Services (DFNS), he verified the ice bin is dirty. He stated an outside company cleans the ice machine. The outside company is not on a regular schedule, when there is a need the (DFNS) calls to make an appointment and if he cannot get an appointment with outside company he cleans himself. The (DFNS) does not follow Manufacturer's guidelines for cleaning the ice machine.

During an interview with (DFNS) on September 25, 2018, at 8:35 a.m., The DFNS stated he does not have the manufacturer's guidelines for cleaning. The DNSF also stated that the Hospital Food and Nutrition department does not keep an ice machine cleaning log. The DNS further stated he does not know when the ice machine was cleaned by the outside company.

During an observation in the dish machine area on September 25, 2018, at 1:15 p.m., a check of the wash and rinse water temperature gauge showed a wash temperature reading of 140 degrees Fahrenheit and rinse temperature of 120 Degrees Fahrenheit. The temperature display did not move as the wash cycle stopped.

The recommended rinse water temperature for a high temperature dish machine is 180 degrees Fahrenheit at the manifold.

During a concurrent interview with (DFNS), the DFNS verified that the dish machine is a high temperature machine. The DNSF stated that an outside service company (Ecolab), provides service to the dish machine. The DFNS did not know why the gauges for the temperature display were not moving. The DFNS also stated that he does not have a tool to validate the sanitizing rinse water temperature.

The hospital was not aware that the machine may not have been adequately sanitizing the dishes prior to being tested by the surveyor. Food service staff were actively washing dishes prior to the check of the machine.

The Condition for Infection Control is not met.
Based on observation, interviews and record reviews, the hospital failed to:

1. Ensure there was an effective system in the prevention of infections, when it failed to maintain a sanitary environment for food storage, preparation and distribution. There were several deficient practices observed in the hospitals kitchen that could contribute to the growth of microorganisms capable of food borne illness due to improper storage of dry, refrigerated and frozen foods, kitchen equipment and work areas that were not kept clean, rubber flooring with holes and tears that can allows food and water to go under and harbor harmful bacteria, improper maintenance of dish washing equipment, improper maintenance of ice machine and ice bin not kept clean. Dietary staff not following personal hygiene not wearing beard covers. The patient census was 86 in addition to staff and visitors. (A749)

2. Ensure the maintenance of dietetic services equipment per manufacturer's guidance (Cross reference A701)

3. Maintain a sanitary physical environment in the hospital. Several deficient practices were observed in the hospital that could contribute to spread of contagious pathogens. There were corrugated cardboard boxes in the storage area, biohazardous material not stored properly to limit the spread of possibly contagious pathogens, a faucet in the nurse's station that was not clean and grab rail in a patient's rest room that was not clean, to prevent harmful agents from passing to patient's hands and a second floor inpatient Detox Unit where patients water, tea, coffee, and snack area was not clean and sanitary. (A749)

4. Evaluate hospital staff immunization status as recommended by the Centers for Disease Control (CDC) and training in preventing and controlling healthcare associated infections. ( A749)

5. Assure Medical Staff had documented Hepatitis B status or waiver; yearly PPD and Flu vaccination in order to provide patient care in a safe and sanitary environment (A749)

These deficient practices could contribute to significant infectious disease and Exposure to and transmission of infections and communicable diseases. The cumulative effect of these systemic problems resulted in the hospitals inability to ensure the Condition of Participation for Infection control was met.

Based on observations, interviews and record reviews the hospital failed to:

1. Ensure infection control practices were followed in Food and Nutrition Services when:

a. Three dairy crates were used to store produce in the walk in refrigerator. A box of egg rolls and three large buckets of ice cream were stored in the freezer open to the air, not covered or sealed to prevent freezer burn and cross-contamination. One large bag of panko breading was open and stored on the kitchen counter next to food preparation sink and one container of granulated sugar with no lid loosely covered with plastic cling wrap stored on a stainless steel storage shelf in the kitchen. The improper storage of food can result in decrease quality of food, cross contamination and growth of microorganism that could cause food borne illness.

b. Kitchen equipment and work areas were not maintained in a clean manner to prevent the potential harborage of pests and the growth of microorganisms; and the can opener blade had gummy, sticky brownish residue with the potential to harbor harmful bacteria. The rubber flooring was old with holes and tears.

c. The ice machine was not maintained in a sanitary manner and proper sanitation practice was not followed to prevent the growth of microorganism resembling mold.

d. Four (4) dietary staff did not practice personal hygiene, they did not wear facial hair restraints (beard covers) in the kitchen. Hair can be a source of food contamination.

e. The Dish machine was operational in a manner that had the potential to affect food quality and increase the potential of growth of microorganism. The hospital failed to verify the dish washing machine was reaching temperatures necessary to sanitize pots and pans and did not have a system in place to validate the accuracy of the temperature gauge on the dish machine.

2. Remove corrugated cardboard boxes from storage areas.

3. Ensure personnel health files were maintained with current health requirements for three (3) of 11 employees and current infection control training for one (1) of 11 employees.

4. Ensure that all employees (LVN 1) received required immunizations, skin tests, titers, or signed declination (where applicable), and that the aforementioned requirements were documented in personnel files in order to safeguard against hospital acquired infection.

5. Confirm that biohazard material was stored properly so as to limit the spread of possibly contagious pathogens.

6. Maintain cleanliness of a nursing staff hand washing station faucet.

7. Assure a grab rail in a patient's rest room was clean so that possibly harmful agents are not passed to his/her hands.

8. Assure Medical Staff had documented Hepatitis B status or waiver; yearly PPD and Flu vaccination in order to provide patient care in a safe and sanitary environment.

9. Assure the second floor inpatient Detox Unit where patients water, tea, coffee and snack area was a clean and sanitary environment.

These deficient practices had the potential to effect patients in addition to staff and visitors who consume the food prepared by the hospital and have contact with facility staff and the environment within the facility.

Findings:

1. a. During an observation in the kitchen on September 25, 2018, at 8:40 AM, three (3) dairy crates were observed in the walk in refrigerator. One (1) dairy crate was filled with tomatoes, another crate was filled with bell peepers and third crate was filled with cucumbers.

During a concurrent interview with the Director of Food and Nutritional Services, (DFNS), he stated "we shouldn't store anything but dairy in the dairy crates". The DFNS further stated we should use plastic containers that are cleaned and sanitized to store produce in the walk in refrigerator. He also stated the produce will be removed from the crates and placed in plastic clean containers.

During a tour of the kitchen on September 25, 2018, at 8:45 AM, a box of frozen growls was noted in the walk-in freezer. The box was noted to be open with the growls exposed to the freezer air. There were three buckets of ice cream noted with lids open, ice cream lids were loosely placed on top and partially covering the buckets.

During a concurrent interview with the DFNS, he stated the box of egg rolls should be closed and ice cream bucket lids should be tightly closed.

During an observation of the kitchen on September 25, 2018, at 9:00 AM, one (1)bag of panko (breading) was noted open on the kitchen counter with no open date label and a container of granulated sugar was stored on metal shelf with no lid. A small piece of saran wrap was placed on top of the container to cover. The container of sugar did not have a label.

The improper storage of food can result in decrease quality of food, cross contamination and growth of microorganism that could cause food borne illness.

During a concurrent interview with DFNS, the DFNS stated panko is used a lot so the cooks placed it close to them next to preparation counter. The DFNS also stated that the facility staf should empty the bag into a container with lid. He added that the container of sugar should be covered with a lid.

A review of the 2017 U.S. Food and Drug Administration Food Code indicated, Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized and also be passed on by food containers.

In addition according to the 2017 U.S. Food and Drug Administration Food Code, certain foods may be difficult to identify after they are removed from their original packaging. The mistaken use of food from unlabeled containers could result in chemical poisoning. For example, food borne illness and death have resulted from the use of unlabeled salt, instead of sugar.

A review of hospital policy titled "Proper Food Handling - Nutritional services", policy No 1300.06 (revised 3/15/17) indicated, "Keep refrigerated foods wrapped or covered and in sanitary containers.

A review of hospital policy titled "Walk in refrigerator floor cleaning", policy No 1300.18 (revised 3/15/17) indicated, "Dietary manager will safeguard all food by ensuring proper storage, maintaining a sanitized environment and inspecting all perishable food items."

A review of hospital policy titled "Kitchen Equipment - Nutritional services", Policy No 1300.21 (revised 3/15/17) indicated, "Food not in its original container shall be stored in the smallest container possible, covered, labeled and dated. It also indicates, foods stored in opened original containers must be covered and dated."

b. During the tour of the food service area on September 25, 2018, at 9:30AM, the following was observed. A deep fryer that was not maintained clean with buildup grease on the side of the equipment, a griddle that was next to the fryer also had built up grease around the edges and on the side walls and surfaces. The floor was covered with debris and grease. The stove was covered with grease and the floor below the stove was covered with debris and grease. The floors behind and under the stove, griddle and fryer was not clean, observed dark spots covered with grease, dust and debris. In addition the rubber flooring in the kitchen looked worn and old. The rubber flooring in the dry storage area had holes and tears in it. The adhesive glue under the rubber flooring had loosened and created air pockets in dry storage room. The rubber flooring in the coffee maker area had holes and tears exposing the tiles below. The flooring next to food preparation area around the fryer and griddle had holes and tears. The flooring by the east ramp leading to the hospitals loading dock was torn and had holes exposing the tiles underneath. Food and water can get under the flooring during food preparation and floor cleaning. This creates an ideal breeding ground for bacteria and spreading harmful microorganism.

During a concurrent interview with the DNFS, the DNFS stated that the kitchen floors are mopped everyday with hot water and disinfectant but the floors get dirty fast. The DNSF also stated the cleaning task list and schedule shows when each area in the kitchen should be cleaned. He further stated that cleaning is also difficult with the holes in the flooring, water often gets in the holes and under the flooring. He added there are air pockets too under the rubber flooring.

During an observation in the kitchen on September 25, 2018, at 9:45AM, one can opener blade was observed to be covered in brownish and sticky residue.

During a concurrent interview with the DNFS, he verified that there is only one can opener in the kitchen and that it was not clean. The DFNS stated can opener blade needs to be cleaned and sanitized after use.

A review of the Cleaning task list dated 9/7/18 to 9/23/18, indicated cleaning kitchen equipment was not on the cleaning schedule. In addition mopping and scrubbing floors was not scheduled on daily basis.

According to the 2017 U.S. Food and Drug Administration Food Code indicated, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these are not kept clean, they may also provide harborage for pests.

In addition a review of the 2017 U.S. Food and Drug Administration Food Code indicated, 'Floors that are smooth, durable construction and that are nonabsorbent are more easily cleaned'. Requirements and restrictions regarding floor coverings, are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized.

A review of hospital policy titled "Kitchen Equipment - Nutritional Services", Policy No 1300.21 (revised 3/15/17) indicated, "All work surfaces, except the cooking surface and all floors in the food preparation area will be cleaned daily with approved disinfectant. Also indicated, all equipment shall be thoroughly cleaned after each use. The can opener must be cleaned daily or after each use by removing all food and can opening residues from the drive gear. Wash the blade using warm soapy water and thoroughly dry with paper towel. This will help prevent unwanted product buildup and harmful bacteria growth.

A review of hospital policy titled "Infection prevention and control -Nutrition Services Department", Policy No DP-5 (revised 3/7/17) indicated, "ranges and grills should be cleaned daily, dirty equipment should never touch food, all work surfaces, utensils and equipment should be cleaned and sanitized after each use and all floor surfaces must be wet-mopped daily and as needed using a bucket with wringer and germicide."

c. During an observation of the ice machine on September 25, 2018, at 8:35AM, the ice machine stored in the kitchen was inspected. A clean paper towel swipe of the ice storage bin ceiling and sides produced a significant amount of brown substance. The DFNS then removed the front panel of the ice machine to reveal the water tubing and internal ice machine system. There was black substance and spots inside the tubes and valves.

During a concurrent interview with DFNS, he verified the ice bin is dirty. The DNSF further stated there is an outside company who cleans the ice machine, and that the outside company is not on a regular schedule. The DFNS stated he calls the outside company and makes an appointment, but when he can't get an appointment early enough he cleans it himself.

During an interview with the DFNS on September 25, 2018, at 8:35AM, The DFNS stated the outside company for the ice machine showed him how to clean the ice machine. He first turns off the ice machine removes the front panel, takes out the water tubing he soaks it in quaternary ammonia disinfectant, and he then removes the ice from the ice bin and cleans the bin with quaternary ammonia disinfectant. He allows the machine to make ice twice and discards it. He also stated that the hospital does not have a cleaning guidelines or procedures for the ice machine, in addition the hospital does not keep an ice machine cleaning log. Dietary staff are responsible for cleaning the ice scoop and holder and also to wipe the ice machine exterior. The outside ice machine company is responsible for providing cleaning service. The DFNS did not know when the ice machine interior water valves, tubing, filter and ice bin had been cleaned.

According to the 2017 U.S. Food and Drug Administration Food Code, because of the high moisture environment, mold and algae may form on the surface of the ice bins and any tubing or equipment stored in the bins. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin.

In addition, equipment contacting food that is not Time/Temperature control for safety food: such as enclosed components of ice makers shall be cleaned at a frequency specified by manufacturer or if manufacturer specifications are absent then at a frequency necessary to preclude accumulation of mold.

A review of the outside company (Westco), a service invoice for the ice machine dated 7/16/18 showed that the ice machine company was in the hospital to provide a repair service. The invoice did not indicate ice machine was cleaned.

A review of hospital policy titled "Kitchen Equipment - Nutritional Services", Policy No 1300.21 (revised 3/15/17) indicated, "The interior of ice dispensers shall be cleaned and preventive maintenance will be performed."

d. During an observation in the kitchen on September 25, 2018, at 8:35AM, the Director of Food and Nutrition Services DFNS was not wearing a beard cover. The (DFNS) was observed in the food preparation area, in the dry storage room, in the dish washing room and walk in refrigerator. The DFNS had a full beard and was not wearing a beard cover.

During an observation in the kitchen on September 25, 2018, at 9:00AM, Dietary Staff 1, (DS1) was getting clean containers from the dish room and was not organizing produce and deliveries in the walk in refrigerator. (DS1) had beard and was not wearing a beard cover.

During an observation in the kitchen on September 25, 2018, at 11:30AM, Dietary Staff 2,(DS 2), was observed mopping the floor. DS2 had a full beard and was not wearing a beard cover.

During an interview with Registered Dietitian (RD) and Director of Food and Nutrition Services (DFNS) on September 26, 2018, at 9:10AM, the RD said that beard covers should be worn anytime entering the kitchen. The DFNS agreed that beard covers should be worn in the kitchen and verified that staff including himself did not wear it during initial kitchen tour on September 25, 2018.

During an observation in the dish washing room on September 27, 2018, at 9:15AM, Dietary Staff 4, (DS4), was observed washing pots and pans using the manual three (3) compartment sink. (DS4) had a full beard and was not wearing a beard cover.

During a concurrent interview with DS4, DS4 stated that "I usually wear a beard cover and I forgot to wear it today".

According to the 2017 U.S. Food and Drug Administration Food Code, hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair.

In addition according to Food Code 2017, food service employees shall wear hair restrains 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 linens and unwrapped single service and single use articles.

A review of hospital policy titled "Infection prevention and control -Nutrition Services Department", Policy No DP-5 (revised 3/7/17), indicated, "Personal Hygiene - Proper attire for food handlers should include a hair covering (hair nets or caps), freshly laundered uniform and work shoes and short, clean fingernails. Mustaches and sideburns must be kept trimmed and beards must be covered."

e. During an observation in the dish machine area on September 25, 2018, at 1:15PM, (DS1) was asked to demonstrate dish machine operation. A check of the wash and rinse water temperature gauge showed a wash temperature reading of 140 degrees Fahrenheit and a rinse temperature of 120 degrees Fahrenheit. When the wash cycle was completed the temperature display did not move and stayed on 140 degrees Fahrenheitand 120 degrees Fahrenheit, respectively. The recommended rinse water temperature for a high temperature dish machine is 180 degrees F at the manifold. Heat in the high temperature dish machine is used to sanitize food contact surfaces to prevent foodborne illness.

During a concurrent interview, (DS1) stated that he checks the water temperature and it's good because the gauge is stuck on wash at 140 degrees Fahrenheit and rinse at 120 degrees Fahrenheit. (DS1) did not know what the dish surface temperature should be to ensure affective sanitization. (DS1) was not sure if the dish machine was high temperature or a low temperature dish machine. (DS1) was asked to verify the accuracy of the temperature gauge and dish surface temperature. (DS1) stated he does not know how to do that.

During an interview with DFNS on September 25, 2018, at 1:20PM, the DFNS verified that the dish machine is a high temperature machine. The DFNS stated that Ecolab,(an outside company that provides service to the dish machine), was recently at the facility and had informed the DFNS that everything is working fine with the dish machine. The DFNS further stated that he does not know why the gauges are stuck and no one had informed him. The DFNS further added that he does not have a tool to measure the temperature of the rinse water and relies on the gauges accuracy. The DNSF stated that Dish machine will be put out of order immediately and the facility will resume manually washing pots and pans.

The recommended temperature at dish surface is 160 degrees Fahrenheit. The hospital did not have a system in place to validate the accuracy of the temperature gauge or explanation as why a repair service not requested for the gauge. The hospital was not aware that the machine may not have been adequately sanitizing the dishes prior to being tested by the surveyor. Food service staff were actively washing dishes prior to the check of the machine.

A review of the outside company Ecolab's service invoice for the dish machine dated 9/21/18 showed that the water softer was changed during 9/21/18 visit.

A review of service request invoice dated 9/26/18 for the dish machine, showed that Ecolab service was requested for dish machine rinse temperature not reaching 180 degrees Fahrenheit. The gauge was replaced and issue resolved.

A review of hospital policy titled "Dishwasher Compliance - Nutritional Services", Policy No. 1300.19 (revised 3/15/17) indicated, "The final rinse cycle will operate with a water temperature of 180 degrees F."

A review of hospital policy titles "Infection Prevention and Control - Nutrition Services Department", Policy No. DP-5(revised 3/7/17) indicated, "The dishwasher should be maintained and run according to manufactures instructions."

According to the 2017 U.S. Food and Drug Administration Food Code, The temperature of hot water delivered from a ware washer sanitizing rinse manifold must be maintained according to the equipment manufactures specifications and temperature to ensure surfaces of kitchenware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. It further indicates the surface temperature of dishes must reach at least 160 Degrees Fahrenheit. The sanitizing rinse temperature at the manifold of 180 degrees Fahrenheit are based on the sanitizing rinse contact time required to achieve the 160 degrees surface temperature.

In addition according to FDA Food Code 2017, a ware washing machine shall be equipped with a temperature measuring device that indicated the temperature of the water in each wash and rinse tank and as the water enters the hot water sanitizing final rinse manifold. Also, although integral temperature measuring devices and a pressure gauge for hot water mechanical ware washers are required. The measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160 degrees Fahrenheit. It indicates that the regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160 degrees Fahrenheit.


36206


2. On 9/25/18 beginning at 8:35 AM, during the initial tour of the facility, a corrugated cardboard box, containing plastic bins, was observed in the nurses station of the unit in 2 West. Another corrugated cardboard box, containing patient supplies, was observed in the supply closet of the unit in 2 East.

On 9/26/18 at 1:15 PM, the infection control officer stated corrugated cardboard boxes were not allowed in the facility.

The facility's policy and procedure titled, "Boxes And Shipping Container Storage," reviewed on 8/10/18, indicated clean or sterile items to be transported to central processing and storage areas within the facility should be removed from their external shipping containers before they enter the storage areas of the department.

3. On 9/26/18 at 1:15 PM, the infection control office (IC Officer) stated Tuberculosis (TB, a lung infection) testing had to be done annually and staff with a history of a positive TB skin test must answer annual screening questions. The infection control officer stated Hepatitis B vaccines were offer by the facility, if the staff declined the vaccine, they must sign a waiver or declination. The infection control officer also stated that infection control training was provided upon hire and annually.

On 9/27/18 at 10:04 AM, the review of the personnel files indicated the following.

a. Registered nurse (RN 3) was hired on 9/10/18. There was no documented evidence of a current tuberculosis (TB or PPD) test in the file. A document titled "Physical/Drug Results," dated 9/11/18, indicated the patient would provide a copy of the TB.

b. Mental health worker (MHW 1) was hired on 9/10/18. MHW's TB skin test was performed on 2/10/17, over a year ago. MHW did not have evidence that infection control training had been completed. MHW 1's file contained an incomplete infection control test, dated 9/2018, most questions were not answered.

c. Licensed vocational nurse (LVN 3) had a history of a positive TB skin test. A questionnaire titled, "Consent for Mantoux Test," dated 9/2017, indicated LVN 3 had to answer the TB screening questions, none were answered.

Concurrently, the Human Resource Director (HR Dir) stated that infection control training was provided upon hire and annually. The HR Dir stated TB testing was required either upon hire or within 6 months for new employees prior to working on the floor. Hepatitis B was offered upon hire, if the staff refused the vaccine they would sign a declination form. The HR Dir verified all the missing documents from files.

The facility's policy and procedure titled, "Annual Employee Health Check," reviewed 8/10/18, indicated all employees shall, annually be screen for tuberculosis. Employees who are historically non-reactive to PPD skin test will undergo a repeat skin test. Employees that are reactive to PPD skin test by history will fill out an annual questionnaire to determine if signs and symptoms of active TB are present.

The facility's policy and procedure titled, "Infection Prevention And Control Plan," reviewed 8/10/18, indicated the infection prevention and control plan is composed of the following, including personnel orientation, education, training and employee health.

8. On 9/27/18 at 10:30am, during a review of randomly sampled Ten Medical staff credentialing files, with the Medical Staff Director (MSD); Two out of ten reviewed medical staff credentialing files did not have documentation of Hep B status or Hep B waiver, MD 6 and MD 7. Five out of ten reviewed medical staff credentialing files; MD 2, MD 5, MD 6, MD 7, and MD 8, did not have current documentation of annual flu vaccination. Four out of ten reviewed medical staff credentials; MD 2, MD 5, MD 6, MD 7, MD 8, did not have annual TB test documented at the time credential files were reviewed.

During an interview with the Infection Control Director on 9/26/18 at 2:15 pm, the Infection Control Director Stated that the facility followed CDC guidelines for infection control. During an Interview with MSD on 9/27/18 at 10:45 am, the MSD stated that the facility had a policy and procedure for yearly Tuberculosis Screening, yearly Flu vaccination and documentation of Hepatitis B status or waiver.

9. During a tour of the Second floor Snack area, on 9/26/18 at 10:20am am with RN 10 and the MSD, a reddish brown material was observed on a metal drain covering by the water fountain. The MSD indicated patients get water and hot drinks from this room. A copy of a cleaning log for the snack room was requested, none was provided.

The Facility failed to follow CDC guidelines and assure patient care was provided in a safe and sanitary environment.

Based on record review and staff interview the facility failed to provide Master Treatment Plan (MTP) interventions/modalities for four (4) of eight (8) active sample patients (A1, A4, A7 and A8) that consistently addressed specific nursing interventions. These interventions were preprinted and identical for patients regardless of different needs/problems and resulted in nursing interventions that were not individualized; did not reflect a comprehensive nursing approach to treatment; and failed to provide nursing staff with direct, consistent approaches based on the individual's needs. The interventions were generic monitoring and discipline functions. This failure potentially results in inconsistent and/ or ineffective treatment. Findings include:

A. Medical Record Review:

1. These nursing interventions for four (4) of eight (8) sample patients (A1, A4, A7 and A8) were as follows:

2. "Engage patient in discussion to orient to time, person, place and situation."

3. "Focus and direct the patient's attention to concrete things in the environment through demonstrating RN acceptance and active listening as tolerated by the patient."

4. "Assure patient is compliant with prescribed medication".

The description of patient problems for the four (4) of eight (8) sample patients (A1, A4, A7 and A8) were as follows:

1. Patient A1's MTP dated 9/18/18 had problem stated as "Psychosis as Evidenced By: Patient has AH (auditory hallucination) commanding pt. to cut [himself/herself] with a kitchen knife."

2. Patient A4's MTP dated 9/11/18 had problem stated as "Psychosis, Delusions, and Disorganized Thought Process As Evidenced By: delusions evidenced by having AH of music, having paranoid delusions of being choked while [he/she] sleeps, that [he/she] is being poisoned, loose associations and therefore [he/she] has not been able to care for [himself/herself]."

3. Patient A7's MTP dated 9/21/18 had problem stated as "Disorganized Thought process and Mania as Evidence By: pt. being manic, acting erratically, delusional, and argumentative as well as disorganized thought process."

4. Patient A8's MTP dated 9/18/18 had problem stated as "Psychosis, and Disorganized Thought Process as Evidence By: Pt. endorsed auditory command hallucinations telling [him/her] to kill [himself/herself]."

B. Staff Interview

In an interview on 9/24/18 at 2:10 p.m. with the Assistant Director of Nursing the Director acknowledged that the nursing interventions were standard discipline functions of nursing staff and did not relate to the goals and were not individualized.

Based on medical record review and staff interview it was determined it was determined that the Director of Nursing failed to ensure/monitor that the Treatment Plan delineated the RN role in the care of the patient for four (4) of eight (8) active sample patients (A1, A4, A7 and A8). The nursing interventions were similar in all Treatment Plans regardless of the problem identified and were simply a list of preprinted interventions that were checked off and were not specific to the individual patient needs/problems. (Refer to B122)