HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to address patient needs determined by assessment and diagnosis.
Findings were:
Facility Policy entitled "Assessing/Reassessing a Patient" stated in part
"Competency -- Assessment, screening and care plan development competencies are defined by organizational policies, departmental/specialty specific scopes of assessment, licensure, certifications, applicable regulations and scope of practice requirements for the professional staff of each discipline.
The professional in a discipline is responsible for validation appropriate competency for technical and assistive personnel who assist in assessment and reassessment activities.
Initial Assessment - an assessment conducted at the first patient contact which establishes a baseline for the patient. Takes into account immediate and emerging needs and considers those needs broadly. This initial assessment is critical to patient safely as it supports staff in determining what care the patient needs as well as any further assessments.
Plan of Care - A written plan based on data gathered during assessment identifies care needs and treatment goals, describes the strategy for meeting those needs and goals, outlines the criteria for terminating any interventions, and documents progress toward meeting the plan's objectives. The plan may include care, treatment, habilitation and rehabilitation.
Care Planning (or planning for care) - Individualized planning and provision of care, treatment, or services that address the needs, safety, and well-being of the patient and may include patient's support system.. The plan, which formulates strategies, goals, and guidelines, clinical paths, care maps, or a combination of these.
Key Points
Plan of Care Process
b. A plan of care is evidenced by:
· Identification of the patient's goals, problems and desired treatment outcomes
· Assignment of priorities and timeframe's, including criteria for terminating any interventions.
· Documentation of appropriate interventions and progress related to the patient's problems
· Educational Plan/Outcomes to meet learning needs identified during assessment
· Consultations as needed
· Discharge planning process that begins on admission"
Facility Policy entitled "Individualized Interdisciplinary Plan of Care" stated in part
1. "The nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan.
a. The attending physician shall be the primary coordinator for the medical and treatment plan of care of the patient with primary responsibility for oversight of the patient.
b. Planning of care treatment and services is individualized to meet the patient's unique needs and circumstances.
c. The patient and/or significant others shall be encouraged to be involved in the planning of care whenever possible.
Plan of Care
1. The Registered Nurse develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan. Each discipline, while maintaining awareness of the overall plan, will establish and update plans of care appropriate to their specific discipline scope of assessment and licensure."

Facility Job Description stated the following:
"Job Title: Nursing Department Supervisor
Job Family: Nursing

Responsibilities:
· Provides direction and support to unit staff. Supervises admissions, conducts assessment of patient's needs, and initiates nursing care plans. Evaluates and documents patient progress.

Job Title: RN I
Job Family: Nursing

· Implements and monitors patient care plans. Monitors, records and communicates patient condition as appropriate.
· Serves as primary coordinator of all disciplines for well-coordinated patient care.
· Notes and carries out physician and nursing orders.
· Assesses and coordinates patient's discharge planning needs with members of the healthcare team.
· Learns and applies Patient Centered Care Nursing Process including the patient / family, Evidence-Based Practices (EBP), Safety and Process Improvement for patient and unit outcomes of care processes."

Review of the following medical records revealed incomplete or missing Plans of Care:
· Patient # 27
· Patient # 29
· Patient # 34
· Patient # 38
In interviews with the Director of Maternity and Critical Care Services and the Charge Nurse of 4th Floor East on January 5, 2016 the above deficits were confirmed.

Based on observation, interview and record review the facility's director of the food and dietetic services failed to ensure staff followed the facility established safety practices for food handling.

Findings Included:

Observations on 1/4/16 at 10:40 a.m. of the facility Dietary Department revealed:
- Four (4) handwashing stations did not have waste receptacles
- Two (2) staff did not wear adequate hair restraints
- A hair was found in a container of raw sliced celery
- One (1) kitchen staff and one (1) food vendor were chewing gum in the food production areas
- Two (2) wet dirty towels were sitting out on the food counters
- Two (2) metal pans were stacked wet and not allowed to completely dry
- Two (2) dirty, wet mops were sitting on the floor
- The laminated wall above the pot washing station had a torn, unclean able, 12 inch by 12 inch
area of missing laminate.
- The stationary manual food slicer had remnants of dried lettuce on the blade.

Review of the facility provided UNIFORM DRESS CODE Policy #E004 (revised 3/11) reflected:
- Wear the approved hair restraint when on duty.
- Do no chew gum during assigned work hours.

Review of the facility provided STORAGE OF POTS, DISHES, FLATWARE, UTENSILS Policy #F017 (revised 1/14) reflected:
Pots, dishes, and flatware are stored in such a way as to prevent contamination
- Air dry all food contact surfaces, including pots ...Do not stack or store when wet.
- Moist cloths used for wiping food spills shall be clean and rinsed frequently in a sanitizing solution used for no other purpose. These cloths shall be stored in the sanitizing solution between uses.

Review of the facility provided HAND HYGIENE Policy #F007 (revised 1/14) reflected:
PROCEDURES:
- Hand wash sinks, including restroom sinks, should be clean and stocked with soap, paper towels and a covered waste receptacle.

During a tour of the Facility's kitchen, in the morning on 1/4/16, Staff # 46, the Food Service Director confirmed the Dietary findings.