HospitalInspections.org

Based on staff interview and personnel record review the facility failed to ensure nursing performance and clinical activities are evaluated for five (5) of five (5) personnel records reviewed; Employees #1, #10, #11, #15, and #18.

Findings Include:

During an interview with the Human Resources Director (HRD) on 06/13/2023 at 9:15 a.m., it was confirmed the facility does provide nursing performance evaluations, and further confirms no nursing performance evaluations completed for Employees #1, #10, #11, #15, and #18.

Review of the personnel record for Employees #1, #10, #11, #15, and #18 revealed no documented evidence of performance evaluations.

The surveyor requested facility policy and procedure for nursing performance evaluations, and no documentation was submitted for review.

During exit conference on 06/15/2023 at 3:00 p.m. with Executive Director, Director of Nursing, Maintenance Director, HRD, Quality/Infection Control Nurse, survey findings were discussed and no further documentation was submitted for review.

Based on observation, staff interviews, and policy/procedure review the facility failed to follow manufacturers recommendations and policies concerning sanitation of dinnerware while using dishwasher for three (3) of three (3) days of survey.

Findings Include:

Observation of the dishwashing machine (ECOLAB ES 2000) on 06/13/2023 at 10:25 A.M. revealed the temperature of the water on the wash cycle reached 100 degrees Fahrenheit and 120 degrees Fahrenheit on rinse cycle. The dishwashing machine was not checked for sanitizer concentration in the water.

An interview with the Dietary Director on 06/13/2023 at 10:27 a.m. confirmed the dishwasher was a low temperature chemical disinfectant machine. Further interview with Dietary Director revealed the Facility is not testing the chemical composition of the sanitizer solution and the facility did not have chlorine test strips or a log recording results of the chlorine test.
An interview on 06/13/2023 at 2:00 P.M. with the Food Specialist, confirmed the dishwasher was a low temperature chemical sanitizing machine and the facility was only recording the temperature of the water.

A telephone interview on 06/13/2023 at 11:10 A.M. with the Manufacturer's representative (District Manager for ECOLAB) confirmed the Facility's dishwasher "model is a chemical disinfectant, low temperature machine that requires chlorine testing prior to every use. This model does not have an internal heater."

An interview on 06/15/2023 at 1:30 P.M. with the Infection Control Manager confirmed the Facility kitchen has not been monitored since she started her role approximately two (2) weeks ago.

Review of the Governing Body Meeting Minutes for 2022 through 2023 confirmed there was no documented evidence the Governing Body was monitoring the dietary department.

Review of ECOLAB ES 2000 dishwasher manufacturer's instructions for operation confirmed the minimum recommended wash temperature to be 100-degree Fahrenheit and the minimum recommended rinse temperature to be 140 degrees Fahrenheit. The recommended sanitizer (chlorine) level is 50 parts per million (PPM).

Review of Manufacturer's instructions (section 3, page 24, #8) for the ECOLAB ES 2000 dishwashing machine revealed " ... ensure that all chemicals being injected to machine have been verified as being at the correct concentrations ..."

Review of Facility policy entitled "Dietary Services; Food Service Responsibilities," (revised 01/2021) revealed " ... provide safe food services for patients and employees ...Dishwasher ...The machine must be maintained and run according to manufacturer's instructions ..." .

Review of Facility policy entitled " Manual Ware Washing," no policy number, January 2021, revealed, " ... The Food service director ensures that the nutrition staff is knowledgeable in proper techniques for processing Dirty dish ware ... The Food Service Director ensures that all dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. The Food Services Director is responsible for insuring appropriate completion of temperature and /sanitizer concentration logs as appropriate ...".

During exit conference on 06/15/2023 at 3:00 p.m. with Executive Director, Director of Nursing, Maintenance Director, HRD, Quality/Infection Control Nurse, survey findings were discussed, and no further documentation was submitted for review.

Based on discharge planning document review, governing body meeting minutes, quality and utilization meeting minutes, policy/procedure review, staff interview, and medical record review, the facility failed to ensure there was a discharge planning process in effect for 10 out of 20 medical records reviewed: Patients #1, #2, #4, #5, #6, #7, #8, #9, #12, #13.

Findings Include:

Interview with the Case Management/Assistant for Discharge Planning on 06/14/2023 at 3:00 p.m. reveals the Facility's Social Worker quit suddenly, and the replacement will start 06/15/2023. And further reveals there is a Discharge Planning group meeting twice a week and the facility has a tool in each patient's records for documentation of discharge planning; however, no one has been filling it out.

Interview with the Case Management/Assistant for Discharge Planning on 06/14/2023 at 3:10 p.m. confirms Patient Records #1, #2, #4, #5, #6, #7, #8, #9, #12, and #13 have no documented evidence of discharge planning.

Interview with the Director of Nursing (DON) on 06/15/2023 at 10:30 a.m. confirms the Case Management/Assistant of Discharge Planning has not been completing the Discharge Planning Tool in each patient record.

Interview with Infection Control/Quality Assurance nurse on 06/15/2023 at 2:30 p.m. confirms that Quality and Utilization Council meetings does not have Discharge Planning on the agenda.

Review of Patient Records #1, #2, #4, #5, #6, #7, #8, #9, #12, and #13 have no documented evidence of discharge planning.

Review of policy entitled, "Discharge Planning Policy," dated 11/12/2019, reveals " ...The Case Management staff will coordinate referrals to the appropriate service providers and paperwork will be completed as necessary ... documentation in the electronic patient record will be completed within 24 hours...".

Review of document labeled, " ...23. Discharge Planning Program and Meeting Minutes (past 12 months) ...", reveals " ...The discharge Planning committee meets twice a week on Tuesday and Thursday mornings at 9 am in ...Documentation of discharge planning needs is maintained in the patient record.

Review of Medical Staff and Governing Body meeting minutes from January 2023 to May 2023 reveals no documented evidence of discussion of Discharge Planning.

Review of Quality and Utilization Council meeting meetings for the year of 2023 reveals no discussion of discharge planning.

During the exit conference on 06/15/2023 at 3:00 p.m. with Executive Director, Director of Nursing, Maintenance Director, HRD, Quality/Infection Control Nurse, survey findings were discussed, and no further documentation was submitted for review.