HospitalInspections.org

Based on record review and interview, the facility failed to:
A. assure all hospital departments and services were participating in the quality assurance program. 23 of 31 Patient/Professional Services failed to report quality data to the Quality Council. Quality Council failed to report 18 of 31 Patient/Professional Services to the Medical Executive Committee and Board of Directors.
B. the governing body failed to follow and enforce its own plan for frequency of data collection and reporting. Departments are not required to report quality data to the Quality Council, Medical Executive Committee, or the Board of Directors on a scheduled basis.
C. to assure the quality of all services provided by the facility. The Board of Directors failed to require the Quality Council to report data for 18 of 31 Patient/Professional Services to the Board.


Findings include:

A. The facility failed to assure all hospital departments and services were participating in the quality assurance program.
Refer to Tag A0275

B. The governing body failed to enforce its own plan for frequency of data collection and reporting.
Refer to Tag A0277

C. The hospital's governing body failed to assure the quality of all services provided by the facility.
Refer to Tag A0310

Based on record review and interview, the facility failed to assure all hospital departments and services were participating in the quality assurance program. 23 of 31 Patient/Professional Services failed to report quality data to the Quality Council. Quality Council failed to report 18 of 31 Patient/Professional Services to the Medical Executive Committee and Board of Directors.


Findings include:

Review of the document entitled, " 2011 Planned Approach To Continuous Quality and Performance Improvement, " revealed the following:
"The Facility is a 536 bed acute care general medical/surgical not-for-profit hospital. Services that impact processes that affect patient care outcomes, directly or indirectly, are included in the Continuing Quality & Performance Improvement Process. Such services and groups include, but are not limited to the following: "

PATIENT/PROFESSIONAL SERVICES
Anesthesia Services
Breast Care Center
Cardiopulmonary Services
-Cath Lab
-CVICU
-CVOR
-CV Rehab
-Noninvasive Lab
-Pulmonary Lab
-Perfusion Service
Case Management
Day Surgery
Diagnostic Reference Lab
Dietary / Food Service
Emergency Services
-Air One Services
-Emergency Department
-Trauma Center
Food/Nutrition Services
G.I. Laboratory Services
Healthy Connections
Hemodialysis
Imaging Services & Mobile Diagnostics
Incontinence Clinic
Laboratory Services
Maternal/Child Care Services
-Family Birthplace
-Pediatric
Medical Staff Services
Neurodiagnostics
-EEG/EMG
-Interop Monitoring
-Sleep Disorders Lab
Nursing Services
-Chaplain/Patient Representative
-Education
-Infection Control
-ICU ' s
-Nursing Units
-Staffing
Nutrition Services
Oncology (Inpatient)
Pain Management
Pathology Services
Pharmacy Services
Psychiatric Services (Behavioral Health Center)
Rehab Services (Acute Care)
Referral Services
Surgical Services
-Inpatient
-Outpatient
Transplant Services
Mammography/Mobile Diagnostics
Wound Care Center

Review of Quality Council Committee minutes, Medical Executive Committee (MEC) minutes, and Board of Directors minutes from September 2010 to October 2011 revealed the following:
A. Departments /Services Reporting Quality Data to the Quality Committee
Behavioral Health
Core Measures
Emergency Department
Employee Health
Fall Risk
Infection Control
Lab
Pulmonary
Security
South Broadway
Staffing Effectiveness
STEMI
Stroke
Transplant
Trauma
Value Based Purchasing (VBP)
VAP (ventilator associated pneumonia)
Core Measures
Wound Healing Center

B. Departments /Services Reporting Quality Data to the MEC
Behavioral Health
Anatomical Pathology Contracted Service
Anesthesiology MDA Contracted Service
Centralized Credentialing Services
Core Measures
Emergency Department
Infection Control
Lithotripsy Contracted Service
Medical Records
Medical Staff
Peer Review
Pharmacy
Schumacher Physician Contracted Service
Sleep Disorders Center Contracted Service
Sleep Lab
Transplant
UR
Virtual Radiologic Consultant Contracted Service
Wound Healing Center Contracted Service

C. Departments /Services Reporting Quality Data to the Board of Directors
Behavioral Health
Anatomical Pathology Contracted Service
Anesthesiology MDA Contracted Service
Centralized Credentialing Services
Core Measures
Emergency Department
Environment of Care Annual Evaluation
Infection Control
Lithotripsy Contracted Service
Medical Records
Medical Staff
Peer Review
Pharmacy
Schumacher Physician Contracted Service
Sleep Disorders Center Contracted Service
Sleep Lab
Transplant
UR
Virtual Radiologic Consultant Contracted Service
Wound Healing Center Contracted Service

D. There was no evidence that the Quality Council received or reviewed any quality data from the following departments:
Anesthesia Services
Breast Care Center
Case Management
Day Surgery
Diagnostic Reference Lab
Dietary / Food Service
Food/Nutrition Services
G.I. Laboratory Services
Healthy Connections
Hemodialysis
Imaging Services & Mobile Diagnostics
Incontinence Clinic
Maternal/Child Care Services
Medical Staff Services
Neurodiagnostics
Nutrition Services
Oncology (Inpatient)
Pain Management
Pathology Services
Pharmacy Services
Rehab Services (Acute Care)
Referral Services
Mammography/Mobile Diagnostics

E. There was no evidence that the MEC or the Board of Directors received or reviewed any quality data from the following departments:
Breast Care Center
Case Management
Day Surgery
Diagnostic Reference Lab
Dietary / Food Service
Food/Nutrition Services
G.I. Laboratory Services
Healthy Connections
Hemodialysis
Incontinence Clinic
Laboratory Services
Maternal/Child Care Services
Nutrition Services
Oncology (Inpatient)
Pain Management
Rehab Services (Acute Care)
Referral Services
Mammography/Mobile Diagnostics

Further review of the document entitled, " 2011 Planned Approach To Continuous Quality and Performance Improvement, " revealed the following:
" The Quality Council has been delegated the authority and responsibility to see that performance improvement is successfully implemented throughout the organization in a timely continuous manner. "
AND
" C. Departmental/Service Responsibilities:
-Department specific continuous Quality Improvement project selection, implementation, project updates, continuous improvement monitoring/trending using appropriate aggregate data driven control charts, corrective action plans, and measured outcomes of those actions shall be reported through the appropriate Vice President and the Quality Council.
-Submit reports to the Quality Council on a bi-monthly basis. "

During an interview on 11/9/2011 at 9:15am in the nursing conference room, staff #23 reported the following:
-There is no set schedule for departmental reporting to the Quality Council
-Some departments and services report directly to the MEC and do not report to the quality council
-The CEO and the Chief of Staff determine what will be reported to the MEC and the Board of Directors
-Generally only one to two departments (in addition to the standing Performance Improvement Teams) report at the quality council meeting; therefore, all departments do not report during a given year.

Based on record review and interview, the facility failed to follow and enforce its own plan for frequency of data collection and reporting. Departments are not required to report quality data to the Quality Council, Medical Executive Committee, or the Board of Directors on a scheduled basis.

Findings include:
Further review of the document entitled, " 2011 Planned Approach To Continuous Quality and Performance Improvement, " revealed the following:
" The Quality Council has been delegated the authority and responsibility to see that performance improvement is successfully implemented throughout the organization in a timely continuous manner. "
AND
" C. Departmental/Service Responsibilities:
-Department specific continuous Quality Improvement project selection, implementation, project updates, continuous improvement monitoring/trending using appropriate aggregate data driven control charts, corrective action plans, and measured outcomes of those actions shall be reported through the appropriate Vice President and the Quality Council.
-Submit reports to the Quality Council on a bi-monthly basis. "
AND
" D. Performance Improvement Team Responsibilities
-Submit appropriate reports to the Quality Council on a bi-monthly basis "
AND
" Chartered Permanent, Medication Use Team: ...Information is summarized for presentation to the Quality Council. "
AND
" Chartered Permanent, Infection Control Team: ...Information is summarized for presentation to the Quality Council. "
AND
" Chartered Permanent, Medical Record Team: ...Information is summarized for presentation to the Quality Council. "

Review of " Attachment A of " 2011 Planned Approach To Continuous Quality and Performance Improvement, " revealed that the Performance Improvement Teams were scheduled to report to the Quality Council on a quarterly, rather than a bi-monthly basis.

Review of Quality Council Committee minutes, Medical Executive Committee (MEC) minutes, and Board of Directors minutes from September 2010 to October 2011 revealed the following:
A. There was no evidence that the Quality Council received or reviewed any quality data from the following departments:
Anesthesia Services
Breast Care Center
Case Management
Day Surgery
Diagnostic Reference Lab
Dietary / Food Service
Food/Nutrition Services
G.I. Laboratory Services
Healthy Connections
Hemodialysis
Imaging Services & Mobile Diagnostics
Incontinence Clinic
Maternal/Child Care Services
Medical Staff Services
Neurodiagnostics
Nutrition Services
Oncology (Inpatient)
Pain Management
Pathology Services
Pharmacy Services
Rehab Services (Acute Care)
Referral Services
Mammography/Mobile Diagnostics

B. There was no evidence that the MEC or the Board of Directors received or reviewed any quality data from the following departments:
Breast Care Center
Case Management
Day Surgery
Diagnostic Reference Lab
Dietary / Food Service
Food/Nutrition Services
G.I. Laboratory Services
Healthy Connections
Hemodialysis
Incontinence Clinic
Laboratory Services
Maternal/Child Care Services
Nutrition Services
Oncology (Inpatient)
Pain Management
Rehab Services (Acute Care)
Referral Services
Mammography/Mobile Diagnostics


During an interview on 11/9/2011 at 9:15am in the nursing conference room, staff #23 reported the following:
-There is no set schedule for departmental reporting to the Quality Council
-Some departments and services report directly to the MEC and do not report to the quality council
-The CEO and the Chief of Staff determine what will be reported to the MEC and the Board of Directors
-The Medication Use, Infection Control, and Medical Record Teams do not make summary reports to the Quality Council
-Generally only one to two departments (in addition to the standing Performance Improvement Teams) report at the quality council meeting; therefore, all departments do not report during a given year

Based on record review and interview, the governing body (Board of Directors) failed to assure the quality of all services provided by the facility. The Board of Directors failed to require the Quality Council to report data for 18 of 31 Patient/Professional Services to the Board.


Findings include:

Review of Quality Council Committee minutes, Medical Executive Committee (MEC) minutes, and Board of Directors minutes from September 2010 to October 2011 revealed no evidence that the MEC or the Board of Directors received or reviewed any quality data from the following departments:
Breast Care Center
Case Management
Day Surgery
Diagnostic Reference Lab
Dietary / Food Service
Food/Nutrition Services
G.I. Laboratory Services
Healthy Connections
Hemodialysis
Incontinence Clinic
Laboratory Services
Maternal/Child Care Services
Nutrition Services
Oncology (Inpatient)
Pain Management
Rehab Services (Acute Care)
Referral Services
Mammography/Mobile Diagnostics

During an interview on 11/9/2011 at 9:15am in the nursing conference room, staff #23 reported the following:
-There is no set schedule for departmental reporting to the Quality Council
-Some departments and services report directly to the MEC and do not report to the quality council
-The CEO and the Chief of Staff determine what will be reported to the MEC and the Board of Directors
-Generally only one to two departments (in addition to the standing Performance Improvement Teams) report at the quality council meeting; therefore, all departments do not report during a given year.

Based on interview and document review the facility failed to ensure the Registered Nurse supervised and addressed the nursing care of 1 of 1 patients.

On 11/8/2011 at 9:30 AM during interview and observation of patient #38 and her family it was revealed the patient was a diabetic, and had four decubiti (1 on her heal, 2 on sacral area and a large area of her abdominal skin fold). It was also revealed during the interview with the family that the patient was eating less than 25% of most meals while hospitalized. the patient was positioned on her back in a low air loss bed for pressure relief. The bed rails were pulled up. The over bed table was within reach of the patient with a 15 GM bottle of Nystatin powder and Xanaderm 60 GM tube resting on the table.

A review of the patient's medical record (MR) revealed the initial nursing assessment recorded the following: There was no physician's order for medication to be left at bed side. The patient was admitted on 11/5/2011. On the initial nursing assessment the notations reflect the current diet is listed as regular, no chewing or swallowing problems are identified and the patient admits to eating less than 50% of her meals. The nurses assessment records a Braden scale of 11-15 High Risk. The nurses assessment reflects a Morse fall scale of greater than 45- a fall risk. Initial laboratory results were recorded on 11/6/2011 for a general chemistry which did not include an albumin or pre-albumin. The WOCN assessment was documented in the MR as completed 11/7/201. The assessment includes a physical description the each of the four (4) wounds (length, width, edges, peri wound tissue, color, percentage of viable tissue, granulation percentage, necrosis, exudate, odor, drainage, debridement, wound improvement, dressing type and Action taken)

An interview with staff #35 revealed she received the referral for the nutritional assessment as part of new patient admission protocol. She indicated she did not realize the patient was diabetic with multiple wounds until after her assessment on 11/8/2011.

The Wound Ostomy Care Nurse (WOCN) was interviewed regarding the patient. She indicated she was familiar with the patient and had completed her wound assessment. When asked if she had made a nutritional referral she stated "no, I could have but I just didn't" The patient's pre-albumin was recorded as 5 and the albumin as 1.3. Normal albumin is 3.5 or greater. A diabetic wound patient with an albumin of 1.3 does not have the protein resources to heal a wound. The patient had four (4) wounds.

Nursing documentation on the medical surgical unit did not indicate the nurses staff was aware of the significance of intervention with a diabetic patient with multiple wounds. There was no nursing documentation in the WOCN assessment indicating laboratory results were reviewed. There was no documentation the WOCN had identified the Low Album level of 1.3. There was no documentation a dietary consult had been recommended to the physician or the dietician. The WOCN did not indicate she made a dietary referral after the wound assessment. The dietary consult occurred greater than 77 hours after admission. The nursing Patient Care Management Report reflected: Plan #1; Admission check list. Plan #2; Patient daily goals to include, turn every Q2H, update Morse scale and Braden scale, .... Plan #4 activity/ mobility and Physical Therapy objectives... Plan #5 diabetes management to include evaluation continuous, American Diabetic Assassination (ADA) diet as ordered, adult subcutaneous insulin as ordered, blood glucose before meals and at bed time/ Plan #6 medication management. Registered Dietician objective: meet patient nutritional requirements, daily weight, monitor intake, monitored fluid balance, nutritional consult per condition at admission, progress diet as tolerated. Plan wound care evaluations ordered, assess comfort needs and manage appropriately, provide patient and family education as needed, wound treatment, turn Q2H.

Based on observation and policy review the facility failed to ensure a drug storage area was administered in accordance with acceptable professional principles as evidenced by 1 of 1 medication cart.

On 11/8/2011 on the 3NC nursing unit the mobile medication cart was found to be unlocked. The cart was not in direct view of any licensed staff. The following medications were documented as unsecured: Carbenzapine 200 mg #8, Haloperidol 5 mg #1, Lactulose 15 ml, Seroquel 50 mg #4, Seroquel 100mg #2, Senna #12, Guifenasin 600 mg, Amlodepine 5mg #2, Tylenol liquid 4 oz bottle, Albuterol and Spireva tablets, Docusate, Cholecalceferol 400 unit tabs,Pradaxa 150 mg #4, Chlorhexadene oral rinse.

On 11/8/2011 during a patient interview, two (2) physician ordered topical skin treatments (Nystatin powder and Xanaderm cream) were observed on the patients over bed table. A review of the patient record revealed no physician order for medication to be kept at the bed side.

A review of facility Pharmacy policy 3.1 revealed the following: Item #6 Drugs kept in stock outside the pharmacy will be secured by the use of locks, security seals, tamper-evident seals, or direct supervision of authorized personnel. Medication carts that are nit under direct supervision by authorized personnel must be locked.

Based on observation, interview and document review the facility failed to ensure safe practices in food handling, supervision of personnel performance of job duties and participation in quality assessment and process improvement for the dietary department.

On 11/8/2011 at 9:30 AM a tour of the dietary department revealed the following: A) observation of melted ice cream, curly fries and hash browns on the floor in the freezer that had not been cleaned. Freezer items opened and rewrapped without a date opened. B) an opened jar of horse radish in the cooler without a use by date, an opened gallon container of salad dressing in the cooler without a use by date,C) thawed pork in the cooler without a thaw date or use by date.

On 11/8/2011 at 10:30 Am the Dietary supervisor confirmed all the findings of deficient practices with concerns to infection control issues and monitoring of refrigerator and freezer temperatures in the Dietary Department.

Also during the tour of the dietary department on 11/8/2011 the refrigeration temperature (temp) logs were reviewed and reflected the following: February 6/28 days had no temp recorded, 17/31 days had no temp recorded, April 6/30 days had no temp recorded, June 10/30 days had no temp recorded, July 12/31 days had no temp recorded, August 10/31 days had no temp recorded, September 20 /30 days had no temp recorded.
A review of freezer temps revealed the following: February 7/28 days had no temp recorded, March 17/31 days had no temp recorded, April 5/30 days had no temp recorded, June 11/30 days had no temp recorded, July 13/31 days had no temp recorded, August 7/31 days had no temp recorded, September 20/30 days had no temp recorded.

Review of Facility policy #8 HACCP:Temperature Records under procedure: Item 2. Bulk storage temperatures (walk-in Cooler and Freezers). these will be checked at least twice per day. No cooler or freezer temp was recorded twice per day. Each temp reflected once daily check with days omitted each month.
Policy #9A1 kitchen sanitation item #1 Spills and dropped food items are to be picked up immediately. #2 Floors are swept and mopped at least once per day using Oasis floor cleaner.
Policy #6A1 Planned approach to quality improvement, under procedure; Quality control indicators will be in place to ensure that all foods area received, stored, prepared and served in a manner that insures the safety, palatability and nutritional content to the greatest extent possible. Current indicators may include: #1. HACCP temperature policies, #1 Safety and/or sanitation inspections by department staff. These two quality indicators were not observed as evidenced by the above findings.

Based on observation, interview, and record review, the hospital failed to ensure that the infection control policies were implemented and enforced in all departments of the facility. These deficient practices have potential to create an environment that puts all patients in the facility at risk for exposure to infectious and communicable diseases.

A. Provide a sanitary environment to ensure patient's health and safety.

Findings included:
1. On 11/7/2011 at 10:00 AM a walking tour of the linen/laundry service area was conducted. Staff # 24 was present to guide the tour and explained the flow of work beginning with the contaminated linen drop off area. Linen was brought into a separated work area in bags. Employees opened the bags and emptied the linen on to the floor. On the initial visit contaminated linen was observed stacked against the right side of the collection area to within 3 feet of the ceiling. The contaminated linen extended to the middle of the collection area. This receiving area held 50 gallon containers of laundry chemicals on wooden pallets and a linen cart. There was 1 ceiling tile that was missing and 2 ceiling tiles that had fallen down in a dropped ceiling over the sorting area. Visible on the floor of the contaminated linen drop area was gloves, disposable patients' chucks, and a Band-Aid as well as soiled linen. Staff #24 explained the linen was emptied by the staff and sorted. The contaminated drop off area lead to the commercial washers. The same staff who emptied the contaminated linen bags filled the commercial washers.

2. During this same tour of contaminated linen sorting, observation revealed that the contaminated area led to the open delivery dock. Contaminated linen was observed on the concrete floor beneath the commercial washer doors and in visibly soiled areas against the sides of the washers and adjacent walls. A small pile of gloves was visible on the floor against the smaller washer used for scrubs. Both staff #24 and #33 reported these gloves had been removed form the drain below the washers and had not been thrown away. Paper debris, large quantities of lint, as well as remnants of plastic bags were visible on the floor very near the commercial washers. Carts, which were being used to store unopened boxes, were observed with soiled covers and casters that were heavily soiled as well as a build up of dirt and lint between the cart casters and the concrete wall. A Commercial washer remained in use even after it had been reported with a large volume of wash water leaking from it. The water had run the length of the back hall to the main contaminated linen sorting area. Staff were walking through the dirty water to load the commercial washers.

3. Staff #24, who is the day supervisor, exited the dirty linen area and entered the clean linen area. Staff were observed sorting clean linen from deep rolling bins. The same employees who were observed on the contaminated linen sorting area were observed taking clean linen from the washers and emptying the clean linen into the deep rolling bins. These rolling bins were pushed to the dryers where the same employees from the contaminated linen side picked up the clean wet linen and placed it into dryers. When the driers stopped the same employees from the contaminated linen side removed the clean linen from the driers and placed the linen into deep rolling bins to be sorted and folded by staff who worked entirely in the clean area. No Personal Protective Equipment (PPE) was worn by any employee from the contaminated linen area during transfer of clean wet linen and clean dry linen. Staff who handled contaminated linen moved freely and frequently between the two areas for the purpose of handling clean linen .

4. During this tour, the floor of the clean linen area was littered with lint, gloves, and clean linen that had fallen from the deep rolling bins. Linen that had fallen to the floor wet was observed as dried and brown in color. There was heavy lint beneath a piece of machinery used to iron and fold sheets. There was visible linen on the floor beneath the same piece of machinery. A table, identified by staff #24 as the sheet folding table, had a second level surface 8 inches above the floor. This surface was covered with unfolded linen, an empty 5 gallon white container, a large book and a broken piece of metal framing. Staff #29 was working at the folding table pulling clean sheets from a tall bin and laying them across the table in preparation to place the sheets into the ironing machine. Linen behind this worker was observed to be stacked against an open corner of the wall and draped across a tall electric fan. The fan was observed to have heavy lint on the blades and grill . All of this linen was adjacent to the linen in the tall bin. Four (4) sheets were observed to be dropped on to the floor by the employee as she pulled sheets from this tall bin. She picked each sheet up and threw it back into the stack of clean linen.

5. During the same tour, bagged linen and unopened boxes were observed on the floor against the wall and against clean linen that was stored on carts with poorly fitting covers. Clean linen was observed being transferred from driers to folding areas and dragging behind the carts on the floor. The linen was then folded and placed into the clean linen carts for delivery to the patient care units of the hospital. Clean folded patient gowns were observed on a square cart next to an open round barrel that had boxes labeled "Laundry" in them. Ceiling tiles were observed missing above the clean linen work area. Heavy lint was observed against the walls and beneath the ironing and folding machinery. Laundry employees were observed taking their break in the immediate area of the loading docks. There was no hand washing observed by employees upon returning from their breaks.

B. The facility failed to insure initial and follow-up in-service training to laundry employees in the area of transporting, processing, and handling of clean or soiled linen for the protection of the both patients and employees in 9 of 9 laundry employees interviewed.

1. On 11/8 -9/2011 through out the day in the laundry department nine (9) department staff were interviewed. Staff ( #24, 25, 26, 27, 28, 29, 30, 31, and 32) confirmed they had not been in-serviced or received any training after they hired on and began working for the hospital in the laundry department. Staff #26 was asked if she had received any training prior to going to work in the laundry department to which she replied. "Why do I need training, I do this at home"? Staff # 27 stated "its just washing and folding."

2. On 11/9/2011 in the 2nd floor conference room a review of employee files for all staff (#24. 25, 26, 27, 28, 30, 31, and 32) confirmed no training since date of hire was documented in staff personnel files.

C. The facility failed to ensure employees who have contact with contaminated linen shall wear gloves and other appropriate personal protective equipment (PPE).
1. During a tour of the laundry department on 11/7/2011 staff #32 was observed opening contaminated linen bags and emptying them in the contaminated linen sorting area. He was not wearing gloves or any other PPE.

2. On 11/8/2011 while looking through the window in the door of the contaminated laundry sorting area staff #31 was observed using only gloves for PPE. Contaminated laundry was stacked within 3 feet of the ceiling on both sides of the corridor.

3. On 11/9/2011 at 1:00 PM, Staff #30 was interviewed in the back hall way of the contaminated linen area. He was not wearing any PPE. Although he stated PPE was used, none was found in the contaminated laundry area.

4. During the three days of observation of laundry services, one staff member working in the contaminated laundry area did not wear gloves, and 2 other staff wore only gloves. No staff was observed using any other PPE. No employee used shoe covers. No employee wore protective gowns over their scrubs when sorting contaminated linen. No staff were observed using hand hygiene after sorting contaminated linen.

5. On 11/9/2011 at 2:00 PM in the 2nd floor conference room, staff #3 was interviewed . When asked if he had ever entered the laundry department for observation he stated, "Yes, I feel like I should burn my shoes each time I leave there." Facility upper management was aware of the lack of sanitation in the laundry area and failed to implement changes that would protect its employees.

D. The facility failed to ensure contaminated linen was handled as little as possible, as evidenced by observation of three (3) days of collected contaminated linen.

1. During an initial tour of the contaminated linen collection site on 11/7/2011, linen was being removed from bags and thrown on the floor. The linen was stacked against one wall in the corridor to with in three (3) feet of the ceiling. The linen was then picked up from the floor and placed in collection carts and taken to the commercial washers. Linen was then removed from the collection carts and placed into the commercial washers.

2. During observation on 11/8/2011, contaminated linen was being removed from bags. The linen was being emptied onto the floor. Linen was stacked to within three (3) feet of the ceiling on both sides of the corridor. The linen was then picked up from the floor and placed in collection carts and taken to the commercial washers. Linen was then removed from the collection carts and placed into the commercial washers.

3. During observation on 11/9/2011, contaminated linen was being removed from bags and emptied onto the floor. The entire corridor was stacked with contaminated linen forming a wall from the left side of the corridor to the right side of the corridor so that no employee was visible from the door.
Laundry staff sorted the linen from the floor into carts and rolled them to the commercial washers. At not time was the floor in the contaminated area free from linen. The linen was then picked up from the floor and placed in collection carts and taken to the commercial washers. Linen was then removed from the collection carts and placed into the commercial washers.

E. The facility failed to ensure that linen were washed in hot water with a temperature of at least 71 degrees Centigrade (160 degrees Fahrenheit) for 25 minutes. As evidenced by no documentation of temperature tracking provided for review.

1. On 11/7/2011, after the tour of the laundry services department, staff #24 was questioned regarding on-going quality assessment or process improvement for the department. Specifically if temperature were tracked. No recorded data for tracking temperature of commercial washers was provided for review. Staff #24 indicated the commercial washers dispensed the detergent automatically and also insured the temperature settings. No data was provided to ensure the commercial washers reached the desired temperature for heat and safe cleansing of contaminated linen.

F. The facility failed to ensure proper food handling techniques of food storage and sanitation in 3 of 3 observations.

1. On 11/8/2011 at 9:30 AM, a tour of the dietary department revealed the following: a) observed melted ice cream, curly fries and hash browns on the floor in the freezer that had not been properly cleaned. b) an opened jar of horse radish without a use by date, an opened gallon container of salad dressing without a use by date, freezer items opened and rewrapped without a date opened. c) thawed pork in the cooler without a thaw date or use by date.

G. The facility failed to ensure the dietary staff complied with job specific duties as evidenced by incomplete refrigerator and freezer temperature logs for 2/2011, 3/2011, 4/2011, 6/2011, 7/2011, 8/2011, and 9/2011.

1. During the tour of the dietary department on 11/8/2011, the refrigeration temperature (temp) logs were reviewed and reflected the following: February 2011: 6 of 28 days had no temp recorded, March 2011: 17 of 31 days had no temp recorded, April 2011: 6 of 30 days had no temp recorded, June 2011: 10 of 30 days had no temp recorded, July 2011: 12 of 31 days had no temp recorded, August 2011: 10 of 31 days had no temp recorded, September 2011: 20 of 30 days had no temp recorded.

2. A review of freezer temps revealed the following: February 2011: 7 of 28 days had no temp recorded, March 2011: 17 of 31 days had no temp recorded, April 2011: 5 of 30 days had no temp recorded, June 2011: 11 of 30 days had no temp recorded, July 2011: 13 of 31 days had no temp recorded, August 2011: 7 of 31 days had no temp recorded, September 2011: 20 of 30 days had no temp recorded.

Review of Facility policy HACCP:Temperature Records Policy #8 Under procedure: Item 2. Bulk storage temperatures (walk-in Cooler and Freezers). these will be checked at least twice per day.

3. No cooler or freezer temp was recorded twice per day. Each temp reflected once daily check with days omitted each month.

Interview with Dietary Department Director on 11/8/2011 confirmed all the findings of deficient practices with concerns to infection control issues and monitoring of refrigerator and freezer temperatures in the Dietary Department..

Based on interview and record review the facility Administrative staff including the Director of Quality, hospital Chief Executive Officer, Medical Staff, and Governing Body failed to take responsibility to ensure that deficiant practices identified in the infection control program were addressed in the hospital wide Quality Assurance Performance Improvement (QAPI) and/or addressed in the Medical Executive Committee.

Findings include:
Review of meeting minutes from the Medical Executive Committee from 10/2010 thru 9/2011 revealed no documentation of infection control issues concerning the Linen and Laundry Department being addressed in these meetings.

Interview with staff #12 on 11/9/2011 confirmed infection control issues found and addressed in the Linen and Laundry Department on weekly facility tours were not addressed in the hospital wide QAPI program. The rounds were made with the Plant Engineer and Director of Housekeeping every Friday morning. All findings were sent to the Director of Safety and then its forwarded up the chain of command. She advised, "The information collected had been forwarded for years and findings were never addressed to our knowlegde. If they were addressed we were never advised of corrective action plans or given any feedback about our concerns. The Director of Linen and Laundry proposed the possibility of moving the department to an off-campus site that could provide adequate space to address some of the crowding issues. We never received any feedback concerning this issue except for amount if would cost to move to another site."

Based on record review and interviews the facility fail to assign an individual to be responsible for outpatient services and accountable to the Quality Committee, Governing Body and failed to ensure services were organized and integrated with inpatient services.

During the review of the Quality Counsel Committee meeting minutes from September 2010 to October 2011, records of the Medical Executive Committee meeting minutes from October 2010 to September 2011 and review of the Board of Directors meeting minutes from October 2010 to September 2011 there was evidence that the facility was monitoring out patient services to ensure services were meeting the needs of the patients in accordance with acceptable standards of practice.

Refer to tag A1077
Refer to tag A 1079

Based on record review and interviews the facility failed to develop policies and procedures for Out Patient Services ' that would provide for a clearly defined and organized department of the hospital.

During the review of the Quality Counsel Committee meeting minutes from September 2010 to October 2011 provided no evidence of reporting by the Out Patient Service Department. No evidence was provided that Out Patient Services was integrated with inpatient services.

During the review of the Medical Executive Committee meeting minutes from October 2010 to September 2011 provided no evidence of reporting by the Out Patient Service Department. No evidence was provided that Out Patient Services ' was integrated with inpatient services.

During the review of the Board of Directors meeting minutes from October 2010 to September 2011 provided no evidence of reporting by the Out Patient Service Department.

During an interview with Staff #2 at 2:15PM on 11/7/2011 in the Nursing Conference Room revealed the facility had no policies and procedures specific to an Out Patient Service Department. When asked who is responsible for the over site and how are the Out Patient Services monitored, tracked and reported for quality and patient safety. Staff #2 provided an explanation that each department that provides an out patient service does their own monitoring and data collection and reports to the Quality Counsel but the information is included in the departmental report and is not reported as an Out Patient Service. The example was given that Staff #4 would be over Radiology, Lab and Nuclear Medicine. Staff #2 was asked who was responsible for the other Out Patients Services the facility provides, (examples given were the off campus Emergency Room Services, Behavioral Health Service, Wound Care Services, and Sleep Center Services). Staff #2 responded, did not know and would have to talk with Staff #4.

During an interview with Staff #23, the Director of Quality, at 10:00AM on 11/9/2011 in the Nursing Conference Room, provided the explanation; Out Patient Services are provided by the hospital ' s departments. The hospital ' s departments are responsible for the quality of services provided along with the monitoring and gathering of data and reporting that to the Quality Counsel. Staff #1, the CEO, would be the Director of those services. Staff #23 was unsure if the hospital departments were reporting on their Out Patient Services.

During an interview with Staff #1, the CEO, at 10:45AM on 11/9/2011 in his office confirmed, each of the hospital ' s departments that provides Out Patient Services do so along with inpatient services. These services are not under an organized Outpatient Service Department. Staff #1 confirmed he was the Director of those services.

Based on record review and interviews the facility failed to appoint a single individual that was accountable for outpatient services provided by the hospital.
During the review of the Organizational Chat revealed the responsibility of hospital ' s Out Patient Services were assigned to four separate staff members. No single person was accountable for the facilities Out Patient Services.
During the review of the Quality Counsel Committee meeting minutes from September 2010 to October 2011 provided no evidence that a single person was accountable for the facilities Out Patient Services.
During the review of the Medical Executive Committee meeting minutes from October 2010 to September 2011 provided no evidence that a single person was accountable for the facilities Out Patient Services.
During the review of the Board of Directors meeting minutes from October 2010 to September 2011 provided no evidence that a single person was accountable for the facilities Out Patient Services.
During an interview with Staff #2 at 2:15PM on 11/7/2011 in the Nursing Conference Room revealed the facility had no policies and procedures specific to an Out Patient Service Department. When asked who is responsible for the over site and how are the Out Patient Services monitored, tracked and reported for quality and patient safety. Staff #2 provided an explanation that each department that provides an out patient service does their own monitoring and data collection and reports to the Quality Counsel but the information is included in the departmental report and is not reported as an Out Patient Service. The example was given that Staff #4 would be over Radiology, Lab and Nuclear Medicine. Staff #2 was asked who was responsible for the other Out Patients Services the facility provides, (examples given were the off campus Emergency Room Services, Behavioral Health Service, Wound Care Services, and Sleep Center Services). Staff #2 responded, did not know and would have to talk with Staff #4.
During an interview with Staff #23, the Director of Quality, at 10:00AM on 11/9/2011 in the Nursing Conference Room, provided the explanation; Out Patient Services are provided by the hospital ' s departments. The hospital ' s departments are responsible for the quality of services provided along with the monitoring and gathering of data and reporting that to the Quality Counsel. Staff #1, the CEO, would be the Director of those services. Staff #23 was unsure if the hospital departments were reporting on their Out Patient Services.
During an interview with Staff #1, the CEO, at 10:45AM on 11/9/2011 in his office confirmed, each of the hospital ' s departments that provides Out Patient Services do so along with inpatient services. These services are not under an organized Outpatient Service Department. Staff #1 confirmed he was the Director of those services.

Based on interview and document review the facility failed to meet the requirement for rehabilitation services as evidenced by rehabilitation service being provided within the hospital without contractual agreement.

On 11/9/2011 at 10:00 Am the Director of the Rehabilitation Department was interviewed in his office. During the interview the Director was questioned regarding the quality assessment and process improvement (QAPI) for his department. He responded by stating "all my data is submitted to the rehab hospital across the street." Upon further investigation it was determined that the rehabilitation hospital across the street is a free standing rehabilitation hospital, not under the provider number for the acute care hospital. The rehabilitation hospital is currently providing staff and services for the acute care hospital. A request was made, of the acute care hospital, for evidence of a contract for provision of rehabilitation services by the rehabilitation hospital. The contract supplied by the acute care hospital was for ancillary services the acute care hospital provided for the rehabilitation hospital. The acute care hospital was unable to provide a contract, facilitating rehabilitation services provided to the acute care hospital,by the rehabilitation hospital.

There was no documentation the Governing Body was aware the acute care facility did not have a contract for services with the rehabilitation hospital. There was no documentation of a review of services in the medical staff or governing body meeting minutes. There was no documentation of approved rehabilitation service within the acute care hospital. There was no documentation of quality assessment and process improvement submitted to the acute care hospital from the rehabilitation hospital.