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Based on observation, interview, and record review, it was determined that the dietary services were not directed and staffed by adequate qualified personnel to ensure food sanitation safety and ensure the patients nutritional needs are being met.
The cumulative effect of the systemic findings resulted in the condition for participation as not being met.

The findings included:

1) During the initial kitchen/food service observational tour conducted with the facility's Dietary Manager on 05/21/18 at 9:30 AM, the following were noted:

(a) The door gasket of the walk-in refrigerator had a large tear of approximately. 1.5 feet and was covered in a black mold type substance. The floor of the unit was rusted with large areas on build-up water. The Manager stated that the floor requires replacement. It was also noted that there were 2 - 5 pound containers of cottage cheese that were expired with an expiration date of 05/17/18/

(b) Observation of the walk-in refrigerator noted that there were foods that were not properly wrapped or covered and were exposed to the freezer air that included uncooked corn, French, fries, and cooked sausage patties.

(c) Observation of the True reach-in refrigerator #3 noted that there was a large crack in the door gasket that could lead to improper holding temperatures. Observation of the refrigerator contents noted undated prepared foods that included; cheese sandwiches, and portions of prepared egg salad. \ It was also noted expired foods with labels that included; pan of sausage gravy - expired 05/10/18 and pan of pureed bread - expired date of 05/07/18

(d) Observation of True reach-in refrigerator #2 noted numerous quart containers of foods without an expiration date that included: canned peaches, canned apples, and canned apricots, parmesan cheese, and cheddar cheese.. It was also noted numerous labeled expired foods that included; pureed fruit - expiration date of 05/18/18 and pureed peaches -expiration date of 05/18/18.

(e) Observation of the hand wash sink noted that a cart of nutritional supplement were stored directly touching the sink area. The supplements could potentially become contaminated stored too close to the sink area.

(f) A chemical test of the cleaning rag bucket revealed that 1 of 3 buckets did not contain a chemical sanitizing solution present as per regulatory requirement. It was also noted that 3 soiled cleaning rags were being stored on clean food preparation surfaces and should have been stored in a chemical solution when not in use.

(g) The floor drain under the food preparation table had an exposed catch basin that was covered in garbage and black mold type matter.

(h) Observation noted that an opened package of raw ground beef (10 pounds) was left on a cart at room temperature. The surveyor requested the cook (Staff A) to take the temperature of the raw ground beef. It was then noted that the cook stuck the raw ground beef without properly calibrating the thermometer and then stuck the beef with the bayonet thermometer without properly sanitizing it prior to taking the temperature. When the thermometer was properly sanitized and calibrated it was noted that the ground beef was not being held at the required internal temperature of 41 degrees F or below and was recorded at 44 degrees. The marinara sauce was recorded at 53 degrees F.

(i) An opened can of food thickener was noted to be located on a food preparation table. An observation of the can revealed that it was not labeled with an opening date.

(j) Observation of the commercial food slicer noted areas of dried food matter around the slicing blade surface and had not been properly cleaned since the last use.

(k) Observation of the dish machine room noted that clean silverware was not being stored in a sanitary manner. Specifically there were 6 cylinders of clean silverware with the eating portion stored in an upright position. The manager stated that the silverware should have been sanitized with the eating portion in the down position.

During a second revisit to the main kitchen accompanied with the Dietary Manger on 05/22/18 at 12 PM the following were noted:

(a) The supplement cart which contained approximately 100 individual portions of supplemental drinks and foods was parked directly on the hand wash sink and trash container. The surveyor again asked the Manager to relocate to an area that the supplements would not be potentially contaminated.

(b) Observation of the large commercial cutting board which is attached to the steam table was noted to have numerous large deep grooves. Further observation noted that these grooves were filled with a black mold type substance. The surveyor requested that the board be removed and properly sanitized or replaced.

(c) Observation of the 3-compartment sink noted that the ceiling air-conditioning vent located above the sanitizing/clean area was heavily dust/dirt laden. The vent was pushing contamination dirt/dust directly down onto clean food preparation equipment.

(d) Observation of the 5 condiment bins located directly above the patient food tray assembly line were noted to be heavily soiled with dirt and dried food matter.

2) During the review of the approved menu for the lunch meal of 05/22/18 it was noted a 4 ounce portion of beef tacos, 4 ounce (#8 scoop) portion of pureed tacos, 4 ounce (#8 scoop) portion of pureed carrots, 4 ounce (3* scoop) portion of whipped potatoes, and 4 ounce cooked hamburger patty was to be served as a standard portion size. Interview conducted with the facility's Registered Dietitian on 005/22/18 also confirmed that a 4 ounce portion of the tacos, pureed meat and vegetable, and hamburger patty were to be served as a minimum serving. During the observation of the patient food tray assembly line on 05/22/18 at 12 PM it was noted that only 3 ounce portions (#12 scoop) of regular taco meat, pureed taco meat, pureed carrots, mashed potato, were being served as a standard serving portion. The hamburger patty was weighed utilizing the facility's portion control scale and was recorded at 3 ounces.

Based on record review and interview it was determined the facility failed to ensure anesthesia services were provided in a well-organized manner under the direction of a qualified doctor of medicine or osteopathy. The cumulative effect of the systematic findings resulted in the condition for participation as not being met.


The findings included:

Review of the facility Medical Staff Bylaws and Rules and Regulations conducted on 05/22/18 revealed no evidence that anesthesia services were under the direction of qualified physician.


Facility policy titled "Organization of the Anesthesia Department" dated 06/2017 documents
This policy establishes the responsibilities of provision of Anesthesia patient care. The designated Chief of Anesthesia will follow established standards of the American Society of Anesthesiologist, Medical Staff Bylaws, Rules and Regulations, and the policies/procedures of the department to direct and supervise patient care including moderate sedation.
The policy is to ensure the Chief of Anesthesia will be a qualified physician on active staff with appropriate clinical and administrative experience who is appropriately qualified and a credentialed licensed independent practitioner and delineates the responsibilities of the Chief of Anesthesia.


Review of the facility documents conducted on 05/22/18 revealed the facility did not include anesthesia services on their organizational chart.


Review of the credentialing files for the Medical Director and The President of The Medical Staff revealed no evidence the physicians have been appointed to supervise the anesthesia services in the facility or were given the authority and responsibility for directing all anesthesia services throughout the hospital. There are no appointments for a Chief of Anesthesia.

Interview with The Risk Manager conducted on 05/23/18 at 11:12 AM and 2:03 PM revealed the facility does not have director of anesthesia, all contracted anesthesiologists are responsible for their own cases.

Interview with The Chief Clinical Officer (CCO) on 05/24/18 at 10:15 AM revealed the facility did not include anesthesia services on the organizational chart and that will be corrected. The CCO explained the president of the medical staff would be responsible for anesthesia services as he is responsible for all physicians.

Upon request, the CCO reviewed the contract for the President of the Medical Staff and confirmed there is no evidence the physician has been appointed or assigned to direct or supervise anesthesia services in the facility.

Based on record review and interview it was determined the facility failed to ensure the institutional plan and budget was prepared as per the regulatory requirement. This failure is evidenced by the lack of medical staff participation.

The findings included:


Review of the facility Institutional Plan and Budget for 2018 conducted on 05/21/18 revealed no evidence the medical staff in the facility participated in the plan and budget preparation.

Interview with The Chief Financial Officer (CFO) conducted on 05/22/18 at 10:16 AM revealed the CFO and the CEO (Chief Executive Officer) prepared the plan and the budget and is approved by the governing body. The CFO confirmed there is no evidence the medical staff in the facility participated in the plan and budget preparation.

Based on record review and interview it was determined the facility failed to maintain a list of all contracted services, including the scope and nature of the services provided.

The findings included:

Review of the facility list of all contracted services provided on 05/21/18 revealed a list of general areas served as contracted services, Dialysis, House Physician, Nursing Agencies, Diagnostic Services, Echocardiogram, Radiology back up, Physical, Occupational and Language Therapy, PICC line insertion services, laboratory, Blood Bank and Surgery and Diagnostic.

On 05/22/18 a 9:22 AM and 1:41 PM, the surveyor requested again the list of contracted services to meet the regulatory requirements.

On 05/22/18 at approximately 2:30 PM, The Director of Quality Management provided a list of contracted services, the list only includes nonclinical contracts and does not include scope and services provided.

The facility failed to provide a list of all contracted services, including the scope and nature of the services provided.

Based on policy review and interview it was determined the facility failed to develop policies and procedures related to Autopsy requirements.


The findings included:


Review of the facility policy titled "Coroner Cases" dated 06/2017 failed to define the mechanism for documenting permission to perform an autopsy and failed to define a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.

Interview with The Director of Quality Management conducted on 05/22/18 at 11:48 AM confirmed the Coroner Cases policy is the only policy the facility has related to autopsies and does not address permission and notification to the medical staff.

Based on record review and interview it was determined the facility failed to ensure medical records were accurate and complete. This failure affected 3 of 6 patients (Patients #22, #23 and #24).


The findings included:

Clinical record review conducted on 05/23/18 revealed the following:

Patient #22 had a surgical procedure on 03/08/18. The perioperative record failed to document the signatures of all the team members present during the procedure.

Patient #24 was admitted to the facility on 11/18/17 and had a surgical procedure on 12/07/17. Review of the Anesthesia forms revealed discrepancies related to the date of service. The form documents the anesthesiologist physical examination prior to the procedure and the anesthesia record was completed on 11/07/17.

Patient #23 had a surgical procedure on 03/05/18. The perioperative record failed to document the signatures of all the team members present during the procedure.

Interview with The Nurse Supervisor who was navigating the electronic and paper record conducted on 05/23/18 at 11:20 AM confirmed the concerns identified above.

Based on record review and interview it was determined the facility failed to ensure results of all consultative evaluations are part of the medical record. This failure affected 2 of 6 sample patients (Patients #23 and #24).


The findings included:


1) Clinical record review conducted on 05/23/18 revealed Patient #23 had consult ordered on 10/28/17 for Plastic Surgery.
The record indicates the Plastic Surgeon performed a surgical procedure on the patient on 11/13/17. There is no evidence of the results of the consultative evaluation leading to the surgical procedure.

2) Clinical record review conducted on 05/23/18 revealed Patient #24 had consult ordered on 11/21/17 for General Surgery.
The record indicates the Surgeon performed a surgical procedure on the patient on 12/07/17. There is no evidence of the results of the consultative evaluation leading to the surgical procedure.

Interview with The Nurse Supervisor who was navigating the electronic record on 05/23/18 at 11:12 AM confirmed there is no evidence of consultation reports by the plastic surgeon for Patient #23 and for the General Surgeon for Patient #24.

Interview with The Registered Nurse, in charge of the surgical services on 05/24/18 at approximately12:17 PM revealed after review of the electronic records there is no evidence of the consults requested for Patient #23 and #24.

Based on record review and interview it was determined the facility failed to ensure medical records were complete. This failure is evident in 3 of 8 closed records reviewed (Patient #21, #23 and #26), which did not contain a discharge or expiration summary.



The findings included:


Clinical record review conducted on 05/23/18 revealed the following:

Patient #21 was admitted to the facility on 02/28/18 and discharged on 04/12/18. The record does not contain a discharge summary.

Patient #23 was admitted to the facility on 10/27/17 and discharged on 11/22/17. The record does not contain a discharge summary.

Patient #26 was admitted to the facility on 03/23/18 and expired on 04/22/18. The record does not contain a discharge or expiration summary.

Interview with The Nurse Supervisor who was navigating the electronic record on 05/23/18 at 11:30 AM revealed there is no evidence of discharge summary reports for Patients #21, #23 and #26. The Supervisor contacted the medical records department and confirmed there are no additional reports for these patients.

Based on observation, interview and facility record review, the facility and the Director of Dietary Services failed to ensure the use of safety standards for food preparation and storage.

The findings included:


1) During the initial kitchen/food service observational tour conducted with the facility's Dietary Manager on 05/21/18 at 9:30 AM, the following were noted:

(a) The door gasket of the walk-in refrigerator had a large tear of approximately. 1.5 feet and was covered in a black mold type substance. The floor of the unit was rusted with large areas on build-up water. The Manager stated that the floor requires replacement. It was also noted that there were 2 - 5 pound containers of cottage cheese that were expired with an expiration date of 05/17/18/

(b) Observation of the walk-in refrigerator noted that there were foods that were not properly wrapped or covered and were exposed to the freezer air that included uncooked corn, French, fries, and cooked sausage patties.

(c) Observation of the True reach-in refrigerator #3 noted that there was a large crack in the door gasket that could lead to improper holding temperatures. Observation of the refrigerator contents noted undated prepared foods that included; cheese sandwiches, and portions of prepared egg salad. It was also noted expired foods with labels that included; pan of sausage gravy - expired 05/10/18 and pan of pureed bread - expired date of 05/07/18

(d) Observation of True reach-in refrigerator #2 noted numerous quart containers of foods without an expiration date that included: canned peaches, canned apples, and canned apricots, parmesan cheese, and cheddar cheese.. It was also noted numerous labeled expired foods that included; pureed fruit - expiration date of 05/18/18 and pureed peaches -expiration date of 05/18/18.

(e) Observation of the hand wash sink noted that a cart of nutritional supplement were stored directly touching the sink area. The supplements could potentially become contaminated stored too close to the sink area.

(f) A chemical test of the cleaning rag bucket revealed that 1 of 3 buckets did not contain a chemical sanitizing solution present as per regulatory requirement. It was also noted that 3 soiled cleaning rags were being stored on clean food preparation surfaces and should have been stored in a chemical solution when not in use.

(g) Observation noted that an opened package of raw ground beef (10 pounds) was left on a cart at room temperature. The surveyor requested the cook (Staff A) to take the temperature of the raw ground beef. It was then noted that the cook stuck the raw ground beef without properly calibrating the thermometer and then stuck the beef with the bayonet thermometer without properly sanitizing it prior to taking the temperature. When the thermometer was properly sanitized and calibrated it was noted that the ground beef was not being held at the required internal temperature of 41 degrees F or below and was recorded at 44 degrees. The marinara sauce was recorded at 53 degrees F.

(h) An opened can of food thickener was noted to be located on a food preparation table. An observation of the can revealed that it was not labeled with an opening date.

(i) Observation of the commercial food slicer noted areas of dried food matter around the slicing blade surface and had not been properly cleaned since the last use.

(j) Observation of the dish machine room noted that clean silverware was not being stored in a sanitary manner. Specifically there were 6 cylinders of clean silverware with the eating portion stored in an upright position. The manager stated that the silverware should have been sanitized with the eating portion in the down position.

During a second revisit to the main kitchen accompanied with the Dietary Manger on 05/22/18 at 12 PM the following were noted:

(a) The supplement cart which contained approximately 100 individual portions of supplemental drinks and foods was parked directly on the hand wash sink and trash container. The surveyor again asked the Manager to relocate to an area that the supplements would not be potentially contaminated.

(b) Observation of the large commercial cutting board which is attached to the steam table was noted to have numerous large deep grooves. Further observation noted that these grooves were filled with a black mold type substance. The surveyor requested that the board be removed and properly sanitized or replaced.

(c) Observation of the 3-compartment sink noted that the ceiling air-conditioning vent located above the sanitizing/clean area was heavily dust/dirt laden. The vent was pushing contamination dirt/dust directly down onto clean food preparation equipment.

(d) Observation of the 5 condiment bins located directly above the patient food tray assembly line were noted to be heavily soiled with dirt and dried food matter.

Based on observation and interview, the facility failed to meet individual patient nutritional needs as evidenced by failure to follow the approved menu for minimum serving portions.

The findings included:

During the review of the approved menu for the lunch meal of 05/22/18 it was noted a 4 ounce portion of beef tacos, 4 ounce (#8 scoop) portion of pureed tacos, 4 ounce (#8 scoop) portion of pureed carrots, 4 ounce (3* scoop) portion of whipped potatoes, and 4 ounce cooked hamburger patty was to be served as a standard portion size. Interview conducted with the facility's Registered Dietitian on 005/22/18 also confirmed that a 4 ounce portion of the tacos, pureed meat and vegetable, and hamburger patty were to be served as a minimum serving. During the observation of the patient food tray assembly line on 05/22/18 at 12 PM it was noted that only 3 ounce portions (#12 scoop) of regular taco meat, pureed taco meat, pureed carrots, mashed potato, were being served as a standard serving portion. The hamburger patty was weighed utilizing the facility's portion control scale and was recorded at 3 ounces.

Based on observation, interview, and record review, it was determined that the hospital failed to provide a sanitary environment to avoid sources and transmission of infection in the central supply storage area, clean linens storage area, and doctors lounge.

The findings included:

1) During the observation of the Central Supply Room accompanied with the Infection Control Nurse on 05/21/18 at 10:30 AM the following were noted:

(a) The entire floor of the room was heavily soiled , stained, and littered with trash. It was noted that there were 9 cases of nutritional supplement/tube feeding (Osmolite-4, Pivot - 1, Vital-2, and Oexpa-2)) stored directly on the soiled floor. The Materials Management Clerk (Staff B) stated the floors are not being cleaned on a regular basis and agreed with the surveyor that the floors were heavily soiled. The clerk also stated that the cases of the nutritional supplement/tube feedings have been on the soiled floors for the last 7 days.

(b) Observation noted in the rear of the room were stored heavily soiled cleaning equipment that included: commercial floor buffers X 3, commercial vacuums, and commercial fan X 1. Further observation noted that these soiled pieces of commercial cleaning machines were stored directly next to cases of gastrostomy feeding tubes, rehabilitation equipment, open patient cups and water pitchers, and assorted patient care supplies and equipment. The clerk (Staff B) stated that the soiled commercial cleaning equipment has always been stored in the central supply room.

(c) Observation noted that there was an uncovered commercial garbage container. Further observation noted that the contained was full and contained food garbage, and soiled food wrappers. The surveyor discussed with the infection control nurse that there should not be eating or drinking allowed in the room and that all containers with organic garbage/trash should be covered at all times as per regulation.

(d) Observation of the emergency water storage room located within the Central Supply Room was noted to have numerous cases (4) of opened cups and cup lids that were stored directly on the heavily soiled floor area.

2) During the observation of the Clean Linen Storage Room accompanied with the Infection Control Nurse on 05/21/18 at 10:45 AM it was noted that room houses all clean resident linens. Further observation noted that the entire floor area was heavily soiled with dirt and trash. There were also large areas of what appeared to be dried food spills. The hand wash sink was noted to have dirty rags stored within with opened clean linens stored directly near the sink area. It was also noted 3 Styrofoam cups with liquids stored on top of the clean linen cart. The beverages appeared to be staff drinking beverages within the clean linen storage room. 2) During the observation of the Clean Linen Storage Room accompanied with the Infection Control Nurse on 05/21/18 at 10:45 AM it was noted that room houses all clean resident linens. Further observation noted that the entire floor area was heavily soiled with dirt and trash. There were also large areas of what appeared to be dried food spills. The hand wash sink was noted to have dirty rags stored within with opened clean linens stored directly near the sink area. It was also noted 3 Styrofoam cups with liquids stored on top of the clean linen cart. The beverages appeared to be staff drinking beverages within the clean linen storage room.

3) On 05/22/18 at approximately 2:30 PM the Life Safety Surveyor requested the that a surveyor observe the findings in a doctors lounge room located on the 4th floor of the hospital. Approaching the door to the lounge, which was just across the hallway to the ICU entrance, a foul small was noted. When trying to enter the room the door would only open slightly was due to mounds of indescribable trash and mess. Upon entering the room the smell the surveyor was overcome with a combination of decaying food, body odor stench, and some type of food frying cooking odor. Upon entering it was hard to maneuver in the approximate 8 x 10 foot room due to mounds and piles of trash, rotting bags of food (5), piles of soiled clothing, medical supplies, and stacks of dirty dishes (plate, cups, bowls, silverware) that were full of food waste that had dried on the surfaces of the dishes due to sitting on the floor for long periods of time. A box on the floor was opened and revealed medical equipment that included bags of syringes however the box had to be closed quickly due to insect infestation. It was noted that there were 3 small refrigerators in the room and upon opening the units it was noted numerous plates of open spoiled/decaying foods. In addition there were numerous bottles of prescription medications, over the counter medications, and opened alcohol containers. A bed located within the room was noted to have a foul smell and the sheets and bed covering were heavily soiled. Further observation of the room noted electric cooking equipment (3) on the floor which were still full of decaying foul smelling food matter. Dresser drawers located were opened to reveal numerous bottles of prescription medications and foul smelling soiled clothing. Observation of the bathroom/shower room noted numerous stacks food plates that still had dried food matter and stacks of plates that appeared to be cleaned by using the shower stall. The sink basin bowl exterior was black in color and soiled rags were also in the basin. The floor of the room had a frying pot with the grease still open in the unit and appeared that the doctor was frying food in the shower stall. The room floor was heavily soiled and soiled clothing and rags were strewn about the room. The surveyors and administrative staff exited the room due to the fouls smells, infection control issues, and pest infestation. Outside of the room during interviews with administrative staff, it was revealed that the room was being occupied by the facility's Medical Director, however it was further stated that the administration was not aware the medical director was living in the room on an on-going basis and unaware of the condition of the room. It was also revealed that the Medical Director would not let housekeeping staff into the room for regular cleaning. Interview with the Life Safety Surveyor revealed that the facility would be cited for the potential fire hazard for cooking within the room.





29151

Based on record review, policy review and interview it was determined the facility failed to ensure patients were informed of their options related to organ donation. This failure affected 2 of 5 sample patients (Patient #21 and #28).



The findings included:



Facility policy titled "Organ and Tissue Donation" dated 08/2014 documents as follows: "On admission, The patient or person authorized to make an anatomical gif on behalf of the patient shall be asked if the patient is a donor. If the patient is unable to give consent, the following persons in order of priority may grant consent. Spouse, adult child, parent, adult sibling and legal guardian.
The patient/family's donation preference will be documented in the section of the medical record as determined by the hospital.
If the patient/family wishes to sign consent for donation on admission, they may do so.
If the patient/family requests more information regarding organ donation, they will be referred to social services or their designee."

Clinical record review conducted on 05/23/18 revealed the following concerns:

Patient #28 was admitted to the facility on 12/17/17. The record provides no evidence the patient was informed of the facility policy related to organ donation.
Document titled "Anatomical Gift by Living Donor" was not completed by the staff.

Patient #21 was admitted to the facility on 02/28/18. The record provides no evidence the patient was informed of the facility policy related to organ donation.
Document titled "Anatomical Gift by Living Donor" was not completed by the staff.

Interview with The Nurse Supervisor who was navigating the clinical record on 05/23/18 at approximately 11:30 AM revealed the facility utilizes the document titled as Anatomical Gift By A Living Donor to document the patients or family preferences in regards to organ donation. The supervisor confirmed the forms related to Patients #21 and #28 were not completed.

Based on record review and interview it was determined the facility failed to develop and establish qualifications and responsibilities for the supervisor of the hospital operating room.


The findings included:


Observation tour of the facility on 05/21/18 at approximately revealed the facility has one operating room (OR) and two recovery beds.

Review of the facility documents revealed surgical services is not a part of the organizational chart.

Review of the personnel files for the person identified as the OR Manager on 05/22/18 revealed no evidence of a job description related to overseeing surgical services.

Interview with The Chief Clinical Officer on 05/24/18 at approximately 10 AM revealed the administrative assistant omitted surgical services on the organizational chart by mistake and confirmed the job description for the nursing supervisor does not delineate qualifications, requirements, and duties related to the management of the OR.

Based on record review and interview it was determined the facility failed to develop required policies and procedures related to surgical services provided in the facility.


The findings included:


Review of the facility policies related to surgical services conducted on 05/22/18 revealed no evidence the facility has developed policies and procedures for Identification of infected (dirty) and non-infected cases (clean) and scheduling of patients for surgery.

Interview with The Risk manager on 05/22/18 at 12:02 PM and on 05/23/18 at 1:48 PM revealed there are no additional policies addressing identification of infected and non-infected cases and scheduling of surgical procedures.

Based on record review and interview it was determined the facility failed to ensure pre-anesthesia evaluation was completed within forty-eight hours of the surgical procedure.


The findings included:

Clinical record reviews conducted on 05/23/18 revealed the following:

Patient #25 underwent a surgical procedure on 01/12/18 under general anesthesia. The record indicates the pre-anesthesia evaluation was completed on 01/09/18 and no update or revisions were noted.

Patient #24 had a surgical procedure on 12/07/17 under Monitored Anesthesia Care. The record indicates the pre-anesthesia evaluation was completed on 12/01/17. The record provides no evidence of revisions to the patient's history.

Interview with The Nurse Supervisor who was navigating the clinical record on 05/23/18 at 11:30 AM revealed confirmed the pre-anesthesia evaluations were not completed or revised within the forty-eight hour requirement.