HospitalInspections.org

Based on record review and interview, the facility staff failed to document that the Patient Rights were offered to and/or received by 6 of 24 patients (Patients #8, 9, 10, 11, 12 and 13); failed to provide the Important Message from Medicare (IMM) within 48 hours of discharge for 1 of 3 inpatients (Patient #8) with Medicare and failed to ensure that a signature on the IMM was completed by a patient who was competent to make medical decisions (Patient #16) out of a total universe of 24 medical records reviewed.

Findings include:

The facility document titled "Patient Consent: Overview and Basic Requirements" last revised 3/2022 was reviewed. This document revealed "7. Persons Authorized to Provide Informed Consent. The following persons are authorized, if otherwise competent, to provide Informed Consent: a. Decisional Adult Patients: An adult (age 18 or over) patient with decision-making capacity...9. Witnesses and Signatures...c. If the patient appears to be in an altered mental state or otherwise congnitively impaired, the care team should ascertain the patient's capacity to make medical decisions prior to proceeding with the informed consent discussion and the documentation and/or obtaining the patient's signature on the informed consent form. If the patient lacks decisional capacity and has no appointed legal representative, a referral should be made for possible guardianship."

Examples of No Documentation of Patient Rights:

A review of Patient #8's closed medical record revealed Patient #8 was admitted to the facility from 06/08/2022 through 06/11/2022. There was no documented evidence found that Patient #8 was offered or received a copy of the "Patient Rights & Responsibilities" form.

A review of Patient #9's open medical record revealed Patient #9 was admitted to the facility on 06/26/2022. There was no documented evidence found that Patient #9 was offered or received a copy of the "Patient Rights & Responsibilities" form.

A review of Patient #10's closed medical record revealed Patient #10 was admitted to the facility from 06/26/2022 through 06/28/2022. There was no documented evidence found that Patient #10 was offered or received a copy of the "Patient Rights & Responsibilities" form.

A review of Patient #11's closed medical record revealed Patient #11 was admitted to the facility from 05/05/2022 through 05/07/2022. There was no documented evidence found that Patient #11 was offered or received a copy of the "Patient Rights & Responsibilities" form.

A review of Patient #12's closed medical record revealed Patient #12 was admitted to the facility from 06/06/2022 through 06/07/2022. There was no documented evidence found that Patient #12 was offered or received a copy of the "Patient Rights & Responsibilities" form.

A review of Patient #13's closed medical record revealed Patient #13 was admitted to the facility on 06/24/2022 for an outpatient surgical procedure. There was no documented evidence found that Patient #13 was offered or received a copy of the "Patient Rights & Responsibilities" form.

The medical record review findings were discussed with and were confirmed on interview by Director of Revenue Cycle X on 06/28/2022 at 3:37 PM who stated there was currently no facility policy regarding documentation of Patient Rights being provided, but that the expectation for Registration staff was that they, "Should be documenting that Patient Rights were offered and/or received for all patients in [the electronic medical record]."

Example of No Important Message from Medicare Provided Prior to Discharge:

A review of the facility's policy titled, "Medicare Beneficiary Notices," last revised 06/2022 revealed, "A. Important Message from Medicare ...The Medicare Form, "An Important Message from Medicare About Your Rights" will be given to all Medicare and Medicare Product insured in-patients by the Patient and Registration Accounts Associates. A signature will be obtained, indicating receipt of a copy and understanding of the letter, by the patient or representative and the staff member giving the letter ...a copy will be kept on the patient's medical record ...f. If the patient is still here after day two, a follow-up review will occur, and signature obtained every two days by nursing associates. Page two of the initial notice will be used for the follow-up signature ..."

A review of Patient #8's closed medical record revealed Patient #8 was admitted to the facility on 06/08/2022 and discharged home on 06/11/2022. The initial IMM was completed on 06/08/2022 at 3:33 PM. There was no follow-up IMM within 48 hours of discharge found in Patient #8's medical record.

The medical record review findings were discussed with and were confirmed on interview by Director of Revenue Cycle X on 06/28/2022 at 3:37 PM who stated, "The discharge IMMs are not consistently being documented as given."

Example of IMM signature obtained by a patient with an Alzheimer's Disease diagnosis and documented as disoriented:

A review of Patient #16's closed medical record revealed Patient #16 was admitted to the facility on 4/9/2022 from a memory care unit and discharged on 4/14/2022. Patient #16 was documented as "confused" under level of consciousness and "disoriented" under orientation on nursing assessment flow sheet the entire length of stay. The "IMM" signature obtained on 4/9/2022 at 11:15 PM documented "Verbal consent from patient" and was cosigned by a facility staff member. Upon review of IMM Risk Management W stated "Yeah there should be a consent from someone in her family or something since she was confused."

Based on record review and interview, facility staff failed to document crash cart and defibrillator monitoring checks daily in 2 of 5 patient care departments with crash carts (Medical/Surgical Unit, ED (Emergency Department)) in a total of 13 hospital departments observed and failed to perform weekly tests for proper functioning of the eye wash station in 1 of 3 departments (Emergency Department) with eye wash stations.

Findings include:

A review of the facility's document titled, "[Organization Name] Life Pack 20 Defib/Monitor Daily Check Sheet," no date, revealed, "Person checking cart should check the following items and initial below...Defib/Monitor & Cart are clean and casings are intact. Defib/Monitor cables are attached and intact. Defib/Monitor is plugged in to red outlet and green 'AC Mains' light is on. Defib/Monitor powers on and does self test with printout at 0300 [3:00 AM]. Display is functional. Time and date are correct. Service light is not on. 2 sets of Adult Medtronic Quik Combo pads in basket. 2 sets of Peds Medtronic Quik Combo pads in basket. 3 packs of adhesive electrodes in basket. At least 1 extra roll of monitor paper. Unit is secured by Red Tag. Medications are restocked and NO meds are sitting in the med room on the counter."

Examples of code carts:

A review of the inpatient medical/surgical unit's "Daily Check Sheet...Adult Crash Cart" forms from 01/01/2022 through 06/28/2022 revealed no documentation of completed crash cart checks on the following dates: 01/11/2022; 01/22/2022; 01/26/2022; 01/27/2022; 02/09/2022; 02/25/2022; 02/26/2022; 02/27/2022; 03/09/2022; 03/10/2022; 03/27/2022; 03/28/2022; 04/07/2022; 04/08/2022; 04/25/2022; 04/26/2022; 04/27/2022; 04/29/2022; 04/30/2022; 05/01/2022; 06/09/2022; 06/10/2022; 06/17/2022; 06/18/2022; 06/19/2022; and 06/22/2022.

A review of the Emergency Department "LifePak 15 Daily Checklist ED Crash Cart #1" forms from 01/01/2022 through 06/28/2022 revealed no documentation of completed crash cart checks on the following dates in January: 01/02/2022, 01/05/2022, 01/08/2022, 01/14/2022, 01/17/2022, 01/19/2022; the following dates in February: 02/22/2022 - 02/24/2022, 1/26/2022 - 01/28/2022, 02/01/2022, 02/05/2022 - 02/08/2022, 02/10/2022, 02/12/2022, 02/13/2022, 02/16/2022, 02/17/2022, 02/20/2022, 02/22/2022, 02/24/2022 - 02/27/2022; the following dates in March: 03/01/2022, 03/02/2022, 03/05/2022 - 03/07/2022, 03/14/2022 - 03/16/2022, 03/21/2022, 03/22/2022, 03/25/2022 - 03/28/2022; the following dates in April: 04/02/2022 - 04/04/2022, 04/08/2022; the following dates in May: 05/03/2022 - 05/05/2022, 05/10/2022, 05/14/2022 - 05/16/ 2022, 05/25/2022 - 05/27/2022; and the following dates in June: 06/04/2022, 06/05/2022, 06/19/2022 - 06/21/2022 and 06/24/2022 - 06/28/2022.

A review of the Emergency Department "LifePak 15 Daily Checklist ED Crash Cart #2" forms from 01/01/2022 through 06/28/2022 revealed no documentation of completed crash cart checks on the following dates in January: 01/05/2022, 01/08/2022, 01/11/2022, 01/17/2022, 01/19/2022, 01/22/2022 - 01/24/2022, 01/26/2022 - 01/28/2022; the following dates in February: 02/01/2022, 02/02/2022 - 02/08/2022, 02/10/2022, 02/12/2022, 02/13/2022, 02/16/2022, 02/17/2022, 02/20/2022, 02/22/2022 - 02/27/2022; the following dates in March: 03/01/2022, 03/02/2022, 03/06/2022, 03/07/2022, 03/15/2022, 03/16/2022, 03/22/2022, 03/25/2022, 03/26/2022, 03/28/2022; the following dates in April: 04/02/2022 - 04/04/2022, 04/08/2022; the following dates in May: 05/04/2022, 05/05/2022, 05/10/2022, 05/14/2022 - 05/16/2022, 05/19/2022, 05/25/2022 - 05/27/2022; and the following dates in June: 06/04/2022- 06/6/2022, 06/09/2022, 06/19/2022 - 06/21/2022, and 06/23/2022 - 06/28/2022.

In an interview on 6/27/2022 at 11:30 AM with ED Manager H when asked about checks of the Crash Carts stated, "The expectation is that the cart and the defibrillators are checked every day, every cart, on the night shift." When asked about a policy for the checking of the Crash Carts, Manager H stated that there currently is not one."

Examples of eye wash stations:

Review of the facility "Policy and Procedure Manual - Forms & Logs Eye Wash Station Testing Log Year 2022 for the Emergency Department" revealed, "Tested weekly to insure adequate water flow, quality, and temperature."

Review of the 2022 Log for Eye Wash testing of the eye wash station in the ED revealed the following checks documented for 2022: 05/03/2022, 05/23/2022, 06/06/2022, 06/13/2022, 06/22/2022.

In an interview on 6/27/2022 at 12:10 PM with ED Manager H when asked about checks of the eye wash station, Manager H stated, "We are obviously not doing it according to our policy."

Based on observation, staff interviews, and review of maintenance records between June 27 through June 29, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

Building 02
K132 Multiple Occupancies-Contiguous Non-Health Care Occupancies
K161 Building Construction Type and Height
K211 Means of Egress - General
K223 Doors with Self-Closing Devices
K225 Stairways and Smokeproof Enclosures
K227- Ramps and Other Exits
K281 Illumination of Means of Egress
K291 Emergency Lighting
K293 Exit Signage
K321 Hazardous Areas - Enclosure
K351 Sprinkler System - Installation
K712 Fire Drills
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers
K781 Portable Space Heaters
K902 Gas and Vacuum Piped Systems - Other
K909 Gas and Vacuum Piped Systems - Information
K911- Electrical Systems -Other
K918 Electrical Systems - Electrical Systems - Essential Electrical System Maintenance and Testing
K919 Electrical Equipment - Other

Medical Office Building
K200 Means of Egress - Others
K700 Operating Features - Others
K900 Healthcare Facilities Code - Others

C926- Proper Ventilation, Lighting and Temperature
C930- Life Safety from Fire

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

See C926, C930, and K-tags for details of the specific findings.

Based on observation and interview the facility failed to provide an unobstructed, uncluttered entrance to the Pharmacy in 1 of 1 Pharmacy observed.

During a tour of the Pharmacy Department on 6/28/2022 at 9:00 AM 43 cardboard boxes were observed on the left wall upon entrance to the department. Six boxes, rested directly on the floor with the remaining 37 boxes on top of them. The boxes contained irrigation fluids. On the far wall of the department 19 additional boxes were observed, 7 directly on the floor, all containing irrigation fluids.

In an interview on 6/28/2022 at 9:05 AM with Pharmacy Manager Q, Manager Q stated, "When I can get supplies I order as much as I can. We have ordered shelving for all of these (boxes). We recently moved into this space and are still trying to make the best use of the space we have."

Based on observation and staff interview, the facility failed to provide proper ventilation in several rooms in accordance with ASHRAE Standard 170 Part 6 Table 7-1, AIA Guidelines for Design and Construction of Health Care Facilities, and CDC guidelines. This deficient practice had a potential of contamination of air in clean spaces with undesirable contaminants.

Findings Include:

1. On 06/27/2022 at 11:44 AM, observation in the biohazard room that exits into the exit passageway on the lower level, revealed there was a no exhaust air out of the room.

2. On 6/27/2022 at 1:30 PM, observation revealed that the door from the hospital to the 2 hour connector to the MOB, did not latch when closed. There was excess airflow from the MOB to the hospital that kept the door from closing. This air is not properly filtered to hospital standards.

The above deficiency was confirmed by interview with Staff Y at the time of discovery.


41127


Based on record review and interview, facility staff failed to document blanket warmer temperatures daily, per facility policy, for 2 of 2 blanket warmers located on the inpatient medical/surgical unit in a total of 13 hospital departments observed.

Findings include:

A review of the facility's policy titled, "Blanket and Fluid Warmers," no date, revealed, " ...B. Monitoring: 1. All blanket warmer temperatures will be monitored and recorded on a daily basis by the department manager or designee ..."

A review of the "North Linen Closet Blanket Warmer" temperature monitoring log from 01/01/2022 through 06/28/2022 revealed no blanket warmer temperature was documented on the following dates: 01/20/2022; 02/21/2022; 05/14/2022; 05/15/2022; 05/16/2022; 06/04/2022; 06/05/2022; 06/09/2022; 06/17/2022; and 06/19/2022.

A review of the "North Clean Utility Blanket Warmer" temperature monitoring log from 01/01/2022 through 06/28/2022 revealed no blanket warmer temperature was documented on the following dates: 04/29/2022; 06/04/2022; 06/05/2022; 06/19/2022.

During an interview on 06/29/2022 at 8:31 AM, Compliance Director A stated blanket warmer temperatures should be documented daily.

Based on observation, staff interviews, and review of maintenance records between June 27 through June 29, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

Building 02
K132 Multiple Occupancies-Contiguous Non-Health Care Occupancies
K161 Building Construction Type and Height
K211 Means of Egress - General
K223 Doors with Self-Closing Devices
K225 Stairways and Smokeproof Enclosures
K227- Ramps and Other Exits
K281 Illumination of Means of Egress
K291 Emergency Lighting
K293 Exit Signage
K321 Hazardous Areas - Enclosure
K351 Sprinkler System - Installation
K712 Fire Drills
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers
K781 Portable Space Heaters
K902 Gas and Vacuum Piped Systems - Other
K909 Gas and Vacuum Piped Systems - Information
K911- Electrical Systems -Other
K918 Electrical Systems - Electrical Systems - Essential Electrical System Maintenance and Testing
K919 Electrical Equipment - Other

Medical Office Building
K200 Means of Egress - Others
K700 Operating Features - Others
K900 Healthcare Facilities Code - Others

As a result of these deficiencies, 42 CFR 485.623(c) Life Safety from Fire was NOT MET.

See K-tags for details of the specific findings.

Based on record review and interview the facility failed to ensure that staff were documenting releasing and repositioning and assessments as per facility policy in patients who had restraints in place in 1 of 2 (Patient # 15): that all staff providing direct patient care had restraint training (House Supervisor GG and Emergency Room Technician EE) and that all patients received a Columbia Suicide Severity Rating Scale (CSSRS) prior to discharge from the Emergency Department in 1 of 1 suicidal (Patient #14), closed medical record reviewed out of a total universe of 24 medical records.

Findings include:

The facility document titled "Restraints Use and Monitoring P&P" last revised 4/2022 was reviewed. This document revealed "Qualified Staff: Health care providers with education and competencies in the appropriate use of restraint. This primarily includes, but is not limited to, RN (Registered Nurse), providers, CNA's (Certified Nursing Aides), and EMT's (Emergency Medical Technicians). RN's participate in all aspects of restraint-related care. Trained assistive personnel participate in monitoring, application and removal of restraint, and provision of personal cares. Qualified staff training occurs during orientation and on a subsequent periodic basis to include the application of restraints, monitoring, assessment and providing care for a patient...c. Initiate the restraint charting in EHR (electronic health record). Flow Sheet and progress note entry in the episode, type of restraint, attempted alternative interventions, all assessments, education, and any untoward events...f. Patient safety, dignity, sense of well-being and individual rights are attended to throughout the time the patient is in restraint. g. Patients in restraints are monitored and assessed during the time they are restrained. h. Assessment and care are provided as follows, with the frequency based on the type of restraint. i. Assessment completed at least every two hours for Protective Restraint or at least every 15 minutes for Violent Restraint will include but is not limited to: 1. Affect/Behavior. 2. Circulation/Skin. 3. ROM (range of motion). 4. Food and Fluids. 5. Hygiene Elimination. 6. Safety. 7. Restraint discontinuation Readiness Attempts. 8. Continued need. ii. Care at least every two hours will include but is not limited to: 1. Care of nutritional/elimination/hygiene needs. 2. Repositioning. 3. Temporary restraint release while awake based on safety. 4. Meeting need for warmth, privacy, personal needs, and comfort. 5. Hygiene/Elimination. 6. Range of Motion. i. Evaluation of continued need for restraint will include reassessment of the patient's physical, emotional, and behavioral status related to the specific episode for which the order was written. The primary focus of reassessment is to move to a less restrictive intervention and/or discontinuation of restraint. j. Patients, families, and/or guardians are education about the reasons for restraint, the behavior expected for release, and the potential consequences of restraint use...C. Education: a. All education should be attempted prior to initiation of restraint use or as soon as possible...c. Family members will receive education at time of initiation of restraint if patient has signed given verbal or written approval...d. Elements of education must include: i. Rationale for restraint. ii. Discussion on alternatives attempted. iii. Reassurance that least restrictive device will be utilized. iv. Monitoring of the safety and continued need for restraint use. v. Reassurance that patient's nutritional/comfort/hygiene/elimination needs will be met. vi. Criteria for discontinuation."

The facility document titled "Suicide Precautions" last revised 4/2022 was reviewed. This document revealed "A. While (facility name) may not actively accept patients displaying a high likelihood to engage in suicidal behavior, it is recognized that this behavior may not be identified until after admission. Patients will be assessed for suicide risk upon admission using the Columbia Suicide Severity Rating Scale (CSSRS). B. Based on the results of the assessment, appropriate triage, care and supervision will be enacted. Attempt will be made to transfer or chapter high suicide risk patients who verbally or physically display intent of injury to self...Suicide Risk Stratification: High Risk: "Yes" response to any of the following: #4 suicidal intent, #5 specific plan or #6 suicidal behavior within the last 3 months."

Examples of no documented release and repositioning while in restraint:

Patient #15's closed medical record was reviewed with Risk Management W. Patient #15 was a 40 year old admitted to the Emergency Department from a group home on 1/15/2022 at 9:09 PM with a medical history of cognitive deficit, suprapubic catheter (to drain bladder), paraplegia (inability to move 2 extremities) and frequent urinary tract infections. Patient #15 was hypotensive (low blood pressure) upon arrival, having difficulty clearing airway of congestion and was combative with staff when they were trying to improve respiratory status and eventually Patient #15 was intubated to maintain a patent airway. Restraints were initiated because the patient continued to be combative and was attempting to remove the airway that staff had placed. Soft wrist restraints were documented as placed on 1/16/2022 at 5:16 AM. Patient #15 was transferred out to an acute hospital in another state on 1/16/2022 at 11:06 AM. There was no documented restraint releasing, repositioning or assessment completed every two hours as per facility policy while Patient #15 was in the facility and restrained. This was confirmed with Risk Management W at the time of medical record review.

Examples of facility staff without documented restraint training:

House Supervisor GG's personnel record was reviewed. House Supervisor GG was hired on 1/24/2022. There was no documented restraint training completed since hire date.

Emergency Room Technician (ER Tech) EE's personnel record was reviewed. ER Tech EE was hired on 12/8/2011. The most recent documented restraint training was completed in 2020.

On 6/29/2022 at 8:45 AM Risk Management W stated "You are right. I missed those and they need to be completed."

Example of no CSSRS completed prior to discharge:

The facility training for "CSSR" was reviewed. This document revealed "Did patient answer yes to any CSSRS question? Yes-Complete suicide protective and risk factors-Implement interventions per protocol based upon level of risk determined by CSSRS tool-Re-screen patient with CSSRS tool prior to discharge...When and Who do we screen: ALL patients 12 and older:...Re-screen Prior to Discharge. Same CSSRS questions in D/C (discharge) Navigator. All patients >12 years of age screened (regardless of risk assessed upon admission)."

Patient #14's closed medical record was reviewed with Risk Management W. Patient #14 was a 16 year old who came into the Emergency Department (ED) on 2/13/2022 at 9:20 PM via ambulance services after an attempted overdose with LSD (Lysergic acid diethylamide-street drug). The ambulance staff had administered "some sedation" and 4 point soft restraints for patient and ambulance safety related to patient being combative. The "Patient Care Timeline" documented patient arrival at 9:20 PM. The first documented CSSRS (Columbia Suicide Screening Rating Scale) was completed on 2/14/2022 at 6:29 AM. Patient #14 answered yes to questions 1-5 indicating a positive "High Risk" CSSRS level of risk. Patient #14 was discharged on 2/14/2022 at 10:06 PM in the custody of father. There was no documented completed CSSRS tool prior to reassess Patient #14's suicide risk level prior to being discharged. Risk Management W confirmed the lack of CSSRS being completed prior to discharge.

Based on observation, record review and interview the facility failed to ensure that staff were monitoring date in, use by and expiration dates on food, that all food was stored covered, that dishwasher rinse temperatures were checked daily in the dietary department and that the facility laundry staff followed infection prevention and control policies and procedures in 2 of 13 hospital departments (Dietary & Laundry) in a total of 13 hospital departments observed.

Findings include:

The facility policy titled "Food Storage Procedure" last revised 5/2022 was reviewed. This document revealed "The purpose of this policy is to ensure that food, non-food items and supplies used in food preparation are stored in such a manner as to prevent chemical, bacteriological, or other contamination and to assure safe food for human consumption...A. The following guidelines have been established...ii. Perishable storage:...3. The temperature of all cool storage facilities should be checked and logged on the appropriate form at least every 24 hours with deviations from the norm reported and action recommended or taken recorded...ii. Storage of Perishable Food Items:...9. All food items stored in the cooler should be in containers with lids or loosely wrapped...10. All food items stored in the cooler must be covered and dated except for single portion items which are being held in cool storage only until the next meal serving period."

The facility policy titled "Job Breakdown Instruction (JBI) Sheet" was reviewed. This document revealed "Food & Nutrition Services will date mark all food items as they are received with "in on" date. Use a black sharpie to write the "in on" date on box or case when it is delivered by distributor. Date should be written in a location that is visible when box/case is on shelf or in its proper storage area. Date should be written as "in on Month/Date/Year"...Once case/item is opened, the appropriate "use by" or "best by" date must be added using the Food Storage Date Marking Guidelines. A "Use by" sticker must be filled out with the appropriate information including the date found on the Food Storage Date Marking Guidelines, the name of the food item if it is taken out of it's original container, and staff members initials. Sticker must be placed on front of package or container so that it is easily visible when item is on shelf or in proper storage area...Individual packages that are removed from the original box are to be dated with the date received. If an item is removed from its original box because it is the last item in the box, item must be labeled with the "in on" date in a visible location. Box/case can then be discarded."

Examples in dietary department:

Observations of dietary department and related food storage areas was conducted on 6/28/2022 at 7:00 AM with Dietary Manager AA with findings in the following areas:

Walk in "Meat Freezer" there was a box of beef roast with an "In" date of 6/28/2020. Dietary Manager AA referred to the facility document "Food Storage Date Marking Guidelines" and stated "That is only good for a year so it should be thrown out."

Walk in refrigerator had the following items with no documented "In" date: bag of broccoli, bag of corn, 50 pound bag of purple onions, 50 pound bag of yellow onions. Additionally there was a container of Teriyaki sauce with a use by date of 6/4/2022 and a storage container (with lid) of ketchup with a use by date of 6/12/2022. Dietary Manager AA stated "Those items should all have in dates on them and the sauce and ketchup should have been thrown out."

Storage room with dry foods had a box of "Trio Low Sodium Dry Gravy" that expired in 10/2021. Dietary Manager AA stated "I hardly ever use that but it should be thrown out."

The "Room Service" refrigerator had no use by dates on individually wrapped pieces of salmon, cod, a bag of chicken breasts, 3 bags of waffles, a bag of blueberries that had a twist tie on one side of the opening but was open to air on the other side and dinner rolls in a metal container with the lid sitting ajar and exposing rolls. Dietary Manager AA stated "Yes all of those items should have a use by date on them based on when they were opened."

The facility document titled "DISH MACHINE FINAL RINSE TEMPERATURE (180 degrees or higher)" was reviewed for the months of March-June 2022 (total of 360 entries as is done three times a day). The month of March was missing 4 entries (3/10/2022 AM and Noon and 3/14/2022 AM and Noon). The month of April was missing 3 entries (4/6/2022 AM and 4/27/2022 AM and Noon). The month of May was missing 3 entries (5/19/2022 AM and Noon and 5/27/2022 AM). The month of June was missing 12 entries (6/5/2022 AM, 6/6/2022 no entries for the day, 6/8/2022 PM, 6/9/2022 PM, 6/10/2022 AM, 6/17/2022 AM, 6/19/2022 AM, 6/22/2022 AM and Noon and 6/27/2022 PM). The dates that had documented entries were all within the established temperatures.

Dietary department tour was completed with Dietary Manager AA who confirmed at the time of observation the missing entries.


41127


Examples in laundry:

During a tour of the Laundry department on 06/27/2022 at 11:33 AM, two commercial washing machines with continuous water temperature monitoring displays were observed. There was one washer that could accommodate a total load of 70 pounds and one that could accommodate a total load of 90 pounds.

A review of the facility's policy titled, "Contaminated Linen," last reviewed 01/2022 revealed, " ...The wash temperature will be checked during the wash cycle and must reach 160 degrees and logged ..."

A review of the Laundry department's "Daily Task Checklist" revealed a section labeled, "Washing Machine Temperature & Number of Loads ...70# [pound] ...90#..." There was one box under the "70#" column for indicating the water temperature, and one box for indicating the number of loads. There was one box under the "90#" column for indicating the water temperature and one box for indicating the number of loads.

A review of the "Daily Task Checklists" for the month of April, 2022 revealed the following:

The water temperature documented for the 70-pound washing machine was less than 160 degrees for 15 of the 20 days the washing machine was utilized (04/04/2022; 04/05/2022; 04/06/2022; 04/07/2022; 04/08/2022; 04/11/2022; 04/12/2022; 04/13/2022; 04/14/2022; 04/18/2022; 04/19/2022; 04/20/2022; 04/21/2022; 04/22/2022; 04/25/2022; and 04/29/2022). There was no temperature documented for 4 of the 20 days (04/19/2022; 04/26/2022; 04/27/2022; and 04/28/2022).

The water temperature documented for the 90-pound washing machine was less than 160 degrees for 19 of the 20 days the washing machine was utilized (04/04/2022; 04/05/2022; 04/06/2022; 04/07/2022; 04/08/2022; 04/11/2022; 04/12/2022; 04/13/2022; 04/14/2022; 04/15/2022; 04/18/2022; 04/20/2022; 04/21/2022; 04/22/2022; 04/25/2022; 04/26/2022; 04/27/2022; 04/28/2022; and 04/29/2022). There was no temperature documented for 1 of the 20 days (04/19/2022).

A review of the "Daily Task Checklists" for the month of May, 2022 revealed the following:

The water temperature documented for the 70-pound washing machine was less than 160 degrees for 20 of the 22 days the washing machine was utilized (05/02/2022; 05/03/2022; 05/05/2022; 05/06/2022; 05/09/2022; 05/10/2022; 05/11/2022; 05/12/2022; 05/13/2022; 05/16/2022; 05/17/2022; 05/19/2022; 05/20/2022; 05/23/2022; 05/24/2022; 05/25/2022; 05/26/2022; 05/27/2022; 05/28/2022; 05/31/2022). There was no temperature documented for 2 of the 22 days (05/04/2022 and 05/18/2022).

The water temperature documented for the 90-pound washing machine was less than 160 degrees for 21 of the 21 days the washing machine was utilized (05/02/2022; 05/03/2022; 05/04/2022; 05/05/2022; 05/06/2022; 05/09/2022; 05/10/2022; 05/11/2022; 05/12/2022; 05/13/2022; 05/16/2022; 05/17/2022; 05/18/2022; 05/19/2022; 05/20/2022; 05/23/2022; 05/24/2022; 05/25/2022; 05/26/2022; 05/27/2022; and 05/28/2022).

A review of the "Daily Task Checklists" for the month of June, 2022 (through 06/27/2022) revealed the following:

The water temperature documented for the 70-pound washing machine was less than 160 degrees for 13 of the 19 days the washing machine was utilized (06/02/2022; 06/03/2022; 06/07/2022; 06/10/2022; 06/13/2022; 06/14/2022; 06/16/2022; 06/17/2022; 06/20/2022; 06/21/2022; 06/22/2022; 06/24/2022; and 06/27/2022). There was no temperature documented for 1 of the 19 days (06/01/2022).

The water temperature documented for the 90-pound washing machine was less than 160 degrees for 19 of the 19 days the washing machine was utilized (06/01/2022; 06/02/2022; 06/03/2022; 06/07/2022; 06/10/2022; 06/13/2022; 06/14/2022; 06/16/2022; 06/17/2022; 06/20/2022; 06/21/2022; 06/22/2022; 06/24/2022; and 06/27/2022).

During an interview with Laundry staff V on 06/27/2022 at 12:41 PM, Laundry V stated that washing machine temperatures were, "Monitored" to ensure the water temperature reached 160 degrees, but that the temperatures were only documented once per day, not per load, and that there was no set point during the wash cycle or time of day that the water temperature was checked and documented.

During an interview with Compliance Director A on 06/29/2022 at 8:29 AM, Director A stated, "There is an inconsistent time of taking the water temperatures" in the laundry department.