HospitalInspections.org

Based on document review and interview, the facility failed to ensure that a physician performed a face to face assessment within one hour of the initiation of a physical restraint for 1 (#46) of 1 patients in behavioral (violent) restraints resulting in the potential for violation of patient rights and the potential for adverse patient outcomes. Findings include:

On 4/25/2018 at 0909, Patient #46's medical record was reviewed and the patient was found to have been placed in behavior restraints on 4/20/2018 at 1803. The one-hour face to face assessment was found to have been completed at 2230 when the restraints were discontinued.

Staff UU was queried on 4/25/2018 at 0912 as to if there were any other documentation available to show the one-hour face to face assessment had been done prior to 2230 to which she stated, "No. There is nothing in the progress notes. It was done at 2230." Staff UU was further queried as to when the physician assessment was to be performed with behavioral restraints to which she replied, "The assessment should be done within an hour."

Facility policy #8168 titled "Restraints: Care of the Patient in Restraints" effective 3/1/2018 was reviewed on 4/25/2018 at 1030. Policy states, "Violent restraints...A face-to-face assessment is required by a Provider within one hour after restraint initiation."

Based on document review and interview, the facility failed to ensure that all medical records were completed within 30 days after discharge resulting in the potential for inaccessible information necessary for health care staff to provide for the patients' health care needs. Findings include:

During record review on 4/25/2018 at 1017, with medical records Staff VV present, the medical records still opened were reviewed with the following findings:

30-60 days 455 records
60-90 days 298 records
90-120 days 240 records
120+ days 438 records

During an interview with Staff VV on 4/25/2018 at 1017, Staff VV stated that the facility had a system of notifying physicians via letter when there were deficiencies present; however, that changed with the new documentation software that had rolled out November 2017 so that the physicians were being notified in their "inbox." Staff VV also stated there was a "glitch" with the new software that had been identified in which the physicians were not getting the information regarding deficiencies and they have not yet been able to correct it. Staff VV further denied that there was a return to the previous process of sending out a letter to the physicians.

Facility policy #21244 titled "HIM Physician Escalation" effective 10/4/2017 was reviewed on 4/26/2018 at 1200. Policy states, "HIM to track records incomplete at 30 days as delinquent records for regulatory and accreditation reporting..."

"Rules and Regulations Medical Staff of Spectrum Health Grand Rapids" last approved 5/2015 was reviewed on 4/26/2018 at 1130. The rules state, "Record Completion...Patient medical records must be completed within 30 days of date of discharge. This applies to all medical staff members..."

Based on observation, interview and policy review, the facility failed to monitor for and remove from availability, expired intravenous (IV) medication solutions that exceeded manufacturer's expiration date, resulting in the potential for poor patient outcomes for seven patients on the HC-CVRI nursing unit.
Findings include:

On 4/24/18 at approximately 1140 a tour Facility (A) nursing units were conducted while accompanied by Nurse Manager Staff R.

On 4/24/18 at 1155 during the tour of the 2 HC-CVRI nursing unit the medication room was observed with Nurse Manager Staff NN while accompanied by Staff R and the following was observed:
There were 13 one liter filled IV solution bags labeled "Plasma- Lyte A Ph 7.4" (multiple electrolytes injection solution) with a manufacturer's expiration date of 10/2017 observed on a medication preparation counter. Staff R explained that she did not know why the bags were on the counter when queried regarding the expired IV solutions. Staff R confirmed the IV solutions were expired. She said she would check with pharmacy. She stated, "pharmacy monitors the dates on IV solutions."

On 4/26/18 at 1300 review of the facility's "Storage and Security of Medication-Related Items" policy dated 05/07/2017, documented:
II. Medication Security:
C. Disposal per entity specific pharmaceutical waste policies
1. Expired, damaged, or contaminated medications are to be stored separately from stock medications to be administered to patients.

On 4/26/18 at 1130 the Chief Nurse Executive Staff E explained she was aware of the aforementioned concern. No further explanation was provided regarding the IV solutions being available for patient use at that time.






27713


On 4/26/18 at approximately 1130, the Pharmacy manger, Staff PPP was interviewed regarding the 13 bags of expired plasma expander found during the initial tour of the HC-CVRI unit medication room. Staff PPP stated that it was Pharmacy's responsibility to remove expired bags of plasma expander from the nursing unit's active inventory. Staff PPP stated that these bags may have been overlooked by pharmacy staff because they were not stored on the "fluid cart" as required. Staff PPP stated that Pharmacy staff replaced the "fluid cart" on the nursing unit every 48 hours, and would remove any expired stock at that time. Staff PPP stated that these bags of plasma expander might have been removed from the "fluid cart" and "hoarded" on the nursing unit during the time period when there was a shortage of the product due to the manufacturer's inability to manufacture supplies normally as a result of hurricane damage in the fall of 2017.

Based on observation, interview and record review the facility failed to ensure that all dietary staff were competent in their duties, resulting in the potential for transmission of infectious agents to all patients served food from the kitchens of Campus A, with a current census of 850 patients (with 105 NPO) and Campus B, with a current census of 158 patients (with 41 NPO). Findings include:

During a dietary tour of the kitchen on Campus A between 11:10 AM - 1:33 PM on 4/24/18, and a dietary tour of the kitchen on Campus B between 2:30 PM- 4:29 PM on 4/24/18, the following observations, interviews and record review took place:

Campus A
1. Upon evaluation of the cold holding units of the facility, Supervisor of Nutrition Services A, staff #32, stated that the facility holds ready to eat potentially hazardous foods (PHF) for three days before they are discarded and that only discard dates are used in the kitchen. At 11:35 AM on 4/24/18 observations of a single door cold holding unit and three roll top preparation units all located on the cook line found the following items held beyond their discard date: Cooked penne noodles dated 4/23, two bags of ready to eat sliced chicken dated 4/23, three containers of thick sliced turkey dated for 4/22, 4/22, and 4/20, and eight individually packaged lasagna all dated for 4/23. At this time staff #32 confirmed that the facilities date-marking procedure was not correctly being followed. Observation of the walk-in cooler revealed: two containers of hummus and three entire expediting carts filled with different types of single service salads and BLT (bacon lettuce tomato) snack wraps (roughly 50 on each cart). All items found were dated for four days (outside the previously stated range) and labeled for discard after 4/27.

At 11:57 AM on 4/24/18 an open package of 50 count hot dogs and two-dozen single portioned unlabeled containers of what the Manager of Nutrition Services, staff #30, stated to be goulash, was found in a single door unit on the cook line of Campus A showing no label or indication of products expiration, this finding was confirmed with staff #30 at the time of discovery. Beginning at 11:24 AM on 4/24/18 in the prepared walk-in cooler of Campus A and in the main walk in freezer and the cook cooler multiple containers of items such as in house prepared pasta sauces, dressings, previously boiled and individually portioned pasta noodles, boiled and sliced potatoes, macaroni and cheese, beans, and a variety of meats were observed without any labels or dating provided.

2. At 11:49 AM on 4/24/18 during the kitchen tour of Campus A, an unlabeled Cambro container of chicken noodle soup identified to its contents by the Supervisor of Nutrition Services A, staff #32, later to be re-identified to its contents by Chef Specialist, staff #31, to be lentil soup, was observed cooling in a large container covered in plastic with visible condensation on the interior of the container. Upon observation Staff #32 stated that this must have been from the third shift cooks cooled from the day before, but was unsure why it was kept for later use. At this time, temperature verification of the product was conducted and it was confirmed to be holding at 78 degrees F. Upon record review of the posted cooling logs on the exterior of the walk-in blast chiller documentation of cooling this product was unable to be found in the facility's cooling logs from the previous day. Staff #32 was unsure why this product was cooled in this manner instead of following the facility's policy of rapidly cooling items for later use in the blast chillers provided at both Campus A and Campus B. At this time staff #32 confirmed this was not the correct cooling procedure to be used for this type of product.

3. At 11:59 AM on 4/24/18 the improper storage of raw foods over top of cooked foods and foods with lower required cooking temperatures was observed in Campus A's walk-in meat cooler. Items such as raw ground beef stored over cooked chicken breasts, raw chicken breasts stored over cooked corned beef, and raw chicken halves stored over flank beef steak. Upon observation the Training/ Project Specialist, staff #34, began collecting the improperly stored items for disposal as they cited placards posted on the walls identifying the facility's process to properly store these items in refrigeration units to prevent against cross-contamination had not been followed. Upon record review of the posted placards it was confirmed that the facility has policies in place for the proper storage of items to prevent against cross contamination from occurring.

4. At 11:31 AM on 4/24/18 during the kitchen tour of Campus A the lack of proper glove use and the apparent lack of knowledge of when handwashing is required was observed as one cook and two dietary aides were observed contaminating their gloves on multiple occasions and continuing with food preparation, plating and serving food. Improper practices were observed such as assembling and plating sandwiches with the same pair of gloves used after wiping up spills, going in and out of the sanitizing bucket to ring out cloth towels then continuing to use the same pair of gloves for meal preparation and serving, adjusting their hair nets and touching their faces and then continuing food preparation activities without changing gloves or performing any form of hand hygiene. Upon observation by the Director of Nutrition Services, staff K, they recalled the plates of food that were in the process of being served and assured the surveyor that this was not the facilities correct procedure to follow.

Campus B
5. At 2:48 PM on 4/24/18 in the produce cooler of Campus B, noted cut and portioned ready to eat produce not labeled or dated.

5. At 3:15 PM on 4/24/18 during the kitchen tour of Campus B, bare hand contact with ready to eat foods was observed. A dietary aide was observed rinsing cucumbers in the vegetable prep sink, then picking them up as a bunch with their bare hands while balancing them against their uniform as they walked across the kitchen to place them on a cutting board for salad prep. This finding was confirmed with the Training/ Project Specialist, staff #34, at the time of discovery. At this time staff #34 provided education to the dietary aide.

Based upon observation and interview the facility failed to maintain the hospital environment to assure the health and safety of the current census of 158 patients in Campus B, its staff and the public. Findings include:

During a dietary tour of the kitchen on Campus B between 2:30 PM- 4:29 PM on 4/24/18, the following observation took place:

1. At 3:40 PM on 4/24/18 during a tour of Campus B's dish room it was observed that a hose with a spray valve attached was located downstream from the plumbing fixture's atmospheric vacuum breaker (AVB). This finding was confirmed with the Supervisor of Nutrition Services A, staff #32, and the Director of Nutrition Services, staff K, at the time of discovery. The AVB observed was an American Society of Sanitary Engineering (ASSE) 1011, which is not approved for constant backpressure. In this current plumbing configuration the water valve is left on, putting undue back pressure on the AVB which over time will ruin the mechanical integrity of the unit and no longer allow the component to adequately protect the facility's water supply from cross contamination as designed.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated April 26th, 2018.
K-0211
K-0902

DPS 1
Based on observation, interview and record review, the facility failed to ensure that 1) Infection Control Policies for handwashing and personal protective equipment (PPE) use were followed for one (#47) of five patients observed with Isolation Precautions, out of a total sample of 110, 2) clean supplies were stored off of the floor in 2 of 2 supply rooms resulting in the potential for transmission of infection, 3) high level dusting was performed in 3 of 3 pediatric intensive care patient ready rooms, and 4) undated and expired perishable food items were removed from use in three out of 25 inspected patient nourishment refrigerators, resulting in the potential for transmission of foodborne illness. Findings include:

1) On 4/25/18 at approximately 0815, Patient #46's room was observed with the Infection Control Manager, Staff WW, and the patient's clinical record was reviewed. Patient #46 was a 67 year old female who was admitted on 4/11/18 with diagnoses which included Guillain Barre syndrome (a disease where the immune system attacks the nervous system), and history of methacillin resistant Staphylococcus aureus (MRSA) infection. The patient was placed on Contact Precautions for MRSA on admission on 4/11/18. A sign on the door of Patient #46's room noted that the patient was on Contact Precautions, with PPE gloves and gown required to enter the room.

On 4/25/18 at approximately 0900, contracted plasmaphoresis nurse Staff CCC was observed as she assembled supplies on the Plasmaphoresis machine outside of Patient #46's room. Staff CCC did not wash or sanitize her hands before assembling the plasmaphoresis supplies and opening their wrappers. Patient #46's staff nurse and nursing care aide were in the patient's room performing morning care. The door to the patient's room was open, and the patient's modesty was protected with curtains closed around the bed. The nurse and aide were observed pulling the curtains back to go to the doorway to get the patient's breakfast tray and additional towels and supplies, and when the nurse administered medications to the patient. Both staff were observed opening the bed curtains and opening cupboards in the area outside the curtain with gloved hands during care for the patient.

On 4/25/18 at approximately 0915, Staff CCC entered Patient #46's room without wearing any PPE (no gloves, no gown) and without hand sanitizing or hand washing, and pulled back the bed curtains with her bare hands to talk to the nurse. Staff CCC then left Patient #46's room without washing or sanitizing her hands, and returned to the plasmaphoresis machine and connected the intravenous tubing (used to do plasmaphoresis) to the plasmaphoresis machine without washing or sanitizing her hands first.

On 4/25/18 at approximately 0950, Staff CCC was asked about handwashing and PPE use for Patients in Contact Isolation Precautions, and reported that she was new and was still on orientation.

On 4/25/18 at approximately 0955, Staff WW was interviewed about Staff CCC's lack of hand washing or sanitizing before assembling plasmaphoresis supplies and stated, "I noticed that too. She should have sanitized or washed her hands before she started assembling supplies, and when she left the isolation room. She shouldn't have gone in the room or touched anything without gown and gloves on."

On 4/26/17 at approximately 1400, review of the facility policy entitled, "Isolation - Transmission Based Precautions", dated 2/22/18, revealed the following statements, "Contact Precautions - ...Hand hygiene must be performed piror to donning PPE's and upon entering the patient's room. PPE is to be worn by all healthcarae personnel entering the patient room. Gloves and gowns must be worn at all times. Hand hygiene must be performed following removal of PPE's and upon leaving the patient's room."

4) On 4/24/18 at 1230 the 6N unit was toured with the Unit Manager, Staff AAA and the Infection Control Manager, Staff WW, and the following undated or expired items were observed in the first nursing station patient nourishment refrigerator inspected:

1. A one quart container of 2% milk was opened and half full, but had no date to indicate when it was opened. Staff AAA was unable to state when asked when it was opened.

2. An undated cream cheese and salmon sandwich was not labeled with an expiration date or a date made. The sandwich had a facility label with a patient's name, but no date. Staff AAA was unable to say how old it was, or whether it was an uneaten item from the patient's meal tray.

3. An undated white creamy substance was in a styrofoam cup with lid. The cup had a facility label with a patient's name, but no date. Staff AAA was unable to say how old it was, or where it came from.

4. An undated sandwich with a discolored, filling which oozed irregularly from a squashed bagel had a facility label containing a patient's name, but no date. When asked, Staff AAA stated, "It looks like tuna salad or chicken salad. It contains mayonnaise." Staff AAA was unable to say how old it was, or whether it was an uneaten item from the patient's meal tray.

Staff AAA replaced the undated items back in the refrigerator and exited the room.

On 4/24/18 at approximately 1240, the second nursing station patient nourishment refrigerator was inspected with Staff AAA and Staff WW and revealed two undated, styrofoam cups with lids which contained an unidentified non carbonated yellow beverage. Staff AAA was unable to say what was in the cups, who they were for, or how long they had been there.

Staff AAA replaced the undated items back in the refrigerator and exited the room.

When queried, Staff WW stated that all perishable foods and beverages should be labeled with an expiration date determined by the food storage policy, and that the manufacturer's "sell by date" would be replaced by a facility expiration date once opened. Staff WW stated, "If we (infection control team) were rounding and found undated patient nourishments, we'd get rid of them."

On 4/26/18 at approximately 1330, review of the facility policy entitled, "Nutrition Services: Food Storage and Stocking on Patient Units", dated 4/24/18 ( date policy was requested) revealed the following statements:

" All unopened bult nourishment items (such as milk or yogurt) once opened are to be dated and discarded after 7 days."

"If a caregiver removes an item from a patient's food tray and this food item is stored in the unit refrigerator, the item must be labeled with the patient's name, room number and the date. All items must be discarded after 24 hours."




36887

2) While touring the pediatric intensive care unit (PICU) at Facility A on 4/24/2018 at 1530, the clean utility was entered on the east side and found to have multiple varied supplies on the floor including syringes and caps which appeared to have fallen from the storage bins on the shelves. Staff 35 and Staff FF confirmed these findings at the time of discovery.

The clean utility on the west side of the PICU was entered on 4/24/2018 at 1534 and found to have two empty cardboard boxes on the floor as well as 5 boxes of supplies stored outside of the shipping box and on the floor under the bottom shelf. These findings were confirmed by Staff 35, Staff GG, and Staff HH at the time of discovery.

Staff HH was queried on 4/24/2018 at 1536 as to if supplies were normally stored on the floor to which she replied "No. I had no idea they were down there." Staff HH proceeded to pick up all of the supplies on the floor and discard them into the garbage can.

3) During facility tour on 4/24/2018 at 1540, pediatric intensive care unit (PICU) Room #808 identified as being patient ready was entered and found to have thick dust on top of the epic dashboard monitor and on top of the monitor boom. These findings were confirmed by Staff 35 at the time of discovery.

On 4/24/2018 at 1547, PICU Room 821 identified as being patient ready and assigned to a fresh surgical case was entered and found to have thick dust on top of the epic dashboard monitor, boom, on top of the television, on top of the monitor and the monitor boom. Additionally a spot of blood was found on the wall above the sink area. Additionally, a shelving area had multiple specks of glitter on it. These findings were confirmed by Staff 35 at the time of discovery.

On 4/24/2018 at 1550, PICU Room 822 identified as being patient ready was entered and found to have dust on top of the epic dashboard monitor, the monitor boom, the monitor, and the television. These findings were confirmed by Staff 18 at the time of discovery.

The Manager of Environmental Services, Staff LL, was interviewed on 4/24/2018 at 1608 and informed of the findings in each PICU room. Staff LL stated, "It looks like we missed some high level dusting. We will definitely look into this and re-educate our staff."

The "Standard Work Activity Sheet" last revised 11/2017 was identified by Staff 18 as "the expected standard for environmental services. This was reviewed of 4/25/2018 at 1026. It identifies "High-Dust the following areas: doors, door frames, medical control arms or booms (if applicable), vents, lights, patient lift tracks, tv monitors..."








28775


4) On 04/24/2018 at approximately 1130 a tour of the 4 West nursing unit at Facility (A) was conducted while accompanied by Nurse Manager Staff O. Nurse Manager R was present for the observation and the following was observed in the patient nourishment refrigerator:

1. A one quart container of 2% milk opened and one quarter full. There was no date that indicated when the milk was opened or when the milk would expire. Staff O said the milk should have been dated when opened.
2. A one pint carton of whole milk with an expiration date of 4/20/18.
3. An undated Styrofoam take out food container in a plastic bag that contained portions of eaten and uneaten fried fish fillets.

At that time Staff O was observed as she discarded the perishable food items. She said the unit clerk was responsible for monitoring the expiration dates of the food products. Staff O said whoever put the take out food in the refrigerator should have dated it.

On 4/26/2018 at 1345 a review of the facility's "Nutrition Services: Food Storage and Stocking on Patient Units" policy, dated 04/24/18 revealed the following statements:

I. Bulk Nourishments:
A. Bulk nourishment items sent to nursing units by Nutrition Services will have an expiration date printed on the container, for example, milk cartons. Unit staff is responsible for discarding these unopened items upon the expiration date, items such as milk, fresh juice and yogurt. All unopened bulk nourishment items, etc., once opened are to be dated and discarded after 7 days.

II. Patient Food Items:
B. "If family members obtain permission to bring food items in for a patient, it is encouraged that the food be obtained from an approved source, such as a store, restaurant, etc. The food should be consumed immediately and not stored in the patient's room. If items are stored in the unit refrigerator, they must be labeled with the patient's name, room number, and the date, in a closed container. Perishable items must be discarded after 24 hours...".

On 4/26/18 at 1130 the Chief Nurse Executive Staff E explained she was aware of the aforementioned concern. No further explanation was provided regarding the perishable food items that were available for patient use at that time.





32000

DPS 2
Based upon observation and interview, the facility failed to provide a sanitary environment and avoid sources of transmission in the kitchen of Campus A and Campus B. This practice could affect all patients served food from the kitchens of Campus A, with a current census of 850 patients (with 105 NPO (nothing by mouth)) and Campus B, with a current census of 158 patients (with 41 NPO). Findings include:

During a dietary tour of the kitchen on Campus A between 11:10 AM - 1:33 PM on 4/24/18, and a dietary tour of the kitchen on Campus B between 2:30 PM- 4:29 PM on 4/24/18, the following observations and interviews took place:
1. On 4/24/18 at approximately 11:20 AM, during the kitchen tour of Campus A, the following observations and interviews occurred:
- An accumulation of rice was observed on the back wall of the dry storage room.
- An accumulation of dirt and food debris was found in multiple gaskets of the cold holding refrigeration units as well as in the drawers of the roll top preparation units on the cook line.
- A pile of mixed vegetables was found between storage racks in the walk-in freezer along with an accumulation of food debris and packaging wrappers on the freezers floor.
- In the produce cooler, an area of the floor was observed with multiple sliced pickles, an individual orange and onion that had been left under the shelving in the cooler.
At this time Supervisor of Nutrition Services A, staff #32, stated that the floors on the walk-in units get mopped once a month and swept out one or two times a week.

On 4/24/18 at 12:37 PM, in the prepared cooler, varying food debris including sausage links, ground beef, food residue, plastic wrappings and plastic bags were observed on the cooler's walls and floor. This finding was confirmed with the Training/ Project Specialist, staff #34, at the time of discovery.

2. During the kitchen tour of Campus B the following observations were made:

On 4/24/18 at 3:12 PM, upon evaluation of the ice machine area, a large shelving unit was observed holding a variety of utensils in 11 bus tub style bins. When asked if these were clean utensils, the Manager of Nutrition Services, staff #30, stated that they were. Looking through the tubs it was evident that a substantial amount of dirt and food debris had accumulated in the bottom of each bin. This finding was confirmed with the Manager of Nutrition Services, staff #30, at the time of discovery. Observations around the surrounding area noted five utensils (tongs, slicer/chopper, and a mechanical scoop) underneath the ice machine located next to the clean utensil storage.

On 4/24/18 at approximately 3:20 PM, the following observations took place:
- A single-door True brand freezer with melted ice cream debris on the sides and floor of the unit.
- An accumulation of burnt food debris and dust on top of the convection oven units was observed with metal cooking racks stored on top of when not in use.
- What appeared to be an onion was observed underneath the preparation table off the cook line, and dried soda residue was observed on the floor of the small dry storage area next to the employee beverage station. This finding was confirmed with the Manager of Nutrition Services, staff #30, at the time of discovery.

On 4/24/18 at 2:47 PM, in the dry storage room, coffee grounds, sugar packets, plastic lids, wrappers, cups, single use utensils and bowls were observed throughout the room on its flooring. This finding was confirmed with the Training/ Project Specialist, staff #34, at the time of discovery.

On 4/24/18 at 3:18 PM labeling stickers in their entirety, partial stickers and sticker residue were observed on numerous clean/ ready for use food containers and lids after being process through the facility's dish machine or 3- compartment sink. This finding was confirmed with the Supervisor of Nutrition Services A, staff #32, and the Training/ Project Specialist, staff #34 at the time of discovery.

On 4/24/18 at approximately 3:20 PM, a substantial amount of dust and debris was observed accumulated on the cook cooler's fan grates, within the bake shop's ventilation hood and on two turbo chef units filters and fan coils. This finding was confirmed with the Supervisor of Nutrition Services A, staff #32.