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Based on interview and review of documentation, the facility failed to ensure that medical records included nursing notes and other information to monitor the patient's condition.
Findings were:
Facility based policy entitled, "Assessment and Legible Documentation of Patient Care", stated in part, "1. Documentation of care should be pertinent and concise and should reflect the patient's status, addressing the patient's needs, problems, capabilities, and functional deficits. Interventions and patient response must be noted."
Facility based policy entitled, "Standardized Use of Restraint and/or Seclusion" stated in part,
"Patient Monitoring and Documentation: Non violent or non self-destructive behavior ...
2. The patient will be monitored in person by trained and competent staff as needed and minimally every two hours by an RN/LVN for the following:
a. Change in condition impacting need for restraint
b. Skin and circulation
c. Respiratory status
d. Review of vital signs
e. Capillary refill distal to restraint
f. Fluid/food as appropriate
g. Elimination and toileting
h. Position change and release of restraint
i. Readiness for discontinuation of restraints.
3. The above assessments and reassessments will be recorded on the appropriate forms or electronic documentation record and will be included in the patient's medical record. By assessing documenting the six items above, the RN will ensure the patient's safety, as well as preservation of personal rights and dignity."
Review of documentation for 2 patients (# 17 and 17) that were in medical restraints on 6/4/14, revealed that 1 patient (Patient # 16) did not have complete documentation of monitoring per facility based policy.
A review of the medical record for Patient # 16 revealed physician orders for "Medical Post Surgical Healing" on 6/3/14 at 1415 and 6/4/14 at 0955.
In an interview on 6/4/14, staff member #4 confirmed that patient # 16 remained in medical restraints that morning. Staff member #4 assisted this surveyor in looking through the electronic medical record for documentation of the medical restraints. Staff member # 4 confirmed there was no documentation of restraint monitoring in the portion of the electronic record for medical restraints for 6/3/14 or 6/4/14. Staff member #4 confirmed this documentation should have been present in the record.
Staff member # 6 also verbally confirmed she had placed patient # 16 into medical restraints on the afternoon of 6/3/14. This staff member # 6 also confirmed that documentation of monitoring the patient while in restraints had not been completed and should have been entered into the medical record.
Further review of the electronic medical record for Patient # 16 revealed documentation in the "Rounds Assessment-ICU" and "Shift Physical Assessment (ICU)" noted that the patient was in medical restraints and included a brief physical assessment. This documentation did not included all of the area that need to be monitored per facility based policy for restraints.
In an interview on 6/5/14 staff member # 8 confirmed that the documentation in the "Medical/Surgical Healing Restraint" portion of the electronic medical record was not completed by nursing staff until the evening of 6/4/14.
Staff member # 8 confirmed the documentation of the medical restraint for Patient # 16 present in the medical record did not meet the requirements for monitoring per the facility based policy.

Based on a tour of the hospital, the facility failed to ensure that dietary services were managed in a safe and sanitary manner.
Findings included:
During a tour of the kitchen and dietary areas the morning of 6/3/14, accompanied by the Food Service Director (Staff # 16), the following was observed:
· There was a mop standing in a mop bucket containing approximately 2 inches of brown water.
· The external doors to the kitchen area had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.
· The temperature logs for Kelvinator reach in freezer were reviewed and found to be not current and incomplete as the May log was posted and there was no June log. This was observed on 6/3/14 and none of the temperatures had been recorded for the month of June. There was no means of determining that freezer temperatures were consistently maintained at a safe food storage temperature to prevent bacterial or other contamination resulting in food-borne illness.
· In the walk-in freezer, there were 2 trays of frozen cinnamon rolls (20 rolls on each tray) which were uncovered and were not labeled with a date, increasing the risk for cross contamination. There were ice stalactites visible on the ceiling of the freezer, and ice stalagmites on the floor of the freezer. The presence of stalactites and stalagmites indicates a potential mechanical issue with the freezer.
· The plate warmer in the dishwashing area was in need of cleaning, as the hinges for the top were dirty with a greasy substance and there were crumbs and debris inside the food warmer where clean plates were stored after washing, available for patient use.
· The large food mixer had a dried substance which appeared to be food, on the mixer above the bowl, indicating a need for cleaning and creating a risk for contamination.
· There was dried food and other debris in two of the food prep table drawers, which contained utensils available for food preparation.
· A large manual can opener mounted on a food prep table was dirty with a dried black substance.
· In a bin containing kitchenware, there were 7 large spoons stored with the bowls up; 3 spoons had a clear liquid which appeared to be water resting in the bowl of the spoon. The utensils had not been dried properly, providing a moist environment and a risk for cross contamination.
The above findings were confirmed with the Food Service Director during the tour the morning of 6/3/14 in the kitchen and dietary area.
Based on direct observation, a review of facility policies, and staff interview, the hospital failed to ensure that dietary services were managed in a safe and sanitary manner.
Findings were:
· During a tour of the facility kitchen on the morning of 6/3/14, the following was observed:
· In the produce refrigerator, there were 5 open plastic bins. Each bin contained one of the following foods: leafy greens, squash, mushrooms, parsley and tomatoes. The open container containing leafy greens was on a shelf below a bottle of prepared salad dressing which was no longer full, and thus had been opened and used. Other ready-for-use food items were also stored above the open bin containing leafy greens.
· The staging area refrigerator log contained no entry for 6/2/14.
· The Box 4 Warmer contained rice and soup. A form entitled "TCS Food Hot Holding Log" on top of the warmer box was completely blank. Thus, there was no information available which showed when the items had been placed in the warmer. In addition, there was no temperature log available for the warmer. The items were identified by kitchen staff upon observation as patient food items ready to be served that day.
· Each shelf of the Box 4 Warmer was grossly stained with what appeared to be old food spills.
· A double-sided stacking shelf unit contained stacked dishes described by kitchen staff as clean and ready for use. One side of the unit included four stacked wet braising pans. On the other side of the unit, each of the four stacking shelves included assorted pans which were all wet. Upon observation, the Food Service Director confirmed the items were still wet from washing.
Facility policy entitled, "Food and Non-Food Storage - Procedure," last date reviewed 5/14, stated, in part:
"PURPOSE:
To establish guidelines to prevent food borne illness/food contamination. Food and non-food items are stored in compliance with applicable federal, state, and local regulations regarding sanitary storage conditions and safety laws.
PROCEDURE:
GENERAL:
1. Temperature appropriate for items, thermometer in all refrigerators and freezers for monitoring purposes...
5. Temperature checks are documented once daily for refrigerated and frozen storage...
REFRIGERATOR STORAGE: ...
6. Keep refrigerated foods tightly wrapped or covered in sanitary containers...
HOT FOOD HOLDING: ...
1. To keep foods hot for service, use steam tables or other equipment that will keep all parts of all food 140 degrees F or above...
EQUIPMENT: ...
4. Shall be dry. If damp store in self-draining position that permits air dry ..."
The above findings were confirmed in an interview with the Food Service Director the morning of 6/3/14 during the tour.

Based on observation and tour, the facility failed to maintain the overall hospital environment in such a manner that the safety and well-being of patients are assured.
Findings were:
During a tour of the facility on 6/3/14 the following infection control issues were noted at the facility.
In the outpatient catheterization lab the following observations were made:
· Dust was observed on high horizontal surfaces such as the top of suction canisters, light fixtures, and monitor. The presence of dust indicated ineffective cleaning of these items.
· In the nourishment room of this unit there was an unlabeled drawer containing: an unlabeled container of peanut butter, 2 rice cakes in an open bag, 2 toothbrushes, and 1 unlabeled container of nut mix.
In the cardiac catheterization lab the following observations were made:
· In the utility closet a ceiling tile was noted with water damage present, approximately 5 inches in circumference. The presence of water damage indicated the area could be contaminated with bacterial particles due to the moist environment.
· A bedside table in the room had a 9 inch area of stick residue present along with a large piece of tape that was 10 inches long. Tape was also observed on the floor by the Pyxis. Tape and tape residue cannot be effectively cleaned.
· A metal cabinet was observed with crumbling rust approximately 10 X 2 inches in size along the bottom edges. Rust cannot be cleaned.
In the CAT Scan/MRI Area the following observations were made:
· In the patient bathroom there was an area of chipped paint, approximately 2 feet in size.
· A stretcher with a threadbare area with exposed foam that was approximately 2 centimeters in size.
· A cabinet under a sink was observed to have warped laminate in the bottom. A black discoloration was noted to the laminate. This indicated a risk for contamination with bacterial particles due to the moist environment.
· Outside the MRI room torn wallpaper was observed that was approximately 6 X 2 inches in size with drywall exposed underneath.
In the Respiratory Area the Bronchoscopy room was toured and following observation was made:
· A cabinet was observed with a piece of tape approximately 4 inches in size on a cabinet. The cabinet also had a 3 inch missing piece of laminate.
In the Radiology Department the following observation was made:
· In Camera Room #3 a patient table was observed with duct tape covering one side, approximately 4 feet X 6 inches in size. Tape cannot be effectively cleaned.
During a tour of the facility on 6/4/14 the following infection control issues were noted at the facility.
In the Medical Intensive Care Unit the following observations were made on Room 10:
· Tape residue was noted on the patient bed in room. A 2 inch piece of tape was also observed on a suction canister.
· A 1 inch area of missing laminate was observed on a cabinet
· A ceiling tile was observed with a 4 inch area of water damage was observed.
During a tour of the facility on 6/5/14 the following infection control issues were noted at the facility.
In the Day Surgery Area in the Operating Room 6 the following observations were made:
· Tape was observed on the arm board of the surgical stretcher. Tape residue was also noted to the stretcher mattress and frame. Tape and tape residue cannot be effectively cleaned.
In the Pre-Operative Area the following observation was made:
· In the Nourishment Area 3 pest control traps were observed that were not provided by the facility pest control provider. 3 traps labeled "Maxforce insect control roach bait station" were observed in cabinets. One cabinet contained bottle nipples, tea bags, and crackers.
The above findings were confirmed with facility staff at the time of the observation during the tours on 6/3/14, 6/4/14 and 6/5/14.

Based on a tour of the facility and staff interview, the facility failed to ensure an acceptable level of safety for patients.
Findings were:
During a tour of the Emergency Department the morning of 6/4/14, accompanied by Staff #9, Interim Nurse Manager, the following was observed:
· In the supply room, a ceiling vent and ceiling tiles were dirty with a black smudged substance and were in need of cleaning and there was a cracked plastic ceiling light fixture. This presents a risk for cross contamination of patient supplies, available for patient use, including syringes, emesis basins, needles, skin stapler, sutures, and other patient supplies.
· In the "pelvic room" there was dirty duct tape on the patient examination table underneath the stirrups. There were reddish and white dried drips on the bedside cabinet in the room.
· In the Trauma room, the defibrillator cart was in need of cleaning, as there were dried drips on the cart.
· The end of the emergency call light cord in the patient bathroom was observed approximately 18 inches above the floor, rendering it out of reach and ineffective for a patient experiencing a fall on the floor to summon help in an emergency. The call light cords were not extended to within 6 inches of the floor; therefore a patient that had fallen would not be able to reach the cord in either of the patient bathrooms.
· In the supply room, the linen cart was covered; however the cover was in need of cleaning as there was black, sticky tape residue. The top of the linen cart also had a layer of black, sticky tape residue. The cart contained linen available for patient use.
The above findings were confirmed during the tour of the Emergency Department by Staff #9 the morning of 6/4/14.
During a tour of the second floor the morning of 6/5/14, accompanied by Staff #26 and Staff #8, the following was observed:
· There were dried drips and debris in a drawer on the unit containing O2 supplies in the NICU.
· In the Labor and Delivery supply room, there was a drawer containing patient supplies (cords and cables) which was in need of cleaning due to dust and debris in the drawer. There were raised fluffs of lint and dust on the floor in the supply room.
· In the Nursery, the handheld bilirubinometer used to test the blood of infants was dirty with old tape and sticky tape residue. The tape was peeling back and there was a black substance adhered to the tape.
· In the Caesarean Section operating room #1, there were two infant warmers available for patient use. The vinyl mattress pads in both warmers were split at the seams, exposing the foam pad. The split seams prevent disinfection, creating a risk for cross contamination.
The above findings were confirmed in an interview the morning of 6/5/14 with Staff #26 and Staff #8 on the second floor of the hospital.

Based on observation, interview and record review the facility failed to ensure an effective implementation of the facility's Infection Prevention and Control Program for disinfecting equipment to prevent and reduce the risk of transmitting infections and communicable diseases among patients and other personnel.
Nursing and rehabilitation staff failed to follow the department's infection control policy for gait belt disinfection.
The facility's failure could affect all 22 patients in the department who required the use of gait belts.
The findings were:
Review of the facility ' s Infection Prevention and Control Program and policy titled " Cleaning And Infection Control Related to Rehabilitation Services " dated July 1998 and last reviewed on November 2013 indicated its purpose was to prevent and reduce the risk of transmitting infections among patients, staff, healthcare workers, visitors and other personnel. The program and policy required all staff to comply with its procedures including the cleaning of all equipment per its cleaning schedule and documented in the department. The policy further required for gait belts to be laundered at least monthly or when visibly soiled with blood or body fluids and to be wiped down after each patient use with a designated wipe.
Review of the facility's Infection Prevention and Control Report for Fiscal Years 2012 through 2014 indicated yearly increases of Hospital Acquired Methicillan-resistant Staphylococcus aureous (infection caused by a strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary staph infections also known as MRSA).
During a tour of the facility ' s Orthopedic/Rehabilitation Department on 06/04/14, nursing and rehabilitation staff were observed to use gait belts (a device made of cotton webbing used to transfer people from one position to another) on patients throughout the department.
In an interview with Staff 18 on 06/04/14, the staff member indicated nursing and rehabilitation personnel used gait belts for multi-use on different patients. She said staff were instructed to sanitize their gait belts with an alcohol based wipe after each patient use or when visibly soiled. The decision for further use of the device or to discard was at the discretion and judgment of the staff member. Staff 18 acknowledged gait belts were not laundered monthly as required by department policy. No clear infection control or equipment disinfection policy or procedure was communicated as a standard to determine the continued use or the discarding of visibly soiled gait belts.
Interview with Staff 19 on 06/04/14 revealed nursing and rehabilitation staff used gait belts for multi-use on different patients. Staff 19 indicated staff were instructed to sanitize their gait belts after each patient use or to discard contaminated belts at the discretion of the employee. There was no clear infection control or equipment disinfection policy or procedures being followed as a standard. Staff 19 indicated no gait belt in the department was laundered monthly or when visibly soiled as required by the facility ' s " Cleaning and Infection Control ... " policy. Staff 19 acknowledged that patients were at risk for possible cross contamination of infectious and communicable diseases.
Further review of facility documents revealed no tracking mechanism to determine how long a gait belt had been in service in the department, no policy to provide clear determination of when to discard a gait belt including when visibly soiled, no evidence of cleaning or disinfection schedule of gait belts and no system to determine the effectiveness of the disinfection using their alcohol based wipes.
During the Exit Conference on 06/05/14, the facility was provided an opportunity to ask questions, provide answers and give additional information. None was given related to implementation of Infection Control Policy and gait belt disinfection procedures.