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Based on observation, interview and policy review, the facility failed to ensure that approximately 100 hard copy (paper) medical records of discharged patients were not accessible to unauthorized persons while stored in the Health Information Services (HIS) office. The average number of patients discharged from the facility daily was 17. This deficient practice had the potential to expose undetected, unauthorized access of personal and medical information of all patients who were discharged. The facility census was 76.

Findings included:

1. Record review of the facility's policy titled, "Release of Medical Information to Patients or Other Authorized Parties," revised 11/12/13, showed the following direction for staff:
- The patient had the right to the confidentiality of medical record information.
- Medical record information was available for review and disclosure to authorized individuals after executing specific protocols for release of information.
- HIS staff and/or clinically qualified staff were required to be present with medical records while reviewed at the facility.

2. Observation on 02/11/14 at 10:50 AM in the HIS department office area showed approximately 100 unsecured paper medical records of discharged patients stacked on desk tops, counter tops, and in five large storage boxes approximately 12" x 10" x 15" (" = inches, a unit of measure) on a mobile cart. The office area was visible and accessible to all persons who entered the department.

3. During an interview on 02/11/14 at 11:20 AM, Staff SS, Director of HIS, stated that all paper medical records of discharged patients were brought to the HIS department daily and stored in the office area for processing. After processed, the medical records remained in the area for approximately one week before they were boxed and taken to an off-site location for storage. She stated that the medical records were always stored in the office area and there was not a policy for storage of the medical records while in the HIS department. She stated on 02/11/14 at approximately 3:30 PM, that housekeeping and security staff had keys to the HIS department. Housekeeping staff cleaned the office area daily after the department closed and HIS staff were gone. She stated that access to the department when HIS staff were not present had the potential for housekeeping and security staff to access the patients medical records undetected.

Based on observation, interview and policy review, the facility failed to ensure:
- Four of four Staff (PP, QQ, RR, and I) wore hair nets, in the kitchen, that contained all hair.
- Four of four kitchen Staff (VV, PP, QQ, and RR) washed their hands before putting on gloves and/or wore gloves while they prepared and touched food and service ware.
- Two of two food containers brought from outside the facility were not stored in patient refrigerators in the kitchen.
- Foods removed from the original containers stored in four of four refrigerators, in the kitchen, observed for food storage were labeled and dated.
- Food preparation, storage and service ware equipment and floor surfaces in the kitchen were clean.
-Six of six food temperatures tested were maintained at expected temperatures.
These failures had the potential to expose all patients, staff and visitors to foodborne illness and poor quality food. The facility census was 76.

Findings included:

1. Record review of the facility's job description titled, "Manager-Nutrition Services," dated 04/03/13, showed that the position managed all employees and all functions of the Nutrition Services Department including general sanitation according to Federal, State, and Occupational Safety Health Administration regulations/standards (a government agency that assures safe and healthful working conditions).

2. Record review of the facility's policy titled, "Food Preparation," dated 11/13, showed the following direction for staff:
- Management monitored food preparation and policy compliance.
- Label and date foods when removed from the original container.
- Wear gloves when food or serving utensils were touched.
- Hand washing occurred before putting on gloves.
- Label and date leftover food.
- Serve milk directly from the walk in refrigerator.

3. Observation on 02/11/14 at approximately 9:45 AM in the kitchen, showed staff VV, Cook, touched food (frozen pre-cooked chicken breast patties) during preparation and touched serving utensils with no gloves on his hands.

4. Observation on 02/11/14 at approximately 8:55 AM showed a large refrigerator located near the salad preparation area with two side by side glass doors:
- Numerous patient food items in single serve dishes (too numerous to count) were stored on all shelves in various containers including large trays.
- Four of seven large trays (each tray held approximately 60 patient food items) had one, one-inch square paper post-it notes placed on one dish on each tray.
- The numbers written each of the notes were "2/8", "2/8", "2/8", "2/10". It was unclear if the number represented the one dish or the entire tray of mixed foods.
- Inside the refrigerator, on the bottom shelf next to patient food were two bags that's contained staffs food brought from home.
Staff failed to label and date all food stored in the refrigerator that had been removed from the original containers and failed to ensure foods brought from home were stored away from patient food.

5. Observation on 02/11/14 at approximately 9:00 AM of the kitchen, showed foods that were removed from the original containers, prepared and not labeled, dated and/or covered. Foods and locations observed were:
- Salad and beverage coolers had uncooked fruit, lettuce salad, gelatin salad, cake, cookies and prepared meats in small single serve dishes too numerous to count that were not labeled or dated.
- The walk-in refrigerator had one large stainless steel container of left-over chili, two baking trays of uncooked chicken meat (approximately 100 pieces) loosely covered not labeled or dated, and one large container of cut potatoes (approximately 20 pounds) not labeled or dated.
- The walk-in freezer had multiple baking trays of uncooked cookies (approximately 50 cookies per tray) loosely covered , more than 20 clear plastic "to-go" containers of baked muffins and cookies, multiple trays (more than 20) of prepared desserts cut into single serve portions arranged on the trays and loosely covered.

6. Record review of the facility's policy titled, "Food and Supply Storage," dated 11/15/13, showed the following direction for staff:
- Maintain high standards of food safety through proper preparation and handling of food.
- Only food is to be stored in refrigerators in patient nourishment areas.
- Label and date all open or partial containers of food in the refrigerators.
- All food will be rotated and used on a first in, first out basis according to date.

7. During an interview on 02/11/14 at 10:05 AM, Staff QQ, Dietary Technician (Tech.) stated that some foods were not labeled and dated if they expected to serve them "soon". She could not define "soon" as related to storage of unlabeled/dated food. She did not know how unlabeled/dated food was monitored to ensure foods were used first in, first out (rotated). She stated that some foods have post-it notes placed on the tray with the date but that the notes fell off. She stated that she threw food away when it looked bad.

8. During an interview on 02/11/14 at 10:15 AM, Staff RR, Dietary Tech., stated that not all food taken from the original containers and prepared for patient trays were labeled and dated while stored in the refrigerators. She was not aware of the expiration dates of prepared foods found in the refrigerator used for patient tray preparation or how staff monitored rotation of the food (first in, first out). She stated staff just knows what to use first and throw out food that looks bad.

9. Record review of the facility's policy titled, "Service Ware," reviewed 02/13 showed the Nutrition Services Department will maintain service equipment in a sanitary manner.

10. Observation on 02/11/14 of the kitchen area beginning at approximately 8:30 AM through 11:00 AM, showed food service equipment in use with areas of built up grime and debris that had accumulated over an extended period of time (not the result of recent use) showed the following:
- Dried debris and dark colored grime was on more than 50% of the surfaces of the door handles, door surfaces, control panels and knobs, inside surfaces and exposed edges of four of four ovens.
- Dried debris and dried liquid stains covered approximately 25% of the surfaces of door handles, door surfaces and the bottom shelves of two refrigerators.
- All shelves on two, five-shelf rolling carts had a moderate amount of dried loose debris on the flat surface of the shelves and dried liquid stains on the edges of the shelves and legs of the carts.
- One rolling cart, that held prepared foods and used by the cook during food tray assembly, had two handles covered with pale gray colored plastic, had been torn in many areas and were coated with a large amount of black colored thick build up of grime.
- Floor surfaces throughout the food preparation areas had built up black grime under equipment and easily visible to staff.

11. Record review of the facility's policy titled, "Uniforms and Personal Cleanliness," revised 01/13/10, directed staff to contain all hair in hairnets at all times, and that Managers and Supervisors were to comply with the policy.

12. Observation on 02/11/14 beginning at approximately 8:30 AM in the kitchen, showed Staff PP, Dietary Manager, wore a hair net that did not contain all of her hair. The hair net was approximately three inches beyond the hairline of her forehead. Uncovered hair hung loosely on her forehead. Staff PP did not wash her hands prior to putting on gloves. She touched serving utensils and prepared food in two walk in coolers without putting on gloves.

13. Observation on 02/11/14 at 9:00 AM in the kitchen, showed Staff QQ, wore a hair net that contained only a ponytail (hair gathered and tied near the hairline just above her neck) the hair net did not cover the hair on her head above the ponytail. Staff QQ did not wash her hands or put on gloves when she prepared foods and touched serving utensils.

14. During an interview on 02/11/14 at approximately 9:10 AM, Staff QQ stated that she only covered her ponytail with the hair net. She stated she washed her hands at the food prep sink before she handled food but not always before putting on gloves. She stated that she forgot to wash her hands and put on gloves before she prepared food. Concurrent observation of the prep sink showed no hand soap dispenser.

15. Observation on 02/11/14 at approximately 9:15 AM in the kitchen, showed Staff RR, wore a hair net that did not contain all of her hair. The hair net was located approximately four inches beyond the hairline of her forehead and exposed loosely styled hair that covered her forehead. Staff RR did not wash her hands before she put on gloves and did not put on gloves prior to food preparation.

16. Observation on 02/11/14 at approximately 10:20 AM in the kitchen, showed Staff I, Manager of Facility Plant Operations, with uncovered facial hair (mustache and beard).

17. During an interview on 02/11/14 at approximately 10:20 AM Staff I stated that he was in the kitchen frequently and he never wore a hair net over his facial hair and if he needed to wear one the Dietary Manager would have told him about it.

18. During an interview on 02/11/14 at approximately 4:00 PM, Staff CC, Infection Control Preventionist, stated that hand hygiene surveillance for the dietary staff had fallen off the "radar" and no monitoring had been conducted. She stated that it had been six months since the dietary manager developed a performance action plan to improve the cleanliness of the kitchen. A follow up was done after the action plan was put in place and the cleanliness had improved. However, other than the oversight and management responsibilities of the Dietary Manager, she was not aware of ongoing surveillance activity related to the use of hairnets, hand washing, glove use or environmental cleanliness of dietary services. She stated that all standards of food safety should be maintained to prevent the risks of forborne illness.

19. During an interview on 02/11/14 at 10:30 AM, Staff PP stated that:
- The facility had a policy that permitted bangs (loose hair on the forehead) to be worn outside of hairnets and facial hair to be uncovered. However, when requested no policy was provided.
- All foods taken from the original containers should have been labeled, dated and rotated and she had not been diligent about monitoring food storage.
- She expected staff to wash their hands before putting on gloves.
- Anyone who prepared or handled food and the supplies used for serving and storing should wear gloves.
- Food brought into the facility, including staff lunch totes should never be stored in the patient refrigerators.
- The cleanliness of the kitchen was a concern and that she did not realize it had gotten so bad. She related recent bad weather conditions, a high patient census, and staff illness to the buildup of grime and debris found on the service equipment and floors. She stated that kitchen staff was responsible for cleaning the kitchen area.

20. Record review of the facility's policy titled, "Food Temperature," reviewed 08/10, showed direction for staff to maintain food safety by monitoring food temperatures. Hot foods were to stay hot and cold foods to remain cold. Maintain specific foods at the following temperatures:
- Extended Entrees (casseroles) at 166° F;
- Meat at 165° F;
- Vegetables at 135-150° F;
- Stock Soups at 190° F;
- All cold foods at or below 41° F.

21. Observation on 02/12/14 at 11:15 AM showed Staff PP test food temperatures of cold foods immediately taken from a refrigerator at the tray preparation line. Temperature measurement results were:
- Cold food (fruit) at 52° F (should have been 41° F or below)
- Cold food (nutrition supplement shake) at 56° F (should have been 41° F or below)
- Milk at 44° F(should have been 41° F or below)
Foods were not maintained at 41° F or below.

Observation on 02/12/14 at 11:47 AM showed Staff PP test the temperatures of the food on the test tray. Food temperatures were:
- Vegetable (carrots) at 103° F (should have been greater than 135-150° F);
- Entrée (lasagna) at 161° F (should have been 166° F or higher);
- Cold food (custard) at 48° F (should have been 41° F or below);
Foods on the test tray did not meet minimum temperatures.

22. During an interview on 02/12/14 at 11:47 AM, Staff PP stated that she had hoped the food tray temperatures would have been better and she did not know why the temperatures were not at the expected ranges.
















31891

Based on observation, interview, record review and policy review the facility failed to:
-Ensure hand hygiene related to glove use was used when they provided care to three patients (#1, #2 and #17) of eight patients observed;
-Follow policy for the care and management of urinary catheter (a flexible tube that is passed through the opening that connects the urinary bladder to the genitals) drainage bags for one patient (#2) of one patient observed;
-Ensure an epidural anesthesia cart (a set of trays/drawers/shelves on wheels used in hospitals to transport supplies and medication to place and administer anesthesia that blocks pain in certain areas of the body, most commonly used for pain relief during labor) located in the labor and delivery suites was clean and free of dried body fluids for one cart of one cart observed.
- Maintain a sealed, cleanable floor in one of one Obstetrical Unit (OB, care of women during pregnancy and childbirth) Operating Room (OR, surgical procedure room) observed.
- Ensure two of two chairs observed in patients rooms (#7 and unoccupied labor and delivery room #4005) were in good repair with cleanable surfaces.
These failed practices increased the risk of spreading infections and cross contamination and placed all patients and personnel at risk for hospital acquired infections (HAI) and contracting communicable diseases. The facility census was 76.

Findings included:

1. Record review of the facility's policy titled, "Infection Control Hand Hygiene," dated 11/04, showed the following:
-Hand washing/hand hygiene is considered to be the most important single procedure for preventing HAI.
-Wash hands before gloving and after touching wounds, whether surgical, traumatic, or associated with an invasive device (a device that requires entry of a needle, catheter, or other instrument into the body).
-After situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous members, blood or body fluids, secretions or excretions;
-After removing gloves;
-Gloves should be worn prior to contact with patients at the treatment station and potentially contaminated surfaces;
-Gloves should be changed between patients and between clean and contaminated sites on the same patient;
-Gloves should be changed after contacting a potentially contaminated site before moving to a clean site.

Record review of the facility's policy titled, "Infection Prevention and Control - Standard Precautions," dated 11/04, showed the following:
-Gloves should be worn whenever there is exposure to mucous membranes, drainage tubes, or when performing venipuncture (the process of obtaining intravenous [IV - within the vein]) access for the purpose of blood sampling or intravenous therapy);
-Nonsterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces;
-Perform hand hygiene after removing gloves.

2. Observation on 02/10/14 at 2:59 PM showed Patient #1 was in contact isolation (precautions used to prevent the spread of disease that requires all persons entering the patient's room to wear gowns and gloves). Staff N, Registered Nurse, (RN) put on personal protective equipment (PPE) of gown and gloves to start a blood infusion for Patient #1. She touched the blood pressure machine and then started the blood infusion (inanimate contaminated objects). She removed her gloves and put on a new pair without performing hand hygiene. She then typed on the computer keyboard, removed her phone from her pocket and answered a call (all inanimate contaminated objects). She then removed her gown and gloves and left the room.

3. During an interview on 02/10/14 at 3:45 PM, Staff L, Nurse Manager, stated that per policy staff was expected to perform hand hygiene in between glove changes. She stated that staff should know the policy and follow it.

4. During an interview on 02/10/14 at 3:50 PM, Staff N, RN, stated that hand hygiene should be done in between glove changes. She stated she didn't know why she didn't wash her hands when she changed gloves.

5. Record review of the facility's policy titled, "Indwelling urinary catheter (Foley) care and management," dated 10/04/13, showed the following:
-Perform hand hygiene before and after any patient care activity.
-Gather the equipment and supplies at the patient's bedside;
-Perform hand hygiene;
-Put on gloves and other personal protective equipment, as needed, to comply with standard precautions;
-Clean the periurethral area (area of tissue surrounding the urethra, which is the tube that allows urine to pass out of the body) with soap and water;
-Remove and discard gloves and perform hand hygiene;
-Don't rest the catheter drainage bag on the floor to reduce the risk of contamination and subsequent catheter associated urinary tract infection.

6. Observation on 02/10/14 at 4:00 PM showed Staff O, RN, entered Patient #2's room. The urinary catheter drainage bag was hanging from the bed frame with approximately one half of the bag folded over on itself laying on the floor. Staff O performed a blood sugar check on the patient and left the room.

7. During an interview on 02/10/14 at 4:15 PM Staff O stated that she did not notice that the urinary bag was laying on the floor. She stated that the drainage bag should not come in contact with the floor in any way.

8. Observation on 02/11/14 at 8:55 AM showed Staff W, RN, failed to perform hand hygiene before putting on gloves to discontinue an IV. Staff W tried to administer medication through the patient's IV line but determined the IV was no longer usable and that is would need to be removed. Staff W left the room to gather needed supplies and when she returned she put on gloves without first performing hand hygiene and proceeded to remove the IV.

9. During an interview on 02/11/14 at 9:15 AM, Staff W, RN, stated she knew to do hand hygiene before and after glove changes and stated she didn't know why she did not do it today.

10. Observation on 02/11/14 at 9:40 AM showed Staff Y, Certified Nurse Assistant, (CNA), prepare a basin of soapy water for routine catheter care for Patient #2. Staff Y pulled the patient's bed linens down and patient's gown up. She positioned patients legs and removed a pillow from underneath patient's right leg. Staff Y cleaned the perineal (portion of the body between the vaginal opening and the rectum for a female) area/catheter tubing and placed the used wash cloths on the counter by the sink. With the same pair of contaminated gloves on Staff Y repositioned the patients legs, replaced the pillow under the right leg, pulled the gown down and pulled the bed linens back up (touching clean surfaces/patient without changing gloves).

11. During an interview on 02/11/14 at 10:00 AM, Staff Y, CNA, stated she should have changed her gloves after she was done with the catheter care but guessed she didn't because she was used to just going right into a patient's bath after completing catheter care. She stated that if this would have occurred then she would have changed her gloves at that time.

12. During an interview on 02/11/14 at approximately 4:00 PM, Staff CC, Infection Control Officer, stated that hand hygiene was not only expected to be done by staff but by patients also. She stated to monitor this they have "spotters" that observe staff once a month with an average of 350-400 observations per month and that the department heads were responsible for reporting to her if any trends were seen. She stated that there have been no trends seen or reported.

13. Observation on 02/10/14 at 3:10 PM, in the OB Unit OR anteroom (a room used for storage of surgical supplies/equipment, a hand washing station, waiting area and opens into the OR), showed a mobile cart labeled "Epidural Cart". The cart had more than five areas of dried blood smears on the drawer handles and five areas of dried blood on the front and edges of the drawers.

14. During an interview on 02/10/14 at 3:10 PM, Staff H, Manager of the Women and Children's Units (WCU), stated that the epidural cart contained epidural supplies and was used for multiple OB patients by Anesthesiologists and Certified Registered Nurse Anesthetists (CRNA's). Anesthesiology department staff took the cart into patient rooms, opened the cart to obtain supplies and placed the sterile supplies on top of the cart for use during epidural procedures. Staff H verified that the cart was soiled with blood and that it should have been cleaned prior to leaving a patients room and that the cart posed a contamination risk to patients and staff. On 02/11/14 at approximately 2:10 PM, Staff H stated that a process for cleaning the epidural cart was not clearly defined.

15. During an interview on 02/11/14 at approximately 1:35 PM, Staff TT, Anesthesiologist, stated that he had not cleaned the epidural cart between procedures after hours.

16. During an interview on 02/11/14 at approximately 1:50 PM, Staff HH, Anesthesiology Technician, stated that she cleaned the anesthesia carts in the OR between procedures but could not always get up to the WCU to clean the epidural cart between procedures and she was not responsible to clean the cart after hours.

17. During an interview on 02/11/14 at approximately 2:00 PM, Staff II, CRNA, stated that she had not always cleaned the epidural cart between procedures.

18. During an interview on 02/11/14 at approximately 4:00 PM, Staff CC, Infection Control Officer, stated that the facility staff were expected to wipe down medical equipment when moved from one room to another, for patient use and that this was covered during staff orientation.

19. Observation on 02/10/14 at 3:15 PM, in the OB Unit OR, showed 10 areas of dried liquid debris throughout the floor of the room. Multiple areas of dark gray lines made by the wheels of mobile carts were present on approximately 50% of the floor surface. The black marks extended from the door, around the OR table and throughout the perimeter of the room. The floor surface did not have a shine and when walked on, made a sound that resulted from the soles of shoes adhering to the floor surface.

20. During an interview on 02/10/14 at 3:15 PM, Staff H stated that the floor appeared dirty and felt tacky when walked on. Staff H stated that housekeeping staff cleaned the floor as needed and no less than daily.

21. During an interview on 02/10/14 at approximately 3:45 PM, Staff F, Environmental Services Supervisor, stated that:
- The environmental services staff (ESS, also known as housekeeping staff) did not clean the epidural cart and the anesthesiology department staff was responsible for cleaning the cart.
- ESS used a micro fiber cloth sprayed with a disinfectant to clean the floors in the OB unit OR.
- The OB unit OR floors were not on a routine daily deep cleaning schedule similar to other OR's in the facility.
- The OB unit OR floor looked dirty and needed to be deep cleaned using the same method as the other OR's in the facility.
- Deep cleaning occurred only when staff requested.
- It had been approximately three months since the floor in the OB unit OR floors were deep cleaned.
- Staff assigned to clean the area were gone for the day and were not available for interview.
- She stated she did not know why the floors in the OB unit OR had not been deep cleaned routinely.

22. Observation on 02/10/14 at 3:00 PM, in the OB Unit Labor and Delivery room #4005 (unoccupied), showed one vinyl chair with more than 10 tears and/or cracks in the seat cushion surface and anterior edge. The torn/cracked areas showed visible porous (able to absorb) materials which were yellowed (showed wear and age) and were stained. The areas were not sealed.

23. Observation on 02/10/14 at 3:35 PM, in the OB Unit, of Pt #7's room showed one vinyl chair with more than 10 tears and/or cracks in the seat cushion surface and anterior edge. The torn/cracked areas showed visible porous materials which were yellowed and were stained.

24. During an interview on 02/10/14 at 3:00 PM, Staff H stated room #4005 regularly had patients assigned. She stated that she was aware the chair surfaces were torn and cracked due to old age, could not be disinfected adequately and should not have been in use. She stated budget concerns prohibited the replacement of all torn chairs in the unit.



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31891