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Based on observation, interview and document review, the hospital failed to ensure that 1 of 47 sampled patients (Patient 64) had the right to personal privacy while in the emergency department (ED). This failure resulted in the patient sharing a single patient treatment bay (an area divided off and used for a particular purpose) with another patient, which reportedly made Patient 64 feel as if there was no personal privacy. This failure created the potential for all patients that received services in the ED to not have the right to personal privacy during interviews, examinations, procedures and/or treatments.

Findings:

On October 22, 2012 at 9:50 AM, a tour of emergency department (ED) #2 was conducted with the Chief Nursing Officer (CNO) and the ED Manager. There were six single patient treatment bays that had oxygen, medical air, suction, respiratory and cardiac monitoring equipment and privacy curtains to accommodate a single patient.

The six single treatment bays were further assessed and the following was noted:

Bay 1 was converted into a duo treatment bay separated by a privacy screen however, there was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 2 was converted into a duo treatment bay separated by a privacy screen however, there was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 3 was converted into a laboratory and respiratory draw station.

On October 22, 2012 at 10:00 AM, an interview was conducted with Patient 64, one of the two patients that shared the single patient treatment bay, which was separated by a privacy screen with less than two feet separating the two patients.

Patient 64's father stated that he was surprised to see the current arrangement, because on a separate occasion he had visited ED #1 where the arrangement was different. Patient 64 and her father stated that the way that ED #2 was arranged did not provide for personal privacy and that they were uncomfortable with the set-up.

An interview was conducted on October 22, 2012 at 10:10 AM with a Clinical Lab Tech (CLT), who was working in a patient bay area which had been converted into a "Lab Station" and "Respiratory Treatment" area. He stated that the patient bay area was converted into a Lab Station and Respiratory Treatment area soon after the hospital opened the patient bay areas. He stated that they used the patient bay area to obtain labs and that respiratory therapists use it to provide respiratory treatments.

Bay 4 was converted into a duo treatment bay separated by a privacy screen. At the time of the observation, there were two patients sharing the single patient treatment bay. There was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 5 was converted into a duo treatment bay separated by a privacy screen. At the time of the observation, there were two patients sharing the single patient treatment bay. There was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 6 was converted into a Nursing Station.

An interview was conducted on October 22, 2012 at 10:15 AM, with RN 1, who was working in the single patient treatment bay area which had been converted into a nurses' station. She stated that the patient bay area was converted into a nurses' station soon after the hospital was licensed to use them as patient bay areas. Additionally she stated, "As you can see we don't have space so we use this as a nurse station."

The CNO confirmed the finding and stated that the six single patient treatment bays were defined as the "Rapid Medical Examination Area." She acknowledged and confirmed that the department had not been notified of the conversions.

There were an additional seven single treatment bay beds towards the back of ED #2 that were not being utilized at the time that the observation was conducted. ED #2 had a total of 13 bays.

An interview was conducted on October 22, 2012 at 10:30 AM with the facility Chief Nurse Officer (CNO). She stated that they use the single bay areas as dual rooms when they have an influx of patients. She was asked why on that day, were they sharing single bay areas if they had open bays and the unit was not full. She stated, "Yeah, I see what you mean."

On October 24, 2012, a review of the hospital-wide policy and procedure titled, "Patient Rights and Responsibilities," dated July 2011, was conducted and indicated the patient's rights to personal privacy will be respected. Privacy curtains will be used in semi-private rooms.

On October 25, 2012, a review of the hospitals "Bed or Service Request," dated December 31, 2011, was conducted and reflected that the request included 10 treatment bay beds, not the dual treatment bays, the nursing station or laboratory draw station/respiratory treatment areas that were observed.

A review of the hospital's "Emergency Department's Scope of Service," dated February 22, 2012 was conducted and indicated that "Each room is equipped with oxygen, medical air, respiratory and cardiac monitoring equipment."

Based on observations, record reviews and interviews, the hospital failed to measure, analyze and track quality indicators of performance that assess processes of nutrition care when:

The Dietitian's recommendations for nutrition care were not carried out and the hospital failed to identify the deficient practice as an opportunity for improvement in patient care.

Physician ordered diets were not being adhered to and the hospital failed to identify the deficient practice as an opportunity for improvement in patient care.

These failures to identify, measure, analyze and track these deficient practices allowed them to continue without remediation in a hospital with a licensed bed capacity of 204. (Cross Refer A-630)

Findings:

During medical record reviews for nutrition care on October 23 and October 24, 2012, it was noted that the registered dietitian's recommendations were not implemented for two patients. During interviews with the registered dietitians (RD 1 and 2) who had completed the nutrition assessments and made the recommendations, they stated that they informed the patient's nurse of their recommendations. They did not follow up to ensure that the physician was given the nutrition recommendations or that they were followed in a timely manner. The nutrition needs of the patients were not being met as a result. (Cross Refer A-630)

During a trayline observation and subsequent interviews with Diet Aide 1 and the Director of Nutrition and Guest Services on October 23, 2012 between 11:45 AM and 12:15 PM, it was noted that the physician ordered diets were not carried out accurately. One patient received too much protein when his diet order was for a restricted protein diet. One patient received only 57 percent of her physician ordered calories for the day when the dietary staff didn't adjust her menus when she ordered inadequate food. The dietary department's computer system allowed the nutrition analysis of each patient's menu to be checked for compliance to the physician order. According to Diet Aide 1, this check was not being consistently implemented. Also according to the Director of Nutrition and Guest Services, it was not the practice of the dietary department to ensure patients on a calorie controlled diet received the physician ordered calories. (Cross Refer A-630)

During an interview with the Director of Nutrition and Guest Services on October 23, 2012 at 12:00 PM, she stated that the computer system that the hospital used for patients to order their meals, also allowed the department to analyze what the patient ordered and correct the menus to be in compliance with the physician orders. She could not explain why the system was not being consistently used. She also couldn't explain why the Diet Aides were not monitored to ensure that they corrected the menus to be consistent with the physician order.

During an interview with the Clinical Nutrition Manager on October 24, 2012 at 11:30 AM, she stated that she had identified a problem with dietitian recommendations not being carried out. She did not have any data driven study to analyze the problem.

A review of the nutrition department's performance improvement plan dated 2012 revealed that these deficient practices had not been measured, analyzed or tracked to ensure improvement in the process could be achieved.

Without analyzing and tracking these deficient practices they were allowed to continue without remediation.

Based on interview and record review, the hospital failed to ensure that the nursing services were organized to meet the needs of all patients:

1. The hospital failed to ensure that Registered Nurse (RN) 2 was competent to work on the telemetry unit (a unit which specialized in the care and monitoring of patients with heart conditions) and that all licensed nurses who floated (nurses who work on units other than their own) were competent and had the specialized qualifications prior to assigning them to work on a specialized unit (specifically the telemetry unit). (Refer to A-0397)

2. The hospital failed to ensure that a Wound Care Nurse was competent and had all of the necessary qualifications to perform her duties as described on her job description. (Refer to A-0397)

3. The hospital failed to ensure that a RN evaluated Patient 48 that had a low oxygen saturation level for approximately 20 minutes. (Refer to A-0395)

The cumulative effect of these systemic problems resulted in the hospital's failure to deliver patient care in a safe manner and in compliance with the Condition of Participation for Nursing Services.

Based on interview and medical record review, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the care for 4 of 47 sampled patients (Patient 21, 22, 23 and 48).

1. For Patient 48 that had a low oxygen saturation ([SpO2 - a measure of oxygen in the blood; low levels may cause dizziness, shortness of breath and mental confusion], normal SpO2 range from 95% to 100%) level for approximately 20 minutes, the RN failed to evaluate the patient timely, which resulted in the patient being found by his wife in respiratory distress with a 65% SpO2 level that required the patient to be resuscitated (to revive from apparent death or from unconsciousness), intubated (to introduce a tube into the trachea to facilitate breathing) and transferred to Intensive Care Unit (ICU) for further treatment and services.

2. For 3 of 6 patients reviewed for nutrition care (Patients 21, 22 and 23) the hospital failed to ensure that a registered nurse supervised the care of these patients when dietitian consults were not ordered per the hospital's protocol for patients at nutrition risk.

Findings:

1. On October 24, 2012, Patient 48's medical record was reviewed with the Director of Health Information Services.

A review of the Patient 48's face sheet indicated that the patient was admitted to the facility on June 27, 2012 with diagnoses that included chest pain.

A review of the nursing notes, dated June 30, 2012 at 8:10 AM, indicated that Patient 48's wife shouted out at the nurses' station that Patient 48's oxygen saturation was 65% (low). The nurse (RN 7) entered the room and confirmed that the patient's SpO2 was 65%. The nursing assessment revealed the patient was pale and had labored breathing. The nurse (RN 7) increased the patient's supplemental oxygen, but the patient was non-responsive to the intervention. The hospital's Rapid Response Team (RRT: a clinical team that provides expert clinical assessment, early intervention and stabilization of the patients to prevent further clinical deterioration or sudden cardiac or respiratory arrest) was called. The team administered oxygen until the patient was intubated by a physician at 8:24 AM.

A review of the patient's continuous oxygen saturation record, dated June 30, 2012, was conducted and showed the SpO2 levels as follows:

7:47 AM - 92 % (normal 95 - 100%)
7:48 AM - 76% (Low)
7:51 AM - 63% (Low)
7:59 AM - 68 % (Low)
8:01 AM - 66% (Low)
8:11 AM - 79% (Low)
8:12 AM - 93 % (Low)

A review of the medical record documentation failed to show evidence that Patient 48 was evaluated when there was change in condition as evidenced by the low SpO2 measurements.

On October 25, 2012 at 11:45 AM, an interview and medical record review was conducted with the ICU Manager. The ICU Manager stated that patients in the Step-Down Unit (a unit providing a lower level of care than the ICU) have their SpO2 continuously monitored via a pulse oximeter (device applied to a finger). The ICUM stated that when the patient's SpO2 was less than 90%, the alarm should have been audible in the patient's room, outside the room, as well as within the nursing station. He confirmed that the medical record did not reflect that the patient was evaluated when the SpO2 levels were less than 90% at 7:48 AM until approximately 8:11 AM. The ICU Manager acknowledged and confirmed that there was a delay in the evaluation of the patient's low SpO2 levels that resulted in the patient's respiratory distress.

On October 25, 2012 at 2 PM, an interview was conducted with the Telemetry (cardiac) Monitor Technician (TMT) 1 that was assigned to monitor the patients' cardiac monitors (which include oxygen saturation monitoring) at the nurses' station on June 30, 2012, during the AM shift. He stated that when the patient's alarm rang at the nurses' station he informed the RN (RN 7). He acknowledged that he did not see whether or not RN 7 went into the room to check on Patient 48. TMT 1 further stated that a few minutes after he had informed the nurse, a lady approached the nurses' station and requested help because the alarm was ringing.

On October 25, 2012 at 2:45 PM, an interview was conducted with Registered Nurse (RN) 7, the primary care nurse for Patient 48 on June 30, 2012, during the AM (morning) shift. She acknowledged that the according to the SpO2 documentation the patient's levels were less than 90% at 7:48 AM through approximately 8:11 AM. During that time RN 7 stated that she did not hear the patient's alarm ringing, nor was she informed by TMT 1. RN 7 stated that she was informed by the patient's wife that the patient was "desaturating" (low SpO2). She stated when she assessed the patient he had labored breathing with a SpO2 of 65%. RN 7 stated at that time she requested the assistance of the RRT.

On October 25, 2012, a review of the "Rapid Response Team Record," dated June 30, 2012 at 8:10 AM, indicated the following:

Primary reason for call - SpO2 was less than 90%

Orders received - bag mask (resuscitation device), oral airway (intubation device)

Situation - The patient was non-responsive

Narrative notes - The patient was non-responsive SpO2 65%; bagging (resuscitating); called emergency room physician for intubation.

Follow-up report/outcome - The patient was transferred to ICU

On October 25, 2012, a review of the policy and procedure titled, "Rapid Response Team (RRT)," dated January 2012, indicated that RRT is to provide expert clinical assessment, early intervention and stabilization of the patients to prevent further clinical deterioration or arrest. The Guidelines for RRT activation may include #4., "Acute change in oxygen saturation (less than 90 % despite oxygen).

On October 25, 2012, a review of the policy and procedure titled, "Patient Care Assessment-Reassessment, " dated September 2010, was conducted and showed:
D. Reassessment of the patient will be conducted by a RN, at least once per shift or more often as warranted by the patient's condition.
1. The patient shall be reassessed:
a. When there is significant change of condition.



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2. A review of the hospital's policy titled, "Nutrition Therapy Plan" dated September 19, 2012 revealed that the purpose of the policy was to provide appropriate nutrition care to patients in a timely and effective manner. It further stated that the Registered Nurse will screen new patients for nutrition risk factors within 24 hours of admission.

During an interview with the Clinical Nutrition Manager (CNM) on October 13, 2012 at 9:00 AM, she stated that if any of the nutrition screen triggers on the nursing assessment were answered affirmative, nursing was required to enter a dietitian consult in the computer system. A dietitian consult then alerted the dietitian that the patient was determined to be at nutrition risk and a nutrition assessment needed to be completed within 24 hours.

a. A review of the medical record for Patient 21 revealed that the patient was admitted on October 15, 2012 with diarrhea, which is a nutrition risk trigger. No dietitian consult was ordered by nursing.

During an interview with the CNM and the Nurse Manager for Patient 21 on October 23, 2012 at 9:00 AM, they stated that a dietitian consult should have been ordered by nursing based on the results of the nursing assessment nutrition screen. The Nurse Manager stated that the nurses thought that the computer system automatically sent a dietitian consult when a nutrition risk factor was triggered on the assessment. The CNM stated that was not the case.

b. A review of the medical record for Patient 22 revealed that the he was admitted on October 17, 2012 with a height of 5 foot 7 inches and a weight of 98 pounds. His BMI (body mass index - and indicator of body fatness) was 15 (less than 18.5 is considered underweight according to the National Institutes for Health). No nutrition risks were triggered on the nursing assessment and no dietitian consult was ordered.

c. A review of the medical record for Patient 23 revealed that the patient was admitted to the hospital on October 18, 2012 with diarrhea and open wounds, both were nutrition risk triggers. No dietitian consult was ordered by nursing.

During an interview with the CNM on October 23, 2012 at 10:30 AM, the CMN confirmed that both patients were at nutrition risk and consults should have been ordered.

Based on interview and record review, the facility failed to ensure that all staff were competent and had the specialized qualifications prior to the assigning of a registered nurse to work on a specialized unit (telemetry unit: a unit designed to provide specialized care for patients who need continuous heart monitoring). The facility failed to ensure that a Wound Care Nurse was competent and had necessary qualifications prior to performing her duties as described on her job description. These failures resulted in 1 of 47 sampled patients (Patient 41) not having her needs met and had the potential to affect the quality of care for a universe of 156 patients receiving care from nurses without the necessary competencies and qualifications.

Findings:

1. A record review was conducted on October 22, 2012 at 12:05 PM, of the facility's "Telemetry North Scope of Service - 2012 (a description of the type of service the unit provided which also included a description of the staff that worked on the unit)". The document revealed the following: The goal of the unit was, "To provide competent staff that can respond to emergency situations and unforeseen situations with promptness and expertise...The unit is staffed with ACLS (Advanced Cardiac Life Support) certified Registered Nurses (RN) who demonstrate competency in basic dysrhythmias (abnormal heart rhythms)...The specific qualifications and competency requirements are outlined in staff job descriptions..."

A record review was conducted on October 22, 2012 at 12:15 PM, of the facility's Telemetry Registered Nurse job description. The document revealed that this nurse: "...Accurately identifies and interprets Dysrhythmia on EKG's (Electrocardiogram - a recording of a heart rhythm) and consistently documents (sign, date and time EKG strips every 4 hrs.) interpretation of rhythm strips per Medical Center policy...Initiates and delivers appropriate interventions related to Dysrhythmia in a timely manner and consistently documents interventions and outcomes...Recognizes, interprets and consistently intervenes with appropriate nursing interventions for patients experiencing side effects from cardiac drugs...Accurately identifies signs and symptoms of cardiac emergencies and intervenes in a timely manner...Demonstrates the ability to provide cardiac and discharge education..."

A record review, on October 22, 2012 at 2:45 PM, revealed that Patient 41 was admitted to the hospital's Emergency Department (ED) on October 21, 2012 with a diagnosis which included unstable angina (a chest pain of short duration) and claudication (pain, weakness and numbness of the leg).

An interview was conducted on October 22, 2012 at 2:40 PM, with RN 2 for Patient 41. She stated that she was a medical surgical nurse and was floating from her department to the telemetry unity. RN 2 stated that she was not ACLS certified because she was told that she did not require it because she was a medical surgical nurse. Additionally, she stated that she did not receive telemetry competencies prior to working on the unit, she did not receive any formal cardiac training for monitoring patients with cardiac problems, she did not know how to interpret dysrhythmias on the EKG strips and that the charge nurse read the EKG strips for her. RN 2 stated that if she had to work independently on the telemetry unit, she would not feel competent.

An interview was conducted on October 22, 2012 at 3:25 PM, with Patient 41. The patient stated that she was not happy with the care that she had received. Additionally, she stated that nurses had not been in to check on her or ask her if she was having pain, which she had been experiencing at a self described level of '8' on a 1 to 10 pain scale (a numerical pain assessment tool used to determine a patient's pain level). Patient 41 stated that her blood pressure had been running low, which was abnormal for her because she typically ran high and that the staff did not seem too concerned. Patient 41 stated that she did not know what her condition was and she did not know what types of tests she was supposed to have done. She stated, "I don't think they even know."

An interview was conducted on October 22, 2012 at approximately 3:30 PM with the Clinical Educator. She stated that the medical surgical nurses who float to the telemetry unit do not require ACLS because they are overseen by the charge nurse and they do not require telemetry competencies.

2. A record review, on October 26, 2012 at 12 PM, of the employee file of a Wound Care Nurse who had been employed by the facility since June 5, 2012, did not contain a job description or competencies specific to her job.

A record review was conducted on October 26, 2012 at 12:20 PM of the facility "Job Description & Competency Based Performance Evaluation, updated on 8/31/04." The job description indicated that the Wound Care Nurse was to demonstrate competencies in line with the facility's core values. Additionally, the "Minimum" qualifications and the required degree for the Wound Care Nurse was a Bachelors of Science in Nursing (BSN).

An interview was conducted on October 26, 2012 at 1:30 PM, with the Human Resource Manager. She stated that the Wound Care Nurse was not an employee of the facility and that she was a traveler (employed by a registry that contracts nurses to facilities). The Human Resource Manager also stated that the Wound Care Nurse did not have competencies from the facility and did not receive a job description from the facility but that she was held to the same standards as the facility's employees.

During an interview, on October 26, 2012 at 1:30 PM, with the Chief Nursing Officer (CNO), she stated that the Wound Care Nurse did not have a BSN.

Based on interview and record review, the facility failed to ensure that all entries for 1 of 47 sampled patients (Patient 41) were dated, timed and authenticated. This failure contributed to the inability to establish the baseline when the orders were written and had the potential to contribute to adverse patient events and affect the quality of care that Patient 41 received.

Findings:

A record review, on October 22, 2012 at 2:45 PM, revealed that Patient 41 was admitted to the hospital's Emergency Department (ED) on October 21, 2012 and admitted with a diagnosis which included unstable angina (a heart condition which can contribute to a heart attack) and claudication (pain, weakness and numbness of the leg).

A record review was conducted on October 22, 2012 at 2:45 PM, of Patient 41's admission orders. The admission orders contained Patient 41's medical diagnosis, lab tests, consultations with specialists, medications, orders for a heart test and an order for angiogram of the leg (a test to view the blood vessels of the legs) that were not authenticated, dated or signed.

An interview was conducted with Patient 41's Registered Nurse (RN), RN 2, on October 22, 2012. She stated that the orders should have been signed by the physician and that they should have been dated and timed. RN 2 was unsure who wrote the orders or when the orders were written and stated, "Maybe they came from the doctor's office."

A record review was conducted on October 26, 2012 at 2:30 PM, of the facility "Medical Staff General Rules & Regulations, reviewed and approved on December 13, 2011." The Rules and Regulations indicated the following: "...All hospital orders shall be timed as well as dated..."

Based on staff interview and record review, the facility failed to ensure telephone and verbal orders were authenticated within 48 hours, as per hospital policy for 1 of 47 sampled patients (Patient 42). This failure had the potential to contribute to transcription errors resulting in the increased risk of harm to patients.

Findings:

A review of the clinical record for Patient 42 was conducted on October 22, 2012 at 12:05 PM. Patient 42 was admitted to the hospital on October 18, 2012 at 6:59 PM at 40 5/7 weeks gestation, for induction (Start) of labor.

a. During a review of the clinical record it was noted that there was a physician's telephone order dated October 18, 2012 at 9:45 PM that included:

1. IV (Intravenous) infusion with Lactated Ringers 1000 ml (Milliliters) via 18 gauge catheter to run @ (at) 125 ml/hour.
2. Continuous fetal monitoring.
3. Vital signs monitoring: blood pressure every 1 hour during first stage of labor, every 30 minutes during active labor, every 15 minutes during second stage, heart rate every 2 hours, temperature every 4 hours and if with ROM (Ruptured of membrane) every 2 hours.
4. Laboratory testing: CBC (Complete blood count), urine drug screen, blood type and screen.
5. Clindamycin (an antibiotic) 900 mg (Milligram) IVPB (Intravenous piggy back), a beta strep prophylaxis, every 8 hours until delivery.

b. The clinical record also revealed a verbal order dated October 19, 2012 noted by an RN (Registered Nurse) at 10 AM that stipulated an order to "Mix a fresh bag of Pitocin (An chemical that stimulates uterine smooth muscle, producing uterine contractions similar to those of spontaneous labor) 20 mu (Milliunit) in LR (Lactated Ringers) 1000 for labor augmentation (Assist) now."

During an interview with the Mother/Baby Unit Charge Nurse (RN 5) and the Nurse Manager (RN 6) for the Labor and Delivery unit and Mother/Baby unit on October 22, 2012 at 12:25 PM, both the Charge Nurse and the Nurse Manager confirmed that the physician's telephone and verbal orders were not signed by the prescribing physician. The Chief Nursing Officer (CNO - RN 7) and the Risk Coordinator Staff were also present.

The hospital policy and procedure titled "Physician Orders (Written, Verbal and Telephone Orders)" origination date of September 2010, indicated under "Authentication of Verbal or Telephone Orders" that, "The ordering physician authenticates verbal/telephone orders within 48 hours of order."

Based on observation and interview, the hospital failed to ensure that an outdated biological was not available for patient use in the emergency department (ED). This failure had the potential to increase the risk of patient harm for a universe of 156 patients and any patient presenting to the ED for treatment.

Findings:

On October 23, 2012 at approximately 10:00 AM, during a tour of the ED with the ED Supervisor, there were two (2) 2000 milliliter bags of peritoneal dialysate (a chemical bath used in dialysis to draw fluids and toxins out of the bloodstream and supply electrolytes and other chemicals to the bloodstream) that had expired in September 2012 and were stored in a cabinet within the clean utility room. The ED supervisor confirmed the finding.

On October 26, 2012 at 4:15 PM, an interview was conducted with the Pharmacy Director regarding the October 23rd observation. He stated that the pharmacy did not maintain oversight of peritoneal dialysate. The Pharmacy further stated that the service was a contracted service, so he was not knowledgeable as to why the peritoneal dialysate was on the hospital premises.

Based on observation, interview and record review, the hospital failed to meet the nutritional needs for 4 of 6 patients reviewed for nutrition care when:

The dietitian recommendations for two patients at nutrition risk were not carried out and there was no evidence that the physician was informed of the recommendations (Patients 23 and 26).
The diets served to two patients were not consistent with the physician ordered diets (Patients 24 and 25). These failures had the potential to contribute to further decline in these patients' nutrition status and overall medical status.

Findings:

1. A review of the medical record for Patient 23 on October 23, 2012 revealed that the patient was admitted to the hospital on October 18, 2012 with diagnoses that included pressure ulcers (bed sores), rule out infection.

A review of the nutrition assessment by Registered Dietitian 1 (RD 1) dated October 20, 2012 showed that the patient was on a regular diet. His estimated nutrition needs were determined to be high based on his need for wound healing. The assessment recommendations included a powdered protein supplement and a liquid nutritional supplement twice a day. A review of the physician orders revealed that the recommendations were not carried out.

During an interview with RD 1 on October 23, 2012 at 10:50 AM, she stated that she spoke to the patient's nurse on 10/20/12 regarding her recommendations. She stated that she did not follow up to ensure that her recommendations were communicated to the physician and carried out. She verified that the patient had been in the hospital for 5 days and the extra calories and protein recommended for wound healing were not ordered.

During an interview with Patient 23 on October 23, 2012 at 11:00 AM, he stated that he would drink a nutrition supplement if he was given one. He stated that he drinks one at home.

A review of the medical record for Patient 26 on October 24, 2012 revealed that the patient was admitted to the hospital on October 16, 2012 with diagnoses that included respiratory failure and renal insufficiency (impaired kidney function).

A review of the nutrition assessment by RD 2 dated October 18, 2012 showed that the patient's estimated nutrition needs included restricted protein needs due to her impaired kidney function. The assessment included a recommendation to restrict the protein in the patient's diet to 50 grams of protein a day. A follow up assessment dated October 21, 2012 by RD 2 again recommended a 50 gram protein restriction. A review of the physician orders revealed that the recommendation was not carried out as of October 24, 2012 at 10:00 AM.

During an interview with RD 2 on October 24, 2012 at 9:50 AM, she stated that she informed the nurse when she finished her assessment and follow up. She stated that she told the nurse that the assessments were in the electronic medical record. She did not follow up to ensure that her recommendations were communicated to the physician and carried out. She verified that her recommendations were not carried out. She stated that the patient would benefit from low protein due to her impaired kidney function.

2. During an observation of trayline (patient meal tray assembly) on October 23, 2012 at 11:45 AM, the meal tray for Patient 24 was noted to include two ounces of chicken, one ounce of rice, 4 ounces of corn, margarine, ice tea and salt free seasoning. One ounce of rice is equivalent to about 2 tablespoons.

During an interview with Diet Aide 1 the same day at 12:00 PM, she stated that the patient's diet order included a 20 gram protein restriction (a very low protein restriction). A review of the patient's medical record confirmed this. She was unable to explain why the patient only was given one ounce of rice, a low protein food.

A review of the nutrition analysis of the food that Patient 24 had been served so far for the day revealed that the he received 32 grams of protein between breakfast and lunch. This was twelve gram greater than his physician ordered diet for only two meals

During a further observation of trayline the same day and time, the meal tray for Patient 25 was observed. The meal tray contained four ounces of strawberries, a green salad, a grilled chicken breast (approximately three ounces) on a 100 calorie roll, two packets of diet mayonnaise, fat free salad dressing and water. The menu indicated that the patient was on a 2000 calorie diabetic diet (to control the amount of sugar in the blood). A review of the patient's medical record confirmed this.

During an interview with Diet Aide 1 the same day at 12:00 PM, she stated that the patient only ordered this amount of food so that was all they sent her. She further stated that the patient had ordered all three meals for the day.

A review of the nutrition analysis of the patient's selections for the day indicated that the total calories selected was only 1145 calories. The physician ordered diet was for 2000 calories.

During an interview with the Director of Nutrition and Guest Services same day at 12:15 PM, she stated that the hospital allows patients on diets with calorie prescriptions, such as 2000 calories, to select their menu choices. The dietary staff honors those selections, even if it doesn't equal 2000 calories. She stated that they don't correct the menu choices to ensure the physician's order is carried out in this case.

Based on observation, staff interview, record review and inspection of the buildings, it was determined that the hospital failed to be constructed, arranged and maintained to ensure the safety of the patients and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The cumulative effect of these systemic problems identified during the Life Safety Code (LSC) portion of the validation survey, resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

This was evidenced by aisles or corridors that were obstructed; by no emergency lights in three of three operating rooms at the surgery center, by one battery backup light that failed and by lights that were not tested as required; by staff that was unfamiliar with fire procedures; by fire alarm manual pull stations that were obstructed; and by sprinkler system valves that were inaccessible.

Findings:

During the facility tour, record review and interviews with hospital staff, from October 22, 2012 through October 25, 2012, the corridors and procedure rooms were observed.

1. There were gurneys and patient equipment in aisles or corridors serving as an exit in the emergency department area. This could delay the evacuation of patients in the event of a fire. During an interview on October 22, 2012 at 2:36 p.m., the Facilities Director reported gurneys and patient privacy screens were used in the exit aisles for patient overflow.

2. The hospital failed to ensure emergency lighting was installed, maintained and operational in all required locations. There was no emergency lighting in three of three operating rooms at the surgery center, one battery backup light failed and there were no records for testing the backup emergency lights. During an interview on October 24, 2012 at 3:51 p.m., the Director of Facilities reported that emergency battery backup lighting was not tested in the offsite locations.

3. During record review and interviews on October 22, 2012, the hospital failed to ensure staff was familiar with fire procedures. Documents failed to indicate that all staff participated in quarterly fire drills. During an interview on October 22, 2012 at 4:20 p.m., the Security Officer reported 4 of 125 Emergency Department Staff attended fire drills during the last 12 months.

4. On October 22, 2012 at 3:20 p.m., one fire alarm manual pull station, in the emergency department, was obstructed by a desk and a computer.

5. On October 22, 2012 at 3:22 p.m., a "Fire Dept. Hose Valve" was blocked from access in the Emergency Department corridor.

6. On October 22, 2012 and October 23, 2012, chairs, gurneys, and other patient equipment obstructed the corridors in and around the Emergency Department.

Based on observation, interviews and record review, the hospital failed to maintain the disaster food within the building approved for food storage by the Office of Statewide Health Planning and Development (OSHPD) when the disaster food was stored in a structure across the street. This failure had the potential to result in compromised safety and well-being of the patients in the event of a disaster in a hospital with a licensed bed capacity of 204.

Findings:

The hospital's disaster food supply and plan was observed and reviewed on October 22, 2012 at 1:00 PM. The disaster food and supplies required to implement the disaster menu were stored in a building across the street from the OSHPD approved hospital building.

During a concurrent interview with the Director of Nutrition and Guest Services, she was unable to state if the building where the food was stored was approved by OSHPD for the safe storage of food in a healthcare facility.

OSHPD is responsible for assuring the safety of buildings used in providing healthcare. This includes the safe storage of food.

Based on observation, facility staff interviews, and building inspections, the hospital did not meet the provisions of the 2000 edition of the Life Safety Code 101 of the National Fire Protection Association. The facility failed to ensure that the exit access was maintained, all emergency battery backup lighting was tested and maintained, all staff were trained on fire protection procedures, corridors were free of obstructions, and the fire alarm and sprinkler systems were accessible. This affected two of eight buildings. The Emergency Department on the Main Level (1st Floor) of the hospital and the Surgery Center were affected. This could result in an increased risk of delay in evacuation in the event of a fire or the spread of smoke and fire.

Findings:

During a tour of the facility, and interviews from October 22, 2012 through October 25, 2012, the hospital was found to be not in compliance with the 2000 edition of the Life Safety Code 101 of the National Fire Protection Association.

Emergency Department - October 22, 2012

1. At 2:26 p.m. and 2:35 p.m., there were gurneys, chairs, a Computer on Wheels (COW), and other medical equipment placed approximately six (6) inches from the fire doors and in the aisles, in Hall 4 and Hall 5.

2. On October 24, 2012 at 2:30 p.m., there were no emergency lights in three of three operating rooms at the surgery center. There were no records for testing the backup emergency lights. During an interview on October 24, 2012 at 2:38 p.m., the Director of Facilities confirmed there was no emergency battery backup lighting in the operating rooms. At 3:51 p.m., the Director of Facilities reported that emergency battery backup lighting was not tested in the offsite locations.

3. At 3:15 p.m., the Emergency Room (ER) Supervisor was interviewed and asked if she knew where the manual pull station was. The ER Supervisor looked up and down the corridors but did not know where it was. The ER Supervisor was asked when she had last participated in a fire drill and she stated that it had been about 3 years ago. She further stated that she had participated in a disaster drill about 6 months ago. During an interview at 4:20 p.m., the Security Officer reported 4 of 125 Emergency Department staff participated in fire drills during the last 12 months.

4. At 3:20 p.m., in the Emergency Department, the manual pull station by the check in desk, next to the entrance to the Triage Room was obstructed by a desk, and a computer.

5. On October 22, 2012 at 3:22 p.m., a "Fire Dept. Hose Valve" was blocked from access in the Emergency Department corridor.

6. On October 22, 2012 and October 23, 2012, chairs, gurneys, and other patient equipment obstructed the corridors in and around the Emergency Department.

Based on observation, policy review and interview, the hospital did not maintain the environment in the cardiac catheterization laboratory (cath lab) and the operating rooms (OR's) to ensure an acceptable level of safety and quality. Cleaning staff were using a disinfectant cleaner for the floor and surfaces (including the OR table/bed) of the cath lab and Ors. The product label states that the product must remain wet on the surface for a 10 minute contact time to ensure proper antisepsis (the destruction of disease-causing microorganisms to prevent infection). The actual contact time used by the staff was 5 minutes. This resulted in the possibility of incomplete antisepsis of the cath lab and OR floors and surfaces increasing the risk of infection of patients cared for in these areas.

Findings:

1. The operating room suite, including the cardiac catheterization lab, was inspected on October 24, 2012 at 9:00 AM. During the inspection of the cath lab, the two housekeepers entered and began to clean the floor with a mop. The Director of Perioperative Services was also present. Housekeeper A was asked what product was being used to clean the floor. She stated that she did not know but that it came from a dispenser in the cleaning supply room. She also stated that when she wet the floor, it would take five minutes to dry. The Director stated that he had timed it and that it did take 5 minutes for the floor and surfaces to dry after mopping. The cleaning supply room was inspected and a dispenser was mounted on the wall. It dispensed a product called Waxie Multi-Purpose Disinfective Cleaner #710. Housekeeper A confirmed that this was the product she used to clean the OR's. The label contained instructions which specified that the product required a 10 minute contact time for maximum effectiveness. The housekeeper and Director both agreed that a 10 minute contact time would be used until they could obtain a product with a shorter contact time.

2. On October 24, 2012, a policy was received from the hospital staff entitled "Between Case Surgery Suite Cleaning" last revised in June 2012. The policy was a general guideline without specific instructions on the use of various products throughout the Surgery area. Under the heading 'equipment', mop bucket and mop supplies were listed. The policy directed staff to wipe down the surgery table, other surfaces and the floor with a mop dipped in germicidal solution. These types of policies are usually nonspecific so that they can be adapted to various disinfective cleaning agents, deferring to the manufacturer's recommendations for contact time and other instructions.

Based on observation, interview and record review:

1. The infection control officer did not ensure the maintenance of a sanitary hospital environment in the cardiac catheterization laboratory (cath lab) and the operating rooms (OR's). Cleaning staff were using a disinfectant cleaner for the floor and surfaces (including the OR table/bed) of the cath lab and OR's. The product label states that the product must remain wet on the surface for a 10 minute contact time to ensure proper antisepsis (the destruction of disease-causing microorganisms to prevent infection). The actual contact time used by the staff was 5 minutes.

This resulted in the possibility of incomplete antisepsis of the cath lab and OR floor and surfaces, increasing the risk of infection of patients cared for in these areas.

2. The hospital failed to develop an effective infection control surveillance system for identifying unsafe food handling practices in the dietary department when:

a. There was no evidence of safe cool down of macaroni and cheese and prepared tuna salad.

b. There was no system for monitoring the shelf life of the macaroni and cheese.

c. There was no system to ensure that raw seed sprouts (a recognized source of food borne illness) were not served to patients.

The lack of surveillance of these unsafe food handling practices had the potential to result in a food borne illness outbreak in a highly susceptible patient population in a hospital with a licensed bed capacity of 212.

Findings:

1a. The operating room suite, including the cardiac catheterization lab, was inspected on October 24, 2012 at 9:00 AM. During the inspection of the cath lab the two housekeepers entered and began to clean the floor with a mop. The Director of Perioperative Services was also present. Housekeeper A was asked what product was being used to clean the floor. She stated that she did not know but that it came from a dispenser in the cleaning supply room. She also stated that when she wet the floor, it would take five minutes to dry. The Director stated he had timed it and that it did take 5 minutes for the floor and surfaces to dry after mopping. The cleaning supply room was inspected and a dispenser was mounted on the wall. It dispensed a product called Waxie Multi-Purpose Disinfective Cleaner #710. Housekeeper A confirmed that this was the product she used to clean the OR's. The label contained instructions which specified that the product required a 10 minute contact time for maximum effectiveness. The housekeeper and Director both agreed that a 10 minute contact time would be used until they could obtain a product with a shorter contact time.

1b. On October 24, 2012, a policy was received from the hospital staff entitled "Between Case Surgery Suite Cleaning" last revised on June 2012. The policy is a general guideline without specific instructions on the use of various products throughout the Surgery area. Under "equipment", mop bucket and mop supplies are listed. The policy directs staff to wipe down the surgery table, other surfaces and the floor with a mop dipped in germicidal solution. These types of policies are usually nonspecific so that they can be adapted to various disinfective cleaning agents, deferring to the manufacturer's recommendations for use.



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2a. According to the 2009 Food and Drug Administration (FDA) Food Code, cooked, potentially hazardous food (PHF - foods that require temperature control) shall be cooled within 2 hours from 135 degrees F to 70 degrees F, and within a total of 6 hours from 135 degrees F to 41 degrees F. Also, PHF shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient (room) temperature, such as reconstituted foods and canned tuna. It further states that if food is not cooled in accordance to this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

During a tour of the kitchen with the Manager of Food Service (MFS) on October 22, 2012 at 10:00 AM, approximately 12 individual portions of macaroni and cheese dated October 21, 2012 were observed in the walk-in refrigerator. The MFS stated that the macaroni and cheese had been portioned on October 21, 2012. He was unable to state when it had been cooked.

Also during the tour of the kitchen at 10:20 AM, 3 containers of tuna salad were observed in the walk-in refrigerator.

During a concurrent interview with Dietary Staff 1, she stated that she made the tuna salad using canned tuna that was stored at room temperature. She further stated that she did not monitor the cool down of the tuna to ensure that it reached 41 degrees Fahrenheit (F) or below within four hours.

During an interview with the Cook 1 and review of the hospital's Cooling Logs on October 22, 2012 at 12:30 PM, he stated that the macaroni and cheese observed earlier was not listed on the log. He was unable to ensure that the macaroni and cheese was safely cooled.

A review of the hospital's policy titled, "Food Preparation" dated September 19, 2012, revealed that the Cook was responsible for ensuring cooked food items were cooled and stored per the policy and procedure and that the Cooling Log was completed. There was no policy for monitoring the safe cooling of the tuna salad.

During a concurrent interview with the MFS, he verified that the macaroni and cheese and the tuna salad were both potentially hazardous foods that require monitoring for safe cooling. He further verified that there was no evidence of safe cooling of the macaroni and cheese and the tuna salad.

b. During a tour of the kitchen on October 22, 2012 at 10:00 AM, approximately 12 individual portions of macaroni and cheese dated October 21, 2012 were observed in the walk-in refrigerator.

During an interview with Cook 1 on October 22, 2012 at 12:30 PM, he stated that it was the staff practice for the macaroni and the cheese sauce to be cooked and stored separately in the refrigerator until needed. Then they were mixed together, portioned and dated. There was no system that made it possible to determine the date that the macaroni and the cheese sauce were originally made. The date on the label was the date that it was portioned. It was not the date that the two ingredients were cooked. The shelf life of the macaroni and cheese could not be monitored.

A review of the hospital's policy titled, "Food Preparation" dated September 19, 2012, revealed that prepared cold food items were to be covered, labeled and dated. Labeling for foods placed in the refrigerator should contain the original date of preparation.

c. According to the 2009 FDA Food Code, in a food establishment that serves a highly susceptible population (such as health care facilities), raw seed sprouts may not be served or offered for sale in a ready-to-eat form. The code states that raw seed sprouts have emerged as a recognized source of food borne illness in the United States. The FDA and the Centers for Disease Control and Prevention have issued health advisories that persons who are at greater risk for food borne disease should avoid eating raw alfalfa sprouts.
During an observation of the hospital's cafeteria on October 22, 2012 at 11:05 AM, the salad bar was noted to have raw alfalfa sprouts.
During an interview with the Director of Nutrition and Guest Services on October 24, 2012 at 8:00 AM, she was unable to state how the hospital could ensure that food served in the cafeteria would not be consumed by patients. Therefore, patients were at risk of consuming the alfalfa sprouts which were a recognized source of food borne illness according to the FDA Food Code.

Based on record review and interview, the hospital failed to ensure that a post-anesthesia evaluation was performed and documented in the patient record for 1 of 47 sampled patients (Patient 13) out of six closed surgical records reviewed. This resulted in the possibility that the patient's recovery from anesthesia was not adequately assessed and that the patient was discharged from the Post Anesthesia Care Unit (PACU) without having adequately recovered from anesthesia.

Findings:

Patient 13 underwent a laparoscopic cholecystectomy (using a scope to remove the gallbladder through a small incision). The record was reviewed on October 23, 2012 at 1:50 PM. There was no post-anesthesia note that could be found in either the electronic or the paper parts of the patient's clinical record. The Director of Health Information Management assisted in the review and concurred that no post-anesthesia evaluation was documented in the record.

Based on staff interview and policy review, the hospital failed to implement it's policy and procedure regarding "Staffing Plan" to ensure the number of qualified personnel were available to provide outpatients with the appropriate level of care and services. This resulted in the increased risk of patient harm by outpatients not receiving the appropriate level of care and services needed.

Findings:

During an interview with the Program Manager of the Wound Care Outpatient Services on October 23, 2012 at 2:28 PM, the Program Manager stated that the census/wound care visits was 26 with 1 Registered Nurse (RN), 1 Licensed Vocational Nurse (LVN) and 3 Medical Assistants (MA's).

During an interview with RN 4 on October 23, 2012 at 2:55 PM, RN 4 confirmed and stated that there was only 1 RN, 1 LVN, and 3 MA's scheduled for the day.

A review of the October 23, 2012 census and staffing schedule revealed that there was 26 wound care visits scheduled with 1 RN, 1 LVN, and 3 MA's.

On October 23, 2012, a policy was received from the Program Manager entitled "Staffing Plan" origination date of March, 2010. The policy stipulated that "Appropriate and adequate staffing is vital to the success of the Wound Care Center."

Under "Evaluation of Staffing Plan" the policy indicated that the minimum staffing requirement per day for providing care to wound care patients was 2 RN's (Registered Nurse), 1 LVN (Licensed Vocational Nurse), 1 MA (Medical Assistant) or 2 RN's and 2 MA's if there are more than 15 patients.

During an interview with the Rehab Services Director on October 23, 2012 at 3:06 PM, the Rehab Director confirmed the staffing ratio and stated, "Should have called the hospital for another RN with competency to cover ...who was on vacation."

Based on observation, interview and document review, the hospital failed to ensure that 1 of 47 sampled patients (Patient 64) had the right to personal privacy while in the emergency department (ED). This failure resulted in the patient sharing a single patient treatment bay (an area divided off and used for a particular purpose) with another patient, which reportedly made Patient 64 feel as if there was no personal privacy. This failure created the potential for all patients that received services in the ED to not have the right to personal privacy during interviews, examinations, procedures and/or treatments.

Findings:

On October 22, 2012 at 9:50 AM, a tour of emergency department (ED) #2 was conducted with the Chief Nursing Officer (CNO) and the ED Manager. There were six single patient treatment bays that had oxygen, medical air, suction, respiratory and cardiac monitoring equipment and privacy curtains to accommodate a single patient.

The six single treatment bays were further assessed and the following was noted:

Bay 1 was converted into a duo treatment bay separated by a privacy screen however, there was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 2 was converted into a duo treatment bay separated by a privacy screen however, there was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 3 was converted into a laboratory and respiratory draw station.

On October 22, 2012 at 10:00 AM, an interview was conducted with Patient 64, one of the two patients that shared the single patient treatment bay, which was separated by a privacy screen with less than two feet separating the two patients.

Patient 64's father stated that he was surprised to see the current arrangement, because on a separate occasion he had visited ED #1 where the arrangement was different. Patient 64 and her father stated that the way that ED #2 was arranged did not provide for personal privacy and that they were uncomfortable with the set-up.

An interview was conducted on October 22, 2012 at 10:10 AM with a Clinical Lab Tech (CLT), who was working in a patient bay area which had been converted into a "Lab Station" and "Respiratory Treatment" area. He stated that the patient bay area was converted into a Lab Station and Respiratory Treatment area soon after the hospital opened the patient bay areas. He stated that they used the patient bay area to obtain labs and that respiratory therapists use it to provide respiratory treatments.

Bay 4 was converted into a duo treatment bay separated by a privacy screen. At the time of the observation, there were two patients sharing the single patient treatment bay. There was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 5 was converted into a duo treatment bay separated by a privacy screen. At the time of the observation, there were two patients sharing the single patient treatment bay. There was no additional equipment (cardiac monitor, oxygen, medical air or suction) for the duo treatment bay.

Bay 6 was converted into a Nursing Station.

An interview was conducted on October 22, 2012 at 10:15 AM, with RN 1, who was working in the single patient treatment bay area which had been converted into a nurses' station. She stated that the patient bay area was converted into a nurses' station soon after the hospital was licensed to use them as patient bay areas. Additionally she stated, "As you can see we don't have space so we use this as a nurse station."

The CNO confirmed the finding and stated that the six single patient treatment bays were defined as the "Rapid Medical Examination Area." She acknowledged and confirmed that the department had not been notified of the conversions.

There were an additional seven single treatment bay beds towards the back of ED #2 that were not being utilized at the time that the observation was conducted. ED #2 had a total of 13 bays.

An interview was conducted on October 22, 2012 at 10:30 AM with the facility Chief Nurse Officer (CNO). She stated that they use the single bay areas as dual rooms when they have an influx of patients. She was asked why on that day, were they sharing single bay areas if they had open bays and the unit was not full. She stated, "Yeah, I see what you mean."

On October 24, 2012, a review of the hospital-wide policy and procedure titled, "Patient Rights and Responsibilities," dated July 2011, was conducted and indicated the patient's rights to personal privacy will be respected. Privacy curtains will be used in semi-private rooms.

On October 25, 2012, a review of the hospitals "Bed or Service Request," dated December 31, 2011, was conducted and reflected that the request included 10 treatment bay beds, not the dual treatment bays, the nursing station or laboratory draw station/respiratory treatment areas that were observed.

A review of the hospital's "Emergency Department's Scope of Service," dated February 22, 2012 was conducted and indicated that "Each room is equipped with oxygen, medical air, respiratory and cardiac monitoring equipment."

Based on observations, record reviews and interviews, the hospital failed to measure, analyze and track quality indicators of performance that assess processes of nutrition care when:

The Dietitian's recommendations for nutrition care were not carried out and the hospital failed to identify the deficient practice as an opportunity for improvement in patient care.

Physician ordered diets were not being adhered to and the hospital failed to identify the deficient practice as an opportunity for improvement in patient care.

These failures to identify, measure, analyze and track these deficient practices allowed them to continue without remediation in a hospital with a licensed bed capacity of 204. (Cross Refer A-630)

Findings:

During medical record reviews for nutrition care on October 23 and October 24, 2012, it was noted that the registered dietitian's recommendations were not implemented for two patients. During interviews with the registered dietitians (RD 1 and 2) who had completed the nutrition assessments and made the recommendations, they stated that they informed the patient's nurse of their recommendations. They did not follow up to ensure that the physician was given the nutrition recommendations or that they were followed in a timely manner. The nutrition needs of the patients were not being met as a result. (Cross Refer A-630)

During a trayline observation and subsequent interviews with Diet Aide 1 and the Director of Nutrition and Guest Services on October 23, 2012 between 11:45 AM and 12:15 PM, it was noted that the physician ordered diets were not carried out accurately. One patient received too much protein when his diet order was for a restricted protein diet. One patient received only 57 percent of her physician ordered calories for the day when the dietary staff didn't adjust her menus when she ordered inadequate food. The dietary department's computer system allowed the nutrition analysis of each patient's menu to be checked for compliance to the physician order. According to Diet Aide 1, this check was not being consistently implemented. Also according to the Director of Nutrition and Guest Services, it was not the practice of the dietary department to ensure patients on a calorie controlled diet received the physician ordered calories. (Cross Refer A-630)

During an interview with the Director of Nutrition and Guest Services on October 23, 2012 at 12:00 PM, she stated that the computer system that the hospital used for patients to order their meals, also allowed the department to analyze what the patient ordered and correct the menus to be in compliance with the physician orders. She could not explain why the system was not being consistently used. She also couldn't explain why the Diet Aides were not monitored to ensure that they corrected the menus to be consistent with the physician order.

During an interview with the Clinical Nutrition Manager on October 24, 2012 at 11:30 AM, she stated that she had identified a problem with dietitian recommendations not being carried out. She did not have any data driven study to analyze the problem.

A review of the nutrition department's performance improvement plan dated 2012 revealed that these deficient practices had not been measured, analyzed or tracked to ensure improvement in the process could be achieved.

Without analyzing and tracking these deficient practices they were allowed to continue without remediation.

Based on interview and record review, the hospital failed to ensure that the nursing services were organized to meet the needs of all patients:

1. The hospital failed to ensure that Registered Nurse (RN) 2 was competent to work on the telemetry unit (a unit which specialized in the care and monitoring of patients with heart conditions) and that all licensed nurses who floated (nurses who work on units other than their own) were competent and had the specialized qualifications prior to assigning them to work on a specialized unit (specifically the telemetry unit). (Refer to A-0397)

2. The hospital failed to ensure that a Wound Care Nurse was competent and had all of the necessary qualifications to perform her duties as described on her job description. (Refer to A-0397)

3. The hospital failed to ensure that a RN evaluated Patient 48 that had a low oxygen saturation level for approximately 20 minutes. (Refer to A-0395)

The cumulative effect of these systemic problems resulted in the hospital's failure to deliver patient care in a safe manner and in compliance with the Condition of Participation for Nursing Services.

Based on interview and medical record review, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the care for 4 of 47 sampled patients (Patient 21, 22, 23 and 48).

1. For Patient 48 that had a low oxygen saturation ([SpO2 - a measure of oxygen in the blood; low levels may cause dizziness, shortness of breath and mental confusion], normal SpO2 range from 95% to 100%) level for approximately 20 minutes, the RN failed to evaluate the patient timely, which resulted in the patient being found by his wife in respiratory distress with a 65% SpO2 level that required the patient to be resuscitated (to revive from apparent death or from unconsciousness), intubated (to introduce a tube into the trachea to facilitate breathing) and transferred to Intensive Care Unit (ICU) for further treatment and services.

2. For 3 of 6 patients reviewed for nutrition care (Patients 21, 22 and 23) the hospital failed to ensure that a registered nurse supervised the care of these patients when dietitian consults were not ordered per the hospital's protocol for patients at nutrition risk.

Findings:

1. On October 24, 2012, Patient 48's medical record was reviewed with the Director of Health Information Services.

A review of the Patient 48's face sheet indicated that the patient was admitted to the facility on June 27, 2012 with diagnoses that included chest pain.

A review of the nursing notes, dated June 30, 2012 at 8:10 AM, indicated that Patient 48's wife shouted out at the nurses' station that Patient 48's oxygen saturation was 65% (low). The nurse (RN 7) entered the room and confirmed that the patient's SpO2 was 65%. The nursing assessment revealed the patient was pale and had labored breathing. The nurse (RN 7) increased the patient's supplemental oxygen, but the patient was non-responsive to the intervention. The hospital's Rapid Response Team (RRT: a clinical team that provides expert clinical assessment, early intervention and stabilization of the patients to prevent further clinical deterioration or sudden cardiac or respiratory arrest) was called. The team administered oxygen until the patient was intubated by a physician at 8:24 AM.

A review of the patient's continuous oxygen saturation record, dated June 30, 2012, was conducted and showed the SpO2 levels as follows:

7:47 AM - 92 % (normal 95 - 100%)
7:48 AM - 76% (Low)
7:51 AM - 63% (Low)
7:59 AM - 68 % (Low)
8:01 AM - 66% (Low)
8:11 AM - 79% (Low)
8:12 AM - 93 % (Low)

A review of the medical record documentation failed to show evidence that Patient 48 was evaluated when there was change in condition as evidenced by the low SpO2 measurements.

On October 25, 2012 at 11:45 AM, an interview and medical record review was conducted with the ICU Manager. The ICU Manager stated that patients in the Step-Down Unit (a unit providing a lower level of care than the ICU) have their SpO2 continuously monitored via a pulse oximeter (device applied to a finger). The ICUM stated that when the patient's SpO2 was less than 90%, the alarm should have been audible in the patient's room, outside the room, as well as within the nursing station. He confirmed that the medical record did not reflect that the patient was evaluated when the SpO2 levels were less than 90% at 7:48 AM until approximately 8:11 AM. The ICU Manager acknowledged and confirmed that there was a delay in the evaluation of the patient's low SpO2 levels that resulted in the patient's respiratory distress.

On October 25, 2012 at 2 PM, an interview was conducted with the Telemetry (cardiac) Monitor Technician (TMT) 1 that was assigned to monitor the patients' cardiac monitors (which include oxygen saturation monitoring) at the nurses' station on June 30, 2012, during the AM shift. He stated that when the patient's alarm rang at the nurses' station he informed the RN (RN 7). He acknowledged that he did not see whether or not RN 7 went into the room to check on Patient 48. TMT 1 further stated that a few minutes after he had informed the nurse, a lady approached the nurses' station and requested help because the alarm was ringing.

On October 25, 2012 at 2:45 PM, an interview was conducted with Registered Nurse (RN) 7, the primary care nurse for Patient 48 on June 30, 2012, during the AM (morning) shift. She acknowledged that the according to the SpO2 documentation the patient's levels were less than 90% at 7:48 AM through approximately 8:11 AM. During that time RN 7 stated that she did not hear the patient's alarm ringing, nor was she informed by TMT 1. RN 7 stated that she was informed by the patient's wife that the patient was "desaturating" (low SpO2). She stated when she assessed the patient he had labored breathing with a SpO2 of 65%. RN 7 stated at that time she requested the assistance of the RRT.

On October 25, 2012, a review of the "Rapid Response Team Record," dated June 30, 2012 at 8:10 AM, indicated the following:

Primary reason for call - SpO2 was less than 90%

Orders received - bag mask (resuscitation device), oral airway (intubation device)

Situation - The patient was non-responsive

Narrative notes - The patient was non-responsive SpO2 65%; bagging (resuscitating); called emergency room physician for intubation.

Follow-up report/outcome - The patient was transferred to ICU

On October 25, 2012, a review of the policy and procedure titled, "Rapid Response Team (RRT)," dated January 2012, indicated that RRT is to provide expert clinical assessment, early intervention and stabilization of the patients to prevent further clinical deterioration or arrest. The Guidelines for RRT activation may include #4., "Acute change in oxygen saturation (less than 90 % despite oxygen).

On October 25, 2012, a review of the policy and procedure titled, "Patient Care Assessment-Reassessment, " dated September 2010, was conducted and showed:
D. Reassessment of the patient will be conducted by a RN, at least once per shift or more often as warranted by the patient's condition.
1. The patient shall be reassessed:
a. When there is significant change of condition.



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2. A review of the hospital's policy titled, "Nutrition Therapy Plan" dated September 19, 2012 revealed that the purpose of the policy was to provide appropriate nutrition care to patients in a timely and effective manner. It further stated that the Registered Nurse will screen new patients for nutrition risk factors within 24 hours of admission.

During an interview with the Clinical Nutrition Manager (CNM) on October 13, 2012 at 9:00 AM, she stated that if any of the nutrition screen triggers on the nursing assessment were answered affirmative, nursing was required to enter a dietitian consult in the computer system. A dietitian consult then alerted the dietitian that the patient was determined to be at nutrition risk and a nutrition assessment needed to be completed within 24 hours.

a. A review of the medical record for Patient 21 revealed that the patient was admitted on October 15, 2012 with diarrhea, which is a nutrition risk trigger. No dietitian consult was ordered by nursing.

During an interview with the CNM and the Nurse Manager for Patient 21 on October 23, 2012 at 9:00 AM, they stated that a dietitian consult should have been ordered by nursing based on the results of the nursing assessment nutrition screen. The Nurse Manager stated that the nurses thought that the computer system automatically sent a dietitian consult when a nutrition risk factor was triggered on the assessment. The CNM stated that was not the case.

b. A review of the medical record for Patient 22 revealed that the he was admitted on October 17, 2012 with a height of 5 foot 7 inches and a weight of 98 pounds. His BMI (body mass index - and indicator of body fatness) was 15 (less than 18.5 is considered underweight according to the National Institutes for Health). No nutrition risks were triggered on the nursing assessment and no dietitian consult was ordered.

c. A review of the medical record for Patient 23 revealed that the patient was admitted to the hospital on October 18, 2012 with diarrhea and open wounds, both were nutrition risk triggers

Based on interview and record review, the facility failed to ensure that all staff were competent and had the specialized qualifications prior to the assigning of a registered nurse to work on a specialized unit (telemetry unit: a unit designed to provide specialized care for patients who need continuous heart monitoring). The facility failed to ensure that a Wound Care Nurse was competent and had necessary qualifications prior to performing her duties as described on her job description. These failures resulted in 1 of 47 sampled patients (Patient 41) not having her needs met and had the potential to affect the quality of care for a universe of 156 patients receiving care from nurses without the necessary competencies and qualifications.

Findings:

1. A record review was conducted on October 22, 2012 at 12:05 PM, of the facility's "Telemetry North Scope of Service - 2012 (a description of the type of service the unit provided which also included a description of the staff that worked on the unit)". The document revealed the following: The goal of the unit was, "To provide competent staff that can respond to emergency situations and unforeseen situations with promptness and expertise...The unit is staffed with ACLS (Advanced Cardiac Life Support) certified Registered Nurses (RN) who demonstrate competency in basic dysrhythmias (abnormal heart rhythms)...The specific qualifications and competency requirements are outlined in staff job descriptions..."

A record review was conducted on October 22, 2012 at 12:15 PM, of the facility's Telemetry Registered Nurse job description. The document revealed that this nurse: "...Accurately identifies and interprets Dysrhythmia on EKG's (Electrocardiogram - a recording of a heart rhythm) and consistently documents (sign, date and time EKG strips every 4 hrs.) interpretation of rhythm strips per Medical Center policy...Initiates and delivers appropriate interventions related to Dysrhythmia in a timely manner and consistently documents interventions and outcomes...Recognizes, interprets and consistently intervenes with appropriate nursing interventions for patients experiencing side effects from cardiac drugs...Accurately identifies signs and symptoms of cardiac emergencies and intervenes in a timely manner...Demonstrates the ability to provide cardiac and discharge education..."

A record review, on October 22, 2012 at 2:45 PM, revealed that Patient 41 was admitted to the hospital's Emergency Department (ED) on October 21, 2012 with a diagnosis which included unstable angina (a chest pain of short duration) and claudication (pain, weakness and numbness of the leg).

An interview was conducted on October 22, 2012 at 2:40 PM, with RN 2 for Patient 41. She stated that she was a medical surgical nurse and was floating from her department to the telemetry unity. RN 2 stated that she was not ACLS certified because she was told that she did not require it because she was a medical surgical nurse. Additionally, she stated that she did not receive telemetry competencies prior to working on the unit, she did not receive any formal cardiac training for monitoring patients with cardiac problems, she did not know how to interpret dysrhythmias on the EKG strips and that the charge nurse read the EKG strips for her. RN 2 stated that if she had to work independently on the telemetry unit, she would not feel competent.

An interview was conducted on October 22, 2012 at 3:25 PM, with Patient 41. The patient stated that she was not happy with the care that she had received. Additionally, she stated that nurses had not been in to check on her or ask her if she was having pain, which she had been experiencing at a self described level of '8' on a 1 to 10 pain scale (a numerical pain assessment tool used to determine a patient's pain level). Patient 41 stated that her blood pressure had been running low, which was abnormal for her because she typically ran high and that the staff did not seem too concerned. Patient 41 stated that she did not know what her condition was and she did not know what types of tests she was supposed to have done. She stated, "I don't think they even know."

An interview was conducted on October 22, 2012 at approximately 3:30 PM with the Clinical Educator. She stated that the medical surgical nurses who float to the telemetry unit do not require ACLS because they are overseen by the charge nurse and they do not require telemetry competencies.

2. A record review, on October 26, 2012 at 12 PM, of the employee file of a Wound Care Nurse who had been employed by the facility since June 5, 2012, did not contain a job description or competencies specific to her job.

A record review was conducted on October 26, 2012 at 12:20 PM of the facility "Job Description & Competency Based Performance Evaluation, updated on 8/31/04." The job description indicated that the Wound Care Nurse was to demonstrate competencies in line with the facility's core values. Additionally, the "Minimum" qualifications and the required degree for the Wound Care Nurse was a Bachelors of Science in Nursing (BSN).

An interview was conducted on October 26, 2012 at 1:30 PM, with the Human Resource Manager. She stated that the Wound Care Nurse was not an employee of the facility and that she was a traveler (employed by a registry that contracts nurses to facilities). The Human Resource Manager also stated that the Wound Care Nurse did not have competencies from the facility and did not receive a job description from the facility but that she was held to the same standards as the facility's employees.

During an interview, on October 26, 2012 at 1:30 PM, with the Chief Nursing Officer (CNO), she stated that the Wound Care Nurse did not have a BSN.

Based on interview and record review, the facility failed to ensure that all entries for 1 of 47 sampled patients (Patient 41) were dated, timed and authenticated. This failure contributed to the inability to establish the baseline when the orders were written and had the potential to contribute to adverse patient events and affect the quality of care that Patient 41 received.

Findings:

A record review, on October 22, 2012 at 2:45 PM, revealed that Patient 41 was admitted to the hospital's Emergency Department (ED) on October 21, 2012 and admitted with a diagnosis which included unstable angina (a heart condition which can contribute to a heart attack) and claudication (pain, weakness and numbness of the leg).

A record review was conducted on October 22, 2012 at 2:45 PM, of Patient 41's admission orders. The admission orders contained Patient 41's medical diagnosis, lab tests, consultations with specialists, medications, orders for a heart test and an order for angiogram of the leg (a test to view the blood vessels of the legs) that were not authenticated, dated or signed.

An interview was conducted with Patient 41's Registered Nurse (RN), RN 2, on October 22, 2012. She stated that the orders should have been signed by the physician and that they should have been dated and timed. RN 2 was unsure who wrote the orders or when the orders were written and stated, "Maybe they came from the doctor's office."

A record review was conducted on October 26, 2012 at 2:30 PM, of the facility "Medical Staff General Rules & Regulations, reviewed and approved on December 13, 2011." The Rules and Regulations indicated the following: "...All hospital orders shall be timed as well as dated..."

Based on staff interview and record review, the facility failed to ensure telephone and verbal orders were authenticated within 48 hours, as per hospital policy for 1 of 47 sampled patients (Patient 42). This failure had the potential to contribute to transcription errors resulting in the increased risk of harm to patients.

Findings:

A review of the clinical record for Patient 42 was conducted on October 22, 2012 at 12:05 PM. Patient 42 was admitted to the hospital on October 18, 2012 at 6:59 PM at 40 5/7 weeks gestation, for induction (Start) of labor.

a. During a review of the clinical record it was noted that there was a physician's telephone order dated October 18, 2012 at 9:45 PM that included:

1. IV (Intravenous) infusion with Lactated Ringers 1000 ml (Milliliters) via 18 gauge catheter to run @ (at) 125 ml/hour.
2. Continuous fetal monitoring.
3. Vital signs monitoring: blood pressure every 1 hour during first stage of labor, every 30 minutes during active labor, every 15 minutes during second stage, heart rate every 2 hours, temperature every 4 hours and if with ROM (Ruptured of membrane) every 2 hours.
4. Laboratory testing: CBC (Complete blood count), urine drug screen, blood type and screen.
5. Clindamycin (an antibiotic) 900 mg (Milligram) IVPB (Intravenous piggy back), a beta strep prophylaxis, every 8 hours until delivery.

b. The clinical record also revealed a verbal order dated October 19, 2012 noted by an RN (Registered Nurse) at 10 AM that stipulated an order to "Mix a fresh bag of Pitocin (An chemical that stimulates uterine smooth muscle, producing uterine contractions similar to those of spontaneous labor) 20 mu (Milliunit) in LR (Lactated Ringers) 1000 for labor augmentation (Assist) now."

During an interview with the Mother/Baby Unit Charge Nurse (RN 5) and the Nurse Manager (RN 6) for the Labor and Delivery unit and Mother/Baby unit on October 22, 2012 at 12:25 PM, both the Charge Nurse and the Nurse Manager confirmed that the physician's telephone and verbal orders were not signed by the prescribing physician. The Chief Nursing Officer (CNO - RN 7) and the Risk Coordinator Staff were also present.

The hospital policy and procedure titled "Physician Orders (Written, Verbal and Telephone Orders)" origination date of September 2010, indicated under "Authentication of Verbal or Telephone Orders" that, "The ordering physician authenticates verbal/telephone orders within 48 hours of order."

Based on observation and interview, the hospital failed to ensure that an outdated biological was not available for patient use in the emergency department (ED). This failure had the potential to increase the risk of patient harm for a universe of 156 patients and any patient presenting to the ED for treatment.

Findings:

On October 23, 2012 at approximately 10:00 AM, during a tour of the ED with the ED Supervisor, there were two (2) 2000 milliliter bags of peritoneal dialysate (a chemical bath used in dialysis to draw fluids and toxins out of the bloodstream and supply electrolytes and other chemicals to the bloodstream) that had expired in September 2012 and were stored in a cabinet within the clean utility room. The ED supervisor confirmed the finding.

On October 26, 2012 at 4:15 PM, an interview was conducted with the Pharmacy Director regarding the October 23rd observation. He stated that the pharmacy did not maintain oversight of peritoneal dialysate. The Pharmacy further stated that the service was a contracted service, so he was not knowledgeable as to why the peritoneal dialysate was on the hospital premises.

Based on observation, interview and record review, the hospital failed to meet the nutritional needs for 4 of 6 patients reviewed for nutrition care when:

The dietitian recommendations for two patients at nutrition risk were not carried out and there was no evidence that the physician was informed of the recommendations (Patients 23 and 26).
The diets served to two patients were not consistent with the physician ordered diets (Patients 24 and 25). These failures had the potential to contribute to further decline in these patients' nutrition status and overall medical status.

Findings:

1. A review of the medical record for Patient 23 on October 23, 2012 revealed that the patient was admitted to the hospital on October 18, 2012 with diagnoses that included pressure ulcers (bed sores), rule out infection.

A review of the nutrition assessment by Registered Dietitian 1 (RD 1) dated October 20, 2012 showed that the patient was on a regular diet. His estimated nutrition needs were determined to be high based on his need for wound healing. The assessment recommendations included a powdered protein supplement and a liquid nutritional supplement twice a day. A review of the physician orders revealed that the recommendations were not carried out.

During an interview with RD 1 on October 23, 2012 at 10:50 AM, she stated that she spoke to the patient's nurse on 10/20/12 regarding her recommendations. She stated that she did not follow up to ensure that her recommendations were communicated to the physician and carried out. She verified that the patient had been in the hospital for 5 days and the extra calories and protein recommended for wound healing were not ordered.

During an interview with Patient 23 on October 23, 2012 at 11:00 AM, he stated that he would drink a nutrition supplement if he was given one. He stated that he drinks one at home.

A review of the medical record for Patient 26 on October 24, 2012 revealed that the patient was admitted to the hospital on October 16, 2012 with diagnoses that included respiratory failure and renal insufficiency (impaired kidney function).

A review of the nutrition assessment by RD 2 dated October 18, 2012 showed that the patient's estimated nutrition needs included restricted protein needs due to her impaired kidney function. The assessment included a recommendation to restrict the protein in the patient's diet to 50 grams of protein a day. A follow up assessment dated October 21, 2012 by RD 2 again recommended a 50 gram protein restriction. A review of the physician orders revealed that the recommendation was not carried out as of October 24, 2012 at 10:00 AM.

During an interview with RD 2 on October 24, 2012 at 9:50 AM, she stated that she informed the nurse when she finished her assessment and follow up. She stated that she told the nurse that the assessments were in the electronic medical record. She did not follow up to ensure that her recommendations were communicated to the physician and carried out. She verified that her recommendations were not carried out. She stated that the patient would benefit from low protein due to her impaired kidney function.

2. During an observation of trayline (patient meal tray assembly) on October 23, 2012 at 11:45 AM, the meal tray for Patient 24 was noted to include two ounces of chicken, one ounce of rice, 4 ounces of corn, margarine, ice tea and salt free seasoning. One ounce of rice is equivalent to about 2 tablespoons.

During an interview with Diet Aide 1 the same day at 12:00 PM, she stated that the patient's diet order included a 20 gram protein restriction (a very low protein restriction). A review of the patient's medical record confirmed this. She was unable to explain why the patient only was given one ounce of rice, a low protein food.

A review of the nutrition analysis of the food that Patient 24 had been served so far for the day revealed that the he received 32 grams of protein between breakfast and lunch. This was twelve gram greater than his physician ordered diet for only two meals

During a further observation of trayline the same day and time, the meal tray for Patient 25 was observed. The meal tray contained four ounces of strawberries, a green salad, a grilled chicken breast (approximately three ounces) on a 100 calorie roll, two packets of diet mayonnaise, fat free salad dressing and water. The menu indicated that the patient was on a 2000 calorie diabetic diet (to control the amount of sugar in the blood). A review of the patient's medical record confirmed this.

During an interview with Diet Aide 1 the same day at 12:00 PM, she stated that the patient only ordered this amount of food so that was all they sent her. She further stated that the patient had ordered all three meals for the day.

A review of the nutrition analysis of the patient's selections for the day indicated that the total calories selected was only 1145 calories. The physician ordered diet was for 2000 calories.

During an interview with the Director of Nutrition and Guest Services same day at 12:15 PM, she stated that the hospital allows patients on diets with calorie prescriptions, such as 2000 calories, to select their menu choices. The dietary staff honors those selections, even if it doesn't equal 2000 calories. She stated that they don't correct the menu choices to ensure the physician's order is carried out in this case.

Based on observation, staff interview, record review and inspection of the buildings, it was determined that the hospital failed to be constructed, arranged and maintained to ensure the safety of the patients and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The cumulative effect of these systemic problems identified during the Life Safety Code (LSC) portion of the validation survey, resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

This was evidenced by aisles or corridors that were obstructed; by no emergency lights in three of three operating rooms at the surgery center, by one battery backup light that failed and by lights that were not tested as required; by staff that was unfamiliar with fire procedures; by fire alarm manual pull stations that were obstructed; and by sprinkler system valves that were inaccessible.

Findings:

During the facility tour, record review and interviews with hospital staff, from October 22, 2012 through October 25, 2012, the corridors and procedure rooms were observed.

1. There were gurneys and patient equipment in aisles or corridors serving as an exit in the emergency department area. This could delay the evacuation of patients in the event of a fire. During an interview on October 22, 2012 at 2:36 p.m., the Facilities Director reported gurneys and patient privacy screens were used in the exit aisles for patient overflow.

2. The hospital failed to ensure emergency lighting was installed, maintained and operational in all required locations. There was no emergency lighting in three of three operating rooms at the surgery center, one battery backup light failed and there were no records for testing the backup emergency lights. During an interview on October 24, 2012 at 3:51 p.m., the Director of Facilities reported that emergency battery backup lighting was not tested in the offsite locations.

3. During record review and interviews on October 22, 2012, the hospital failed to ensure staff was familiar with fire procedures. Documents failed to indicate that all staff participated in quarterly fire drills. During an interview on October 22, 2012 at 4:20 p.m., the Security Officer reported 4 of 125 Emergency Department Staff attended fire drills during the last 12 months.

4. On October 22, 2012 at 3:20 p.m., one fire alarm manual pull station, in the emergency department, was obstructed by a desk and a computer.

5. On October 22, 2012 at 3:22 p.m., a "Fire Dept. Hose Valve" was blocked from access in the Emergency Department corridor.

6. On October 22, 2012 and October 23, 2012, chairs, gurneys, and other patient equipment obstructed the corridors in and around the Emergency Department.

Based on observation, interviews and record review, the hospital failed to maintain the disaster food within the building approved for food storage by the Office of Statewide Health Planning and Development (OSHPD) when the disaster food was stored in a structure across the street. This failure had the potential to result in compromised safety and well-being of the patients in the event of a disaster in a hospital with a licensed bed capacity of 204.

Findings:

The hospital's disaster food supply and plan was observed and reviewed on October 22, 2012 at 1:00 PM. The disaster food and supplies required to implement the disaster menu were stored in a building across the street from the OSHPD approved hospital building.

During a concurrent interview with the Director of Nutrition and Guest Services, she was unable to state if the building where the food was stored was approved by OSHPD for the safe storage of food in a healthcare facility.

OSHPD is responsible for assuring the safety of buildings used in providing healthcare. This includes the safe storage of food.

Based on observation, facility staff interviews, and building inspections, the hospital did not meet the provisions of the 2000 edition of the Life Safety Code 101 of the National Fire Protection Association. The facility failed to ensure that the exit access was maintained, all emergency battery backup lighting was tested and maintained, all staff were trained on fire protection procedures, corridors were free of obstructions, and the fire alarm and sprinkler systems were accessible. This affected two of eight buildings. The Emergency Department on the Main Level (1st Floor) of the hospital and the Surgery Center were affected. This could result in an increased risk of delay in evacuation in the event of a fire or the spread of smoke and fire.

Findings:

During a tour of the facility, and interviews from October 22, 2012 through October 25, 2012, the hospital was found to be not in compliance with the 2000 edition of the Life Safety Code 101 of the National Fire Protection Association.

Emergency Department - October 22, 2012

1. At 2:26 p.m. and 2:35 p.m., there were gurneys, chairs, a Computer on Wheels (COW), and other medical equipment placed approximately six (6) inches from the fire doors and in the aisles, in Hall 4 and Hall 5.

2. On October 24, 2012 at 2:30 p.m., there were no emergency lights in three of three operating rooms at the surgery center. There were no records for testing the backup emergency lights. During an interview on October 24, 2012 at 2:38 p.m., the Director of Facilities confirmed there was no emergency battery backup lighting in the operating rooms. At 3:51 p.m., the Director of Facilities reported that emergency battery backup lighting was not tested in the offsite locations.

3. At 3:15 p.m., the Emergency Room (ER) Supervisor was interviewed and asked if she knew where the manual pull station was. The ER Supervisor looked up and down the corridors but did not know where it was. The ER Supervisor was asked when she had last participated in a fire drill and she stated that it had been about 3 years ago. She further stated that she had participated in a disaster drill about 6 months ago. During an interview at 4:20 p.m., the Security Officer reported 4 of 125 Emergency Department staff participated in fire drills during the last 12 months.

4. At 3:20 p.m., in the Emergency Department, the manual pull station by the check in desk, next to the entrance to the Triage Room was obstructed by a desk, and a computer.

5. On October 22, 2012 at 3:22 p.m., a "Fire Dept. Hose Valve" was blocked from access in the Emergency Department corridor.

6. On October 22, 2012 and October 23, 2012, chairs, gurneys, and other patient equipment obstructed the corridors in and around the Emergency Department.

Based on observation, policy review and interview, the hospital did not maintain the environment in the cardiac catheterization laboratory (cath lab) and the operating rooms (OR's) to ensure an acceptable level of safety and quality. Cleaning staff were using a disinfectant cleaner for the floor and surfaces (including the OR table/bed) of the cath lab and Ors. The product label states that the product must remain wet on the surface for a 10 minute contact time to ensure proper antisepsis (the destruction of disease-causing microorganisms to prevent infection). The actual contact time used by the staff was 5 minutes. This resulted in the possibility of incomplete antisepsis of the cath lab and OR floors and surfaces increasing the risk of infection of patients cared for in these areas.

Findings:

1. The operating room suite, including the cardiac catheterization lab, was inspected on October 24, 2012 at 9:00 AM. During the inspection of the cath lab, the two housekeepers entered and began to clean the floor with a mop. The Director of Perioperative Services was also present. Housekeeper A was asked what product was being used to clean the floor. She stated that she did not know but that it came from a dispenser in the cleaning supply room. She also stated that when she wet the floor, it would take five minutes to dry. The Director stated that he had timed it and that it did take 5 minutes for the floor and surfaces to dry after mopping. The cleaning supply room was inspected and a dispenser was mounted on the wall. It dispensed a product called Waxie Multi-Purpose Disinfective Cleaner #710. Housekeeper A confirmed that this was the product she used to clean the OR's. The label contained instructions which specified that the product required a 10 minute contact time for maximum effectiveness. The housekeeper and Director both agreed that a 10 minute contact time would be used until they could obtain a product with a shorter contact time.

2. On October 24, 2012, a policy was received from the hospital staff entitled "Between Case Surgery Suite Cleaning" last revised in June 2012. The policy was a general guideline without specific instructions on the use of various products throughout the Surgery area. Under the heading 'equipment', mop bucket and mop supplies were listed. The policy directed staff to wipe down the surgery table, other surfaces and the floor with a mop dipped in germicidal solution. These types of policies are usually nonspecific so that they can be adapted to various disinfective cleaning agents, deferring to the manufacturer's recommendations for contact time and other instructions.

Based on observation, interview and record review:

1. The infection control officer did not ensure the maintenance of a sanitary hospital environment in the cardiac catheterization laboratory (cath lab) and the operating rooms (OR's). Cleaning staff were using a disinfectant cleaner for the floor and surfaces (including the OR table/bed) of the cath lab and OR's. The product label states that the product must remain wet on the surface for a 10 minute contact time to ensure proper antisepsis (the destruction of disease-causing microorganisms to prevent infection). The actual contact time used by the staff was 5 minutes.

This resulted in the possibility of incomplete antisepsis of the cath lab and OR floor and surfaces, increasing the risk of infection of patients cared for in these areas.

2. The hospital failed to develop an effective infection control surveillance system for identifying unsafe food handling practices in the dietary department when:

a. There was no evidence of safe cool down of macaroni and cheese and prepared tuna salad.

b. There was no system for monitoring the shelf life of the macaroni and cheese.

c. There was no system to ensure that raw seed sprouts (a recognized source of food borne illness) were not served to patients.

The lack of surveillance of these unsafe food handling practices had the potential to result in a food borne illness outbreak in a highly susceptible patient population in a hospital with a licensed bed capacity of 212.

Findings:

1a. The operating room suite, including the cardiac catheterization lab, was inspected on October 24, 2012 at 9:00 AM. During the inspection of the cath lab the two housekeepers entered and began to clean the floor with a mop. The Director of Perioperative Services was also present. Housekeeper A was asked what product was being used to clean the floor. She stated that she did not know but that it came from a dispenser in the cleaning supply room. She also stated that when she wet the floor, it would take five minutes to dry. The Director stated he had timed it and that it did take 5 minutes for the floor and surfaces to dry after mopping. The cleaning supply room was inspected and a dispenser was mounted on the wall. It dispensed a product called Waxie Multi-Purpose Disinfective Cleaner #710. Housekeeper A confirmed that this was the product she used to clean the OR's. The label contained instructions which specified that the product required a 10 minute contact time for maximum effectiveness. The housekeeper and Director both agreed that a 10 minute contact time would be used until they could obtain a product with a shorter contact time.

1b. On October 24, 2012, a policy was received from the hospital staff entitled "Between Case Surgery Suite Cleaning" last revised on June 2012. The policy is a general guideline without specific instructions on the use of various products throughout the Surgery area. Under "equipment", mop bucket and mop supplies are listed. The policy directs staff to wipe down the surgery table, other surfaces and the floor with a mop dipped in germicidal solution. These types of policies are usually nonspecific so that they can be adapted to various disinfective cleaning agents, deferring to the manufacturer's recommendations for use.



28135

2a. According to the 2009 Food and Drug Administration (FDA) Food Code, cooked, potentially hazardous food (PHF - foods that require temperature control) shall be cooled within 2 hours from 135 degrees F to 70 degrees F, and within a total of 6 hours from 135 degrees F to 41 degrees F. Also, PHF shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient (room) temperature, such as reconstituted foods and canned tuna. It further states that if food is not cooled in accordance to this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

During a tour of the kitchen with the Manager of Food Service (MFS) on October 22, 2012 at 10:00 AM, approximately 12 individual portions of macaroni and cheese dated October 21, 2012 were observed in the walk-in refrigerator. The MFS stated that the macaroni and cheese had been portioned on October 21, 2012. He was unable to state when it had been cooked.

Also during the tour of the kitchen at 10:20 AM, 3 containers of tuna salad were observed in the walk-in refrigerator.

During a concurrent interview with Dietary Staff 1, she stated that she made the tuna salad using canned tuna that was stored at room temperature. She further stated that she did not monitor the cool down of the tuna to ensure that it reached 41 degrees Fahrenheit (F) or below within four hours.

During an interview with the Cook 1 and review of the hospital's Cooling Logs on October 22, 2012 at 12:30 PM, he stated that the macaroni and cheese observed earlier was not listed on the log. He was unable to ensure that the macaroni and cheese was safely cooled.

A review of the hospital's policy titled, "Food Preparation" dated September 19, 2012, revealed that the Cook was responsible for ensuring cooked food items were cooled and stored per the policy and procedure and that the Cooling Log was completed. There was no policy for monitoring the safe cooling of the tuna salad.

During a concurrent interview with the MFS, he verified that the macaroni and cheese and the tuna salad were both potentially hazardous foods that require monitoring for safe cooling. He further verified that there was no evidence of safe cooling of the macaroni and cheese and the tuna salad.

b. During a tour of the kitchen on October 22, 2012 at 10:00 AM, approximately 12 individual portions of macaroni and cheese dated October 21, 2012 were observed in the walk-in refrigerator.

During an interview with Cook 1 on October 22, 2012 at 12:30 PM, he stated that it was the staff practice for the macaroni and the cheese sauce to be cooked and stored separately in the refrigerator until needed. Then they were mixed together, portioned and dated. There was no system that made it possible to determine the date that the macaroni and the cheese sauce were originally made. The date on the label was the date that it was portioned. It was not the date that the two ingredients were cooked. The shelf life of the macaroni and cheese could not be monitored.

A review of the hospital's policy titled, "Food Preparation" dated September 19, 2012, revealed that prepared cold food items were to be covered, labeled and dated. Labeling for foods placed in the refrigerator should contain the original date of preparation.

c. According to the 2009 FDA Food Code, in a food establishment that serves a highly susceptible population (such as health care facilities), raw seed sprouts may not be served or offered for sale in a ready-to-eat form. The code states that raw seed sprouts have emerged as a recognized source of food borne illness in the United States. The FDA and the Centers for Disease Control and Prevention have issued health advisories that persons who are at greater risk for food borne disease should avoid eating raw alfalfa sprouts.
During an observation of the hospital's cafeteria on October 22, 2012 at 11:05 AM, the salad bar was noted to have raw alfalfa sprouts.
During an interview with the Director of Nutrition and Guest Services on October 24, 2012 at 8:00 AM, she was unable to state how the hospital could ensure that food served in the cafeteria would not be consumed by patients. Therefore, patients were at risk of consuming the alfalfa sprouts which were a recognized source of food borne illness according to the FDA Food Code.

Based on record review and interview, the hospital failed to ensure that a post-anesthesia evaluation was performed and documented in the patient record for 1 of 47 sampled patients (Patient 13) out of six closed surgical records reviewed. This resulted in the possibility that the patient's recovery from anesthesia was not adequately assessed and that the patient was discharged from the Post Anesthesia Care Unit (PACU) without having adequately recovered from anesthesia.

Findings:

Patient 13 underwent a laparoscopic cholecystectomy (using a scope to remove the gallbladder through a small incision). The record was reviewed on October 23, 2012 at 1:50 PM. There was no post-anesthesia note that could be found in either the electronic or the paper parts of the patient's clinical record. The Director of Health Information Management assisted in the review and concurred that no post-anesthesia evaluation was documented in the record.

Based on staff interview and policy review, the hospital failed to implement it's policy and procedure regarding "Staffing Plan" to ensure the number of qualified personnel were available to provide outpatients with the appropriate level of care and services. This resulted in the increased risk of patient harm by outpatients not receiving the appropriate level of care and services needed.

Findings:

During an interview with the Program Manager of the Wound Care Outpatient Services on October 23, 2012 at 2:28 PM, the Program Manager stated that the census/wound care visits was 26 with 1 Registered Nurse (RN), 1 Licensed Vocational Nurse (LVN) and 3 Medical Assistants (MA's).

During an interview with RN 4 on October 23, 2012 at 2:55 PM, RN 4 confirmed and stated that there was only 1 RN, 1 LVN, and 3 MA's scheduled for the day.

A review of the October 23, 2012 census and staffing schedule revealed that there was 26 wound care visits scheduled with 1 RN, 1 LVN, and 3 MA's.

On October 23, 2012, a policy was received from the Program Manager entitled "Staffing Plan" origination date of March, 2010. The policy stipulated that "Appropriate and adequate staffing is vital to the success of the Wound Care Center."

Under "Evaluation of Staffing Plan" the policy indicated that the minimum staffing requirement per day for providing care to wound care patients was 2 RN's (Registered Nurse), 1 LVN (Licensed Vocational Nurse), 1 MA (Medical Assistant) or 2 RN's and 2 MA's if there are more than 15 patients.

During an interview with the Rehab Services Director on October 23, 2012 at 3:06 PM, the Rehab Director confirmed the staffing ratio and stated, "Should have called the hospital for another RN with competency to cover ...who was on vacation."