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Based on observation, interview, and review of the facility's policy, it was determined the facility failed to develop, implement, and evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable disease within the hospital. The facility failed to maintain a sanitary physical environment in techniques for cleaning and disinfecting patient laundry and laundry equipment. The facility failed to implement a procedure to disinfect patient use washing machines between each patient to minimize the risk of contamination. The facility also failed to maintain a water temperature logs for laundry equipment.

The findings include:

Review of the facility's policy titled, "General Hospital Policies" Section 7 (seven); Infection Control; Subsection VIII, Patient Laundry - Washer/Dryers on Unit Use, reviewed 05/12, revealed washers and dryers should be kept clean and should not be allowed to become a source of contamination. Further review revealed, the washers were to be cleaned after an unusually dirty load of clothing, by running the empty washer through a complete cycle using one box of regular bleach and a small amount of detergent. Additionally the washers were to be routinely cleaned nightly by running the empty washer through a complete cycle using one box of bleach and a small amount of detergent.
Interview, on 12/07/12 at 10:00 AM, with Environmental Staff (ES) #9 revealed the patient linens (sheets, pillow cases and blankets) were under contract to be sent out to be laundered. ES #9 stated the facility laundered the cleaning cloths and mop heads for environmental services and the cleaning cloths for dietary on site. The patient clothing was laundered in the patient care areas. ES #9 further stated he no longer recorded the hot water temperatures in the log books. He stated he stopped recording the temperatures in the log book in July 2011 when the facility started to outsource the linens. Furthermore, ES #9 revealed he did not know if the current laundry procedure the facility was utilizing was appropriately destroying bacteria.
Interview with the Director of Laundry Services Unit Administration, on 12/07/12 at 12:40 PM, revealed the hot water temperatures were not being recorded. The patients were responsible for washing their own laundry and that was done in the patient care areas. Additionally, the Director of Laundry Services Unit Administration did not know when the washers were cleaned. Further interview revealed the patient care areas were issued residential type detergent (Purex) in a single use boxes.
Interview with the Infection Control Nurse, on 12/07/12 at 2:20 PM, revealed the patients' personal clothing was laundered on the unit by the patients or staff. Further interview revealed Purex was used for the personal laundry and that the washing machines were cleaned on a regular schedule with a dry powder bleach, but was not sure the frequency of the cleaning.
Interview with the Infection Control Clinical Specialist, on 12/07/12 at 2:55 PM, revealed she was unaware that the temperatures were not being recorded at the time the washing machines were in use. Further interview revealed her expectation would be to run the empty washer through a complete cycle using one box of regular bleach and a small amount of detergent between each individual patient's laundry to prevent infection and keep the washer clean as to not become a source of contamination.

Based on record review and staff interviews, it was determined the facility failed to ensure a medication was administered in a safe manner as evidenced by the Physician's and Registered Nurse's (RN's) failure to check pertinent laboratory values before the order or the administration of a medication for one (1) of thirty-one (31) sampled patients (Patient #7).

The findings include:

Interview with the Acting Director of Nursing (DON), on 12/07/12 at 4:45 PM, revealed the facility did not have a policy to address mandatory checking of laboratory values before ordering or administering medications.

Review of Patient #7's medical record revealed he/she arrived at the Central Triage Center (CTC) of the facility, on 11/30/12 at 4:11 AM, with diagnoses which included Depression, Substance Abuse, Post-Traumatic Stress Disorder (PTSD) and Crohn's Disease. Patient #7 had received care in an acute care hospital emergency department (ED) on 11/29/12 and had been released to a mental health group which called the referral to the facility. Further review of the record revealed Patient #7 was sent to the facility on a court order for involuntary admission. He/she was transported to the facility via law enforcement. The record further revealed documents from the prior ED visit were sent with the patient. One of the documents was an "Interfacility Transfer Form". This form stated Patient #7 was stable and did not mention any medical problems. Another document was a laboratory report of a blood acetaminophen level of 47 micrograms per milliliter (mcg/ml) which was collected on 11/29/12 at 11:30 PM. Therapeutic levels for acetaminophen were 10 to 30 mcg/ml. Toxic levels of acetaminophen were greater than 40 mcg/ml if the specimen was collected twelve (12) hours after ingestion; greater than 75 mcg/ml if the specimen was collected eight (8) hours after ingestion; and greater than 150 mcg/ml if the specimen was collected four (4) hours after ingestion. Further review of the medical record revealed Patient #7 had been prescribed, from a previous acute care facility admission and had on his/her possession, Bupap (a combination drug of acetaminophen, a pain reliever and fever reducer and butalbital, a barbiturate which was a pain reliever and relaxant) 50/650 milligrams (mg), 50 mg of butalbital and 650 mg of acetaminophen. Further review of Patient #7's record in the CTC revealed his/her Physician gave a verbal order to RN #4, on 11/30/12 at 5:20 AM, for Patient #7 to use his/her own supply and take one (1) Bupap 50/650 mg orally now. An additional order written by Patient #7's Physician, on 11/30/12 at 5:30 AM, revealed Patient #7 was sent to the facility with an acetaminophen level high at 47, and there was no way to know when the last dose of Bupap may have been (before the dose given at 5:20 AM) or if levels would climb. Patient #7 was ordered to be transported to another acute care hospital ED for medical clearance at that time. Further review of the medical record revealed Patient #7's acetaminophen level drawn at the acute care hospital ED, on 11/30/12 at 7:46 AM, was less than 15 mcg/ml which was in the therapeutic range. Liver enzyme levels, specimen drawn at the same time, were not elevated. Patient #7 was transported back to the facility in stable condition, on 11/30/12 at 4:15 PM.

Interview with RN #4 via telephone, on 12/07/12 at 3:00 PM, revealed Patient #7 had come to the facility with his/her own supply of Bupap. She further revealed Patient #7, upon arrival to the CTC in the facility, was pacing, agitated and in pain. She stated no nurse from the prior ED visit had called report to a nurse at the facility, and all she saw in Patient #7's documents sent with him/her was the "Interfacility Transfer Form" which stated the patient was stable. RN #4 stated she did not see the elevated acetaminophen level. She further revealed she did not ask Patient #7 when the last time was that he/she took a Bupap or how many he/she had taken that day.

Interview with Patient #7's Physician via telephone, on 12/07/12 at 4:00 PM, revealed Patient #7 asked if he/she could take Bupap because of pain. She further revealed she had not seen the patient or the chart but, because the patient was agitated and in pain, ordered the Bupap, one (1) pill, hoping to avoid having to give him/her something stronger if Patient #7 got out of control. The Physician further stated she should have looked at Patient #7's paper work that was sent with him/her before prescribing the Bupap. She also said once she discovered the elevated acetaminophen level, approximately ten (10) minutes after the Bupap was given, she ordered Patient #7 to go to an acute care hospital ED for evaluation. Patient #7's Physician also revealed she believed the prior ED should have kept the patient until his/her acetaminophen levels were in the therapeutic range.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure that established policies and procedures were maintained for safe food handling practices. The facility failed to ensure opened food products were label and dated, dented canned goods remained unavailable for use, expired food items were not served, and employees maintained good hand hygiene. Additionally, the walk in refrigerator had a large rubber type garbage bin under the cooling unit to collect leakage from the unit.

The findings include:

Review of the facility's policy titled "Dietetic Services", with a review date of 05/12, revealed all opened foods stored in the refrigerators and freezers shall be covered, labeled and dated. Additionally, out of date or expired food items shall not be served and dented cans shall not be stored on shelves or used. The policy further stated that staple food items should not be stored in an area that was subject to contamination by condensation or leakage.

Observation during the initial tour of the kitchen, on 12/04/12 at 1:50 PM, revealed the pass through refrigerator contained four (4) opened styrofoam containers with no label or date; eight (8) sandwiches wrapped in plastic wrap with no label or date and one (1) opened pack of sliced cheese with no label or date. The walk in refrigerator contained nineteen (19) food items including shredded cheese, onions, pickles, broccoli, green peppers, chopped eggs and pineapple chunks that were dated but had no label per the facility's policy. The refrigerator also contained one (1) multi-bag box of shredded cabbage with an expiration date of 12/2/12. Additionally, the walk in refrigerator contained a large rubber type garbage bin between two (2) food storage shelving units in the walk in refrigerator. This rubber garbage bin contained approximately four (4) inches of brownish black liquid with two (2) opened milk cartons and one bag of unidentifiable contents floating in the liquid. The dry storage room contained one (1) opened pack of hamburger buns with no date; one (1) container of Equal sweetener with no date; one (1) opened bottle of honey with no date; one (1) bottle of vegetable oil opened with no date and one (1) opened container of Rainbow Rotini with no date. Additionally there were six (6) dented food can items including Hunts Manwich sauce, pineapple chunks, Mexican style chili, tomato sauce, tomato ketchup and fruit cocktail found on the shelf in rotation with each of the like canned food items. The spice table contained open containers of vanilla extract, honey, Worcestershire sauce, vinegar, browning seasoning, chocolate fudge icing, apple cider vinegar, soy sauce and a small pitcher with unknown contents with no label and date. The Wendell One (1) nourishment room contained opened popcorn oil with no label or date; opened liquid butter with no date; orange powder substance in an open styrofoam container with no label or date; red liquid in a pitcher with no label or date; two (2) opened bottles of soda with no date and two (2) opened bottles of coffee creamer with no date. The Wendell Four (4) nourishment room contained opened popcorn oil with no date; an opened container of thickener with no date and a scoop it the powder; and an opened bottle of vegetable oil with no date. The Wendell Intensive Service Unit (ISU) nourishment room contained three (3) pitchers of liquid with no label or date; one (1) opened bottle of soda with no date; opened popcorn oil with no date and one (1) bag with an unknown substance with no label or date.

Interview with the Director of Dietary Services, on 12/4/12 during the initial tour at 2:10 PM, revealed the employee refrigerator was broken and personal food items were being stored with facility food items. The interview further revealed that dented cans were not to be used for consumption, but the facility did not have a process for storing the cans away from availability of use. The Director of Dietary Services stated the food items should have a dated when opened but if the item was identifiable when unwrapped or uncovered, there was no need to label it. The interview further revealed the large rubber garbage bin was placed in the refrigerator to collect the condensation leakage from the cooling unit and he did not know when the bin was last emptied or cleaned.

Interview with the Unit Manager UM #14, on 12/4/12 at 3:35 PM, revealed the food items should have been label and dated. Further interview revealed the scoop should not have been in the thickener. UM #14 stated that could be an infection control issue.

Observation, on 12/6/12 at 4:45 PM, revealed Dietary Staff (DS) #10 bent over with gloved hands and picked up trash from the floor and while continuing to hold trash, picked up plastic lid and placed lid on a salad bowl and passed the bowl to another Dietary Staff member to put on the patient tray.

Observation, on 12/6/12 at 5:04 PM, revealed Dietary Staff (DS) #13 placed cheese cake and salads onto patient trays without gloving resulting in bare hands touching patients food.

Interview with Dietary Staff (DS) #13, on 12/6/12 at 5:15 PM, revealed he normally wore gloves when placing items on the food tray but "just got in a rush and forgot".

Interview with Cook Supervisor (CS) #4, on 12/6/12 at 5:20 PM, revealed staff normally did wear gloves and should have been wearing gloves when handling food items. Interview further revealed it was the facility's policy to wash hands and don gloves prior to serving and re-wash hands and re-don gloves as needed and before going back to the food line. Interview further revealed the opened food items should have been label and dated.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to develop, implement, and evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable disease within the hospital. The facility failed to maintain a sanitary physical environment in techniques for cleaning and disinfecting patient laundry and laundry equipment. The facility failed to implement a procedure to disinfect patient use washing machines between each patient to minimize the risk of contamination. The facility also failed to maintain a water temperature logs for laundry equipment.

The findings include:

Review of the facility's policy titled, "General Hospital Policies" Section 7 (seven); Infection Control; Subsection VIII, Patient Laundry - Washer/Dryers on Unit Use, reviewed 05/12, revealed washers and dryers should be kept clean and should not be allowed to become a source of contamination. Further review revealed, the washers were to be cleaned after an unusually dirty load of clothing, by running the empty washer through a complete cycle using one box of regular bleach and a small amount of detergent. Additionally the washers were to be routinely cleaned nightly by running the empty washer through a complete cycle using one box of bleach and a small amount of detergent.
Interview, on 12/07/12 at 10:00 AM, with Environmental Staff (ES) #9 revealed the patient linens (sheets, pillow cases and blankets) were under contract to be sent out to be laundered. ES #9 stated the facility laundered the cleaning cloths and mop heads for environmental services and the cleaning cloths for dietary on site. The patient clothing was laundered in the patient care areas. ES #9 further stated he no longer recorded the hot water temperatures in the log books. He stated he stopped recording the temperatures in the log book in July 2011 when the facility started to outsource the linens. Furthermore, ES #9 revealed he did not know if the current laundry procedure the facility was utilizing was appropriately destroying bacteria.
Interview with the Director of Laundry Services Unit Administration, on 12/07/12 at 12:40 PM, revealed the hot water temperatures were not being recorded. The patients were responsible for washing their own laundry and that was done in the patient care areas. Additionally, the Director of Laundry Services Unit Administration did not know when the washers were cleaned. Further interview revealed the patient care areas were issued residential type detergent (Purex) in a single use boxes.
Interview with the Infection Control Nurse, on 12/07/12 at 2:20 PM, revealed the patients' personal clothing was laundered on the unit by the patients or staff. Further interview revealed Purex was used for the personal laundry and that the washing machines were cleaned on a regular schedule with a dry powder bleach, but was not sure the frequency of the cleaning.
Interview with the Infection Control Clinical Specialist, on 12/07/12 at 2:55 PM, revealed she was unaware that the temperatures were not being recorded at the time the washing machines were in use. Further interview revealed her expectation would be to run the empty washer through a complete cycle using one box of regular bleach and a small amount of detergent between each individual patient's laundry to prevent infection and keep the washer clean as to not become a source of contamination.