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Based on interview and record review, the facility failed to ensure the Registered Nurse (RN) completed an accurate evaluation, for 6 of 35 sampled patients (Patients 2, 5, 7, 16, 17, and 24), by failing:

1. To identify the nutritional risk factor(s) during the initial nutritional screening for Patients 17 and 7. This failure caused a delay in the Registered Dietitian (RD) assessment; and a delay in identifying potential nutritional concerns and interventions. Subsequently, the nursing staff failed to develop and implement a nutrition plan of care;

2. To identify an incomplete medication reconciliation of home medications and clarify the order from the physician for Patient 16. This failure had the potential to result in the patient receiving the medication (Prednisone - an anti-inflammatory) if the physician determined the need to continue the medication;

3. To ensure that fluid restriction protocols were implemented as ordered for two patients (Patients 2 and 5). Failure to implement fluid restrictions as prescribed had the potential to compromise the patient's medical care; and

4. To implement neurological checks including pupil checks for Patient 24, diagnosed with a subdural hematoma (bleeding in the brain). This failure could result in an expanding hematoma, potentially resulting in non-reversible brain injury.

Findings:

1a. On August 27, 2012, Patient 17's record was reviewed with the Director of Critical Care (DCC). Patient 17, an 87 year old female, was admitted to the facility on August 24, 2012, with diagnoses that included a fracture of the right hip.
The patient was scheduled for surgery on August 25, 2012, to repair the right hip fracture.

The "Adult Patient History (completed by an RN)" dated August 24, 2012, at 11:11 p.m., was reviewed. The section, "Nutritional Screen...Nutritional Risk Factors" indicated the patient had no risk factors. Included in this section (not marked) was "Geriatric surgical patient."

The Orthopedic Consult dated August 24, 2012, at 8:30 p.m., indicated, "To Operating Room scheduled 1 p.m. tomorrow...NPO (nothing by mouth) after midnight..."

The Orthopedic Consult dated August 25, 2012, at 2 p.m., indicated, "Surgery canceled secondary to low platelets. (Physician's name) to schedule..."

The Physician's Order indicated:

- August 24, 2012, "Dextrose 5% with 1/2 NaCl (Sodium Chloride) at 75 ml/hr (milliliter per hour) IV (intravenously)"; and

- August 26, 2012, at 8:52 a.m., "Regular diet."

There was no oral diet or any nutritional alternate given to Patient 17 on August 25, 2012.

On August 27, 2012, at 2:45 p.m., the DCC and Director of Food and Nutritional Services (DFNS) were interviewed. The DCC stated all patients were evaluated by the Registered Nurse when admitted in the inpatient units, which included the nutritional assessment. The DFNS stated when a "Nutritional Risk Factor" was identified, an RD assessment would automatically be generated by the electronic medical record system and that the RD would need to assess the patient within 24 hours. The DCC and DFNS were unable to find documented evidence Patient 17 had been assessed by an RD.

On August 27, 2012, at 3 p.m., Patient 17's record was reviewed with RD 4. RD 4 stated she was scheduled to see Patient 17 today to conduct an initial nutritional assessment. RD 4 stated if any of the "Nutritional Risk Factors (such as Geriatric surgical patient)" were triggered, a RD consult should occur within 24 hours. RD 4 stated Patient 17 should have been seen within 24 hours of admission.

During a concurrent record review, Patient 17's record indicated that a nutrition plan of care was not developed and implemented.

b. On August 30, 2012, at 8:25 a.m., review of the medical record for Patient 7 showed the patient was admitted on August 15, 2012. On admission, the patient had a right ankle wound. Review of the nutrition section of the initial nursing assessment, completed on August 15, 2012, showed that the patient's wound was not identified as a trigger for high nutritional risk, and a nutritional consult was not triggered based on this risk factor. The RD completed the nutritional assessment on August 17, 2012, 48 hours after admission. In a concurrent interview with the Registered Dietitian (RD 1), and two Nurse Managers from the Intensive Care Unit at Facility 1 (NM 2 and NM 3), they agreed that Patient 7's wound should have triggered a nutrition consult.

The facility policy titled, "Nutrition Assessment: Standards of Care (dated August 2011)" was reviewed and indicated, "...A Registered Nurse completes an admission assessment within 8 hours of the patient's stay, and 4 hours for ICU patients...Nursing will then generate a nutrition consult if a positive nutritional screen is identified to Nutritional Services alerting the dietitian of needs for further nutritional intervention...The dietitian will then complete a nutritional assessment within 24 hours for all consults..."

The facility policy titled, "Assessment/Reassessment of Patient (dated) July 2012)" was reviewed and indicated, "Purpose: To establish guidelines delineating responsibility of all healthcare team members in the data gathering process to establish individual plan of care and establish treatment plan...An initial assessment of each patient's...nutritional status...is completed by a Registered Nurse (RN) at time of admission..."

The policy further indicated, "...The initial assessment is used to determine...The need for any further assessment...Nutritional requirements include...Initial assessment of patient by a dietitian, with diagnosis and nutritional status in collaboration with physician and nursing service to provide optimal nutrition throughout hospitalization and discharge..."

2. On August 27, 2012, Patient 16's record was reviewed with the DCC. The patient was admitted to the Medical Surgical (M/S) Unit on August 23, 2012. The "Medication Reconciliation Physician Orders for Admission" dated August 23, 2012, included, "Prednisone 5 mg (milligrams) oral tablet 1 tab daily." The order had a section to indicate whether to "Continue or Discontinue" the medication. The section was left blank.

The electronic Medication Administration Record (MAR) was reviewed and did not indicate the patient received or was receiving the Prednisone.

The facility policy titled, "Medication Reconciliation Across the Continuum of Care (dated June 2012)" was reviewed and indicated, "...The admitting/ordering physician compares the home medication list with the medication(s) ordered for treatment during hospital stay, reconciles the two lists and authenticates the medication order(s) within 24 hours of admission. If the ordering physician has not completed this task, order clarification will occur per policy..."

On August 30, 2012, at 12 p.m., Patient 16's record was reviewed with the Director of Nursing (DON). The DON stated Patient 16's unmarked Prednisone order in the "Medication Reconciliation Physician Orders for Admission" should have been clarified by the licensed nurse with the physician.



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3. On August 27, 2012, at 3:45 p.m., review of the facility policy titled, "Fluid Restriction", showed the following: "The total amount of oral fluid allowed will be divided among Nutritional Services and Nursing as follows:

1200 ml - 800 ml Nutrition Services, 250 ml (0700-1900 Nursing Service), 150 ml (1900-0700 Nursing Service);

1500 ml - 1000 ml Nutrition Services, 275 ml (0700-1900 Nursing Service), 225 ml (1900-0700 Nursing Service).

Nursing care providers will ensure that water pitchers are not filled/used."

a. On August 27, 2012, at 2:38 p.m., review of the medical record for Patient 2 showed the patient was admitted on July 27, 2012. As of August 8, 2012, Patient 2 was prescribed a 1200 ml fluid restriction. On August 27, 2012, at 2:55 p.m., observation of the patient showed that he was in bed, awake, with a water pitcher at bedside. A Certified Nursing Assistant (CNA 1) was in the room. In a concurrent interview with CNA 1, she stated she provided one-on-one supervision to Patient 2. She stated the water pitcher currently was empty, but was full when she came on shift. She stated that she was waiting for the nurse to fill the water pitcher as the patient was prescribed thickened liquids.

On August 27, 2012, at 3:05 p.m., in an interview with the Registered Nurse (RN 3) assigned to Patient 2, he stated he was not aware that Patient 2 was prescribed a fluid restriction. RN 3 confirmed there was no sign posted in the patient's room alerting staff the patient was prescribed a fluid restriction. When asked how the fluid restriction would be implemented, RN 3 stated there should not be a water pitcher at the patient's bedside. RN 3 stated the patient would be offered 70% of the fluid restriction by nursing during the day shift and the remainder during the night shift. He did not know how much fluid would be provided by nutritional services on the patient meal trays.

b. On August 29, 2012, at 10:22 a.m., observation of Patient 5 showed that she was in bed, awake, with family at bedside. A sign above the patient's bed read, "Fluid Restriction 1500 cc/24 (hours)". The patient was interviewed utilizing the family member as a translator as the patient was non-English speaking. The patient was asked why she was on a fluid restriction and responded by stating that she did not understand the reason for the fluid restriction, had not been educated about it, and would like more information on it.

On August 29, 2012, at 10:30 a.m., review of the medical record for Patient 5 showed she was admitted on August 22, 2012. On August 23, 2012, Patient 5 was prescribed a 1500 ml fluid restriction. There was no documentation in the medical record showing that the patient had been provided education regarding the fluid restriction order.

On August 29, 2012, at 10:52 a.m., in an interview with the Registered Nurse (RN 4) assigned to Patient 5, she stated she did not know why the patient had not received education regarding fluid restriction. When asked how the patient's fluid restriction would be implemented, RN 4 stated that the patient was provided a water pitcher at bedside that was filled with 275 cc of water (on the day shift) and the patient would be offered water from the pitcher during medication pass. She stated that a regular cup and straw (not graduated or marked) were provided. When asked how nursing staff would determine the patient's consumption when the cup was not graduated, she stated they would have to estimate.

On August 30, 2012, at 10:20 a.m., in an interview with the Director of Nursing (DON), she stated that there was some ambiguity in the fluid restriction policy. She stated that the patient should have been educated on the purpose of the fluid restriction, by nursing staff, at the time the order was prescribed.



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4. A review of Patient 24's record was conducted on August 27, 2012. Patient 24 was admitted to the facility's emergency room on August 24, 2012, with a diagnosis of subdural hematoma (bleeding in the brain) after sustaining a fall. Patient 24 was subsequently transferred from the emergency room to the intensive care unit for further observation and treatment.

A review of the Physician's order for Patient 24, dated August 24, 2012, at 8:50 p.m. indicated, "Neuro (neurological) checks every hour to start now." (Neurological checks-include pupil checks, together form the basis in assessing if a patient has ongoing bleeding and/or further brain damage).

An interview with and a review of Patient 24's neurological assessment form which included an assessment of the patient's pupils (indicating if a patient's pupils are equal and/or reactive to light) was conducted with the Registered Nurse (RN 2) on August 27, 2012, at 2 p.m.

After reviewing Patient 24's record, RN 2 stated that on August 24, 2012, at 9:03 p.m. and at 9:49 p.m. the record failed to show that the assessment of Patient 4's pupils was conducted every hour per the Physician's order.

A review of the facility policy, "Physician's Order (Revised: 5/2012)" was conducted the policy indicated, "Physician's orders will be accurately processed and promptly followed."

Based on observation, interview and record review the facility failed to ensure a care plan for bladder incontinence was implemented for one of 35 patients, (Patient 25) after a Foley Catheter (tube which drains urine from the bladder) was removed.

Findings:

A review of Patient 25's record was conducted on August 27, 2012. Patient 25 was admitted to the facility on August 21, 2012, with gastrointestinal bleeding. The record reflected that Patient 25 had a Foley Catheter inserted on August 22, 2012. The Foley Catheter was subsequently removed on August 25, 2012.

An interview was conducted with Patient 25 on August 27, 2012, at 10:15 a.m. Patient 25 stated she was unhappy because she had been unable to control her bladder since her Foley Catheter was removed but the hospital would not let her wear the diapers her caregiver brought in for her. Patient 25 further stated when she moves, the urine leaked out and she was always wet, which upset her.

A review of Patient 25's Interdisciplinary Plan Of Care (care plan) failed to show a care plan was implemented which addressed the patient's incontinence (inability to control ones bladder) after the Foley Catheter was removed.

A review of the facility policy, "Care Planning: Patient (Review: 4/2011)," was conducted. The policy indicated, "The patient's care plan shall be revised/updated to reflect changes in patient status, as evaluated and assessed by the Registered Nurse and other members of the healthcare team."

An interview was conducted with the Registered Nurse (RN 1) on August 21, 2012, at 11:20 a.m. RN 1 stated a care plan which addressed Patient 25's incontinence should have been implemented after the patient's Foley Catheter was removed. RN 1 further stated the patient's request to use diapers was the patient's choice and should have been reflected in the plan of care.

Based on observation, interview, and record review, the facility failed to administer medications in accordance to the acceptable standards and the facility's policy and procedure by failing to:

1. Ensure documentation on the medical record reflected the facility followed protocol for the medication used for sedation;

2. Ensure injectable antibiotic medications via intravenous piggy-back (IVPB) were prepared and administered in accordance to the manufacturer's recommendations without a significant dose not being administered to the patients;

3. Ensure that physician orders for Hydralazine and Labetalol (both medications are used to treat high blood pressure) were clarified and/or administered as ordered for Patients 26 and 27. These failures could lead to drug related injuries; and

4. Ensure the pneumonia vaccine was administered as ordered by the physician for Patient 17. This failure resulted in the delay in administration of the vaccine.

Findings:

1. Patient 3's medical record was reviewed on August 27, 2012, and it was noted that there was a physician order for propofol (medication used for sedation) to maintain the patient sedated at RAAS sedation score of -2 since August 22, 2012.

RAAS, Richmond Agitation Sedation Scale ranges from +4 to -5 with -2 being light sedation.

Review of the record indicated there was lack of documentation of titration every five minutes as indicated in the facility's sedation protocol and inconsistent documentation of the reason for rate change even though there was no documented change in the level of sedation.

On August 22, 2012, between 7 p.m. and 8 p.m., propofol infusion rate was changed from 25 ml/hr to 12.9 ml/hr without documented change in the patient's sedation level and without any other documented reason.

On August 25, 2012, between 12 p.m. and 1 p.m., propofol infusion rate was changed from 10.3 ml/hr to 12.9 ml/hr without documented change in the patient's sedation level and without any other documented reason in the patient's medical record.

During an interview on August 28, 2012, at 2 p.m., RN 2 agreed that there was inconsistent documentation of initial titration.

During a concurrent interview, the Director of Pharmacy (DOP) agreed that documentation for rate changes and initial titration every five minutes was not evident.

2. During medication pass observation for Patient 31, on August 28, 2012, at 8:30 a.m., it was observed there was an IVPB bag containing Tigacil (an antibiotic) 50 mg. The bag was connected to the Tigacil vial via a connector called, addEASE Binary Connector with 17 Gauge Needle (addEASE for short).

It was observed, there was yellow liquid remaining inside the Tigacil vial approximately between 1 and 2 ml in volume.

During a concurrent interview, RN 500 explained that the Tigacil vial, which came as powder, was dissolved in liquid, and the liquid was squeezed into the vial from the IVPB bag. The dissolved powder was transferred to the IVPB bag, which was hung and administered to the patient. RN 500 stated only enough liquid was transferred to the vial to mix and dissolve the powder antibiotic.

During a concurrent interview, the DOP agreed that there was between 1 and 2 ml of dissolved Tigacil remaining in the vial and acknowledged that the amount could be significant enough that the patient would not be able to receive the full prescribed dose.

The DOP stated that staff might not be using the proper technique and might not be following the manufacturer's instructions.



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3 a. A review of Patient 26's record was conducted on August 27, 2012. Patient 26 was admitted to the facility on August 25, 2012, with a diagnosis of a subdural hematoma (bleeding in the brain).

Physician's orders were written for Patient 26 on August 26, 2012, at 6:30 a.m. The orders indicated Labetalol 10 milligrams IV (intravenously) to be administered every 15 minutes as needed for a systolic blood pressure greater than 150, hold for heart rate less than 60 and Hydralazine 10 milligrams IV every 15 minutes to be administered as needed for a systolic blood pressure greater than 50.

A review of Patient 26's medication administration record (MAR) indicated on August 26, 2012, at 9:59 p.m., Patient 26's systolic blood pressure was 155. Further record review failed to show that either Labetalol or Hydralazine were administered or that the physician was notified in order to clarify the orders.

Further review of the MAR indicated on August 27, 2012, at 8 a.m., the systolic blood pressure was 151; at 11:12 a.m. the systolic blood pressure was 154; and at noon the systolic blood pressure was 154. Further record review failed to indicate that either Labetalol or Hydralazine were administered during these times or that the physician was notified in order to clarify the orders.

An interview was conducted with the Nurse Manager (NM 1) on August 27, 2012, at 3 p.m. NM 1 stated the orders for Labetalol and Hydralazine for Patient 26 are not written clearly. The orders should have stated which medication to administer first, in addition, the Hydralazine parameters (give for a systolic blood pressure greater than 50) were not correct.

b. A review of Patient 27's record was conducted on August 27, 2012. Patient 27 was admitted to the facility on August 26, 2012, with multiple skull fractures after being struck by a motor vehicle.

Physician's orders were written for Patient 27 on August 25, 2012, at 10:40 p.m. The orders indicated, Hydralazine 10 milligrams IV every 15 minutes as needed for a systolic blood pressure greater than 150 and Labetalol 10 milligrams IV every 15 minutes as needed for a systolic blood pressure greater than 150, hold for a heart rate less than 60, use Labetalol first.

Further review of Patient 27's record indicated on August 26, 2012, at 11:45 p.m., the Patient's systolic blood pressure was 162. Further record review failed to show that either Labetalol or Hydralazine were administered as ordered.

A review of the facility policy, "Physician's Orders (Revised: 5/2012)" was conducted. The purpose indicated, "To establish guidelines for obtaining and processing physician's orders to ensure prompt quality patient care is provided." The policy indicated, "Physician's orders will be accurately processed and promptly followed."



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4. On August 27, 2012, Patient 17's record was reviewed with the Director of Critical Care (DCC). Patient 17 was admitted to the facility on August 24, 2012, with diagnoses that included a fracture of the right hip.

The "Adult Patient History" dated August 24, 2012, at 11:11 p.m., included:

- "Pneumococcal Vaccine (Offer year round)...Pneumococcal Screen Contraindications (list)" and indicated Patient 17 did not have a contraindication;
- "Pneumococcal Screen Indications: Patient is 65 years of age or older";
- "Pneumococcal Vaccination Decision: Administer Pneumococcal vaccine 0.5 ml (milliliter) IM (intramuscular) x 1 dose in AM"; and
- "Vaccine will be administered at 0900 (9 a.m.) the following day unless physician rescinds by writing a separate order."

The "Admitting/Intra-facility Transfer Orders" dated August 24, 2012, at 5:30 p.m., included, "Vaccination Screening and Administration Protocol (Pneumococcal - All year... for medical inpatients.)..."

On August 28, 2012, at 9:15 a.m., Patient 17's electronic medication administration record (eMAR) was reviewed with the Quality Staff (QS 1) and Medical/Surgical East (M/S East) Manager. The eMAR indicated the pneumonia vaccine was "unscheduled" and had not been administered. The M/S East Manager stated the facility's practice was to administer the pneumonia vaccine the following day when a patient was determined to be a candidate to receive it, unless a contraindication was identified.

On August 28, 2012, at 10 a.m., the Director of Pharmacy (DOP) was interviewed. The DOP stated when the facility still used "paper records," the pharmacist would schedule the administration of pneumonia vaccine the next day the patient had been identified as a candidate to receive it, and would indicate the time of administration. Since the facility's conversion to the electronic medical record system (end of July 2012), the system did not allow the pharmacist to "schedule" the administration of the pneumonia vaccine.

The facility policy titled, "Vaccination: Screening and Administration (dated June 2012)" was reviewed and indicated:

"During the patient's admission and prior to discharge or transfer to another healthcare facility, the Registered Nurse (RN) will perform the screening process for the pneumococcal and influenza vaccines..."

"Vaccination indicated: The Pharmacist will review the completed Vaccination Protocol form, enter the vaccine in the patient's medication profile and notify the RN. The RN will administer the vaccine to the patient and document on the MAR, including the vaccine lot number and expiration date."

Based on interview and record review, the facility failed to ensure the physician documented that an informed consent was obtained prior to the blood transfusion for Patient 17. This failure resulted in an inaccurate medical record and had the potential to result in a patient receiving a procedure without being given the necessary information to make an informed decision.

Findings:

On August 27, 2012, Patient 17's record was reviewed with the Director of Critical Care (DCC). Patient 17 was admitted to the facility on August 24, 2012, with diagnoses that included a fracture of the right hip.

The Order and Consent for Blood / Blood Products dated August 25, 2012, at 11:05 a.m., indicated, "One unit PRBC (packed red blood cells) and two units platelet pack (blood component)." The form had two sections which indicated:

(First section) "Physician spoke with the patient via phone and discussed the risks, benefits, and alternatives of blood administration with the patient. Questions were answered and the patient agrees to proceed with the above plan." or

(Second section) "Prior informed consent for transfusion is on the medical record."

Both sections were left blank by the licensed nurse.

The Blood Transfusion Record, dated August 25, 2012, at 1:46 p.m., indicated the patient was started on platelets (blood component) infusion intravenously (IV).

The History and Physical, dated August 25, 2012, at 2:53 p.m., indicated, "...platelets on admission was 50,000, repeated this morning was 25,000...She is getting 2 packs of platelets, the first one is being transfused as we speak. Spoke to daughter and son-in-law at the bedside and they understood all the risks and benefits involved with surgery and accepted all of it..."

The DCC was unable to find an informed consent, which included the discussion of risk, benefits, and alternatives of the blood transfusion, documented in Patient 17's record prior to the procedure.

On August 27, 2012, at 3:15 p.m., Patient 17's family members were interviewed and stated the physician discussed the blood transfusion with them prior to the initial administration of the platelets.

The facility's policy titled, "Blood and Blood Products: Refusal, Consent, Administration, Reaction (dated April 2011)" was reviewed. The policy indicated, "Consent to receive Blood or Blood Products...The physician is to discuss the risks, benefits and alternatives of blood administration with the patient or surrogate decision-maker and document that discussion in the medical record...Patients will be given the opportunity to ask questions before signing the consent..." The policy further indicated, "Procedure (This is conducted prior to blood or blood product administration)...Assure that the physician documentation of informed consent and the patient's verification of consent are in the medical record..."

Based on observation, interview, and record review, the facility failed to control medications in order to provide patient safety by failing to:

1. Ensure insulin sliding scale protocol provided complete coverage of all possible blood sugar levels;

2. Ensure pharmacy processing and verification of orders was not ambiguous and was completed without duplication of therapy; and

3. Ensure the pharmacy department clarified the incomplete medication reconciliation orders for Patient 16's admission (Prednisone - an anti-inflammatory drug). This failure had the potential to result in missed doses of the medication.

Findings:

1. On August 27, 2012, at 10:30 a.m., Patient 35's preprinted Humalog (Insulin to treat diabetes) sliding scale order written on August 17, 2012, was reviewed with Pharmacist 500.

The preprinted order titled, "Standard Basal & Insulin Sliding Scale Orders" included the following instructions:

Blood glucose level (mg/dl) less than 60, then notify Physician. If symptomatic: Give 25 grams (50 ml) Dextrose (type of sugar) 50% IV once.
120-149, zero units Humalog;
150-199, 1 unit Humalog;
200-249, 2 units Humalog;
250-299, 3 units Humalog;
300-349, 4 units Humalog;
350-399, 5 units Humalog;
Greater than 400, notify physician.

The preprinted order did not provide instructions for blood glucose level readings of 60 to 119 mg/dl.

During a concurrent interview, Pharmacist 500 stated the instruction was missing an insulin coverage for blood sugar reading between 60 and 119 mg/dl. Pharmacist 500 acknowledged that the instruction should have been clarified.

Review of the facility's policy and procedure titled, "Medication Order Review by a Pharmacist" indicated, "All concerns, issues, or questions will be clarified by the pharmacist with the prescriber before dispensing."

2a. During review of Patient 32's record conducted on August 28, 2012, at 10 a.m., it was noted that one of the listed medications on the patient's medication reconciliation (a process that list medications taken at home by the patient) was ordered by a physician to be continued as follows:

"Metoprolol (metoprolol tartrate 50 mg oral tablet [blood pressure medication]) 100, Oral, BID."

Review of the Pharmacy medication profile for Patient 32, indicated the processing pharmacist entered the order as, "metoprolol tartrate 50 mg 1 tablet Oral(ly) BID (twice a day)."

During an interview on August 28, 2012, at 11:05 a.m., Pharmacist 501 stated the medication order should have been clarified because he could not tell from the order if the patient had been taking 50 mg or 100 mg twice a day at home.

The facility policy titled, "Medication Order Review by a Pharmacist" indicated, "All concerns, issues, or questions will be clarified by the pharmacist with the prescriber before dispensing."

The pharmacy failed to clarify home medication reconciliation that was ambiguous and confusing.

b. During review of Patient 32's medical record conducted on August 28, 2012, at 10 a.m., it was noted that there was physician orders on August 27, 2012, at 8:10 p.m., for the following medications:

- Timolol maleate (for glaucoma) ophthalmic solution 1 drop on left eye twice a day;

- Lotemax (for swelling) ophthalmic solution 1 drop on left eye twice a day;

- Alphagan (for glaucoma) ophthalmic solution 1 drop on left eye twice a day; and

- Azopt (for glaucoma) ophthalmic solution 1 drop each on both eyes twice a day.

On August 27, 2012, at 9 p.m., there was a physician order written as follows:

Clarification:
Dorzolamide-timolol 2%-0.5% (for glaucoma) ophthalmic 1 drop each to both eyes twice a day.

Review of the Pharmacy medication profile for Patient 32 revealed that a pharmacist verified and dispensed timolol, Lotemax, Alphagan, and Dorzolamide-timolol eye drops for Patient 32.

Review of the electronic Medication Administration Record (eMAR) revealed the patient received all four eye drops on August 27, 2012, at 10:29 p.m.

During a concurrent interview, the DOP stated the order clarification was likely for the Azopt (an eye drop the patient was taking at home) which was confused with another drug called Cosopt (a combination eye drop containing dorzolamide and timolol). As written on the physician order sheet, Azopt could have been mistaken for Cosopt. The DOP acknowledged the clarification order created a duplicate order with the patient being given both timolol eye drop and dorzolomide-timolol eye drop.

During an interview on August 28, 2012, at 11:05 a.m., Pharmacist 501 acknowledged that the error in clarifying the order caused duplication of therapy.

Review of the facility's policy and procedure titled, "Medication Order Review by a Pharmacist" indicated, "The pharmacist will review each order and consider the following information before the medication is dispensed...therapeutic duplication..."

The final clarification on eye drops ended up being a duplication of therapy.



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3. On August 27, 2012, Patient 16's record was reviewed with the Director of Critical Care (DCC). The patient was admitted to the Medical Surgical (M/S) Unit on August 23, 2012. The "Medication Reconciliation Physician Orders for Admission" dated August 23, 2012, included, "Prednisone 5 mg (milligrams) oral tablet 1 tab daily." The order had a section to indicate whether to "Continue or Discontinue" the medication. The section was left blank.

The electronic Medication Administration Record (MAR) was reviewed and did not indicate the patient received or was receiving the Prednisone.

On August 27, 2012, at 10:40 a.m., the Clinical Supervisor (CS 1) was interviewed regarding the process of medication reconciliation. She stated when a patient was admitted, the medications were gathered and "documented" in the patient's electronic medical record (eMR). The printed list (Medication Reconciliation Physician Orders for Admission) was reviewed and the physician decided whether to continue or discontinue the medication(s). CS 1 stated the signed list was sent to the pharmacy for processing.

The facility policy titled, "Medication Reconciliation Across the Continuum of Care (dated June 2012)" was reviewed and indicated, "...The admitting/ordering physician compares the home medication list with the medication(s) ordered for treatment during hospital stay, reconciles the two lists and authenticates the medication order(s) within 24 hours of admission. If the ordering physician has not completed this task, order clarification will occur per policy..." The policy further indicated, "...The completed medication reconciliation orders will be sent to pharmacy for patient profiling. The Pharmacist reviews the medication orders and performs order clarification as necessary, including collaborating with the RN, when indicated..."

On August 30, 2012, at 12 p.m., Patient 16's record was reviewed with the Director of Nursing (DON). The DON stated Patient 16's unmarked Prednisone order in the "Medication Reconciliation Physician Orders for Admission" should have been clarified by the licensed nurse with the physician. The DON stated the pharmacy department should have identified and clarified the order.

Based on observation, interview and record review, the facility failed to:

1. Ensure expired laboratory culture tubes, laboratory blood tubes, scrub sponges, and bacteriostatic latex free lubricating jelly were not available for patient care use; and

2. Ensure opened "single use" four fluid ounce containers of "PVP Prep Solution" were not available for multiple patient use in the "Emergency Department Fast Track" examination rooms.

This had the potential to result in expired or contaminated products being used for patients.

Findings:

1. During a tour of Facility 1, Two West Unit, on August 27, 2012, at 9:50 a.m., the following was observed in the "Exam Room":

a. Thirteen (13) packets of "Bacteriostatic Latex Free Lubricating Jelly" 0.1 ounces (3 grams) with an expiration date of June 2009.

During a concurrent interview with the Trauma Program Manager (TPM), she stated the packets of lubricating jelly should have been removed from the exam room and discarded. In addition, the TPM stated the lubricating jelly should not have been available for patient care use.

During a tour of Facility 1's, Emergency Department (ED), on August 28, 2012, at 9:20 a.m., the following was observed:

a. In the Intravenous (IV) cart located in the "Treatment and Procedure" area, five yellow top pediatric laboratory blood tubes, three with an expiration date of March 2012, and two with an expiration date of July 2012.

b. In the Suture Cart located in the "Treatment and Procedure" area, two "Scrub Care Surgical Scrub Brush - Sponge Nail Cleaner" with an expiration date of July 2012.

c. In the ED "Fast Track" area:
- Five red top "Transport Swab" culture tubes with an expiration date of December 2011;
- One "Starswab II" culture tube with an expiration date of January 29, 2012; and
- One "Nucleic Acid Transport Swab" culture tube with an expiration date of May 2012.

During an interview with the Emergency Department Director (EDD), Emergency Department Manager (EDM), and TPM, on August 28, 2012, at 11 a.m., they stated the yellow top pediatric laboratory blood tubes, the scrub brushes, and the swab culture tubes were expired. They stated the staff checks for outdates when they restock the units, and expired products should be discarded and removed from patient care areas.

During a tour of Facility 2's, ED, on August 29, 2012, at 10:25 a.m., the following was observed:

a. One "Starswab II" culture tube with an expiration date of January 29, 2012.

The facility "Pocket Pearls - Little Book of Big Information" dated May 2012, revealed "... Expiration Dates - Medications and supplies such as sutures, vacutainers, blood tubes, food and sterile supplies should never be used past expiration dates. ..."

The facility policy and procedure titled "Specimen Rejection and Acceptance of Irretrievable Specimens" revised August 2011, revealed "... General conditions for rejection: ... Unsuitable specimens such as specimens in incorrect or expired containers or media, ..."

2. During a tour of Facility 1's, Emergency Department (ED) "Fast Track" area, on August 28, 2012, at 10:50 a.m., the following was observed:

a. In Exam Room 4, an opened four fluid ounce bottle of "PVP (Povidone-Iodine) Prep Solution."
b. In Exam Room 3, and opened four fluid ounce bottle of "PVP Prep Solution."

During a concurrent interview with the TPM, she stated the bottles of "PVP Prep Solution" were open and should have been discarded after they were used.

During an interview with the Associate Director, Patient Safety and Quality Outcomes (ADPSQO), on August 29, 2012, at 8 a.m., she stated the "PVP Prep Solution" was a single use product and should have been discarded once opened. In addition, the ADPSQO stated the ED management team did not know why the bottles of "PVP Prep Solution" were opened and left in the exam room cupboards.

The facility policy and procedure titled "Drug Admixture/Sterile Parenteral Solutions Guidelines" revised July 2012, revealed "... Single-use sterile drugs and devices shall not be reused. Unused portions of single-use sterile drugs shall not be saved for later use. ..."

Based on interview and record review, the facility failed to have their cardiac enzymes (diagnostic laboratory studies to assist in diagnosing problems with the heart muscle) drawn in a timely manner for 2 of 35 sampled patients (Patients 25 and 27). This failure could negatively impact the provision of medical care and the medical outcomes for these two patients.

Findings:

1. A review of Patient 25's record was conducted on August 27, 2012. Patient 25 was admitted to the facility on August 21, 2012, with gastrointestinal bleeding. Patient 25 also had a history of high blood pressure, atrial fibrillation (an irregular heart beat) and coronary artery disease.

A review of a Physician's order written on August 21, 2012, at 1:25 p.m. indicated, "Cardiac Care: Serial CK and Troponin (cardiac enzymes) to be drawn every six hours times three." Also indicated was that this order included laboratory tests done in the emergency department.

A review of the laboratory results for Patient 25 indicated the initial CK and Troponin levels were drawn on August 21, 2012, at 2:41 p.m., and the second levels were drawn at 5:50 p.m. The first and second levels were drawn three hours and 9 minutes apart. The third CK and Troponin levels were drawn on August 22, 2012, at 1:09 a.m., seven hours and 19 minutes after the second levels were drawn.

A review of the facility document, "Laboratory Scope Of Service 2012," was conducted. An objective reflected in the Scope of Service indicated the Laboratory Services were to provide accurate and timely laboratory results in order to ensure the delivery of quality patient care.

2. A review of Patient 27's record was conducted on August 27, 2012. Patient 27 was admitted to the facility on August 26, 2012, with multiple skull fractures after being struck by a motor vehicle.

A review of a Physician's order written on August 26, 2012, at 9 p.m., indicated, cardiac enzymes and troponin level to be drawn every eight hours for three times and to notify the physician if a critical value is drawn. The initial laboratory draw was completed per the Physician's order.

The second laboratory draw for cardiac enzymes including a troponin level was completed on August 27, 2012, at 3:47 a.m. and did not include a troponin level.

An interview was conducted with the Registered Nurse (RN 2) on August 27, 2012, at 3:30 p.m. RN 2 stated the troponin level for Patient 27 should have been drawn according to the Physician's order, on August 27, 2012, at 3:30 p.m.

Based on document review and staff interview, the facility failed to ensure the organizational structure of the dietary department included qualified staff, full time, in key management positions. This failure could result in inadequate oversight of the Food and Nutrition department and subsequent system failures.

Findings:

On August 27, 2012, at 10:10 a.m., review of the organizational structure of the Food and Nutrition Department, showed that there was one Director of Food and Nutrition Services (DFNS) who was responsible for the oversight of operations at both Facility 1 and Facility 2. Reporting to the DFNS, was a Food Service Manager (FSM), who also had oversight responsibilities of operations at both Facility 1 and Facility 2. Reporting to the FSM, was a Food Service Supervisor (FSS) at each facility.

On August 28, 2012, at 8:40 a.m., review of the personnel files of the DFNS, FSM, and FSS showed the following:

FSM - Minimum Essential Education for the position of FSM was listed as "A certification as a Dietetic Service Supervisor." There was no evidence in the personnel file of the FSM of certification as a Dietetic Service Supervisor.

FSS 2 - (FSS for Facility 2) - Minimum Essential Education for the position of FSS was listed as "High School diploma or equivalent." Possession of certification as a Dietetic Service Supervisor or a Food Manager was "preferred." FSS 2 possessed a high school diploma, but no Food Manager or Dietetic Service Supervisor certificate.

FSS 1 - (FSS for Facility 1) - Minimum Essential Education for the position of FSS was listed as "High School diploma or equivalent." Possession of certification as a Dietetic Service Supervisor or a Food Manager was "preferred." FSS 1 did possess a Dietetic Service Certificate. However, the duty statement showed the individual in that position was not empowered the same way the FSM was empowered to monitor employee competencies or to consult with the Nutritional Services Director on any identified departmental concerns.

DFNS - Was a Registered Dietitian with responsibilities split between two facilities, making oversight of each facility on a part time basis.

The facility did not have a qualified, full time person, in charge of Food and Nutrition operations at each campus (Facility 1 and 2).

On August 27, 2012, at 11 a.m., in an interview with the DFNS, she acknowledged that she split her time between Facility 1 and 2, and was, therefore, not considered full time at either site, and that the FSM was not qualified in accordance with State regulations, but stated the FSM was enrolled in courses to achieve the appropriate certification. She acknowledged that FSS 2, although full time, was also not qualified in accordance with State regulations, and that FSS 1, although qualified, was not empowered via duty statement or position on the organizational chart to provide oversight of operations at Facility 1.

Based on observation, staff interview, and document review, the facility failed to ensure that the Director of Food and Dietetic Services monitored written procedures, according to standards of practice for operational processes. Failure to monitor standardized procedures may result in patients/staff being exposed to foodborne illness and cross contamination which may further compromise medical status for patients.

Findings:

1. On August 27, 2012, at 12 p.m., two opened cans of Ensure Nutrition Powder were noticed to be stored on a shelf adjacent to the tray line. The scoop in each can was observed to be embedded in the product and covered with nutrition powder. The Director of Food and Nutrition Services (DFNS) stated that she did not want staff to lose the scoops and therefore she allowed them to store the scoops in the cans as long as they wore gloves when retrieving them.

According to the Food Code, 2009, Section 3-304.12 In-Use Utensils, Between-Use Storage, "During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored:
1. (A) Except as specified under ? (B) of this section, in the food with their handles above the top of the food and the container;
2. (B) In food that is not potentially hazardous (time/temperature control for safety food) with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon."

There was no provision for allowing the handle of the scoop to touch the product to be dispensed as long as staff wore gloves. The guideline was established as a cross-contamination stop-gap.

Further observation of the cans of Ensure Nutrition Powder showed that they were labeled by facility staff to "Use By 4/1/14." April 1, 2014, coincided with the date imprinted on the Ensure Nutrition Powder cans, as the shelf life of the product as long as it remained closed. The manufacturer recommendation for the opened product was as follows: "Once opened, use contents within 3 weeks." In a concurrent interview with the DFNS, she acknowledged that the cans of Ensure Nutrition Powder should have been labeled by staff with a "Use By" date of three weeks after opening and not the manufacturer imprinted expiration date.

2. On August 29, 2012, at 11:28 a.m., during an observation of the cafeteria meal service in Facility 2, several food items were noted in the hot food steam table. A temperature of the food items was taken in various areas of the pan (front, middle, and back), at the same depth, and was documented as follows:

Mixed Vegetables: 120, 140, 130 degrees Fahrenheit (F)
Pasta Primavera: 120, 140, 130 degrees F
Mashed Potatoes: 130, 140, 130 degrees F

A pan of chicken cordon bleu was observed to be placed in the steam table at 11:40 a.m. A temperature check of one of the pieces of chicken at 11:42 a.m., showed 128 degrees F.

On August 29, 2012, at 11:45 a.m., in an interview with Food Service Worker 2 (FSW 2), she stated the top of the food items cools off. When asked if she mixed the food around to maintain temperatures, she stated, "Sometimes I do for some things like the pasta, but not for the mashed potatoes."

The DFNS, present at the time of the observation, could not explain why the chicken cordon bleu, that had just been retrieved from the kitchen's holding oven two minutes prior to the temperature check, measured 128 degrees F. She stated that a work order would be placed for both the holding oven and the tray line steam table to check for any malfunctions.

On August 29, 2012, at 3:55 p.m., review of the facility policy titled, "Infection Control Process: Nutritional Services", reviewed April 2011, showed the following: "Steam Tables: All steam tables for Nutritional Services usage are able to maintain hot foods at temperatures of 140?F or above."

Based on staff interviews and document review, the facility failed to ensure standard menus, analyzed for the nutritional components to meet the current national standards including the RDA (Recommended Dietary Allowances) and the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council, were compared to a reference group representative of the majority of the patients served by the hospital, and that patient food items were prepared and served as planned and in accordance with prescribed orders. This had the potential for the patients in the hospital to not receive adequate nutrition or to receive more than the recommended allowances of certain nutrients which may negatively impact the patients' health.

Findings:

1. The DRI/RDA consist of nutrient based references whose purpose is to plan diets for individuals, focusing on optimizing health status, disease prevention and ensuring consumption of nutrients in adequate amounts, consistent with one's age group. The provisions of the Dietary Reference Intakes, which include the Recommended Dietary Allowances (RDA's), Adequate intake, and Acceptable Macro and Micronutrient distribution ranges, developed by the Food and Nutrition Board under the auspice of the Institute of Medicine are used to evaluate nutritional adequacy of patient/resident menus.

On August 27, 2012, at 10:20 a.m., the hospital's nutrient analysis for the hospital diets was reviewed. The analysis provided was shown to be compared to the reference information for a 26 year old male. On August 27, 2012, at 3:45 p.m., review of the hospital census for Facility 1, showed that 86% of the population that day was over the age of 50 years old. Review of the census printed on August 28, 2012, for Facility 2, showed that 77% of the population that day (excluding the obstetrics wing) was over the age of 50. The average age of patients for a six month period from January 2012 to July 2012, provided by administration, was 58 years for Facility 1 and 61 years for Facility 2 (minus obstetrics).

On August 29, 2012, at 2:45 p.m., in an interview with the Director of Food and Nutrition Service (DFNS), she acknowledged that the reference for the menu analysis was a 26 year old male. The Recommended Dietary Allowances (RDA) differed in some key nutrients such as protein. The RDA for protein was 56 grams per day for a 26 year old male versus 46 grams per day for a female over 50 years old. Overconsumption of protein may be taxing on the kidneys of the elderly.

2. On August 29, 2012, at 9:30 a.m., in an interview with Food Service Worker 1 (FSW 1) at Facility 2, she stated she made the turkey sandwiches to be served on tray line for the lunch meal. FSW 1 stated that each sandwich should contain two ounces of meat and no cheese.

On August 29, 2012, at 9:45 a.m., in an interview with the Lead Cook (LC), responsible for oversight of meal preparation activities, he stated that the turkey sandwiches should be made with four ounces of turkey and one slice of cheese.

On August 29, 2012, at 9:50 a.m., review of the recipe for turkey sandwich, showed that each sandwich should contain three ounces of turkey luncheon meat and one slice of cheddar cheese.

On August 29, 2012, at 9:55 a.m., Food Service Supervisor 1 (FSS 1) weighed the turkey meat on one of the sandwiches. The turkey meat weighed between two and a half and two and three quarters ounces. She acknowledged that there was no cheese on any of the sandwiches. The turkey and cheese are counted as protein sources during the nutritional analysis of the meal.

3. On August 29, 2012, beginning at 12 p.m., during an observation of the lunch tray line at Facility 2, chicken breasts were noted to be served. One chicken breast was placed on each patient plate for regular diets along with a six ounce scoop of pasta primavera. On August 29, 2012, at 12:15 p.m., a randomly selected chicken breast was placed on the scale by FSS 1 and weighed between two and two and one half ounces. Review of the lunch "Production Tally" for August 29, 2012, showed that chicken pasta primavera was to be served in either a six ounce portion or a three ounce portion. There was no direction as to how much chicken should be served separately from the pasta primavera.

In a concurrent interview with the DFNS, she stated that the original chicken pasta primavera recipe was changed to only pasta primavera and the chicken was now to be served separately in a three ounce portion. She stated that the chicken was purchased in four ounce portions and was supposed to cook down to three ounce portions. She could not explain why the chicken breast that was weighed, was between two and two and one half ounces.

4a. On August 27, 2012, beginning at 12:07 p.m., during an observation of the lunch tray line at Facility 1, patients prescribed regular diets were served six ounces of "Rosa's Beef Burgundy", while patients prescribed chopped diets were served three ounces of chopped beef and 2 ounces of regular gravy. Concurrent review of the "Production Tally" and the menu showed that patients prescribed chopped diets should have received six ounces of "Chopped Rosa's Beef Burgundy."

Further review of the lunch meal showed that Patient 1, prescribed a 2000 calorie ADA (American Diabetes Association), renal, cardiac diet, was to receive two ounces of beef with the lunch meal, in accordance with the prescribed protein restriction. Patient 1 was served a six ounce ladle of "Rosa's Beef Burgundy", which contained 3 ounces of beef. The DFNS, present at the time of the observation, acknowledged that a different serving utensil should have been used to ensure the patient received the correct diet as prescribed.

b. On August 27, 2012, at 1:50 p.m., review of the medical record for Patient 1 showed that the patient was admitted on August 19, 2012, and was prescribed a 2000 calorie ADA, renal, cardiac diet as of August 20, 2012. Review of the nutritional assessment completed by the Registered Dietitian (RD) on August 22, 2012, showed the patient's estimated caloric needs, based on his clinical condition, were 1700-2040 calories per day. The RD documented that the patient's diet was appropriate as ordered (2000 ADA, Cardiac, Renal).

On August 27, 2012, at 3:15 p.m., Patient 1's menu was reviewed for the following day. In a concurrent interview with the Diet Clerk (DC), she stated that she adjusted the patient's menu based on the renal and diabetic restrictions, but did not verify whether the menu met the 2000 calorie requirement as prescribed. An estimated calculation of the calories to be provided to Patient 1 based on the following day's menu was approximately 1000 calories.

On August 28, 2012, at 8 a.m., in an interview with the DFNS, she acknowledged that the diet as prescribed to Patient 1 was not feasible to provide 2000 calories, and the most amount of calories that Patient 1 would be able to receive based on this diet order was 1230 calories. She stated that the diet should have been liberalized and/or modified to meet the patient's caloric needs.

Based on staff interview and record review, the facility failed to ensure that the hospital's approved diet manual, reflected a cardiac diet that was consistent with standards of practice for care of cardiac patients. Failure to follow standards of practice may result in a negative impact on the patients' nutritional status.

Findings:

On August 27, 2012, at 9:45 a.m., review of the approved diet manual for the hospital showed that it was the Nutrition Care Manual by the American Dietetic Association, with an approved diet manual "Addendum" to some of the diets established by the Director of Food and Nutrition Service (DFNS). Review of the Cardiac diet guidelines as indicated in the Diet Manual "Addendum" showed the following: "In the event a cardiac diet is ordered, Nutritional Services will provide a regular, 3-4 gram (3000-4000 mg) sodium diet with no added salt. Patients will select items from the heart healthy menu designed to provide less than or equal to 30 percent of total calories from fat, less than 10 percent of total calories from saturated fat, and less than 300 milligrams of cholesterol daily."

Review of the American Heart Association guidelines showed the following:

"Limit saturated fat intake to less than 7 percent of total daily calories.

Limit cholesterol to less than 300 mg per day, for most people. If you have coronary heart disease or your low-density lipoprotein (LDL) cholesterol level is 100 mg/dl or greater, limit cholesterol intake to less than 200 mg per day.

Reduce sodium intake by preparing foods with little or no salt, and aim to eat less than 2300 mg of sodium per day."

The American Dietetic Association's recommendations were similar - with a cholesterol recommendation of less than 200 mg per day and a sodium recommendation of less than 2000 mg per day.

On August 29, 2012, at 8:15 a.m., the DFNS acknowledged that the Cardiac Diet recommendations, as specified in the Diet Manual "Addendum", were not consistent with the standards of practice in the industry for management of cardiac patients.

Based on observation, staff interview, and document review, the facility failed to ensure that a plan for the provision of food and water to staff and visitors in the case of an emergency was in place. This failure could result in compromised care to patients in an emergency secondary to staff becoming lethargic due to hunger and thirst.

Findings:

On August 27, 2012, beginning at 9:07 a.m., during a tour of the kitchen at Facility 1, disaster food supplies were noted in the dry storage room, along with the disaster policy and procedure manual. In a concurrent interview with the Director of Food and Nutrition Services (DFNS) and the Food Service Manager (FSM), they stated that the disaster plan for both food and water was based on the licensed bed capacity at each Facility plus a small additional amount (approximately 30 servings) for emergency beds. Staff and visitors were not included in the disaster plan for the provision of food and water. This was verified by a review of the facility policy titled, "Disaster Plan - Nutritional Services", reviewed July 2012, on August 30, 2012, at 11 a.m.

On August 30, 2012, at 11:30 a.m., in an interview with the Director of Critical Care/Emergency Management (DCC), he also confirmed that there was no existing plan in place for the provision of food and water to employees/visitors in the case of a disaster.

Based on observation, staff interview and document review, the facility failed to ensure that disaster water supplies were stored in accordance with supplier recommendations and that the hot water supply for handwashing in the cafeteria was maintained at a temperature that would prohibit potential burns to staff while washing their hands. This failure could impact the shelf life of the stored disaster water supply and could result in accidental burns to employees washing their hands in the cafeteria sink.

Findings:

1. On August 28, 2012, at 10:15 a.m., observation of the disaster water supply storage at Facility 1, showed that the water bottles were stored in an outside shed. There was no temperature control or ventilation in the shed. There was no thermometer in the shed. The outside air temperature on that day reached 100 degrees F (Fahrenheit).

On August 29, 2012, at 9 a.m., observation of the disaster water supply storage at Facility 2, showed that the water bottles were stored in an outside storage unit. There was no temperature control, but there was ventilation. There was no thermometer in the storage unit. The outside air temperature on that day reached 96 degrees F.

On August 30, 2012, at 8:15 a.m., review of a letter provided by the vendor of the disaster water supply showed that the recommendation by the vendor was for the water to be stored in a "cool" location. A definition of "cool" was not provided. Acceptable ranges for temperature definitions were as follows (Scripps Labs, 2010):

"Cool - Any temperature between 8?C and 15?C (46?F to 59?F)."
"Controlled Room Temperature - A temperature maintained thermostatically that encompasses the usual and customary working environment of 20?C to 25?C (68?F to 77?F) that allows for brief deviations between 15?C and 30?C (59?F to 86?F) that are experienced in pharmacies, hospitals, and warehouses."

This issue was discussed with the COO of Facility 1 on August 30, 2012, at 8:30 a.m. The COO could not confirm the temperature in the sheds.

2. On August 29, 2012, at 11:40 a.m., the temperature of the water from the handwashing sink located in the cafeteria of Facility 2, measured 129 degrees Fahrenheit (F). The Director of Food and Nutrition Services (DFNS), present at the time of the observation, stated that the dietary department had previously placed work orders with plant operations to lower the temperature. Skin could begin to scald at temperatures of 120 degrees F (Burn Foundation).

On August 30, 2012, at 12:15 p.m., a review of provided documents showed a work order submitted by the dietary department on March 3, 2012, that documented the following, "Follow up the water is still too hot 120 needs to be 100." According to the maintenance logs, the problem was corrected on March 5, 2012.

A County Health Inspection report of the cafeteria at Facility 2, dated June 21, 2012, showed the following, "The hand sink near the soda machine is providing water of 122?F through the mix valve. The temperature is too hot for handwashing. Adjust the sink plumbing so the water is 100?F." There was no evidence of a work order request coinciding with the date of the County Health Inspection report or proof that the problem was remedied.