HospitalInspections.org

Based on dishwashing observations and dietary staff interview and dietary document review the facility failed to ensure 1 staff member (Dietary Staff 2) was fully trained in equipment monitoring when DS 2 did not monitor the pressure of the dish machine.

Findings:

During review of the dishwashing procedures on 10/17/17 beginning at 8 a.m., with Dietary Staff 2 it was noted that the pressure gauge on the machine ranged from 20 psi (pounds per square inch-a unit of measure) to greater than 45 psi. In a concurrent interview DS 2 stated determination of whether the machine was operating properly was accomplished by checking the three temperatures dials associated with the wash, rinse and sanitation cycle of the machines. He was unfamiliar with the 4th (pressure) dial on the machine. Review of the Dishmachine log beginning 10/1/17 confirmed equipment monitoring was limited to temperature functions.

In a concurrent interview with Dietary Management Staff 3 he acknowledged staff do not evaluate the pressure level of the machine, rather the department relied on engineering staff to check it as part of their rounds. DMS 2 acknowledged that while engineering checked on the machine the current monitoring would not allow early recognition of equipment malfunctions.

Based on interview and record review, the nursing staff failed to coordinate with the patient, a specific date and time of discharge for 1 of 36 sampled patients. (23)

As a result the patient was unable to coordinate contact with her landlord for entrance into her apartment.

Findings:

Patient 23 was admitted to the facility by ambulance on 9/24/17, with diagnoses to include altered mental status, according to the facility's Face Sheet.

A record review was conducted on 10/19/17.

On 9/25/17 at 11:27 A.M., a social worker documents on the Clinical Resource Management (CRM) form, a discharge summary for Patient 29. The initial CRM assessment dated 9/25/17 at 4:45 P.M. had no indication of the patient anticipated discharge date.

According to the Clinical Resource Management (CRM) document dated 9/26/17 at 11:09 P.M., LN 23 documented the patient stated, "...no one informed her of DC [discharge]. The patient's concern for the late notice of the discharge was due to her inability to enter her apartment and her landlord was not available.

During an interview with the Director of Clinical Resource Management on 10/19/17 at approximately 11:30 A.M., there was unclear communication between the CRM staff and the patient of the anticipated discharge date and time for Patient 23.