HospitalInspections.org

Based on observation, staff interview, and review of facility documents, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the facility. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

482.28: Food and Dietetic Services

482.42: Infection Control

Based on staff interview, review of facility policy and procedure, facility documentation, and medical record review, it was determined that the facility failed to protect all patients' personal health information (PHI).

Findings include:

Reference: Facility policy, Overview of HIPAA/HITECH Compliance Program, states, "... Purpose: --[facility]-- is committed to protecting the privacy and confidentiality of its patients. --[facility's initials]-- complies with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) which establishes requirements with respect to patient privacy, confidentiality, and information security applicable to --[facility's initials]--. ... The Program is a detailed and specific set of policies and procedures with which all personnel who use, disclose or access Protected Health Information (PHI) and Personally Identifiable Information (PII) must comply. The Program defines the term violation or breach to mean the unauthorized acquisition, access, use, or disclosure of PHI by workforce members who are not directly involved in the treatment, payment or health care operations to do their jobs. ..."

1. On 10/27/15 at 3:15 PM, Staff #22 stated in interview that the facility gives --- Visiting Nurses Association (VNA) a list of all patient admissions on a daily basis. He/she stated the list of patients is an all inclusive list of patients, even patients that --- VNA is not following.

a. Staff #22 stated in interview on 10/28/15 at 10:50 AM, that the intent of providing the list of all admitted patients to --- VNA agency was to assist in the identification of the facility's "frequent flyers" and for care coordination.

2. Staff #22 provided a copy of the list of patients admitted 10/26/15 (twenty patients total), that was provided to the VNA on 10/27/15. The list identifies each patients' full name, account number, medical record number, reason for visit/diagnosis, room and bed assignment, and their attending physician.

3. Review of the facility's Notice of Privacy Practices within the 'Patient's Bill of Rights and Responsibilities' form each patient is provided and signs for on admission, indicates under 'Privacy and Confidentiality', second bullet, that the patients have the right "To be assured confidentiality about your patient stay. Your medical record and financial records shall not be released to anyone outside the hospital without your approval, unless you are transferred to another facility that requires the information, or release of the information is required and permitted by law."

4. On 10/28/15 at 12:33 PM the ICU was toured in the presence of Staff #8 and Staff #26. Patient #18 was observed being picked up by ambulance transport. Per Staff #8, Patient #18 was being transferred to another acute care hospital for a cardiac catheterization.

a. Review of Medical Record #18 indicated the patient was admitted and signed for the facility's Notice of Privacy Practices on 10/26/15.

b. Review of the above provided copy of the list of patients admitted 10/26/15, identified Patient #18 as one of the patient admissions, and his/her full name, account number, medical record number, reason for visit/diagnosis, room and bed assignment, and attending physician.

c. Review of the social work and case management notes in Medical Record #18 indicated the patient was admitted from home, had a cardiac catheterization scheduled for November 4th, and his/her doctor was going to work on the patient's transfer to another acute care hospital for an earlier cardiac catheterization. The notes indicate that the transfer to the other acute care facility's cardiac catheterization lab was arranged on 10/27/15 with a pick up time of 12:15 PM.

5. There was no evidence in the medical record that the patient utilized the --- VNA services, or that the facility anticipated the need for VNA services for the patient following his/her discharge/transfer.

6. The facility disclosed the PHI of Patient #18 to -- VNA, when the VNA was not directly involved in his/her treatment. The facility did not implement its policy referenced above.

7. There was no evidence that the facility obtained Patient #18's approval to release his/her PHI to the --- VNA, as per their Notice of Privacy Practices.

Based on review of a Quality Improvement Performance Improvement (QAPI) project documentation, review of Performance Improvement (PI) committee meeting minutes, and staff interview, it was determined that the facility failed to specify the frequency of data collection, report all collected data to the PI Committee, and analyze all data collected.

Findings include:

1. On 10/28/15, review of the facility's PI Plan indicated the facility's methodology for PI is the PDCA (Plan -Do -Check -Act) cycle.

2. On 10/29/15 at 3:00 PM the facility's QAPI project for a bed bath bathing product was reviewed in the presence of Staff #1. The 'Do' section indicates the facility will monitor satisfaction with staff regarding usage of the bathing product, and monitor pressure ulcer outcomes as skin care can contribute to limiting pressure ulcers and/or their severity.

a. There was no specification as to the method or frequency of data collection for this project.

3. The facility was able to show evidence of monitoring of staff satisfaction with the bathing product, but there was no evidence that this data was reported to the PI Committee.

a. In interview on 10/20/15 at 3:15 PM, Staff #63 stated that the initial survey with staff regarding their satisfaction with the bathing product was sometime last winter, most likely December 2014.

4. There was no evidence of pressure ulcer data in the PI meeting minutes, or if it is being evaluated for correlation to the use of the new bathing product.

a. In interview, Staff #63 reported that the pressure ulcer rates have not changed significantly, and are not different from the rates prior to implementing the bathing product.

Based on observation, staff interview, and review of facility policy and procedure, it was determined that the facility failed to administer all insulin injections in accordance with its policies and procedures.

Findings include:

Reference #1: Facility policy, Interdisciplinary Assessment/Reassessment and Discharge Planning, states, "... Guidelines ... *Registered Nurses will utilize the Lippincott's Nursing Procedure book as a clinical reference for procedures and their rationale. ..."

Reference #2: Lippincott's Nursing Procedures, fifth edition states on page 306 Drug Administration, "... [5th bullet] Don't aspirate for blood return when giving insulin or heparin. It isn't necessary with insulin and may cause a hematoma with heparin. ..."

1. On 10/28/15 during tour of the ICU in the presence of Staff #8 and Staff #26, Staff #28 was observed administering an insulin injection to a patient. While administering the insulin injection, Staff #28 pulled back on the insulin syringe to aspirate for a blood return.

a. In interview, Staff #28 stated he/she always aspirates for a blood return with insulin injections.

2. Staff #28 did not implement the facility's guidelines for drug administration as per Reference #2.

Based on observations, staff interview, document review, and review of facility policy and procedure, it was determined that the facility failed to ensure that organized dietary services are directed and staffed by adequate qualified personnel.

Findings include:

1. The facility failed to ensure the Director of Food & Nutrition provides effective daily management of the Food Service Department. Refer to Tag A0620.

A. Based on staff interview, document review, and review of facility policy and procedure, it was determined that the facility failed to ensure that the director of food services provides effective daily management of the Nutritional Services Department in accordance with the "Director of Nutritional Services" job description.

Findings Include:

Reference #1: The Director of Nutritional Services job description states, " ... Evaluates and maintains appropriate documentation of employee performance on a regular basis. Is accountable for hiring, orientation, training, and inservice education of nutritional services employees and disciplinary action and, if necessary, termination of nutritional services employees ... implementation of safety and sanitation programs, and operating within the budget ... Develops, evaluates and supervises all aspects of the department's quality improvement plan. Complies with the standards set forth by the State of New Jersey Department of Health and the Joint Commission on Accreditation of Hospitals ... In depth knowledge of Chapter 24 NJ Board of health food code."

1. Staff #45 could not produce the 2014 and 2015 dietary services quality assurance plan.

2. The above finding was confirmed by Staff #45 on 10/28/15 at 2:30 PM.




35697

B. Based on staff interview, facility document review, and review of facility policy and procedure, it was determined that the facility failed to employ a qualified director of food services.

Findings Include:

Reference #2: NJ Department of Health requirement states that there shall be a food service director who has a baccalaureate degree from an accredited college or university in food, nutrition, food services management, or a related area, or has at least four years of experience in food services management in a health care facility and successful completion of Food Management Certification (FMC) and Dietetic Assistant programs or their equivalents.

1. Review of the Food Service Director's personnel file lacked evidence of the following:

a. A baccalaureate degree from an accredited college or university in food, nutrition, food services management, or a related area.

b. Four years of experience in food services management in a health care facility and successful completion of Food Management Certification (FMC) and Dietetic Assistant programs or their equivalents.

2. During interview, Staff #44 stated that his/her baccalaureate degree was in business and not in food service or nutrition.

3. Staff #2 and Staff #5 confirmed the above findings on 10/28/2015.

C. Based on Staff interview, facility document review, review of facility policy and procedure, and a tour of the kitchen, it was determined that the Food Service Director was unable to demonstrate knowledge and perform daily management of the dietary services in accordance with the his/her job description.

Findings Include:

Reference #3: N.J.A.C. 8:24-4.7(a) states, "Equipment food-contact surfaces and utensils shall be sanitized." 8:24-4.7(b) states, "Utensils and food-contact surfaces of equipment shall be sanitized before use and after cleaning."

Reference #4: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #5: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately the concentration in mg/L of sanitizing solutions shall be provided. 8:24-4.8(i) states, "Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device."

Reference #6: N.J.A.C. 8:24-4.11(2) states, "Clean equipment and utensils shall be stored: (i) In a self-draining position that allows air drying; and (ii) Covered or inverted."

Reference #7: N.J.A.C. 8:24-6.2(n) states, "Requirements for the protection of outer openings shall include the following: 1. Except as specified in (n)2 and 3 below, outer openings of a retail food establishment shall be protected against the entry of insects
and rodents by: (i) Filling or closing holes and other gaps along floors, walls and ceilings; (ii) Closed, tight-fitting windows; and iii. Solid self-closing, tight-fitting doors."

Reference #8: N.J.A.C. 8:24-4.6(b) states, "The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations."

Reference #9: N.J.A.C. 8:24-6.2(f) states, "Wall and ceiling covering materials shall be attached so that are easily cleanable, except that in areas used only for dry storage, concrete, porous blocks, or bricks used for indoor wall construction shall be finished and sealed to provide a smooth, nonabsorbent, easily cleanable surface."

1. On 10/27/2015, in the presence of Staff #2, #26, #44, and #45, the following deficient practices were observed in the kitchen:

a. The warewashing area ceiling tiles and drains were not clean. The ceiling tiles had visible stains and debris on them. (Refer to Reference #3 and Reference #8)

(i) The warewashing area had two clogged drains with dried black and brown residue on them. One drain in the warewasher area had a significant large cracked opening. The dishwashing area had fruit flies and other insects. (Refer to Reference #6)

(ii) The double exit doors from the kitchen to the loading dock had large sweep gaps and an opening in the middle of the double doors. Fruit flies and other insects were observed around the sweep gaps. (Refer to Reference #2 and Reference #6)

(iii) A large standing floor fan in the dish washing room was covered in heavy dust. (Refer to Reference #2)

(iv) Wet trays and silverware were stacked together after they were removed from the warewashing machine. (Refer to Reference #5)

b. Two deep fryers in the cooking area had cooking oil that was cloudy and thick. The deep fryers had encrusted brown substance around the edges.

(i) Staff #44 stated that they do not have fried foods on the menu. Staff #44 was unable to comment on when the deep fryers were last used or cleaned. (Refer to Reference #3 and Reference #7)

c. Staff #46 was using a QAC sanitizer test strips for pot washing.

(i) The QAC sanitizer test strips are not the correct test strips. (Refer to Reference #4)

(ii) Staff #46 stated that he/she had not been oriented on how to use or check the sanitizer for pot washing.

(iii) Staff #44 obtained two sets of the correct brand of testing strips on 10/28/2015, however the testing strips had expired on 7/30/2012 and 12/15/2014.

2. The contracted pest control and sanitation reports were reviewed in presence of Staff #44. The reports recommended the following:

(a) The contracted pest control and sanitation report dated 4/24/2015 indicated the kitchen drains were dry and dirty with broken tile and grout. The sanitation report recommendation was to clean and flush food debris down drains nightly and repair the floor to prevent harborage area for fruit flies.

(b) The contracted pest control and sanitation report dated 5/23/2015 indicated the dishroom drains were dirty and food service floors were not being cleaned under equipment. The sanitation report recommendation was to clean food debris nightly, use fan to dry floors to prevent fruit fly breeding sites, and clean under equipment using 0E-30 to break-up fruit fly breeding sites.

(c) The contracted pest control and sanitation report dated 6/27/2015 indicated that the dishwasher drain backs up. The sanitation report recommendation was to have a professional drain cleaning company address the problem.

(d) The contracted pest control and sanitation report dated 7/31/2015 indicated that overflowing drains in the dishroom were a breeding site for fruit flies. The sanitation report recommendation was to keep drains clear and free flowing.

(e) The contracted pest control and sanitation report dated 8/28/2015 indicated the drain under the dishwasher backs up leaving food debris on floor. The sanitation report recommendation was to have the drain repaired to prevent breeding site for fruit flies.

(f) The contracted pest control and sanitation report dated 9/25/2015 indicated there was a damaged tile in the kitchen near the soup pots. The sanitation report recommendation was to repair tile floor.

(3) Staff #44 was unable to provide the action plan for implementing the pest control and sanitation company recommendations for the months of April 2015 through September 2015.

Based on observation, documentation review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that an adequate infection control program that seeks to minimize infections and communicable diseases is maintained.

Findings include:

1. The facility failed to ensure implementation of policies and procedures addressing the use of multi-dose medication vials in an immediate patient care area. Refer to Tag A0749.

2. The facility failed to ensure that its Infection Control policy on Intravenous Therapy is implemented. Refer to Tag A0749.

3. The facility failed to ensure that its policy on High-Level Disinfection (HLD) is implemented. Refer to Tag A0749.

4. The facility failed to ensure it provides a sanitary environment for the provision of surgical services that adheres to nationally-recognized Infection Control guidelines. Refer to Tag A0749.

5. The facility failed to ensure that it it complies with OSHA regulations. Refer to Tag A4709.

6. The facility failed to ensure that a safe and sanitary environment for the provision of surgical services. Refer to Tag A4709.

7. The facility failed to ensure that its Hand Hygiene policy is implemented. Refer to Tag A4709.

A. Based on observation, document review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure implementation of policies and procedures addressing the use of multi-dose medication vials in an immediate patient care area.

Findings include:

Reference: Facility policy, Multiple Dose Vials, states, "Safe Injection Practices Under Standard Precautions ... 9. Do not keep multi-dose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable."

1. On 10/27/15 at 11:40 AM, the following opened multi-dose vials were found in the Minor Procedure Room:

a. Two 50 ml vials of Lidocaine 10 mg/ml

b. One 30 ml vial of Lidocaine 1% with Epinephrine 1:100,000

2. On 10/27/15 at 11:45 AM, the following opened multi-dose vials were found in Endoscopy Room #2:

a. Atropine Sulfate 8 mg/20 ml

b. Lidocaine 2%, 20 ml

3. On 10/27/15 at 12:15 PM, the following opened multi-dose vials were found in Operating Room #3:

a. Rocuronium 10 ml

b. Succinylcholine 10 ml

c. Bloxiverz 10 ml

4. On 10/27/15 at 12:20 PM, the following opened multi-dose vials were found in the Cystoscopy Room:

a. Succinylcholine 10 ml

b. Bloxiverz 10 ml

c. Atropine 20 ml

These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 10/27/15, day of survey, upon receipt of an acceptable plan of correction.

5. During interview on 10/29/15 at 11:45 AM, Staff #63 stated that he/she would remove a multi-dose vial of Lantus insulin from the drug dispensing device, prepare a syringe from the vial at the patient's bedside, and then return the opened vial to the drug dispensing device. The vial would be used in this manner for multiple patients.

a. Interview with Staff #10 confirmed that this was the practice throughout the facility. He/she stated that the vial had to be taken to the bedside in order to scan the vial, a process that was necessary during medication administration.

These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 10/29/15, day of survey, upon receipt of an acceptable plan of correction.


33800


B. Based on observation, staff interview, facility document review, and review of facility policy and procedure conducted on 10/28/2015, it was determined that the facility failed to ensure that its Infection Control policy on Intravenous Therapy is implemented.

Findings include:

Reference: Facility policy, Intravenous Therapy, states, "Guidelines ... Perform hand hygiene prior to catheter insertion or manipulation. Standard for accessing all or any intravenous site: a. Disinfect catheter hubs and injection ports with each access using an alcohol swab."

1. During observation of procedure in the CVIR (Cardiovascular Interventional Radiology) unit at 11:25 AM, Staff #62 was observed to access an IV port without performing hand hygiene prior and without cleansing the injection port using an alcohol swab before injecting medication into the port.

2. At 12:00 PM, during the same procedure, Staff #37 was observed to access the IV port without performing hand hygiene prior and without cleansing the injection port using an alcohol swab before injecting medication into the port.

3. These findings were confirmed with Staff #1.

C. Based on observation, staff interview, facility document review and review of facility policy and procedure conducted on 10/27/15, it was determined that the facility failed to ensure that its policy on High-Level Disinfection (HLD) is implemented.

Findings include:

Reference #1: Facility policy, Cleaning, High Level Disinfection, and Reprocessing Flexible Endoscopes, states, "... Process Validation/QA ... 5. The concentration of the HLD used in the AER is validated by measuring the Minimal Effective Concentration (MEC) with each load, using a strip specific to the biocide. MEC test results are logged for QA purposes. ..."

Reference #2: Acecide-C manufacturer's IFU states, "Directions for Use ... a) Monitor the MRC of PAA with ACECIDE test strips prior to each reprocessing cycle ..."

Reference #3: Cidex OPA manufacturer's IFU states, "... It is important to test for the presence of the MEC when using a high level disinfectant."

1. During a tour of the Same Day Surgery (SDS) unit on 10/27/15 at 10:30 AM, in the presence of Staff #1, Staff #4, and Staff #13, two AERs were observed:

a. One Olympus OER -PRO that uses Acecide-C high-level disinfectant solution

b. One Johnson & Johnson Advanced Sterilization OER that uses Cidex OPA high-level disinfectant solution

2. Staff #34 was asked by this surveyor regarding the testing of the MEC of the high-level disinfectants.

a. The documentation of MEC testing was requested.

3. A review of the MEC testing records lacked evidence that the MEC is checked with each reprocessing cycle performed.

a. Staff #34 stated, "We only document the first one."

4. This finding was confirmed with Staff #1, Staff #4, and Staff #13.

D. Based on observation, lack of facility documents, and staff interviews conducted on 10/26/15, 10/27/15 and 10/28/15, it was determined that the facility failed to ensure it provides a sanitary environment for the provision of surgical services that adheres to nationally-recognized Infection Control guidelines.

Findings include:

Reference #1: AORN 2015 Guidelines for Perioperative Practice "Guideline for Surgical Attire" section states on page 103, "I.e. Health care personnel should change into street clothes whenever they go outside of the building."

1. On 10/26/15, during the entrance interview with Staff #4 at 11:00 AM, he/she stated that the facility follows AORN and AAMI guidelines for its Infection Control program.

2. During a tour of the offsite Endoscopy facility between 11:45 AM to 12:30 PM, Staff #4 was observed to leave the hospital building without changing into street clothes.

3. The facility's policy and procedure on Surgical Attire was requested.

a. A copy of the "Guideline for Surgical Attire" section, pages 97-112 of the AORN 2015 Guidelines for Perioperative Practice was received from Staff #4. He/she stated, "This is our policy and procedure."

4. The facility failed to ensure that its Surgical Attire policy is implemented.

5. The facility failed to ensure that the nationally recognized Infection Control guidelines it has selected are followed.

Reference #2: AAMI Sterilization in Health Care Facilities, 2014 edition, ST 79 section 3.3.6.6 " Relative Humidity " states, " Relative humidity should be controlled between 30% to 60% in all work areas ... Relative humidity should be recorded daily. "

1. On 10/26/15, during a tour of the Endoscopy offsite facility, the documentation of temperature and relative humidity monitoring was requested from Staff #4 but not received.

2. On 10/27/15, in an interview with Staff #3 at 2:00 PM, he/she stated, "We do not monitor relative humidity in the Endoscopy Decontamination and Scope Cleaning Rooms."

3. The facility failed to implement environmental monitoring and controls in accordance with the nationally recognized guidelines it has selected for its Infection Control program.

Reference #3: AAMI (Association for the Advancement of Medical Instrumentation) Sterilization in Health Care Facilities, 2014 edition ST 58 Chemical sterilization and high-level disinfection in health care facilities section 6.6.4.2 states, " ... The cleaning agent manufacturer ' s written IFU should be followed. "

Reference #4: AAMI (Association for the Advancement of Medical Instrumentation) Sterilization in Health Care Facilities, 2014 edition ST 79 section 3.3.7.1 states, " The sink should be constructed with three sections- for soaking, washing, and rinsing ..."

1. On 10/28/15 at 10:25 AM, in the presence of Staff #42 and Staff #43, the sink in the Respiratory Therapy Department Dirty Equipment Room was observed to contain two sections.

a. There were no labels on the sink, to designate soaking, washing, and rinsing.

2. Staff #41 was observed manually cleaning the soiled equipment. He/she stated that the instruments are soaking in Endozime enzymatic cleaner solution.

3. The soaking sink did not contain a demarcation or calibration for the water level. Staff #41 stated that he/she did not measure the water in the soaking sink.

a. The Endozime manufacturer's directions for use states, "Add one (1) ounce of Endozime to one (1) gallon (8 ml/liter) of water."

4. The facility failed to ensure its Instrument Reprocessing adheres to the nationally recognized guidelines it has selected.

E. Based on observation and staff interview conducted on 10/28/15, it was determined that the facility failed to ensure that it complies with OSHA regulations.

Findings include:

Reference : OSHA 29 CFR part 1910.1030(g)(1)(i)(A) states, "Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials ..."

1. At 10:20 AM, during a tour of the Respiratory Therapy Department, in the presence of Staff #42 and Staff #43, the TEE scopes were removed from the transport container by Staff #41.

a. The transport container did not have a biohazard warning label affixed on it.

b. A tag labeled "dirty" was contained inside the transfer container.

i. Staff #41 stated that the tag should be outside, not inside the container.

2. The facility failed to ensure that a biohazard warning label is affixed on transport containers containing regulated medical waste, in accordance with OSHA regulations.

F. Based on observation and staff interviews conducted on 10/26/15 through 10/27/15, it was determined that the facility failed to ensure a safe and sanitary environment for the provision of surgical services.

Findings include:

Reference #1: Facility policy, Cleaning, Disinfection and Sterilization of Patient Care Equipment, states, "Standards of Cleanliness ... 1. Equipment (including underneath) should be visibly clean with no blood and body substances, dirt, debris, dust, adhesive tape, stains or spillages. 2. The environment of care (sic) including but not limited to, furniture, fixtures, floors, carpets, and window treatments should be visibly clean with no blood and body substances, dirt, debris, dust, adhesive tape, stains, or spillages."

Reference #2: AAMI (Association for the Advancement of Medical Instrumentation) Sterilization in Health Care Facilities, 2014 edition ST 79 section 3.3.7.2 Decontamination equipment states, " The external surfaces of decontamination equipment should be cleaned at least once daily."

1. During a tour of the Same Day Surgery department on 10/27/15 at 10:20 AM in the presence of Staff #1, Staff #4, and Staff #13, the following were observed:

a. The sink containing the eyewash station was soiled with brownish residues and greenish stains.

b. The pass-through window contained whitish-yellow sticky residues.

c. The overhead cabinet door contained chipped surfaces.

i. The chipped surface is not a cleanable surface.

d. The Scope Cleaning sink was soiled with white residues.

e. The exterior surface of the Olympus OER contained yellowish-brown sticky residues.

2. Staff #4 stated, "This room is not terminalized daily."

3. The facility failed to ensure a safe and sanitary environment in accordance with its Infection Control policy.


33802


G. Based on observation, facility policy review, and staff interview, it was determined that the facility failed to ensure that its Hand Hygiene policy is implemented.

Findings include:

Reference #1: Facility policy, Hand Hygiene and Skin Antisepsis, states, "... Decontaminate Hands with Alcohol Hand Sanitizer: ... 7. After removing gloves"

Reference #2: Guideline for Hand Hygiene in Health Care Settings: Recommendation of the Healthcare Infection Control Practices Advisory Committee [HICPAC] and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, published in the CDC (Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report at MMWR 2002; 51 (No. RR-16) page 32 states, "Recommendations: 1. Indications for Handwashing and Hand antisepsis ... C. Decontaminate hands before having direct contact with patients. ... E. Decontaminate hands before inserting ... peripheral vascular catheters, or other invasive devices ... F. Decontaminate hands after contact with a patient's intact skin ... G. Decontaminate hands after contact with ... a patient's nonintact skin ... I. Decontaminate hands after contact with inanimate objects ... in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves."

1. On 10/27/15, in Operating Room #1, Staff #30 and Staff #33 were observed performing multiple glove changes without sanitizing their hands.

a. These findings were confirmed with Staff #4.

A. Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to include, in all discharge planning evaluations whether the patient will require specialized medical equipment, if the equipment was available, and whether the patient and/or support person can provide care of the patient, in 2 (two) out of 5 (five) medical records reviewed for discharge planning (Medical Records #12 and #13).

Findings include:

Reference: Facility policy, Interdisciplinary Assessment/Reassessment and Discharge Planning, states, "... Purpose: To assess, determine, and provide the appropriate care, treatment and services to meet a patient's initial needs as well as his or her changing needs; to establish long and short-range patient care goals and plan of care. ... Guidelines: ... 6. Initial assessment determines the need for care and the type of care required. * ... j. Environmental needs, special equipment used by patient (cane, hearing aid, glasses) ... p. Referral to community resources, such as home health care, ..., durable medical equipment companies, ... rehabilitation services. ..."

1. On 10/27/15, review of Medical Record #12, in the presence of Staff #8, #22, and #23, indicated the following:

a. Patient #12 is 87 (eighty-seven) years old, and was admitted from home on 10/23/15 for a left hip fracture. Review of the nursing admission assessment completed 10/24/15 at 00:49 indicated the patient's medical history includes anemia, arthritis, COPD, CHF, CAD, dementia, DM, diverticular disease, fractures, HOH, HTN, hyperlipidemia, and CVA.

i. The patient had a Foley catheter in place upon admission to the facility, lives in a home environment with staff, needs maximum assistance, and is a high risk for falls and skin breakdown/pressure ulcer development.

b. Review of the Social Worker's discharge screening notes dated 10/25/15 indicated a SNF the patient's daughter chose, and that the patient has a history with a VNA. The patient was ultimately accepted to the SNF when he/she was ready for discharge.

2. Patient #12's Nursing Admission Assessment's Discharge Planning section was not completed on admission. The Rehabilitation section did not identify any Community Resources the patient has used in the past, or is currently using, as indicated in the social worker's notes.

3. On 10/27/15, review of Medical Record #13, in the presence of Staff #8, #22, and #23, indicated the following:

a. Patient #13 is 86 (eighty-six) years old, and was admitted from home on 10/20/15, and lives with his/her spouse. Review of the nursing admission assessment completed 10/20/15 indicated the patient's medical history includes COPD, MI, SZ, BiPap, and Emphysema.

i. The respiratory section indicates the patient is on oxygen via nasal cannula.

ii. The rehabilitation section indicates the patient wants to go home, and has no difficulty ambulating.

iii. The fall risk section indicates "yes" for crutches/cane/walker. The patient was identified as a low fall risk.

b. Review of the Social Worker's discharge screening notes dated 10/21/15 at 13:09 indicates the patient lives at home with his/her spouse, has a walker, and is oxygen dependent. The note identifies the DME company the patient uses for the oxygen delivery. The note identifies the VNA as a current service provider for the patient, and indicates the patient is agreeable to continue to receive VNA services.

i. A social work note dated 10/27/15 indicated the patient's spouse was discharged home from this same facility on 10/26/15 with new oxygen, and the patient also wants to be discharged home with VNA and possible hospice.

ii. The assessment does not indicate if Patient #13's spouse, that was indicated as his/her support person, would be able to assist Patient #13 at home, with the VNA services and possibly hospice.

4. Patient #13's Nursing Admission Assessment's Functional Screening section did not identify the DME company the patient uses for the oxygen or walker.

a. The "Community Services you are currently using" section does not identify the VNA company that is currently following the patient, as indicated in the the social worker's notes.

5. The above was reviewed and confirmed by Staff #8, #22, and #23.

B. Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that all discharge planning evaluations include an assessment of the patient's insurance coverage and how the insurance may or may not provide for post-hospital services in three out of five medical records reviewed for discharge planning. (Medical Records #12, #13, and #15).

Findings include:

Reference: Facility policy, Discharge Planning, states, "... Identification and Assessment ... 2. Assessment ... and financial impact of an illness on the patient and family represents the essential base for building a realistic discharge plan. ..."

1. On 10/27/15, review of Medical Records #12, #13, and #15, in the presence of Staff #8, #22, and #23, lacked evidence of an assessment of the patients' insurance coverage.

2. Discussion and interview with Staff #8, #22, and #23, indicated that the facility's Case Management Staff document insurance coverage in a separate computer system, All-scripts. All-scripts is not part of the patients' permanent medical record, and can only be accessed by the Case Management Staff.

Based on review of one closed medical record and facility policy and procedure, it was determined that the facility failed to include all necessary discharge instructions, specific for the patient's needs.

Findings include:

Reference: Facility policy, Discharge of Patient, states, ... Guidelines ... 5. Written discharge instructions are given, if applicable, in a manner that the patient and/or family or caregiver can understand. ..."

1. On 10/27/15, review of Medical Record #16, in the presence of Staff #8, #22, and #23, indicated in the Integument section of the Nursing Flowsheet dated 9/21/15, that the patient had an abdominal dressing that was clean, dry, and intact.

a. The Social Worker's notes dated 9/21/15 at 11:36 AM indicated the patient was discharged this date, status post a hernia repair, with orders for visiting nurse services.

2. Review of the Discharge instructions dated Monday, 9/21/15, included instructions for a follow up appointment with "wound care as scheduled on Wednesday."

a. There was no indication where, or what provider the patient was to follow up with for wound care (i.e. the primary care provider he/she was instructed to see within one week, or if the visiting nurse that was scheduled to visit on Wednesday, was to provide the wound care).

b. The Discharge Instructions did not include instructions for the patient's abdominal wound. There was no indication if the patient was to leave the dressing on, or remove it, or if the patient could shower/bathe. There were no instructions as to wound care prior to Wednesday.

3. The Discharge Instructions stated "... Activity:- Activity as tolerated. Additional activity instructions if written below. ..." There was no directive in the instructions if the patient was able to do any lifting status post his/her hernia repair, and what weight he/she was limited to.

Based on staff interview and document review, it was determined that the facility failed to evaluate patient readmissions to determined whether the readmissions were potentially due to problems in the discharge planning process, or implementation of the original discharge plan.

Findings include:

1. On 10/27/15 and 10/28/15 the facility's Discharge Planning processes were reviewed.

a. On 10/27/15, review of Medical Record #15, in the presence of Staff #8, #22, and #23, indicated Patient #15 was discharged from this facility, four (4) days ago, on 10/23/15, and readmitted 10/24/15.

b. Per the nursing admission assessment, "yes" was indicated for the patient being in a hospital within the past thirty (30) days.

c. Staff #23 stated in interview on 10/27/15 at 1:03 PM, the nurse case managers do a thirty (30) day readmission review to see if the patient's readmission was preventable within twenty-four (24) hours of the patient's admission. Staff #23 stated the patient is flagged in All-scripts, and the case manager reviews the readmission on the next business day, Monday thru Friday.

d. Staff #22 and Staff #23 checked All-scripts and verified that the readmission review for Patient #15 was not completed by the case manager.

2. Staff #22 stated in interview on 10/28/15 at 10:45 AM that the facility does not conduct admission reviews, for patients readmitted to the facility within 30 (thirty) days of a prior in-patient discharge. Staff #22 stated there is a tool in place to assist with re-admission reviews, but it is in its beginning stages, and not implemented at this time.

A. Based on staff interview, document review, and review of facility policy and procedure, it was determined that the facility failed to ensure that the director of food services provides effective daily management of the Nutritional Services Department in accordance with the "Director of Nutritional Services" job description.

Findings Include:

Reference #1: The Director of Nutritional Services job description states, " ... Evaluates and maintains appropriate documentation of employee performance on a regular basis. Is accountable for hiring, orientation, training, and inservice education of nutritional services employees and disciplinary action and, if necessary, termination of nutritional services employees ... implementation of safety and sanitation programs, and operating within the budget ... Develops, evaluates and supervises all aspects of the department's quality improvement plan. Complies with the standards set forth by the State of New Jersey Department of Health and the Joint Commission on Accreditation of Hospitals ... In depth knowledge of Chapter 24 NJ Board of health food code."

1. Staff #45 could not produce the 2014 and 2015 dietary services quality assurance plan.

2. The above finding was confirmed by Staff #45 on 10/28/15 at 2:30 PM.




35697

B. Based on staff interview, facility document review, and review of facility policy and procedure, it was determined that the facility failed to employ a qualified director of food services.

Findings Include:

Reference #2: NJ Department of Health requirement states that there shall be a food service director who has a baccalaureate degree from an accredited college or university in food, nutrition, food services management, or a related area, or has at least four years of experience in food services management in a health care facility and successful completion of Food Management Certification (FMC) and Dietetic Assistant programs or their equivalents.

1. Review of the Food Service Director's personnel file lacked evidence of the following:

a. A baccalaureate degree from an accredited college or university in food, nutrition, food services management, or a related area.

b. Four years of experience in food services management in a health care facility and successful completion of Food Management Certification (FMC) and Dietetic Assistant programs or their equivalents.

2. During interview, Staff #44 stated that his/her baccalaureate degree was in business and not in food service or nutrition.

3. Staff #2 and Staff #5 confirmed the above findings on 10/28/2015.

C. Based on Staff interview, facility document review, review of facility policy and procedure, and a tour of the kitchen, it was determined that the Food Service Director was unable to demonstrate knowledge and perform daily management of the dietary services in accordance with the his/her job description.

Findings Include:

Reference #3: N.J.A.C. 8:24-4.7(a) states, "Equipment food-contact surfaces and utensils shall be sanitized." 8:24-4.7(b) states, "Utensils and food-contact surfaces of equipment shall be sanitized before use and after cleaning."

Reference #4: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #5: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately the concentration in mg/L of sanitizing solutions shall be provided. 8:24-4.8(i) states, "Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device."

Reference #6: N.J.A.C. 8:24-4.11(2) states, "Clean equipment and utensils shall be stored: (i) In a self-draining position that allows air drying; and (ii) Covered or inverted."

Reference #7: N.J.A.C. 8:24-6.2(n) states, "Requirements for the protection of outer openings shall include the following: 1. Except as specified in (n)2 and 3 below, outer openings of a retail food establishment shall be protected against the entry of insects
and rodents by: (i) Filling or closing holes and other gaps along floors, walls and ceilings; (ii) Closed, tight-fitting windows; and iii. Solid self-closing, tight-fitting doors."

Reference #8: N.J.A.C. 8:24-4.6(b) states, "The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations."

Reference #9: N.J.A.C. 8:24-6.2(f) states, "Wall and ceiling covering materials shall be attached so that are easily cleanable, except that in areas used only for dry storage, concrete, porous blocks, or bricks used for indoor wall construction shall be finished and sealed to provide a smooth, nonabsorbent, easily cleanable surface."

1. On 10/27/2015, in the presence of Staff #2, #26, #44, and #45, the following deficient practices were observed in the kitchen:

a. The warewashing area ceiling tiles and drains were not clean. The ceiling tiles had visible stains and debris on them. (Refer to Reference #3 and Reference #8)

(i) The warewashing area had two clogged drains with dried black and brown residue on them. One drain in the warewasher area had a significant large cracked opening. The dishwashing area had fruit flies and other insects. (Refer to Reference #6)

(ii) The double exit doors from the kitchen to the loading dock had large sweep gaps and an opening in the middle of the double doors. Fruit flies and other insects were observed around the sweep gaps. (Refer to Reference #2 and Reference #6)

(iii) A large standing floor fan in the dish washing room was covered in heavy dust. (Refer to Reference #2)

(iv) Wet trays and silverware were stacked together after they were removed from the warewashing machine. (Refer to Reference #5)

b. Two deep fryers in the cooking area had cooking oil that was cloudy and thick. The deep fryers had encrusted brown substance around the edges.

(i) Staff #44 stated that they do not have fried foods on the menu. Staff #44 was unable to comment on when the deep fryers were last used or cleaned. (Refer to Reference #3 and Reference #7)

c. Staff #46 was using a QAC sanitizer test strips for pot washing.

(i) The QAC sanitizer test strips are not the correct test strips. (Refer to Reference #4)

(ii) Staff #46 stated that he/she had not been oriented on how to use or check the sanitizer for pot washing.

(iii) Staff #44 obtained two sets of the correct brand of testing strips on 10/28/2015, however the testing strips had expired on 7/30/2012 and 12/15/2014.

2. The contracted pest control and sanitation reports were reviewed in presence of Staff #44. The reports recommended the following:

(a) The contracted pest control and sanitation report dated 4/24/2015 indicated the kitchen drains were dry and dirty with broken tile and grout. The sanitation report recommendation was to clean and flush food debris down drains nightly and repair the floor to prevent harborage area for fruit flies.

(b) The contracted pest control and sanitation report dated 5/23/2015 indicated the dishroom drains were dirty and food service floors were not being cleaned under equipment. The sanitation report recommendation was to clean food debris nightly, use fan to dry floors to prevent fruit fly breeding sites, and clean under equipment using 0E-30 to break-up fruit fly breeding sites.

(c) The contracted pest control and sanitation report dated 6/27/2015 indicated that the dishwasher drain backs up. The sanitation report recommendation was to have a professional drain cleaning company address the problem.

(d) The contracted pest control and sanitation report dated 7/31/2015 indicated that overflowing drains in the dishroom were a breeding site for fruit flies. The sanitation report recommendation was to keep drains clear and free flowing.

(e) The contracted pest control and sanitation report dated 8/28/2015 indicated the drain under the dishwasher backs up leaving food debris on floor. The sanitation report recommendation was to have the drain repaired to prevent breeding site for fruit flies.

(f) The contracted pest control and sanitation report dated 9/25/2015 indicated the

A. Based on observation, document review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure implementation of policies and procedures addressing the use of multi-dose medication vials in an immediate patient care area.

Findings include:

Reference: Facility policy, Multiple Dose Vials, states, "Safe Injection Practices Under Standard Precautions ... 9. Do not keep multi-dose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable."

1. On 10/27/15 at 11:40 AM, the following opened multi-dose vials were found in the Minor Procedure Room:

a. Two 50 ml vials of Lidocaine 10 mg/ml

b. One 30 ml vial of Lidocaine 1% with Epinephrine 1:100,000

2. On 10/27/15 at 11:45 AM, the following opened multi-dose vials were found in Endoscopy Room #2:

a. Atropine Sulfate 8 mg/20 ml

b. Lidocaine 2%, 20 ml

3. On 10/27/15 at 12:15 PM, the following opened multi-dose vials were found in Operating Room #3:

a. Rocuronium 10 ml

b. Succinylcholine 10 ml

c. Bloxiverz 10 ml

4. On 10/27/15 at 12:20 PM, the following opened multi-dose vials were found in the Cystoscopy Room:

a. Succinylcholine 10 ml

b. Bloxiverz 10 ml

c. Atropine 20 ml

These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 10/27/15, day of survey, upon receipt of an acceptable plan of correction.

5. During interview on 10/29/15 at 11:45 AM, Staff #63 stated that he/she would remove a multi-dose vial of Lantus insulin from the drug dispensing device, prepare a syringe from the vial at the patient's bedside, and then return the opened vial to the drug dispensing device. The vial would be used in this manner for multiple patients.

a. Interview with Staff #10 confirmed that this was the practice throughout the facility. He/she stated that the vial had to be taken to the bedside in order to scan the vial, a process that was necessary during medication administration.

These findings resulted in an Immediate Jeopardy which immediately curtailed this practice. The Immediate Jeopardy was removed on 10/29/15, day of survey, upon receipt of an acceptable plan of correction.


33800


B. Based on observation, staff interview, facility document review, and review of facility policy and procedure conducted on 10/28/2015, it was determined that the facility failed to ensure that its Infection Control policy on Intravenous Therapy is implemented.

Findings include:

Reference: Facility policy, Intravenous Therapy, states, "Guidelines ... Perform hand hygiene prior to catheter insertion or manipulation. Standard for accessing all or any intravenous site: a. Disinfect catheter hubs and injection ports with each access using an alcohol swab."

1. During observation of procedure in the CVIR (Cardiovascular Interventional Radiology) unit at 11:25 AM, Staff #62 was observed to access an IV port without performing hand hygiene prior and without cleansing the injection port using an alcohol swab before injecting medication into the port.

2. At 12:00 PM, during the same procedure, Staff #37 was observed to access the IV port without performing hand hygiene prior and without cleansing the injection port using an alcohol swab before injecting medication into the port.

3. These findings were confirmed with Staff #1.

C. Based on observation, staff interview, facility document review and review of facility policy and procedure conducted on 10/27/15, it was determined that the facility failed to ensure that its policy on High-Level Disinfection (HLD) is implemented.

Findings include:

Reference #1: Facility policy, Cleaning, High Level Disinfection, and Reprocessing Flexible Endoscopes, states, "... Process Validation/QA ... 5. The concentration of the HLD used in the AER is validated by measuring the Minimal Effective Concentration (MEC) with each load, using a strip specific to the biocide. MEC test results are logged for QA purposes. ..."

Reference #2: Acecide-C manufacturer's IFU states, "Directions for Use ... a) Monitor the MRC of PAA with ACECIDE test strips prior to each reprocessing cycle ..."

Reference #3: Cidex OPA manufacturer's IFU states, "... It is important to test for the presence of the MEC when using a high level disinfectant."

1. During a tour of the Same Day Surgery (SDS) unit on 10/27/15 at 10:30 AM, in the presence of Staff #1, Staff #4, and Staff #13, two AERs were observed:

a. One Olympus OER -PRO that uses Acecide-C high-level disinfectant solution

b. One Johnson & Johnson Advanced Sterilization OER that uses Cidex OPA high-level disinfectant solution

2. Staff #34 was asked by this surveyor regarding the testing of the MEC of the high-level disinfectants.

a. The documentation of MEC testing was requested.

3. A review of the MEC testing records lacked evidence that the MEC is checked with each reprocessing cycle performed.

a. Staff #34 stated, "We only document the first one."

4. This finding was confirmed with Staff #1, Staff #4, and Staff #13.

D. Based on observation, lack of facility documents, and staff interviews conducted on 10/26/15, 10/27/15 and 10/28/15, it was determined that the facility failed to ensure it provides a sanitary environment for the provision of surgical services that adheres to nationally-recognized Infection Control guidelines.

Findings include:

Reference #1: AORN 2015 Guidelines for Perioperative Practice "Guideline for Surgical Attire" section states on page 103, "I.e. Health care personnel should change into street clothes whenever they go outside of the building."

1. On 10/26/15, during the entrance interview with Staff #4 at 11:00 AM, he/she stated that the facility follows AORN and AAMI guidelines for its Infection Control program.

2. During a tour of the offsite Endoscopy facility between 11:45 AM to 12:30 PM, Staff #4 was observed to leave the hospital building without changing into street clothes.

3. The facility's policy and procedure on Surgical Attire was requested.

a. A copy of the "Guideline for Surgical Attire" section, pages 97-112 of the AORN 2015 Guidelines for Perioperative Practice was received from Staff #4. He/she stated, "This is our policy and procedure."

4. The facility failed to ensure that its Surgical Attire policy is implemented.

5. The facility failed to ensure that the nationally recognized Infection Control guidelines it has selected are followed.

Reference #2: AAMI Sterilization in Health Care Facilities, 2014 edition, ST 79 section 3.3.6.6 " Relative Humidity " states, " Relative humidity should be controlled between 30% to 60% in all work areas ... Relative humidity should be recorded daily. "

1. On 10/26/15, during a tour of the Endoscopy offsite facility, the documentation of temperature and relative humidity monitoring was requested from Staff #4 but not received.

2. On 10/27/15, in an interview with Staff #3 at 2:00 PM, he/she stated, "We do not monitor relative humidity in the Endoscopy Decontamination and Scope Cleaning Rooms."

3. The facility failed to implement environmental monitoring and controls in accordance with the nationally recognized guidelines it has selected for its Infection Control program.

Reference #3: AAMI (Association for the Advancement of Medical Instrumentation) Sterilization in Health Care Facilities, 2014 edition ST 58 Chemical sterilization and high-level disinfection in health care facilities section 6.6.4.2 states, " ... The cleaning agent manufacturer ' s written IFU should be followed. "

Reference #4: AAMI (Association for the Advancement of Medical Instrumentation) Sterilization in Health Care Facilities, 2014 edition ST 79 section 3.3.7.1 states, " The sink should be constructed with three sections- for soaking, washing, and rinsing ..."

1. On 10/28/15 at 10:25 AM, in the presence of Staff #42 and Staff #43, the sink in the Respiratory Therapy Department Dirty Equipment Room was observed to contain two sections.

a. There were no labels on the sink,