HospitalInspections.org

Cross refer to:

C0225

Based on observation, the facility did not have housekeeping and maintenance programs to ensure that the premises were clean and orderly.

Findings were:


-During a tour of the kitchen on 2-22-17, the following was noted:
-Saucepans of varying sizes were stacked together while still wet on a wet shelf.
-A tray of clear, plastic dessert bowls had been stacked while still wet.
-5 trays of plastic drinking glasses had been stacked while still wet.

-4 cutting boards had been stacked horizontally while still wet.

-A trayful of wet silverware was sitting on the counter, ready to be packaged in paper sleeves for use on patient trays. The bowls of the spoons were facing upright and each held a small amount of water. When handed a wet spoon and asked how the spoons would be dry enough to package in the paper sleeves, staff #6 demonstrated by picking up a nearby towel and drying the spoon.

-Solution in the red sanitizer bucket was dipped with a test strip at the request of the surveyor. When the test strip gave no indication that the solution contained sanitizer, staff #6 stated that the solution was only soap and water.

-The container of sanitizer test strips was unsealed with the lid partially open. The test strips inside the container were discolored and misshapen.

-2 pantries contained dry goods (to include individual juice servings and canned goods) that had not been marked with the date they were received into the facility.

-A plastic tub of homemade cookies in a dry goods pantry had been stored on the shelf with the lid unsealed.

-A plastic bucket marked "corn meal" (filled with a yellow, granular substance) in a dry goods pantry was found with the lid unsealed and askew.

-7 uncovered, plastic pans (containing meat slicer parts, ladles, serving spoons, spatulas and tongs) had been stored under the preparation counter and contained debris including food crumbs.

-The 2-drawer warming unit contained plastic bags, paper napkins, nylon utensils and utensils with plastic handles. In an interview with staff #4, staff #4 confirmed that the warming unit was still operational.

-A potato slicer was mounted on the wall to a piece of unfinished plywood (the surface of which was porous and could not be cleaned). The slicer blades contained food particulates.

The facility based "Infection Control Policy and Produce Manual" included a policy entitled, "Infection Control Program" which stated in part,
"1. GOALS
The goal of the Infection Control program are to:
A. Prevent Hospital Acquired Infections in patients and residents
B. Decrease the risk of infection to Hospital District personnel and visitors
C. Monitor for occurrence of infection and implement appropriate control measure
D. Identify and correct problems relating to infection control practices
E. Ensure compliance with state and federal regulations relating to infection control...
III. Division of Responsibilities for Infection Control
The Chief Executive Officer (CEO) is ultimately responsible for the Infection Control program.
A. Infection Control Practitioner
Responsibility is delegated to the infection control practitioner (ICP) to carry out the functions of the infection control program. REFER TO: ICP job description. The ICP has knowledge and interest in infection control.
B. Infection Control Committee
The infection control committee meets on a regular basis and provides input and direction for the infection control program."

The facility based "Dietary Control Policy and Produce Manual" included a policy entitled, "Dishwashing Machine Use" which stated in part,
"1. The following guidelines will be followed when dishwashing:
f. After running items through entire cycle, allow to air-dry..."

The facility based "Dietary Control Policy and Produce Manual" included a policy entitled, "Food Services Manager" which stated in part, "1. The Food Service Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. "
The facility based "Dietary Control Policy and Produce Manual" included a policy entitled, "QAPI-Role of the Dietician/Food Services Manager" which stated in part,
"Duties and responsibilities the QAPI Program include, but are not limited to:...
4. Inspecting food storage rooms, utility/janitorial closets, etc., for upkeep and supply control...
8. Developing, implementing, and maintaining an ongoing QAPI Program for the dietary department."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 2-22-17.

Cross refer to:

C0241

Based on observation,a review of documentation and an interview with staff, the facility failed to have a governing body or an individual to assume full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment.

Findings were:


-During a tour of the kitchen on 2-22-17, the following was noted:

-Saucepans of varying sizes were stacked together while still wet on a wet shelf.

-A tray of clear, plastic dessert bowls had been stacked while still wet.

-5 trays of plastic drinking glasses had been stacked while still wet.

-4 cutting boards had been stacked horizontally while still wet.

-A trayful of wet silverware was sitting on the counter, ready to be packaged in paper sleeves for use on patient trays. The bowls of the spoons were facing upright and each held a small amount of water. When handed a wet spoon and asked how the spoons would be dry enough to package in the paper sleeves, staff #6 demonstrated by picking up a nearby towel and drying the spoon.

-Solution in the red sanitizer bucket was dipped with a test strip at the request of the surveyor. When the test strip gave no indication that the solution contained sanitizer, staff #6 stated that the solution was only soap and water.

-The container of sanitizer test strips was unsealed with the lid partially open. The test strips inside the container were discolored and misshapen.

-2 pantries contained dry goods (to include individual juice servings and canned goods) that had not been marked with the date they were received into the facility.

-A plastic tub of homemade cookies in a dry goods pantry had been stored on the shelf with the lid unsealed.

-A plastic bucket marked "corn meal" (filled with a yellow, granular substance) in a dry goods pantry was found with the lid unsealed and askew.

-7 uncovered, plastic pans (containing meat slicer parts, ladles, serving spoons, spatulas and tongs) had been stored under the preparation counter and contained debris including food crumbs.

-The 2-drawer warming unit contained plastic bags, paper napkins, nylon utensils and utensils with plastic handles. In an interview with staff #4, staff #4 confirmed that the warming unit was still operational.

-A potato slicer was mounted on the wall to a piece of unfinished plywood (the surface of which was porous and could not be cleaned). The slicer blades contained food particulates.

The facility based "Infection Control Policy and Produce Manual" included a policy entitled, "Infection Control Program" which stated in part,
"1. GOALS
The goal of the Infection Control program are to:
A. Prevent Hospital Acquired Infections in patients and residents
B. Decrease the risk of infection to Hospital District personnel and visitors
C. Monitor for occurrence of infection and implement appropriate control measure
D. Identify and correct problems relating to infection control practices
E. Ensure compliance with state and federal regulations relating to infection control...
III. Division of Responsibilities for Infection Control
The Chief Executive Officer (CEO) is ultimately responsible for the Infection Control program.
A. Infection Control Practitioner
Responsibility is delegated to the infection control practitioner (ICP) to carry out the functions of the infection control program. REFER TO: ICP job description. The ICP has knowledge and interest in infection control.
B. Infection Control Committee
The infection control committee meets on a regular basis and provides input and direction for the infection control program."

The facility based "Dietary Control Policy and Produce Manual" included a policy entitled, "Dishwashing Machine Use" which stated in part,
"1. The following guidelines will be followed when dishwashing:
f. After running items through entire cycle, allow to air-dry..."

The facility based "Dietary Control Policy and Produce Manual" included a policy entitled, "Food Services Manager" which stated in part, "1. The Food Service Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. "
The facility based "Dietary Control Policy and Produce Manual" included a policy entitled, "QAPI-Role of the Dietician/Food Services Manager" which stated in part,
"Duties and responsibilities the QAPI Program include, but are not limited to:...
4. Inspecting food storage rooms, utility/janitorial closets, etc., for upkeep and supply control...
8. Developing, implementing, and maintaining an ongoing QAPI Program for the dietary department."

In an interview with staff #15, staff #15 stated that staff #14 had been designated as the infection control professional. A review of the personnel file for staff #14 revealed no documented formal or informal infection control training. In an interview with staff #14, staff #14 confirmed that [staff #14] had never received any formal or informal infection control training.

The facility based job description for the "Infection Control Nurse" stated in part,
"Qualifications/Standards:..
LICENSURE/CERTIFICATION REQUIREMENT:...Completion of Basic Training program for infection control."

When asked to provide documentation of infection control committee meetings held in 2016 and 2017, the facility staff was unable to do so. In an interview with staff #15, staff #15 confirmed that no infection control committee meetings had been held in 2016 or 2017.

The facility based "Infection Control Policy and Produce Manual" included a policy entitled, "Infection Control Program" which stated in part,
"1. GOALS
The goal of the Infection Control program are to:
A. Prevent Hospital Acquired Infections in patients and residents
B. Decrease the risk of infection to Hospital District personnel and visitors
C. Monitor for occurrence of infection and implement appropriate control measure
D. Identify and correct problems relating to infection control practices
E. Ensure compliance with state and federal regulations relating to infection control...
III. Division of Responsibilities for Infection Control
The Chief Executive Officer (CEO) is ultimately responsible for the Infection Control program.
A. Infection Control Practitioner
Responsibility is delegated to the infection control practitioner (ICP) to carry out the functions of the infection control program. REFER TO: ICP job description. The ICP has knowledge and interest in infection control.
B. Infection Control Committee
The infection control committee meets on a regular basis and provides input and direction for the infection control program."


Facility based policy entitled, "Nutritional Services" stated in part, "B. A nutritional assessment will be conducted by the dietician with 24 hours of the patient's admission to Swing Bed."

Review of medical records revealed that 3 of 3 swing bed patients (#6, 7, and 8) did not have a nutritional assessment completed by the dietician with 24 hours of the patient's admission to Swing Bed status, per facility based procedure.


The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 2-22-17.

Cross refer to:

C0278

Based on an interview with staff, the facility failed to establish, implement and enforce patient care policies regarding a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Findings were:

In an interview with staff #15, staff #15 stated that staff #14 had been designated as the infection control professional. A review of the personnel file for staff #14 revealed no documented formal or informal infection control training. In an interview with staff #14, staff #14 confirmed that [staff #14] had never received any formal or informal infection control training.

The facility based job description for the "Infection Control Nurse" stated in part,
"Qualifications/Standards:..
LICENSURE/CERTIFICATION REQUIREMENT:...Completion of Basic Training program for infection control."

When asked to provide documentation of infection control committee meetings held in 2016 and 2017, the facility staff was unable to do so. In an interview with staff #15, staff #15 confirmed that no infection control committee meetings had been held in 2016 or 2017.

The facility based "Infection Control Policy and Produce Manual" included a policy entitled, "Infection Control Program" which stated in part,
"1. GOALS
The goal of the Infection Control program are to:
A. Prevent Hospital Acquired Infections in patients and residents
B. Decrease the risk of infection to Hospital District personnel and visitors
C. Monitor for occurrence of infection and implement appropriate control measure
D. Identify and correct problems relating to infection control practices
E. Ensure compliance with state and federal regulations relating to infection control...
III. Division of Responsibilities for Infection Control
The Chief Executive Officer (CEO) is ultimately responsible for the Infection Control program.
A. Infection Control Practitioner
Responsibility is delegated to the infection control practitioner (ICP) to carry out the functions of the infection control program. REFER TO: ICP job description. The ICP has knowledge and interest in infection control.
B. Infection Control Committee
The infection control committee meets on a regular basis and provides input and direction for the infection control program."


The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 2-22-17.

Based on review of documentation and interview, the facility failed to enforce procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices with respect to inpatients receiving post hospital SNF care.

Findings included:

Facility based policy entitled, "Nutritional Services" stated in part, "B. A nutritional assessment will be conducted by the dietician with 24 hours of the patient's admission to Swing Bed."

Review of medical records revealed that 3 of 3 swing bed patients (#6, 7, and 8) did not have a nutritional assessment completed by the dietician with 24 hours of the patient's admission to Swing Bed status, per facility based procedure.

In an interview on 02/22/17, staff member #14 confirmed the above findings.

Cross refer to:

C0336

Based on a review of documentation and an interview with staff, the facility failed to provide an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.

Findings were:

When asked to provide documentation of QA meetings performed in 2016 and 2017, staff #15 provided meeting minutes for QA meetings held on 2-29-16 and 11-14-16. The meetings did not indicate participation by all departments and specific quality indicators were not discussed. In an interview with staff #15 on 2-22-17, staff #15 confirmed that an effective quality assurance program had not yet been established and that the individual hospital departments had not decided on department-specific quality indicators (despite being instructed to do so).

The above was confirmed an in interview with the CEO and other administrative staff on the afternoon of 2-22-17.