HospitalInspections.org

Based on review of the Patient Tray Assessments Forms from 05/03/20 to 07/23/20 and interview it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that temperatures of foods were documented to be above or below the recommended food temperature 12 out of 17 days with no corrective action. The failed practice did not ensure the safety of food served to patients in the facility. The failed practice had the potential to affect anyone receiving food from the kitchen. Findings follow:

A. Review of Patient Tray Assessment form showed: "A score of less than 90% requires a corrective action plan."
B. Review of the Patient Tray Assessment Forms showed the following:
1) 05/03/020 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 77%. No corrective action.
2) 05/06/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of <89%. No corrective action.
3) 05/13/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 64%. No corrective action.
4) 05/18/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 89%. No corrective action.
5) 05/24/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 90%. No corrective action.
6) 05/26/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 86%. No corrective action.
7) 06/11/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 77%. No corrective action.
8) 06/16/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 80%. No corrective action.
9) 06/30/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 76%. No corrective action.
10) 07/08/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 88%. No corrective action.
11) 07/15/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 90%. No corrective action.
12) 07/23/20 - Hot and cold food and beverage temperatures out of range with overall quality unsatisfactory score of 90%. No corrective action.

C. During an interview with the Sodexo Area Manager on 08/05/20 at 1:15 PM he stated that no corrective action was provided after food temperatures were shown to be out of range.

D. The above findings in A and B were verified with the Sodexo Area Manager on 08/05/20 at 1:20 PM.

Based on review of personnel files, policy and procedure review, and interview it was determined that 5 (RN #1-#5) of 11 (RN #1-#11) Registered Nurses, personnel files did not have evidence of an offer or refusal for Hepatitis B vaccination. Failure to offer Hepatitis B vaccination or declination of vaccination did not ensure employees were informed of the availability of vaccination and the occupational risk and potential spread of infection associated with their work environment.

A. Review of the Facilities' Policy titled "Employee Health Services" showed: "Employees who have potential for exposure to blood or body fluids will be offered and encouraged to have the Hepatitis B vaccine. The employee may choose to decline the vaccine. If the employee chooses not to be vaccinated, a Hepatitis B Declination form must be signed."
B. Review of personnel files of RN #1 - #5 showed no record of Hepatitis B vaccination being offered or declined by the employee.
C. The above finding were verified with the Quality Coordinator on 08/05/20 at 2:30 PM.

Based on observation and interview while on tour of the COVID-19 pre testing waiting room for surgeries/procedures on 08/05/20 at 11:30 AM it was determined the facility failed to ensure a sanitary environment in that 11 out of 29 chairs available for patient seating were cloth covered and there was no hand sanitizer available for patient use. The failed practice did not ensure the environmental surfaces were clean, free of contaminants, and remained clean and as free of contaminants as possible with the availability of hand sanitizer for patient use. The failed practice had the potential to affect all patients getting tested for COVID-19 prior to a surgical procedure. Findings follow:

A. During tour of the COVID-19 pre testing waiting room for surgeries or procedures on 08/05/20 at 11:30 AM showed 11 out of 29 chairs available for patient seating were cloth covered.
B. During tour of the COVID-19 pre testing waiting room for surgeries or procedures on 08/05/20 at 11:30 AM showed no availability of hand sanitizer for patient use while waiting.
C. Findings in A and B were verified by the OR (Operating Room) Manager on 08/05/20 at 11:30 AM.