HospitalInspections.org

Based on random observation, testing, and interview, the provider failed to ensure the following areas and items were maintained cleanable, in good repair, and in a safe condition:
*Two of two wooden particle board shelves in the emergency room (ER) by the medication cart had unpainted surfaces.
*Three of three incandescent bulbs were not shielded in the housekeeping supply room.
*One of two (2) rooms, in post labor and delivery had a broken towel rack.
*The cabinet floor in one of one dirty utility room of the patient wing was soiled and wet to the touch
*The ante room in one of one isolation room had soiled and bulged ceiling tiles.
*The patient wing, x-ray area, and the clinic fill rooms randomly had:
-Frayed fill hoses for chemicals.
-Missing floor tile.
-Damaged walls.
-Raw wood shelves and brackets.
Findings include:

1. Observation on 11/18/14 from 2:00 p.m. to 4:45 p.m. revealed:
a. Two particle board shelves in the ER by the medication cart had raw wooden finishes on the end of the boards. Interview with the housekeeping supervisor at the time of the observation confirmed that finding and agreed it was not a cleanable surface.
b. Three incandescent bulbs in the housekeeping supply room were not shielded or shatterproof. Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She stated she was not aware those bulbs must be shielded or shatterproof if patient care items were stored in that room.
c. Room 2 in labor and delivery had a broken towel rack in the bathroom. Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She stated she was unaware the rack was broken.
d. The cabinet floor in the dirty utility room of the patient wing had a circle of missing paint about the size of a coffee filter (photo 19). The circle was bulged and wet to the touch. Interview with the housekeeping supervisor at the time of the observation confirmed that finding and agreed it was not in good condition.
e. The ante room for the isolation room had a bulged, soiled, and damaged ceiling tile (photo 26). Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She was not aware those tiles were damaged, soiled, and needed to be replaced.
f. The fill rooms for the patient wing, x-ray, and the clinic had either frayed fill hoses, damaged walls, damaged floors, and/or raw wooden shelves and brackets for housekeeping tools (photos 18, 20, 21, 22, and 25). Interview with the housekeeping supervisor at the time of the observations confirmed those findings.

Continued interview at 4:45 p.m. on that same day with the housekeeping supervisor revealed her staff would let maintenance know of any concerns or repairs needed in the patient rooms or patient areas. She stated she had relied on her staff to deliver any concerns to the proper department.

Interview on 11/20/14 at 8:55 a.m. with the director of plant operations revealed he had no preventive maintenance (PM) checklist for the floors, walls, ceilings, and other environmental concerns throughout the hospital. He did have a PM checklist for the equipment located throughout the hospital. He also had no system for work orders. He stated if the staff needed something they would just pick up the phone and call.

20031

A. Based on random observation, interview, and policy review, the provider failed to ensure and/or follow recommended practices for sterilization, disinfection, and management of the surgical and procedural areas as evidenced by:
*The soiled scopes were cleaned in one of one procedure room and then carried to the ante room of the operation suite.
*Improper traffic flow used between the scope procedure room and the central sterilization (CS) area.
*No hair attire worn in one of one CS area.
*Street clothes were not completely covered in one of one CS area and restricted areas.
*The same gowns were worn between dirty, clean, and sterile areas.
*A large plastic barrel used to store soiled linen in the hall and was covered with a patient gown.
*One of one bottle of Cidex test strips not labeled with an open date.
*One of one scope cabinet not provided with ventilation ports.
*No distinct separation of clean and sterile areas in one of one CS.
*A desk and office chair located in one of one CS semi-restricted area.
*Routine unrestricted traffic not restricted from the procedure room, operating room suite, or surgical area.
*A clean gurney stored in the hall.
*A recall procedure not in place to track instruments for one of one CS.
Findings include:

Surveyor: 26632
1. Observation on 11/19/14 from 9:30 a.m. through 10:00 a.m. revealed:
*Licensed practical nurse (LPN) S placed a used colonoscope in a plastic tub in the procedure room.
The colonoscope had been used in that procedure room during a colonoscopy.
*The plastic tub had been filled with water and an enzymatic cleaning agent.
*LPN S cleaned the used colonoscope and then rinsed it in the hand washing sink in that procedure room. She then dumped the contaminated enzymatic cleaner into the hand washing sink.
*LPN S then carried the colonoscope uncovered on top of the plastic lid of the tub.
*She took it through the hall from the procedure room, through the CS area, and into the ante room of the surgical suite.
*She then placed it into the Steris machine (automatic disinfection machine).
*While she did those steps she was still wearing the gown she had worn during the colonoscope procedure.
*She also had the same shoe covers on she had worn during the colonoscope procedure.
*A large plastic barrel was used for soiled linen from the procedure room. That barrel was stored in the hall outside of the room and was covered with a patient gown.
*An open bottle of Cidex test strips was noted in the drawer beneath the automatic disinfection machine. Those test strips had not been labeled with an open date.

2. Observation, tour, and interview on 11/19/14 from 10:00 a.m. through 10:30 a.m. with registered nurse (RN) C of the surgical and sterilization area revealed:
*This surveyor and surveyor 32572 had only been asked to put a patient gown on over street clothes.
*No hair cover was offered.
*RN C took this surveyor and surveyor 32572 through the central sterilization room into the surgical ante room where shoe covers were put on.
*We toured the operating suite, soiled utility room, and the central sterilization room with this attire on.
*RN C had been asked before we entered those areas what attire was to have been worn. She stated since there was no surgical case for that day just a clothes cover and shoe covers were all that were necessary.

Surveyor: 20031
3. Observation and interview on 11/19/14 from 3:00 p.m. through 4:30 p.m. with RN C revealed:
a. The 2014 Association of periOperative Registered Nurses (AORN) standards and recommended practices were used in the surgical, procedural, and CS areas.
b. She was asked what the provider expected for attire in the CS area. RN C stated she only required cover gowns over street attire and stated she kept those gowns in the hall, so staff could place them over their uniforms or clothes before they entered (photo 27) the above areas. She had no set time when those gowns in the hall were considered soiled and replaced with new ones. She did not require a hair cover or shoe covers in the CS area or ante area to the OR.
c. She confirmed the above procedure room observation:
-The colonoscopes were cleaned with enzymatic cleaner in a tote in the procedure room.
-They were then rinsed in the handwashing sink.
-The contaminated cleaner was poured down the drain of the hand sink.
-They were brought across the hall, through the clean area of CS, into the ante room for the OR, and then hooked up to the Steris (automatic scope disinfection machine).
-She was unaware if that handsink was cleaned prior to the next case.
-The dirty linen, gowns, and surgical attire were placed into a large soiled linen container. That container was covered with a patient gown and was located in the hall.
d. She confirmed she had not dated the opened bottle of Cidex test strips. She was aware she must date the bottle once it was opened. She was not aware the clean scope cabinet in the procedure room must have ventilation ports.
e. She confirmed there was no separation of clean and sterile (semi-restricted and restricted) in the CS area. She stated she kept a desk and her paperwork in the restricted CS area so she could get work done while the instruments were being processed.
f. She confirmed there was no signage on the procedure room door, OR room doors, or CS to restrict traffic into those areas. There was signage "Employees Only" on the cross-corridor doors in the east and south hall that led to CS and the surgical and procedure areas. Those halls led from the common areas, and the signage could not be seen when the doors were propped against the wall. The one sign on the CS door stated "PLEASE.... Remember to wear your cover gown. Thank you!" (photo 27).
g. She confirmed a clean gurney, set up for the next day, sat in the hall unprotected outside of the procedure room.
h. She stated she ran a biological test weekly.
-She revealed she would have to "run" around the entire hospital and the clinic to find instruments if there was a failed biological test.
-She did not keep a record or a log of the instruments that were sterilized daily or weekly.
-She stated the instrument packages had a sterilization date and number.
-Those items were what they would have to look for if there was a recall.
-She stated they would also have to unwrap instrument sets to ensure an instrument on the recall was not inside the set.
-She stated she could not ensure a possible recalled instrument or instrument set would not be used during the week in the hospital.

Review of the CS infection control policies and procedures obtained from RN C with no issued date revealed:
"When entering the area, a clean gown should be worn over the uniform."
"Recall of supplies will be necessary if biological indicators are positive or if chemical indicators do not indicate sterility. All items sterilized on that date will be recalled by CSR staff."
No other policies or procedures related to the above items were given to this surveyor by RN C.

Review of the 2014 AORN standards and recommended practices revealed:
*Facility-approved, clean, and freshly laundered or disposable surgical attire should have been put daily in designated dressing areas before entry or reentry into the semi-restricted and restricted areas.
*The semi-restricted area personnel were required to wear surgical attire and cover all hair and facial hair.
*Traffic patterns should have included the following:
-Patient privacy.
-Patient, personnel, and visitor safety should have been ensured.
-Supplies and equipment should have been protected from tampering and theft.
*The surgical suite should have been divided into three designated areas that were defined by the physical activities performed in each area. Increasing environmental controls and surgical attire as progression was made from unrestricted to restricted area decreased the potential for cross-contamination.
*During transport to the decontamination area soiled flexible endoscopes must be contained (such as enclosed by a plastic bag container or with a lid) in a manner to prevent exposure.
*Flexible endoscopes should have been stored in a closed cabinet with venting that allowed air circulation around the flexible endoscopes.
*Flexible endoscopes and accessories should not have been decontaminated in scrub or hand sinks. Cleaning soiled instruments in a scrub or hand sink could contaminate the sink and faucet.
*Information should have been recorded from each sterilization cycle and should have included the load contents (such as major set, Kelly clamps).

B. Based on observation, testing, interview, cleaning checklists, preventive maintenance checklists, and policy review, the provider failed to comply with proper hygiene, food handling practices, and sanitation in one of one main kitchen and three of three patient rooms (209, 211, and 213) as evidenced by the following:
*Improper handwashing and glove application.
*Uncleanliness and unapproved construction of food contact surfaces:
-The Kitchen Aide mixer.
-The Hobart mixer.
-The can opener.
-The cardboard self-service condiment box.
-The foil lined cardboard potato chip box.
-Approximately twenty-five percent of the melamine resin (hard plastic) serving trays were chipped or cracked.
*Uncleanliness, disrepair, and unapproved construction of non-food contact surfaces:
-The filters and the hood over the range.
-The inside and outside of the convection oven.
-The dishwasher hood.
-The metal legs of two of two preparation tables.
-Layers of ice and frost on the walk-in freezer ceiling and around the condenser.
-Cloth kitchen towels were used to cover the slicer, the Hobart mixer, and a container of dinner rolls.
-A cardboard box was used to hold silverware containers.
*Improper food storage and display:
-Box of watermelon on the floor in the walk-in cooler.
-Four boxes of frozen vegetables on the floor in the walk-in freezer.
-Common use tubs of margarine in the dining room.
*Uncleanliness and disrepair of the floors, walls, and ceilings:
-Floors and walls throughout the kitchen, dishwashing room, and janitor's closet were in need of a deep cleaning or repair.
-Ceiling vent grates were covered with layers of dust.
*Unshielded light bulb in the walk-in cooler.
*No knowledge of how to use sanitizer test strips.
*No implementation of checking cold food temperatures during preparation, holding, or service.
*A plastic bucket on top of a light was used to catch water from a leaking roof.
*Three of three patient rooms (209, 211, and 213) had small kitchenettes that were cleaned with a disinfectant.
Findings include:

1. Observation on 11/18/14 from 9:45 a.m. to 10:45 a.m. and 11:15 a.m. to 11:45 a.m., and on 11/19/14 from 9:35 a.m. to 10:00 a.m. and again at 3:00 p.m. revealed:
a. Employees M, P, and Q would randomly:
-Go between different work stations.
-Complete tasks in different food preparation areas.
-Set-up food trays for the patients.
-Serve food at the cafeteria window.
-Leave the kitchen and reenter the kitchen.
-Go to the store room.
-Take work breaks in the cafeteria.
-Load dirty dishes in the dishwasher and then unload the clean dishes.
-Wash dirty pots, pans, and utensils in the three compartment sink and then restock those clean pots, pans, and utensils.

Interview on 11/18/14 at 10:45 with employees M, P, and Q revealed they had been trained by their dietary manager and the registered dietician/licensed nutritionist (RD/LN). The had been trained about proper handwashing and when to wash their hands.

Those same employees, at the same above times and dates, would apply new gloves from boxes located throughout the kitchen. They would apply those gloves whenever they would prepare, serve, or handle food. At no time was it witnessed those employees washed their hands after removing their soiled gloves or before applying new gloves.

Interview on 11/18/14 at 10:45 a.m. with employees M, P, and Q confirmed it was easier to have several boxes of gloves around the kitchen. That way they could just apply them when needed. They also confirmed they had been trained by their dietary manager and the RD/LN about proper glove use and to wash their hands before applying new gloves.

b. The Kitchen Aide mixer had splattered food debris of varying colors that had dried on the underside (splash area) of the mixer (photo 9). The large Hobart mixer also had splattered and dried colored food debris on the guard over the bowl (photo 10). The can opener had jelled food debris and metal shavings on the blade and surrounding area. Interview with cook M at the time of the observation confirmed those findings. He stated staff were to wash all the areas of the mixers after they were done with them. The can opener was to be washed as often as needed.

Self-service condiments were stored in a reused cardboard box with dividers (photo 6). Bags of potato chips were stored in a foil lined reused cardboard box (photo 29). Interview with cook M at the time of the observation confirmed those findings. He stated he was not aware cardboard boxes could not be reused for food or non-food storage.

Approximately twenty-five percent of the melamine resin serving and cup trays were cracked or chipped. Interview with cook M at the time of the observation confirmed those findings. He stated those serving trays and cup trays had been in-use since he had started over ten years ago.

c. The filters in the range hood and the hood itself were layered with globs of grease and lint covered grease (photos 7 and 8). The globs and strings of grease had dripped onto surfaces below the hood. Interview with cook M at the time of the observation confirmed those findings. He stated he could not remember the last time the hood had been cleaned.

The motor guard and casing outside of the convection oven was covered with lint and grease. The inside vent guard of the motor had dried and burned debris on it. The inside of the convection oven had a variety of dried and solid debris that had overflowed or burned onto it (photo 11). Interview with cook M at the time of the observation confirmed those findings. He stated they had a cleaning checklist for each month, and the stoves were on that list.

The dishwasher hood had layers and globs of congealed lint and debris inside the hood and up the shaft (photo 3). The inside of that hood and the edges were rusted (photo 4). Interview with cook M at the time of the observation confirmed those findings. He stated the hood did not work very well, and it was supposed to be repaired. He stated he could not remember the last time the hood had been cleaned.

Two metal set prep tables had chipped white paint that revealed the metal surface on all four legs of each table. The paint was so sparse there was more metal than paint (photo 5). Interview with cook M and dietary aide P at the time of the observation confirmed those findings.

Layers of ice and frost had built-up on the ceiling around the condenser in the walk-in freezer. The ice and frost was approximately three inches thick and as big as a large bath towel (photo 15). Interview with cook M at the time of the observation confirmed that finding. He stated they had cleaned the ice and frost off the ceiling once before months ago, and it just kept coming back.

Cloth kitchen towels were used to cover the slicer, two mixers, and a large container of old dinner rolls (photo 16). Interview with cook M at the time of the observation confirmed those findings. He stated he was not aware cloth towels could not be used to cover equipment and food containers. Interview on 11/19/14 at 10:45 a.m. with the RD/LN revealed she was aware towels could not be used to cover equipment and food containers.

d. A box with a watermelon was stored directly on the floor in the walk-in cooler. Three boxes of vegetables and a box of meat was stored directly on the floor in the walk-in freezer. Interview with cook M at the time of the observation confirmed those findings. He stated they simply did not have enough room and some food would get stored on the floor.

Small tubs of margarine were in-use on the dining room tables. A large tub of margarine was in-use by the toaster. Interview on 11/19/14 at 10:45 a.m. with the RD/LN revealed she was not aware common use tubs of margarine could not be used due to possible contamination by users.

e. The floors throughout the kitchen, dishwashing room, and janitor's closet were in need of a deep cleaning. The floors had layers of debris and filth that had piled into the corners and under the equipment (photos 1 and 17). The wall in the dishwashing room had a large amount of crumbled plaster (photo 2).

The following was noted in the janitor's closet:
-The paper had been torn from the gypsum board from a previous chemical supply machine (photo 13).
-The shelf was bulged and had exposed raw wood (photo 14).
-The floor sink had missing and eroded caulk around the edge.

The ceiling vent grates throughout the kitchen and in the janitor's closet were clogged and covered with lint and debris (photos 12 and 28).

f. The incandescent light bulb in the walk-in cooler had no cover, and that bulb was not shatter resistant. Interview with cook M at the time of the observation confirmed that finding. He stated he was not aware the cover was missing from the light bulb.

g. Cook M located a container of test strips used to monitor the correct concentration of quaternary sanitizer used throughout the kitchen. The test strips had turned from orange to white from exposure to light. Interview with cook M at the time of the observation confirmed that finding. He stated neither he nor the aides used those strips, as the sanitizer was mixed automatically to the right solution. Neither cook M nor the two kitchen aides P and Q knew how to use the test strips. This surveyor then educated those employees on how to check the sanitizer for proper concentration levels.

h. Observation of cook M during the noon meal service revealed he had taken temperatures of the hot food on the steam table. He stated he never took the temperatures of the cold food during preparation, holding, or service, because "it was already cold."

i. A plastic ice cream bucket sat on top of a light fixture in the kitchen. Interview with cook M at the time of the observation revealed that bucket was used to catch water from a leak in the ceiling. He stated he thought the roof had been fixed but could not remember for sure.

j. Patient rooms 209, 211, and 213 had small kitchenettes that included coffee pots, microwaves, and dorm size refrigerators. Interview with the housekeeping supervisor at the time of the observation revealed her staff were responsible for cleaning those items. She stated they used the same disinfectant as was used in the rooms. She was not aware a food grade sanitizer must be used for food service appliances.

2. Interview on 11/19/14 at 10:45 a.m. with the RD/LN revealed she was aware the dietary manager (DM) was out sick. She stated the lack of cleanliness was not due to the DM being gone. She confirmed she had noticed the cleanliness had continued to get bad over the last few months. She stated she was not aware staff were not properly washing their hands or applying gloves. She stated staff were also aware of correct food storage, taking both hot and cold temperatures, and the use of sanitizer test strips. She stated she knew the DM had monthly meetings with the staff but was not aware of any subjects she covered in those meetings. She revealed she had held training yearly in a variety of subjects that covered almost everything in the kitchen. She also stated she and the DM used the state food code for guidelines in the kitchen and service areas.

Review of the cleaning checklist for November 2014 revealed the only item to be cleaned monthly was the convection oven.

Review of the dietary policy and procedure manual reviewed, revised, and updated 1/24/14 revealed the following:
*"Careful handwashing by personnel is of prime importance in disease control:
1. When beginning work.
2. Between handling of dirty dishes or equipment and handling clean food utensils.
3. After toilet use.
4. After break.
5. Between handling of cooked and uncooked food."
*"Equipment: Grease filter located in the hood: 1. Clean with detergent and the end of each week to remove obvious grease and soil. This done by maintenance personnel."
*"Storage refrigerators - walk-in cooler: C. Boxes of food shall not be stored on the floor of the refrigerator."
*"Housekeeping and Sanitation: B. Floors should be moped daily with a detergent approved by the Infection Control Committee."
*"3. Care of clean dishes. Always wash your hands before you touch the clean dishes."
*5. Keep the machine and dishwasher area clean. Scrub the dish tables, rack and floors each day."
*"Cleaning Schedule:
Walls and Floors - Daily - Kitchen Staff.
Can opener - 3 times/day - Cook.
Ovens - 1 time/month - Morning and Afternoon Cook.
Walk-in Freezer - 2 times/year - Kitchen staff."
*Defrosting walk-in freezer: Purpose: To clean the unit enabling it to work more efficiently."

Review of the handwashing policy for nutritional services revised on 12/23/08 revealed:
"Handwashing: 1. Before coming on duty (after changing your clothes and/or putting on your hair net.) 3. After each restroom visit, smoking eating, leaving or returning to the kitchen, handling any unclean object (such as dirty dishes, money, telephone, garbage or trash, door handles, cupboard doors or touching chemicals.)"

Review of the undated PM checklist provided by the director of plant operations revealed:
"KITCHEN:
-Filters on exhaust hood over stove: 1. Clean and treat once a week. 2. Clean exhaust hood once a week.
-Refrigerator and deep freeze units: 2. Clean once every 3 weeks."

C. Based on observation, document review, and interview, the provider failed to ensure the contracted laundry service used a disinfection process for the hospital laundry. Findings include:

1. Review of a letter dated 9/3/13 from the contracted laundry service to the provider revealed it pertained to an increase in rates. It gave no information to what type of disinfection procedure was used for the laundry process. It also gave no direction as to how the dirty and clean laundry was transported.

Review of additional information from the laundry contractor revealed a copy of a facsimile (fax) sheet sent to another business by the laundry contractor. The handwritten notes on the fax cover sheet were "In your case we use hydrogen peroxide in place of chlorine to preserve color. But it is still a bleach." The information contained in the attached letter with the fax stated: "Formulas vary a great deal given what they are used for. Will heat up to 154-157 F (Fahrenheit) for the alkali and detergent. Than will cool down to about 140 F or less for the bleaching step. Than it is heated up again for the final rinses. To some extent we follow the guidelines for healthcare linen services provided by the Joint Commission on Accredidation of Healthcare Organizations. But these guidelines are a little outdated since they were introduced in 1993!"

No other information was provided to ensure the hydrogen peroxide was registered with the Environmental Protection Agency as a disinfectant. Nor was there any further information to ensure the final rinse temperature was at least 160 degrees F.

No policy could be provided at the time of survey for the handling, storage, processing, and delivery of dirty and clean laundry.

Surveyor: 26632
D. Based on observation, interview, and policy review, the provider failed to ensure one of one certified registered nurse anesthetist (CRNA) (R) had labeled pre-drawn injectable medications in one of one anesthesia medication cart (procedure room). Findings include:

1. Observation on 11/19/14 at 9:30 a.m. of the procedure room anesthesia medication cart revealed pre-drawn injection medication that included:
*Two syringes of Versed (pre-operative sedative).
*Two syringes of Fentanyl (narcotic pain medication).
*One syringe of succinylcholine (general anesthetic).
*On syringe of rocuronium (general anesthetic).
*One syringe of Neo-Synephrine (to treat low blood pressure during surgery).
*Those syringes had been labeled only as to what they contained.
*There was no date or time that indicated when they had been drawn up.
*There were no initials that indicated who had drawn them up.

Interview on 11/19/14 at 9:30 a.m. with CRNA R revealed:
*She had drawn the above medications up earlier that morning.
*She had been running late so had not put the date, time, or her initials on the syringes.
*She was aware the medications should have been labeled with the medication name, date, time, and initials of who had drawn up the medication.

Review of the provider's revised December 2009 medication administration policy revealed no procedure for the labeling, dating, timing, or initialing of pre-drawn medications.

E. Based on record review, interview, and policy review, the provider failed to ensure 6 of 13 sampled patients' (48, 50, 51, 52, 54, and 55) inpatient care plans had been written and/or revised to ensure all patients' needs had been identified. Findings include:

1. Review of patient 48's medical record for his hospital stay from 1/16/14 through 1/21/14 revealed:
*Diagnoses included alcohol withdrawal, closed fracture of great toe, cellulitis, and diabetes mellitus.
*His plan of care only addressed a risk for falls.

2. Review of patient 50's medical record for his 9/18/14 hospital stay revealed:
*Diagnoses included alcohol intoxication, attempted suicide by hanging, depression, and diabetes mellitus.
*His plan of care only addressed anxiety, altered coping, and stress tolerance.

3. Review of patient 51's medical record for his hospital stay from 6/22/14 through 6/24/14 revealed:
*Diagnoses included chest pain, hyponatremia (low sodium in blood), and rib fractures.
*His plan of care only addressed pain.

4. Review of patient 52's medical record for her hospital stay from 7/02/14 through 7/04/14 revealed:
*Diagnoses included pneumonia, diabetes mellitus, fever, and hemiplegia (one sided weakness) from a previous stroke.
*Her plan of care only addressed potential for or actual impaired skin integrity and ineffective airway clearance.

5. Review of patient 54's medical record for her hospital stay from 8/02/14 through 8/04/14 revealed:
*Diagnoses included acute kidney injury, diabetes mellitus, sepsis, and pyelonephritis.
*Her plan of care only addressed alteration in comfort.

6. Review of patient 55's medical record for his hospital stay from 9/17/14 through 9/23/14 revealed:
*Diagnoses included acute urinary tract infection, fever, and urinary retention.
*His plan of care only addressed risk of falls.

7. Interview on 11/20/14 at 8:55 a.m. with the registered nurse/quality assurance performance improvement director revealed:*The night shift nurses were responsible for completing, reviewing, and updating the plans of care for all patients.
*When time allowed the admitting nurse was to initiate the plan of care.
*She agreed the plans of care for patients 48, 50, 51, 52, 54, and 55 did not reflect most of their needs based on their admitting diagnoses.
*She stated no audits had been completed for plans of care.
*The electronic medical record (EMR) did not reflect the nursing assessments into the plan of care.
*The revised May 2006 Care Planning policy did not reflect the EMR plan of care. It only had how to put the care plan on the Kardex.

Review of the provider's revised May 2006 Care Planning policy revealed:
*An individualized plan of care for each patient was to have been developed by the patient care team.
*The care planning process included patient assessments, goal setting, interventions, referrals, evaluation of patient responses to treatment, and revision of care and treatment
*The patients' nursing care needs were to have been determined through the patient assessment process.
*Medical and nursing orders on the Kardex represented the current plan of care.

Surveyor: 20031
F. Based on random observation, testing, and interview, the provider failed to ensure the following areas/items were maintained, cleanable, and/or in good repair:
*Intensive care units (ICU) one of three rooms (four) Carecliner had ripped and torn vinyl on the arm rests.
*One of one tub room for ICU had two chairs with uncleanable untreated wooden arm rests.
*Floor mop sinks in five of five random fill rooms throughout the hospital held the open jug of disinfectant.
Findings include:

1. Observation on 11/18/14 from 2:00 p.m. to 4:45 p.m. revealed:
a. ICU room four's Carecliner had ripped and torn vinyl on the arms (photo 23). Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She agreed it was not a cleanable surface and could create a possible skin tear.
b. The two office chairs in the ICU tub room had worn unsealed wooden arm rests (photo 24). Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She agreed it was not a cleanable surface. She relayed she had no idea why those chairs were used in the tub room.
c. Five fill rooms were used by housekeeping and randomly located throughout the hospital. A one gallon jug of disinfectant sat in the bottom of the basin of the floor mop sink (photo 20). Upon removal of the bucket that covered the jug of disinfectant, it was noted there were soiled drops and splashes on the neck and opening. Interview with the housekeeping supervisor at the time of the observation confirmed that finding. She revealed that was the disinfectant used throughout the hospital. She agreed it was not a good practice to sit the opened jug of disinfectant on the bottom of the floor mop sink basin. She also confirmed the pure chemical might have become contaminated from splash and spill of the contaminated water dumped into that floor sink.

Continued interview at 4:45 p.m. on that same day with the housekeeping supervisor revealed her staff would let maintenance know of any concerns or repairs needed in the patients rooms or patient areas. She stated she had relied on her staff to deliver any maintenance concerns to the proper department.

Interview on 11/20/14 at 8:55 a.m. with the director of plant operations revealed he had no preventive maintenance (PM) checklist for the floors, walls, ceilings and other environmental concerns throughout the hospital. He did have a PM checklist for the equipment located throughout the hospital. He also had no system for work orders. He stated if the staff needed something they would just pick up the phone and call.