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Based on interview and document review the facility failed to complete 6 of the 12 required fire drills. The 6 fire drills conducted were on the night shift. The facility failed to provide a fire drill policy.

On 5/13/2015 at 9:00 a.m. during an interview in the office of the Plant Operations Director (POD), the POD confirmed he had not completed the required 12 fire drills. POD stated he had gotten behind and been unable to catch up.

On 5/13/2015 in the conference room the facilities policies for Fire Safety were reviewed and no policy requiring fire drills was identified. Further review of the fire drill documentation revealed the following drills were completed on:
1/8/2014 at 5:25 a.m.
2/20/2014 at 4:59 a.m.
4/9/2014 at 5:05 a.m.
5/31/2014 at 5:16 a.m.
8/16/2014 at 5:35 a.m.
9/20/2014 at 6:05 a.m.

All drills were documented as conducted on the 7 p.m.-7 a.m. (Night) shift. No fire drills were documented on the 7a.m.-7 p.m. (day) shift.

On 5/13/2015 at 10:30 a.m. at the nurses station random nurse were interviewed and all agreed fire drills were conducted but normally on the night shift.

Based on observation the facility failed to maintain food at a safe temperature. The facility provided no policy establishing safe temperature parameters for food handling. Food was observed un-covered and open to the enviornment of the kitchen.

On 5/12/2015 at 9:00 a.m. during a tour of the dietary department, given by the Dietary Supervisor a three (3) tiered stainless steel food cart was observed as follows: The top shelf held one (1) steam table sized stainless steel pan full of chopped mixed vegetables. The vegetables were not covered. The second shelf looked identical to the first shelf. On the lower shelf of the cart was a steam tables sized stainless steel pan of fish steaks in water. The water did not have ice in it and the fish was not covered.

The pan felt cool to touch. The cook was asked to use the kitchen thermometer and check the temperature. The cook read the thermometer at 68 degrees. When she was told the temperature was too warm to hold fish and the fish should be iced down she replied, "I'm fixing to work with it does it still need ice". This was witnessed by the Dietary Supervisor. The fish was rinsed and iced.

The recommended safe holding temperature for raw fish is 40 degrees, per the United States Department of Agriculture. Fish that has been thawed should be used within two (2) days and should be kept in refrigeration at 40 degrees. The Fish should be cooked within 30 minutes of removal from refrigeration.

On 5/12/2015 at 10:30 a.m. in the conference room the dietary policies were reviewed and found no policy establishing holding temperatures for raw fish.

Based on document review and interview the facility failed to insure the Anesthesia provider conducted and documented a post anesthesia evaluation on 1 (#24) of 4 surgery patients reviewed. (#6,#7,#24 and #30)

On 5/14/2015 at 1:00 p.m. in a front office the Medical Records (MR) for surgery patients #6,#7,#24 and #30 were reviewed and the following was identified: Pt # 24 had no post anesthesia evaluation documented on the form which contained both pre-evaluation and post-evaluation headings. The Signature was not legible.

The above findings were confirmed by the informatics specialist who was assisting in the electronic MR review.

Based on interview and document review, the facility failed to provide documentation that all patient care service departments were evaluated through an effective quality assurance program.

On 05/11/2015 at 9:30 a.m. in the Imaging Department director's office, an interview conducted with staff #25 revealed the radiology department was not participating in the facility's quality assurance program. When asked how the hospital ensured that radiology services were provided consistent with acceptable standards of practice, staff #25 revealed the radiology department was not participating in the quality assurance program.