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Based on observation, interview and policy review the facility failed to ensure drugs commonly used in life-saving procedures (Lidocaine) were readily available for treating emergency cases.
The findings include:
1. A tour of the emergency department was conducted with a Licensed Practical Nurse (LPN) on 10/18/2010 at approximately 9:10AM. During the tour the contents of the adult crash cart located in the trauma room were observed in the presence of the LPN. The crash cart contained 2-250 ml bags of 1 gram Lidocaine 4 mg/ml that expired October 1, 2010. The expired medication was verified by the LPN.
2. The facility Crash Cart Policy and Procedure (revised June 2010) was reviewed on 10/19/2010. The policy states, " The facility pharmacist is responsible for reviewing the crash carts throughout the facility on a weekly basis and signing off on the PAR level sheet in the affixed binder placed with the corresponding crash cart. During the review of the crash carts if a medication is noted to be expired or will be expiring prior to the pharmacist visit, remove the medication and place in the bin in the pharmacy labeled expired medications to be returned, do not throw them away the hospital does get credit for returning out of date medications. "
3. An interview was conducted with the pharmacist on 10/19/2010 at approximately 12:20 PM. The pharmacist stated the policy and procedure concerning her checking the crash carts weekly for expired medications could not be fulfilled as she was not contracted to be at the hospital weekly.

Based on observation and interview, the facility failed to dispose of garbage and refuse properly to prevent the harborage and feeding of pests.

The findings:

On 10/19/10 at approximately 8:45a.m., the outside dumpster was viewed by two surveyors. The ground around the dumpster was littered with debris. The debris included items such as bones, bottles, cigarette butts, egg shells, and a cake box. The cake box was observed to be infested with ants and a roach.

The dumpster had six lids, three of which were standing wide open. A live mouse was observed inside the dumpster. The mouse was stuck to an adhesive type trap, and the trap was on top of a bag of garbage. The mouse appeared to have been caught elsewhere in the facility and thrown into the dumpster.

On 10/19/10 at approximately 8:55a.m., the dumpster was viewed with the Maintenance Director. The Maintenance Director observed the mouse caught in the adhesive trap. The Maintenance Director stated that the pest man puts out traps. He did not know where the mouse was caught.

Based on observation and interview, the facility failed to keep the premises clean and orderly.

The findings:

On 10/18/10 beginning at approximately 10:08 AM, an observation of the Radiology department was conducted. In the main X-Ray room there were two vents that were blocked by material resembling a pillow. The vent on left was surrounded by a blackish substance. The next room had an air vent in the ceiling. There was blackish material on the ceiling around the vent. The bathroom had a panel of the drop-down ceiling removed, providing access to the ductwork. The call bell in the bathroom did not work.

An interview was conducted with the Director of Radiology during the observation. The Director stated that the bathroom is primarily for staff, but occasionally patients do use it. A staff member is in the immediate vicinity when patients use the bathroom.

On 10/18/10 beginning at approximately 11:15 AM, an observation of the Computerized Tomography (CT) room was conducted. The room was observed to have three ceiling vents. The vent near the front was covered in dust. The two vents in the back of room had a brownish substance on them.

On 10/18/10 at approximately 11:08 AM, the female bathroom in the main waiting area was observed to have a dusty ceiling vent and the bottom right side of the door frame appeared to be rusted.

On 10/18/10 beginning at approximately 12:36 PM, a tour of the kitchen was conducted. In the main kitchen, near the wall by the dish-room, was a vertical duct that extended floor to ceiling. The duct was covered with thick dust. There were several ventilation grates near the top of the duct. The grates were covered in a black substance that easily wiped off.

There was a stand-up type fan near the duct that was covered in dust.

Near the fan was an ice dispenser. The top of the dispenser was covered with dust.

The lid of the Deep Freezer was covered with visible dirt that easily washed off.

There was dust on the back of the stove and behind the stove on electrical wiring, ductwork, and the wall.

The floor under the stove had debris and a thick discolored build-up. Debris and discolored build-up was also observed on the floor under the counter tops which ran along the wall.

An interview was conducted with the Dietary Manager (DM) during the tour. The DM stated that the kitchen was cleaned by the weekend dietary staff. The DM stated that the housekeeping department did not clean the kitchen, dietary staff were required to do this.

On 10/19/10 at approximately 9:40 AM, a follow-up interview was conducted with the Dietary Manager. The Manager stated that no logs or checklists were utilized for routine cleaning of equipment in the kitchen to include refrigerators, freezers, walls, and floors. The DM stated that cleaning logs had not been used for a couple of years, and that she was waiting for the Dietician to make a new cleaning checklist.

Based on observation, interview and record review, the facility failed to ensure that the governing body was monitoring policy development and implementation in the Dietary Department and failed to ensure that all medical staff were selected, or maintained , based on selected criteria for character, competence, training, experience, and individual judgement, for 5 of 5 medical staff selected for review.

The findings:

1. On 10/18/10 beginning at approximately 12:36 PM., an observation of the kitchen area was conducted. The walk-in refrigerator was observed to have pooled water and condensation dripping on food items. Dirt and debris was observed on the floors under appliances and in the bottom of refrigeration units. There was dust on equipment, walls and ducts.
A record review of the Dietary Policies and Procedures Manual was conducted. There were four different forms in the book for Kitchen inspections. There were no dates on the forms, and no policies developed to go with the forms. It was impossible to tell which form was currently in use and how often the inspections should be conducted. There was a form for key staff to sign indicating that the Dietary policies had been reviewed. The form had not been signed by the Chief of Staff, the Administrator or the Dietary Manager. The form was signed by a Director of Nursing who had not been employed at the facility for approximately 3 years. See C 280.

The Governing Body failed to ensure that kitchen sanitation and equipment issues were incorporated into the Quality Assurance (QA) Committee meetings. On 10/19/10 at approximately 1:13 PM., and interview was conduction with the QA Coordinator. The QA coordinator stated that the Dietician had not given the sanitation inspection reports to the QA committee. Dietary has not reported any concerns to the QA committee regarding the kitchen.



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2. On 10/19/2010, at 9:00 am a review of 5 medical staff (4 Medical Doctors and one Certified Registered Nurse Anesthetist (CRNA) credentialing files were conducted.
MD #1, was reappointed by the governing body for a two year period starting on 12/15/2009. There was no quality assurance or case reviews evident for this reappointment.
MD #2, was reappointed by the governing body for a two year period starting on 1/1/2010. There was not quality assurance or case reviews evident for this reappointment.
MD#3, was originally appointed by the governing body for a two year period starting on 4/26/2010. There were no measures selected for review of this physician.
MD #4, was originally temporarily appointed by the governing body starting on 9/17/2010. There were no measures selected for review of this physician.
CRNA #1, was originally temporarily appointed by the governing body starting on 9/1/2010. There were no measures selected for review of this mid-level practitioner.
On 10/19/2010, at 11:00, interviews of the assigned staff to credentialing were conducted. She stated that there is nothing of quality assurance or case evaluations in her files. She stated that the QA Coordinator may know about this. Interview was conducted with the QA Coordinator. She stated they no longer do any case review for quality. She stated that only the Medicaid patients ' cases are reviewed . Further, she stated that no case reviews have been completed. When asked if criteria had been selected for appointments or reappointments; she said there were none

Based on observation, interview, and record review, it was determined the hospital failed to ensure the provision of services related to medication storage (refer to C 276); failed to ensure sanitary food storage and the development of dietary policies (refer to 279 and C 280); failed to ensure nursing services were provided in accordance with standards of practice and hospital policy (refer to C 296, C 297, C 298). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and record review it was determined the hospital failed to ensure an accurate accounting of medications stored in the anesthesia cart.

Findings:

1) A tour of the Endoscopy suite was conducted on 10/19/2010 at 2:00 PM. A single anesthesia cart was observed and opened by the endoscopy Registered Nurse (RN). The cart was noted to contain 2 drawers with assorted medications used during endoscopy procedures. On top of the cart was the anesthesia medication log. The log was reviewed and did not contain any current count of the contents in the cart.

2) An interview was conducted at this time with the endoscopy RN and she stated she used a personal "worksheet" to keep the count. The worksheet revealed 2 columns listing the count of each medication. One column was dated 10/6/2010 and the second column was undated. There was a discrepancy between the 2 columns regarding Lidocaine 2% and Propofol. The RN stated the documentation of the counts was completed by outside Nurse Anesthetists that had privileges at the hospital but were not hospital employees. The form did not contain any persons name or title. The RN had no explanation of why the counts did not match or why there was no date on the first column.

3) An interview was conducted on 10/19/2010 at 12:20 PM with the hospital's consultant Pharmacist. She was provided a copy of the anesthesia work sheet for review. The pharmacist stated the hospital should maintain an accurate count of the medications at all times and was not aware outside practitioners were counting hospital medications.

Based on observation, interview and record review, the facility failed to ensure that nutritional needs were met in accordance with recognized dietary practices. Food was not stored in a sanitary environment. Food storage areas were not kept properly cleaned. Food items were exposed to water dripping from the condenser in the walk-in refrigerator.

The findings:

1. Walk-in Refrigerator
On 10/18/10 at approximately 8:45a.m., a brief initial kitchen tour was conducted with the Dietary Manger (DM). The walk-in refrigerator was observed to have pooled water in the corner across from the door. The area of pooled water measured approximately 2 feet square and about 1 inch deep. An interview was conducted the DM. The DM stated that the staff have to keep sweeping the water out, and that it pools about an inch deep. The DM stated that she did not know where the water was coming from.

On 10/18/10 beginning at approximately 12:36 PM., a follow-up kitchen tour was conducted with the Dietary Manager. The fan/condenser of the walk- in refrigerator was observed to have water dripping from it. There was a large open cooler under the left side of the condenser. Several inches of water had collected in the cooler. Water was also observed on the floor of the refrigerator under the condenser. The water was running along the side of the cooler and pooling in a corner on the opposite end near the entrance. The puddle was about an inch deep. There was corrosion on the floor of the cooler. The water dripping from the right side of the condenser was passing over food items and through storage shelves. The water was observed to be dripping directly on heads of cabbage on the bottom shelf. Water was also dripping on gallon size jars of mustard, pickles, and jalapeno peppers. Water was dripping on a box containing individual servings of salad dressing. The Dietary Manager (DM) stated that the cabbages would be returned.

There was a box containing several single-service containers of sour cream. (about 24). About half of the containers had expired on Sept 28, 2010. The other half had no date on them. A box of lettuce that appeared to be spoiling (yellow mushy outer leaves) was observed on the bottom shelf. The Dietary Manager (DM) stated that the lettuce was being held to return to the supplier. There was no label or other marking on the box to indicate the lettuce should not be used.

An observation of the walk-in refrigerator was conducted with the Maintenance Director the next day, 10/19/10 at approximately 8:15 AM. The puddle of pooled water was larger, measuring approximately 3 feet by 2 feet. Water was continuing to drip on the mustard, pickles, jalapeno peppers, the box of salad dressing and the cabbage. There was no label on the cabbage indicating that it was not to be used. The cooler under the left side of the condenser had about 3 inches of water in it. The Maintenance Director was aware of the problem. He stated that the refrigerator was as old as the hospital. It was bricked into place, and had several inches of concrete over it. The manufacturer was no longer in existence and parts were unavailable. The drainage line had been checked, and was functioning properly.

On 10/19/10 at approximately 1:30 PM., a final observation of the walk-in refrigerator was conducted. There were still several inches of water in the cooler, the pooled water in the corner measure approximately 3 x 2 feet. There was still water dripping on the mustard, pickles, jalapeno peppers, dressing packets and the cabbage. The cabbage was still not labeled for discard only.

Kitchen inspection records conducted by the Dietician during the last 12 months were reviewed. The most recent inspection report, dated 9/28/10, stated, "standing water on floor of walk-in fridge".

2. Reach-in Refrigerator
During the tour on 10/18/10, the reach-in refrigerator was observed with the Dietary Manager (DM). There was a substance spilled on the floor of the refrigerator. The DM identified the substance as lemonade. The DM found a half-empty container of concentrated lemonade - the type typically found in freezers. Food items were observed sitting in the spilled lemonade. The DM disposed of the container of lemonade. The door frame had dirt and debris on it.

The next day, on 10/19/10 at approximately 1:30 PM ., a second observation of the reach-in refrigerator was conducted. The spilled lemonade remained in the bottom of the refrigerator. Food items were still in contact with the spill.

3. Reach-in freezer:
The reach-in freezer was observed to be missing shelves. Grates had been placed on the floor of the freezer. The food, mostly in boxes, had been stacked on the grates. The stacked food had fallen over. Debris was observed under the grates on the floor of the freezer.

An interview was conducted with the Dietary Manager on 10/18/10 during the observation. The Dietary manager stated that "We need shelves. We don't have any".

Kitchen inspection records conducted by the Dietician during the last 12 months were reviewed. There were only three inspection reports dated 10/27/09, 4/20/10 and 9/28/10. All three reports documented the lack of freezer shelving.

4. Hair nets
On 10/18/10 there were observations of two staff members working in the kitchen at approximately 8:45a.m. and 12:36 PM . Both staff were wearing hair nets that only covered about 2/3 of their hair. The front third of their hair was exposed, and not covered by a net.

On 10/19/10 there were observations of three staff members working in the kitchen at approximately 8:15 AM ., 9:40 AM . and 1:30 PM . Two of the staff were again observed wearing hair nets that only covered about 2/3 of their hair. The front third of their hair was exposed, and not covered by a net.

A record review was conducted of the "Dress code" policy for food service personnel. The policy stated that "Hair nets, covering all of the hair, will be worn at all times."

An interview was conducted with the Dietary Manager on 10/18/10 after the tour at approximately 12:36 PM .. The DM stated that the kitchen was cleaned by the weekend dietary staff. Dietary staff cleaned all equipment, surfaces and floors. The DM stated that the housekeeping department did not clean the kitchen, dietary staff were required to do this.

On 10/19/10 at approximately 9:40 AM ., an interview was conducted with the Dietary Manager. The DM was asked about cleaning schedules and cleaning logs. The Manager stated that no logs or checklists were utilized for routine cleaning of equipment in the kitchen to include refrigerators, freezers, walls, and floors. The DM stated that cleaning logs had not been used for a couple of years, and that she was waiting for the Dietician to make a new checklist.

The DM was asked for policies and procedures related to food storage and sanitation. The DM was unable to locate any policies or procedures. She stated that the Dietician might have them.

The Dietician was not at the facility, and was unavailable for interview during the survey. The Dietician did bring the dietary policy and procedure book back to the facility on 10/19/10, but did not remain at the facility for interview.

The "Infection Control for Dietary" policy was reviewed. Number 8 of the policy stated that, "All kitchen equipment and utensils should be effectively washed, rinsed, and disinfected or sanitized." There were no specifications as to how often equipment should be cleaned or how they were to be cleaned. Number 10 of the policy stated that, "Use safe food storage practices. Food should be stored above the floor on clean surfaces where it is not exposed to water, moisture or sewage drippage".

Based on record review and interview, the facility failed to review and revise the dietary policies and procedures.

The findings:

A record review of the Dietary Policies and Procedures Manual was conducted.

The cover sheet stated "The Dietary Policies and Procedure Manual has been reviewed and revised and is approved for use in the (Facility Name)." There were signature blanks for the Chief of Staff, Administrator, Dietician, Dietary Manager and a space for the date. The form was undated. There were no signatures on the blanks for Chief of Staff, Administrator or Dietary Manager. The form was signed by a formerly employed Dietician and Director of Nursing.

On 10/19/10 at approximately 10:30 AM ., an interview was conducted with the administrator to determine the last date of review for the dietary manual. The Administrator stated that one of the employees who signed the cover page had not worked at the hospital in about 3 years.

There were no policies delineating which procedure was to be utilized for kitchen inspections and/or how often inspections were to occur.

The Dietician was unavailable for interview.

There was a checklist entitled "Dietary Daily Cleaning Schedule", but the Cleaning Schedule checklist was not in use.

On 10/19/10 at approximately 9:40 AM ., an interview was conducted with the Dietary Manager. The Dietary Manager stated that the Cleaning Schedule checklist had not been used in a couple of years. The checklist was outdated, and some of the equipment on the checklist was no longer in service. The Dietary Manager stated that she had been waiting for the Dietician to make a new checklist.

Based on interview, record review and facility policy review the facility failed to ensure medication orders were signed by the prescribing practitioner for 1 of 21 current inpatients. (#15)
The findings include:
1. Verbal orders documented as received on 10/1/2010, for patient #15, were not signed/dated by the physician as of 10/18/2010, at 3:00 PM. This was verified by the hospital RN on duty at this time. Verbal orders were for the admission medications and treatments including: Cardiac Diet, Oxygen 2 LPM, Respiratory services for Albuterol every 4 hours as needed, Megace 600 mg every day, IV fluids 100 /0.9 % with Protonix, Aspirin 81 mg daily, Flomax 0.4 mg at bedtime, Lovenox Injection 60 mg daily, Xanax 0.5 mg three times a day, Diflucan 100 mg every evening, Nystatin Suspension 5 ml , Protonix Injection 40 mg IVPB (intravenous piggy back) daily and Zofran Injection 5 mg three times daily prn.
Two additional verbal orders for patient #15, remain unsigned/undated by the physician were 10/12/2010, 1345, for D/C (discontinue) Maxipine; and 10/12/2010, 1400, Tygacil Injection 50 mg twice a day for 3 days.
The facility policy for General Rules for Medication Administration effective 8/04 was reviewed on 10/19/2010. Section I.F. of the policy states the telephone, standing and verbal orders must be verified and initialed by the physician upon his/her first subsequent visit within 24 hours to the hospital.

Based on record review and interview it was determined that the hospital failed to develop patient care plans that were reflective of patient's identified problems or conditions for 3 of 21 open sampled patients. ( #14, #15, #17)
Findings Include:

1. A record review for patient #14, was conducted on 10/18/2010. The patient was admitted on 10/17/2010, renal hypertension and respiratory pneumonia. A review of the care plan did not contain identified and observed conditions including; fluid retention, renal precautions, shortness of breath with oxygen use and smoking cessation program using nicotine patches. An interview was conducted with the on duty RN on 10/18/2010 at 3:10 PM. The surveyor asked the RN, if additional care plan information was available for this patient, and the nurse responded " no " .
2. A record review for patient #15, was conducted on 10/18/2010. The patient was admitted on 10/1/2010, and is currently on swing-bed status. A review of the care plan failed to address identified and observed conditions including; open pressure ulcer, poor oral intake of meals, combative behaviors, and respiratory insufficiency with oxygen use. The surveyor asked the RN if other portions or nursing care existed. The RN stated no other information or care plan was available.
3. A record review for patient #17, was conducted on 10/18/2010. The patient was admitted on 10/17/2010, for respiratory and cardiac insufficiency, elevated blood glucose, and pneumonia. A review of the patient care plan failed to address current problems including; respiratory insufficiency and oxygen use, unmanaged diabetes, and fluid retention. No additional information was available upon request of the Registered Nurse.

Based on observation, interview and record review, the facility failed to incorporate kitchen sanitation and inspections into the Quality Assurance Plan.

The findings:

On 10/18/10 beginning at approximately 12:36 PM ., an observation of the kitchen area was conducted. The walk-in refrigerator was observed to have pooled water and condensation dripping on food items. Dirt and debris was observed on the floors under appliances and in the bottom of refrigeration units. There was dust on equipment, walls and ducts.

A record review of kitchen inspections was conducted. According to provided documentation, the Dietician conducted three kitchen inspections in the last 12 months on 10/27/09, 4/20/10 and 9/28/10. On all three inspections, the Dietician recorded missing freezer shelving. On the most recent report of 9/28/10, the Dietician additionally recorded standing water on the floor of the walk-in refrigerator and overhead light covers that needed to be replaced.

On 10/18/10 at approximately 12:36 PM ., an interview was conducted with the Dietary Manager. The Dietary Manager stated that the Dietician gave a copy of the inspections to herself, and to Quality Assurance (QA).

The minutes of the QA committee meetings were reviewed. The Dietician's inspections were not attached to the meeting minutes. There was no discussion of kitchen sanitation issues, or problems with kitchen equipment in the the meeting minutes.

On 10/19/10 at approximately 1:13 PM ., an interview was conduction with the QA Coordinator. The QA Coordinator stated that the Dietary Manager attends the QA meetings. Neither the refrigerator problems nor the shelving had been brought up in the quarterly meetings. The Dietician had not given the sanitation inspection reports to the QA committee. Dietary has not reported any concerns to the QA committee regarding the kitchen.

Based on review of the quality assurance program and interview of the Quality Assurance (QA) Coordinator, infection control is not incorporated into the quality assurance program.
Findings Include:
On 10/19/2010, a review of three quarters of quality assurance committee meetings was conducted. Information which was documented as reported included; medication error, new medication system problems, nutritional risk assessments, and equipment safety checks. There was no information included on infection data collection, preventative measures, infection control projects, or measures to incorporate house wide.
Interview of the QA Coordinator on 10/19/2010, at 12:30 PM, she stated that each department has their own quality measures. When asked how infection control and the collection of any data was part of the quality program; none was available