HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 1 (Medical Doctor - MD #5) physician, the governing body failed to ensure a focused professional practice evaluation (FPPE) was initiated, for the addition of privileges, in accordance with its' bylaws. This has the potential to affect all physicians providing services at the hospital and all patients receiving services from the hospital.

Findings include:

1. The Medical Staff Bylaws (revised by the hospital 1/24/2020, changes unrelated to citation) was reviewed on 3/12/2020 at approximately 1:00 PM. On page 76, section B. 2., the bylaws indicated FPPEs "are conducted for initial appointments or additional / new privileges being requested..."

2. The physician credential files were reviewed on 3/11/2020 at approximately 3:10 PM, with the Administrative Assistant (E#9). MD#5's reappointment privileges, dated 8/26/2019 indicated a request for the addition of "Detoxification... Assessment for addiction problems... Deliver direct addiction recovery and treatment... Supervise addiction treatment providers" privileges. The privileges were approved by the governing body on 9/20/2019. No FPPE was initiated.

3. During an interview with E#9 conducted during the review, E#9 stated "We added that so that (MD#9) could do detox and work in those areas. No, we didn't do an FPPE and it looks like we should have.".

B. Based on document review and interview, it was determined for 3 of 3 (Medical Doctor - MD#2, MD#4, MD#5) physicians, the governing body failed to ensure its focused professional practice (FPPE) process was completed, in accordance with its' bylaws for physicians placed on focused professional practice evaluation (FPPE) related to questions regarding practitioner's practice. This has the potential to affect all physicians providing services at the hospital and all patients receiving services from the hospital.

Findings include:

1. The Medical Staff Bylaws (revised by the hospital, 1/24/2020, changes unrelated to citation) was reviewed on 3/12/2020 at approximately 1:00 PM. On page 76, section B. 2., the bylaws indicated FPPEs "are conducted for initial appointments... b. If questions arise regarding a practitioner's practice during the course of the ongoing professional practice evaluation."

2. The physician credential files were reviewed on 3/11/2020 at approximately 3:10 PM, with the Administrative Assistant (E#9). MD#2's reappointment date was 4/20/2018. On 7/20/2018, a letter from the medical staff indicated FPPE would be initiated for a three month period due to a rate of 37 % discharge summary completion for the 2nd quarter of 2018, a re-evaluation would occur at that time, and a decision as to whether to continue FPPE would be made. Between 7/20/2018 and October 2018, there were no peer reviews completed. The 3rd quarter of 2018 indicated a decreased rate of 35% discharge summary completion. The file lacked any further evaluation, recommendations, and/or determination to continue FPPE or not. The FPPE process was not completed and/or evaluated

3. The physician credential files were reviewed on 3/11/2020 at approximately 3:10 PM, with the Administrative Assistant (E#9). MD#4's initial appointment date was 5/5/2017. On 11/17/2017, a letter from the medical staff indicated FPPE would be initiated for a six month period, which physician was assigned as proctor/peer reviewer, the number of admissions that would be reviewed, and what performance indicators that would be monitored. The peer review form indicated a meeting time, an area for signatures of those present, and an area for recommendations/actions. Between 12/29/2017 and 2/28/2018, four out of four peer reviews lacked the above documentation. The FPPE process was not completed and/or evaluated

4. The physician credential files were reviewed on 3/11/2020 at approximately 3:10 PM, with the Administrative Assistant (E#9). MD#5's initial appointment date was 9/15/2017. On 10/18/2017, a letter from the medical staff indicated FPPE would be initiated for a six month period, which physician was assigned as proctor/peer reviewer, the number of admissions that would be reviewed, and what performance indicators that would be monitored. The peer review form indicated a meeting time, an area for signatures of those present, and an area for recommendations/actions. Between 12/29/2017 and 2/28/2018, four out of four peer reviews lacked the above documentation. On 10/18/2017, the "FPPE Proctoring Recommendations" form was incomplete and lacked signatures. The FPPE process was not completed and/or evaluated

5. During an interview with E#9 while conducting the review, E#9 stated, "I didn't realize these weren't being done. No, we aren't following our bylaws and we should be."

Based on document review and interview, it was determined in 1 of 4 youth (Pt # 25) patients' record reviewed, the hospital failed to ensure the patient was involved in the development and implementation of the patient's treatment plan. This has the potential to affect all patients serviced by the hospital with a current census of 68 patients.

Findings Include:

1. The policy titled "Interdisciplinary Treatment Planning Process (revised by the hospital, 7/12/2019). The policy noted "C. Additional Provisions... 1. The treatment plan will be signed by the patient..."

2. Pt #25 Date of service: 2/27/2020.
Diagnosis: Suicidal Ideation. The record was reviewed throughout 3/11/2020 to 3/13/2020. The record included a master treatment plan dated 2/28/2020. The treatment plan lacked a patient/parent or guardian signature to verify the plan was reviewed with the patient/parent or guardian.

3. During an interview with the Youth Manager (E# 11) on 3/13/2020 at approximately 11:30 AM, E #11 verbally confirmed the lack of documentation of the signature from the patient/ parent/ guardian. E #11 stated, "It should have been signed by the parent or guardian, because (Pt #25) is a minor."

Based on document review and interview, it was determined in 3 of 4 (Pt #17, Pt #19, Pt #20) records reviewed, the hospital failed to ensure a respiratory assessment was completed post opiod administration, in accordance with its' policy. This has the potential to affect all patients serviced by the hospital with a current census of 68.

Findings include:

1. The policy "Monitoring of Patients during Opiod Therapy" (revised/reviewed by the hospital, 6/11/2019) was reviewed on 03/13/2020 at approximately 9:00 AM. The policy stated "Prior to and following administration of any opiod medication, a respiratory assessment... will be completed".

2. Three patient records (Pt #17, Pt #19, Pt #20), reviewed 3/12/2020 through 3/13/2020 for respiratory assessments before and after opiod administration, lacked a respiratory assessment after an opiod medication was administered:
a. Pt #17: Opiod medication was administered 03/11/2020 and 03/12/2020.
b. Pt #19: Opiod medication was administered 03/11/2020 and 03/12/2020.
c. Pt #20: Opiod medication was administered 03/11/2020 and 03/12/2020.

3. An interview was conducted 03/12/2020 at approximately 4:00 PM with the Chief Nursing Officer (E#2) and the Infection Control Preventionist (E#12). Both stated that nursing does the respiratory assessment before the opiod medication is given. They did not answer as to the respiratory assessment after the opiod administration.

A. Based on document review, observation, and interview, it was determined the hospital failed to ensure insulin was safely stored and dispensed, in accordance with its' policy. This has the potential to affect all patients serviced by the hospital with a current census of 68 patients.

Findings include:

1. During a tour of the third floor adult medication room on 3/11/2020 at approximately 10:00 AM, with the Nurse Manager (E#4), an opened medication vial was in a drawer with the blood glucose kit. The vial had a label with the opened and expired dates. The label covered the medication label. E#4 removed the label and identified the medication as Humalog (insulin medication to treat diabetes). E#4 verbally agreed the label should not have covered the medication name and strength. E#4 verbally agreed the nurse could not verify the dose and type of insulin and it should be verified.

2. The policy titled "Insulin Administration" (reviewed by the hospital on 1/2020) was reviewed on 3/13/2020. The policy noted "Two nurses must sign the MAR (Medication Administration Record) to indicate that both have verified the dose and type of insulin... The insulin should be stored in the patients' cassette..."

B. Based on document review and interview, it was determined in 1 of 1 (Pt #1) patient record reviewed who received insulin, the hospital failed to ensure the patient requiring insulin was monitored and medications administered per physician's order. This has the potential to affect all patients serviced by the hospital who require the use of insulin.

Findings include:

1. Pt #1 Date of Service (DOS): 3/2/2020.
Diagnosis: Suicidal Ideation. The record was reviewed on 3/11/2020. The physician ordered blood glucose monitoring (checking blood sugar level) to be conducted 4 times daily and ordered insulin (medication for diabetes) doses to be administered based on blood glucose levels greater than 151. The following deficiencies were identified:
a. On 3/4/2020 at 9:31 PM, the record noted a blood glucose level of 177. The record lacked documentation 2 units of insulin was administered per physician order.
b. On 3/7/2020 at 5:41 PM, the record noted a blood glucose level of 173. The record lacked documentation 2 units of insulin was administered per physician order.
c. On 3/7/2020 at 7:18 PM, 96 minutes after the previous untreated elevated blood glucose level, the blood glucose level was 272. The record noted 2 units of insulin was administered at 7:18 PM, although the physician order noted 6 units to be administered.
d. On 3/7/2020 at 8:18 PM, the record noted a blood glucose level of 223. The record lacked documentation 4 units of insulin was administered per physician order.

2. During an interview on 3/13/2020 at approximately 12:10 PM, the Chief Nursing Officer (E#2) reviewed Pt #1's record and verbally agreed the insulin had not been administered as ordered and it should have been.

Based on document review and interview, it was determined in 4 of 4 (Pt #1, Pt #7, Pt #9, Pt # 11) patients' records reviewed, the hospital failed to ensure medical records were accurate and complete, in accordance with its' policy. This has the potential to affect all patients serviced by the hospital with a current census of 68 patients.

Findings include:

1. The policy titled "Documentation Guidelines/Maintaining a Legally Sound Medical Record" (reviewed by hospital, 12/4/2019) was reviewed on 3/13/2020. The policy noted "... Each entry should include date, time and signed with credentials... Entries must be authenticated by the person making the entry... The labels containing the patient's identifying information must be affixed in the box labeled for this purpose of each sheet within the patient's medical record... All fields on assessments. flowsheets, checklists, etc... should have some entry..."

2. Patient records were reviewed 3/10/2020 through 3/13/2020. Pt #1 was admitted on 3/2/2020 with a diagnosis of suicidal ideation. The record lacked the following documentation:
1) Case Management Processing Group Notes and Flows for 3/5/2020 and 3/7/2020;
2) Activity Therapy Group Notes for 3/6/2020;
3) Daily Check-In/Goals Group Flow for 3/6/2020;
4) Mental Health Technician Daily Vitals for 3/6/2020.

3. Patient records were reviewed 3/10//2020 through 3/13/2020. Pt #7 was admitted on 3/6/2020 with a diagnosis of aggression. The record lacked the following documentation:
1) Activity Therapy Group Notes for 3/7/2020;
2) Mental Health Technician Daily Vitals for 3/7/2020, 3/9/2020 and 3/10/2020;
3) Psychiatry Progress Notes for 3/7/2020, 3/8/2020, 3/9/2020, 3/10/2020 and 3/11/2020.

4. Patient records were reviewed 3/10/2020 through 3/13/2020. Pt #9 was admitted on 3/3/2020 with a diagnosis of depression. The record lacked documentation of Case Management Processing Group Notes and Flows for 3/5/2020 and 3/6/2020.

5. Patient records were reviewed 3/10/2020 through 3/13/2020. Pt #11 was admitted on 3/4/2020 with a diagnosis of suicidal ideation. The record lacked documentation of Case Management Processing Group Notes and Flows for 3/7/2020.

6. During an interview on 3/13/2020 at approximately 11:00 AM, the Chief Nursing Officer (E#2) reviewed the records of Pt #1, Pt #7, Pt #9, and Pt # 11 and verbally agreed the records lacked the above documentation and therefore were not accurate and complete.

7. During a tour of the 2nd floor child and adolescent unit on 3/12.2020 at approximately 10:30 AM, the CPAP (continuous positive airway pressure) and Nebulizer logs were reviewed. The logs indicated a "check out time" for patient use of the machine, a "check in time" when the patient was done with the machine, and a "cleaned" column for when the machine was cleaned. The logs lacked the following documentation:

a. Pt #2-date of service (DOS)-3/4/2020. The CPAP log lacked the check out times on 3/10/2020 and 3/11/2020 and lacked the check in times for 3/9/2020, 3/10/2020, 3/11/2020 and 3/12/2020;

b. Pt #31-DOS-2/26/2020. The Nebulizer Cleaning Log noted the first name and last initial of Pt #31 in the Patient Label box. It was unable to be determined who the patient was. The log lacked documentation of the check in time on 2/28/2020 and 3/1/2020;

c. Pt #32-DOS-2/26/2002. The Nebulizer Cleaning Log noted the first name in the Patient Label box. It was unable to be determined who the patient was. The log lacked documentation of the check in time on 3/11/2020.

8. During an interview on 3/12/2020 at approximately 1:00 PM, E#2 reviewed the logs and stated, "I don't know who (Pt #32) is. There are 4 people on the unit with the same name."

9. The 3rd floor Adult unit Accu-Chek Perma Control Testing Logs (blood glucose control logs), dated 1/29/2020 through 3/12/2020, were reviewed on 3/12/2020 at approximately 12:00 PM. The logs noted entries dated 4/9/2020, 4/10/2020, 4/11/2020, and 4/12/2020, all one month ahead of time.

10. During an interview on 3/12/2020 at approximately 12:15 PM, the Nurse Manager (E#4) verbally agreed the accucheck logs were incorrectly dated.

Based on observation, document review, and interview, it was determined the hospital failed to ensure outdated medications, stored in the Pharmacy, were not available for patient use. This has the potential to affect all patients serviced by the hospital with a current census of 68 patients.

Findings include:

1. The policy titled "Physical Plant, Security and Inventory (reviewed by the hospital January, 2020)" was reviewed on 3/11/2020 at approximately 1:00 PM. The policy noted "...Inventory... Every thirty days, the pharmacist and/ or technician will check the stock for expired medications, pulling the items that have expired."

2. On 3/11/2020 at approximately 10:55 AM, an observational tour was conducted in the pharmacy with the Pharmacist (E #7). During the tour of the medication room, 10 tablets of Venlafaxine 37.5 milligrams each were on the pharmacy shelf, available for patient use, with an expiration date of 2/2/2020.

3. During the observational tour, E #7 verbally confirmed the medication was outdated and should have been removed.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on March 10, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on March 10, 2020, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review and interview, it was determined the hospital failed to ensure the quality control testing of the blood glucose equipment was monitored, in accordance with its' policy. This has the potential to affect all patients who require blood glucose monitoring by the hospital.

Findings include:

1. The "Accu-Chek Performa Control Testing Log" (blood glucose control log) was reviewed on 3/11/2020 at approximately 10:45 AM. The log noted "Control testing should be performed :daily prior to patient use... to check the performance of the system... All test results are to be documented on the glucometer quality control log... Both Level 1 and Level (using 2 Inform ll solutions) control must be checked."

2. The 1st floor Adult unit Accu-Chek Perma Control Testing Logs dated 2/27/2020 through 3/12/2020 were reviewed on 3/12/2020. The logs lacked documentation control testing was conducted on 3/4/2020, 3/5/2020, 3/6/2020, 3/9/2020, 3/10/2020, 3/11/2020 or 3/12/2020. The following patients records noted accuchecks were conducted on days in which control testing had not been conducted:
a) Pt #1 Date of service (DOS): 3/2/2020 Accuchecks were conducted on 3/6/2002 and 3/10/2020.
b) Pt #12 DOS: 3/6/2020 Accuchecks were conducted on 3/9/2020, 3/10/2020 and 3/12/2020.
c) Pt #13 DOS: 3/5/2020 Accuchecks were conducted on 3/6/2020, 3/9/2020, 3/10/2020 and 3/11/2020.
d) Pt #23 DOS: 3/4/2020 Accuchecks were conducted on 3/5/2020, 3/6/2020, 3/9/2020 and 3/10/2020.

3. The 3rd floor Adult unit Accu-Chek Perma Control Testing Logs, dated 1/29/2020 through 3/12/2020, were reviewed on 3/12/2020. a. The entries between 3/5/2020 and 3/7/2020 were illegible and lacked a Level 2 control.
b. On 2/18/2020, the log lacked documentation control testing was conducted. Pt #14's record noted accuchecks were conducted on 2/18/2020.

4. During an interview on 3/13/2020 at approximately 12:00 PM, the Director of Quality (E#1) reviewed the Accu-Chek Perma Control Testing Logs and verbally agreed the above control tests were either not conducted or were not documented on the logs and that patient accurchecks should not have been performed before the controls were conducted.

A. Based on document review, observation, and interview, it was determined in 6 of 10 ( Pt #1, Pt #5, Pt #7, Pt #9, Pt #11, Pt #26) patients, the hospital infection prevention and control program failed to follow facility policy to ensure mitigation of risks associated with communicable disease threats. This has the potential to affect all visitors, staff, and patients of the hospital.

Findings include:

1. The policy titled "Coronavirus Control Plan" (no date) was reviewed on 3/10/2020 at approximately 11:00 AM. The policy noted "5. Screening of patients: A list of questions provided to Intake staff so that each patient is asked of their travel... or come into contact... showing respiratory symptoms... The staff member also to wear a mask while conducting the screening.... 7. Screening of Visitors: a. Receptionist at front desk have been educated that each visitor must provide answers to travel to foreign country and anyone positive for travel to china will not be allowed to visit family member. b. Any visitor with respiratory symptoms will be provided with facial mask to wear during course of visit... d. Masks and gloves are available at the reception desk." Attachments to the Coronavirus Control Plan were reviewed to be a questionnaires about travel and respiratory symptoms titled Admission Health Screen, Corona Virus (COVID-19) Screening Forms and Visitor Health Screen form. Both required signatures of the patient or visitor.

2. On 3/10/2020 at approximately 9:45 AM, five visiting persons came to the facility's front desk and on 3/11/2020 between approximately 8:00 AM and 9:15 AM, four visiting persons came to the facility's front desk, The persons were not screened for travel or respiratory symptoms per policy. The front desk reception area was observed on 3/10/2020 and 3/11/2020 to not have gloves or masks available for use.

3. The "Confidential Visitor Sign-In Log" forms and the "Visitor Health Screen" forms for 3/8/2020 to 3/10/2020 were reviewed 3/12/2020 at approximately 12:55 PM.
--- On 3/8/2020, 42 out of 53 visitors lacked COVID-19 visitor screenings.
--- On 3/9/2020, 32 out of 32 visitors lacked COVID-19 visitor screenings.
--- On 3/10/2020, 38 out of 38 visitors lacked COVID-19 visitor screenings.

4. During an observation of the patient intake process on 3/11/2020 at approximately 12:30 PM, the Intake Director (E#4) and the Intake Nurse (E#5) were observed to not wear a mask while conducting the intake process on a patient. E#4 and E#5 did not conduct the "Coronavirus Screening" on the patient.

5. The following records were reviewed during the survey on 3/11/2020 through 3/13/2020 and lacked documentation of the Corona Virus (COVID-19) Screening Form:
a) Pt #1, Date of Service (DOS): 3/2/2020;
c) Pt #5, DOS: 3/4/2020;
d) Pt #7, DOS: 3/6/2020 (in chart although not completed);
e) Pt #9, DOS: 3/3/2020;
f) Pt #11, DOS: 3/4/2020;
h) Pt #26, DOS: 3/5/2020;

6. During an interview on 3/12/2020 at approximately 9:45 AM, the Director of Performance Improvement (E#1) stated the front desk receptionist should screen each person that presents to the front desk verbally and by completing the Visitor Health Screen form, as well as have masks and gloves available. E#1 verbally agreed all patients should be screened for the Corona Virus and documented in the chart via the screening forms. On 3/12/2020 at approximately 1:30 PM, E#1 stated "The mask is to be worn by the patient and the staff if the patient answers yes to any of the screening questions... but yes they (E#4 and E#5) should have done the Coronavirus Virus Screening before the assessment was even started".

B. Based on observation and interview, it was determined the hospital failed to ensure a sanitary environment was maintained. This has the potential to affect all visitors, staff and patients of the hospital.

Findings include:

1. During a tour of the adult east unit clean linen room on 3/10/2020 at approximately 12:45 PM, the Nurse Manager (E#4) picked up a cloth covered positioning wedge from the floor and placed it on top of the clean laundry cart. E#4 stated "That (positioning wedge) shouldn't be there (on the floor)."

3. During an interview on 3/11/2020 at approximately 11:30 AM, the Chief Nursing Officer (E#2) verbally agreed the positioning wedge should not have been stored on the floor nor placed on top of the clean laundry cart since it was contaminated. E#2 verbally agreed the cloth positioning wedge could not be adequately disinfected and should not have been available for patient use.





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C. Based in document review and interview, it was determined for 16 of 16 patient care staff and 5 of 5 physicians, the hospital failed to ensure hepatitis-B status was assessed, with follow-up, if needed, in accordance with its' policy and contract. This has the potential to affect all patients, visitors, and staff of the hospital.

Findings include:

1. The Policy #: IC-16, Hepatitis B Immunization (last reviewed/revised by the Hospital 12/06/2019) was reviewed 3/12/2020 at approximately 9:00 AM. The policy indicated, "IV. Policy: B. Hepatitis B Immunization will be offered by (contracted occupational medicine group) to all new employees determined to have regular potential for exposure."

2. The Master Occupational Medicine Services Agreement, dated 9/1/2019, was reviewed on 3/12/2020 at approximately 9:15 AM. On page 7, the "Statement of Work" indicated a list of laboratory tests, which included the Hepatitis B core titer and antibody surface titer and the Hepatitis B vaccination series along with their respective cost. The contract lacked any provision for the sharing of the testing and potential follow up vaccination status.

3. The employee health files were reviewed on 3/11/2020 at approximately 11:30 AM with the Director of Human Resources (E#8). 16 out of 16 patient care staff and 5 out of 5 physician files lacked the final laboratory results for the Hepatitis B laboratory testing's and whether the staff members/physicians were immune or not. The files lacked whether the non-immune staff/physicians were offered, and/or received/declined immunization administration . During the personnel file review, E#8 stated, "I get the paperwork back and put it in their employee file. They should have them at the hospital, but we don't get a copy of that. They (contracted occupation medicine group) would take care of that." E#8 verbally agreed they do not know whether any of their employees had negative results, were offered the hepatitis B vaccination, and/or received/declined the hepatitis B vaccination.

4. During an interview with the Chief Nursing Officer (E#2) on 3/12/2020 at approximately 9:00 AM, E#2 stated, "We should have the results (Hepatitis B tests and vaccination status) in the fie. We send them next door with the lab orders. We should be getting the results. We don't have any proof in these records." On 3/13/2020 at approximately 10:00 AM, E#2 and the Infection Control Preventionist (E#12) stated they had discussed the above finding and E#12 verbally agreed not having been given the laboratory test results to review for follow up.



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D. Based on document review and interview, it was determined for 2 of 3 (Pt #4, Pt #30) records reviewed, the hospital failed to ensure weekly lice checks were completed and documented on the youth unit, in accordance with its' policy. This has the potential to affect all staff, visitors, and patients at the hospital.

Findings include:

1. The policy "Treatment for Head/Body Lice" (revised by the hospital 05/01/2019) was reviewed on 03/13/2020 at approximately 10:00 AM. The policy stated, "All youth patients will be checked again weekly... for the presence of lice/nits.". The youth unit services the age range of 3 years to 17 years of age).

2. Pt #4 Date of service: 02/17/2020
Diagnosis: Depression with Suicidal Ideation. Pt #4's record was reviewed on 03/12/2020 at approximately 11:00 AM. The record lacked documentation of weekly lice checks from 02/22/2020 through 03/09/2020.

3. Pt #30 Date of service: 12/12/2019.
Diagnoses: Disruptive Mood Regulation Disorder and Attention Deficit Hyperactivity Disorder. Pt #30's record was reviewed on 03/12/2020 at approximately 12:30 PM. The record lacked documentation of weekly lice checks from 12/15/2019 through 03/12/2020.

4. An interview was conducted with the Youth Manager (E #11) on 03/12/2020 at approximately 3:00 PM. E #11 reviewed the records of Pt #4 and Pt #30 and stated "We do their weights on Saturdays and the lice checks on Sundays...they should be there".



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E. Based on observation, document review, and interview, it was determined the hospital failed to ensure that all containers of food were dated as to when opened and when to discard to assure the prevention of spoilage. This has the potential to affect all patients (current census of 68), visitors, and staff who consume food from the Dietary Department.

Findings include:

1. On 3/11/2020 at approximately 1:20 PM, a tour was conducted of the Dietary Department with the Director of Patient Operations (E#3). During the tour the following was observed:
a. 1 opened container of garlic salt- lacked date of when it was opened or a date to discard after opened.
b. 1 opened container onion powder- lacked date of when it was opened or a date to discard after opened.
c. 1 opened container of Sprinkles with a use by date of 1/5/2020.
d. 2 opened bags of Nacho Chips with received date 1/31/2020, lacked date of when it was opened and date to discard after opened.
e. 1 bag opened chocolate nuggets with use by date of 2/28/2020.
f. 1 bag Fritos labeled as opened 2/7/2020, lacked date to discard after opened.

2. During an interview with E#3 on 2/4/2020 during the tour. E#3 confirmed the lack of any dates on the opened food containers and that all opened containers of food should have the dates of when they were opened and/or expiration/discard dates. E#3 stated uncertainty as to whether or not the hospital had a policy related to dating food items with the date opened and the date to discard.

3. During an interview with the Director of Performance Improvement (E#1) on 3/12/2020 at approximately 9:30 AM, E#1 stated having looked at several policies and none addressed this issue. E#1 stated, "We will have to address this."

F. Based on observation, document review, and interview, the Hospital failed to ensure equipment was thoroughly disinfected in order to prevent/control infections and communicable diseases, in accordance with its' policy. This has the potential to affect all patients (current census of 68 patients), staff, and visitors.

Findings include:

1. The policy titled "Ice Handling" was reviewed on 3/11/2020 at approximately 2:50 PM. The policy noted "...III Procedure: A. The outside of the ice machine is cleaned daily...The ice machine in the kitchen is emptied and disinfected every six months..."

2. On 3/11/2020 at approximately 1:30 PM, a tour was conducted of the Dietary Department with the Director of Dietary (E# 10). During the tour the record of cleaning/ disinfectant was requested for the ice machine.
On the side of the machine was a yellow sticky note that included "10/19 filter changed and 1/15/2020 cleaned." There was no documentation of what was specifically cleaned on 1/15/2020. The Dietary Department lacked documentation for daily cleaning and disinfection every six months of the ice machine.

3. During an interview with E# 10 on 3/11/2020 at approximately 1:45 PM, E# 10 verbally confirmed the lack of documentation of the cleaning and disinfectant of the ice cart.