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Based on observation, staff interview and review of pertinent documents, it was determined that the facility failed to ensure that all New Jersey Department of Health Licensing Standards were met.
Findings include:
Reference #1: N.J.A.C Title 8 Chapter 43G Hospital Licensing Standards section 8.1(e)2 states, " Methods for processing reusable medical devices shall conform with Association for the Advancement of Medical Instrumentation(AAMI) ST79:2006 Comprehensive guide to Steam Sterilization and sterility assurance in health care facilities (ST 79 replaces and supersedes ST46 by consolidating ST 46 with 4 other AAMI standards [ST33, ST37, ST42, and ST35] approved 7/10/2009). "
Reference #2: AAMI ST 79 section 4.5.2 regarding 'Decontamination area states; "Before leaving the decontamination area, employees should remove all protective attire, being careful not to contaminate the clothing beneath or their skin, and wash their hands. Employees should also remove and discard hair coverings before leaving the decontamination area .... PPE and hair coverings might become contaminated in the decontamination area and should be removed when employees leave the area; otherwise, contaminants could be shed onto uniforms or environmental surfaces."
Reference #3: The Facility policy regarding 'Supply Processing and Distribution: Dress code,' states; "1) Soiled receiving, processing and cart wash room: Scrub suit provided by and laundered by Englewood hospital; fluid resistant gown; head cover; gloves; when working at the sink, goggles or face shield will be worn; upon leaving this area, gloves, cover gown and head cover will be removed and disposed of in plastic lined garbage can. 2) Clean processing area: Scrub suit or uniform provided by and laundered by Englewood hospital; head cover; head cover will be removed upon leaving area."
1. On 11/29/11 at 11:30 AM, after touring the soiled receiving and decontamination area, Staff #15 was observed going through the clean processing room of the central processing department wearing the same scrub uniform and head cover which were worn inside the soiled receiving and decontamination room.
2. On 11/28/11 at 11:00 AM, Staff #31 was accompanied the surveyor into the soiled utility room located within the operating room corridors, where he/she cleans and washes the laryngoscope blades. Suction bottles filled with blood and bodily fluids and numerous sets of soiled instruments were observed stored in this soiled utility room. When Staff #31 was questioned regarding special Personal Protective Equipment (PPE) requirements for staff entering this soiled utility room, he/she was not aware of any special PPE requirements.
Reference #4: AAMI ST 79 section 8.8.2 regarding 'Open Tray Flash Cycles' states, "Flash sterilized items should be used immediately, not stored for later use. Procedures for transferring the items from the sterilizer to the point of use should be based on the assumption that condensate will be present within the tray so care should be taken to avoid contamination of the sterilized items. The tray and the items within it will also be hot, so care should be taken to avoid thermal injury. Personnel should wear sterile gloves and may use sterile towels as "potholders" when removing items from the sterilizer. The tray should never be placed on a nonsterile surface. These procedures should be developed in consultation with the supervisor of the department and the infection control professional, with the objective of ensuring the best practice possible for aseptic transfer within the physical constraints of the facility. "
Reference #5: The Facility policy regarding 'Sterilization in the Perioperative Practice Setting' states, " FLASH STERILIZATION: 3) Specialized Transfer trays are utilized to transport flash sterilized items when flash sterilization is necessary and the OR room is not directly next to the substerile area(autoclave location). 7) Special handling of unwrapped measures is taken to prevent contamination during transfer to the sterile field."
3. On 11/29/11, Staff #3 stated that the facility utilizes the 'traditional' open tray flash sterilization method in the substerile rooms of the operating room clusters, and that special handling policies and procedures have not been developed to ensure aseptic transfer of instruments.

Reference #6: AAMI ST 79 section 11.2.4. states, "Procedures for flash sterilization should be based on a documented quality process that measures objective performance data."

Reference #7: CDC Guidelines for 'Prevention of Surgical site Infection, 1999, section C. Recommendations, Intraoperative d.2' states, "Do not flash sterilize for reasons of convenience, as an alternative to purchasing additional sets, or to save time."

Reference #8: Facility policy regarding 'Sterilization in the Perioperative Practice Setting' states, "FLASH STERILIZATION: Flash sterilization is used in situations when there is insufficient time to process instruments by the preferred wrapped or container method."

4. Review of sterilizer #11's flash sterilization records from 11/3/11 to 11/23/11, and interview with Staff #3, revealed that a total of 51 loads of instruments were flash sterilized with over 20 loads reasons coded as 'Unsterile from SPD.'

Reference #9: AAMI ST 79 section 3.3.7.3 on 'Sterilization area' states,
"Preferably, sterilizers should be located in a restricted access area. Sterilizers should not be located in high traffic areas or near any potential sources of contamination, such as scrub sinks, clinical sinks or hoppers, wash sinks or containers for the disposal of linen and trash."

5. On 11/28/11, Cidex OPA, a chemical which is used as a high level disinfectant, was observed stored in two plastic containers located under an enclosed ventilation hood located in substerile Room #1, where instruments are exposed to open tray flash sterilization. Staff #3 stated that the ventilation hood is not turned on during operation. Staff #3 stated that 'TEE [transesophageal echocardiogram] transducer tips' and laryngoscope blades routinely undergo high level disinfection in this substerile Room #1. Rinsing requirements for the OPA high-level disinfectant, in accordance with the manufacturer's instructions for use, (i.e., three successive rinses with large volumes of fresh water) allow for the creation of potential sources of contamination to "flashed" instruments in open trays as a consequence of possible splashing and higher traffic in substerile room #1. In addition, possible insufficient ventilation of OPA vapors may provide another potential source of instrument contamination.

Reference #10: N.J.A.C. 8:43G-30.1 Scope of renal dialysis standards state, "These standards shall apply to both hemodialysis and peritoneal dialysis units. In addition to the rules of this subchapter, hospitals providing inpatient renal dialysis services or an on-site, separate designated unit or service for ambulatory patients shall also comply with N.J.A.C. 8:43A-24 in accordance with N.J.A.C. 8:43G-30.3 and 30.4."

Reference #11: N.J.A.C. 8:43A-24.10 on 'Water treatment ' states, "Water treatment equipment, water and dialysate shall satisfy the requirements specified in the Association for the Advancement of Medical Instrumentation publication entitled, "Water treatment equipment for hemodialysis applications," RD62:2006, "Dialysate for hemodialysis," RD52:2004, Hemodialysis systems," RD5:2003, and "Concentrates for hemodialysis, "RD61:2000, incorporated herein by reference, as amended and supplemented."

Reference #12: Facility policy and procedure regarding 'Monthly Reverse Osmosis(RO) Water Bacteriological Analysis' states, "In accordance with AAMI standards, total viable microbial count shall not exceed 200 CFU/ml with an action level of 50 CFU/mL in RO product water used for dialysis."

6. A total of five portable RO water sample results reviewed from June to December 2010 were observed exceeding the AAMI action level of 50 CFU/mL with values ranging from 50 to 150 CFU/mL. Documentation of follow up corrective action taken by the hospital was requested from Staff #10. However evidence of resampling and/or disinfection was not provided to the surveyor.

Based on document review, interview, and observation, it was determined that the governing body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Condition of Participation:

CFR 482.13 Patient Rights

Based on document review, interview, and observation, it was determined that the governing body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The facility failed to ensure compliance with the Conditions of Participation for Patient Rights.

See the following Standard Level deficiencies:
CFR 483.13(c) (2)
CFR 483.13(e) (8)

A. Based on observation made during a tour of the facility and staff interview, it was determined that the facility failed to ensure a safe environment for all patients.

Findings include:

1. During a tour of the Radiology Department conducted at approximately 1:30 PM on 12/1/11, in the presence of Staff #28, the following were identified:

a. In the Nuclear Medication area there was an unsecured oxygen tank standing on the floor next to the crash cart.

b. In the Nuclear Medication area there was an unsecured oxygen tank standing on the floor near the door of Nuclear Medication area.

c. In the MRI waiting area there were 2 unsecured oxygen tanks standing on the floor.

2. These findings were confirmed by Staff #28.


B. Based upon review of 5 medical records, staff interview, and review of facility Policies and Procedures it was determined that the facility failed to ensure a safe environment for patients on Observation Levels.

Findings include:

Reference 1: When asked for the Policy for monitoring patients on precautions, facility staff presented: Psychiatric Department Unit Specific Structure Standards, Element VII states:
(a) Standard Observations, (3) Standard observation consists of observing patients every half hour on all shifts. * Assignment of rounds are made by Care Manager/Charge Nurse. * Each Patient must be observed and accounted for with certainty by assigned personnel, q 30 minutes. * Assigned staff member is responsible for documenting and initialing observation rounds checklist. 4E rounds checklist is used as a worksheet and is not a permanent record on individual charts. (b) Intensive Observations, (3) Intensive observation consists of observing the patient every 15 minutes on all shifts. Care Manager/Charge Nurse assigns rounds each shift.

Reference 2: When asked for the Policy for monitoring patients on precautions, facility staff presented: Psychiatric Unit Suicide Management Protocol (Approved by Clinical Standards Committee- 1999) states:
Assessment: Assess patient through verbal interaction at least every 4 hrs. for: > Increased feelings of worthlessness, hopelessness > Verbalizations of actual plan or intent (staff may need to initiate by asking straight forward questions) > Presence of command hallucinations > Refusal of reluctance to agree to a no harm contract
Management: All patients on this protocol are to be on intensive observation.
Emergency Care: Safety : Provide a safe environment by following patient level of observation as ordered by Psychiatrist.

1. Five of 5 medical records (MR) reviewed (MR# 26, 27, 28, 29, and 30) for safety precaution management were found lacking evidence of observations as required by policy.

a. MR# 26 - Patient presented with suicidal thoughts, Intensive Observations were ordered on 3/2/11. No evidence of observations being performed every 15 minutes was present in the MR.

b. MR# 27 - Patient presented with drug overdose, suicidal, Intensive Observations were ordered on 2/26/11. There was no evidence in the MR of observations being performed every 15 minutes.

c. MR# 28 - Patient presented with aggressive behavior, Constant Observations were ordered on 4/29/11. There was no evidence in the MR of observations being performed every 30 minutes.

d. MR# 29 - Patient presented suicidal, Intensive Observations were ordered on 4/27/11. There was no evidence in the MR of observations being performed every 15 minutes.

e. MR# 30 - Patient presented with suicide attempt, depression, Intensive Observations were ordered on 4/29/11. There was no evidence in the MR of observations being performed every 15 minutes.


2. Five of 5 medical records (MR) reviewed (MR# 26, 27, 28, 29, and 30) for safety precaution management lacked assessments every 4 hours as required by policy.

a. MR# 26 - 12 of 14 days reviewed (3/3/11- 3/16/11) lacked evidence of the required assessment being performed every 4 hours.

b. MR# 27 - 2 of 4 days reviewed (3/2/11-3/6/11) lacked evidence of the required assessment being performed every 4 hours.

c. MR# 28 - 5 of 5 days reviewed (4/30/11-5/4/11) lacked evidence of the required assessment being performed every 4 hours.

d. MR# 29 - 8 of 8 days reviewed (4/27/11-5/4/11) lacked evidence of the required assessment being performed every 4 hours.

e. MR# 30 - 4 of 4 days reviewed (4/28/11-5/2/11) lacked evidence of the required assessment being performed every 4 hours.

Based on review of facility policies and procedures and review of four of six medical records of patients who were physically restrained in the emergency department, it was determined that the facility failed to ensure the implementation of hospital policies when the use of restraints was necessary.

Findings include:

Reference #1: The VIOLENT OR SELF-DESTRUCTIVE PATIENT MANAGEMENT (Previously Behavioral Health Care Restraint Management) section of facility policy and procedure titled 'Restraint Management Policy' indicated: ".....RELEASE FROM RESTRAINT:
5. When evaluating a patient for release from a restraint, the RN/MD or other independent licensed health provider must do a comprehensive assessment. This includes evaluating the presenting behaviors exhibited by the patient, with the goal to be to reduce the use of restraints when possible.
.....
* Early release form [sic] restraint requires an MD/LIP order and documented reason for releasing a patient before the order expires.
....."
1. A BEHAVIORAL HEALTH RESTRAINT ORDER sheet dated 11/24/11 at 0413 (4:13am) in the medical record of Patient #34 indicated that the patient be placed in 4 point leather restraints for up to 4 hours. The REASON FOR RESTRAINT section of the order indicate the entries: "Agitated, Combative, Danger to Self/Others, Physically Threatening, Impulsive." Restraint Flowsheet entries dated 11/24/11 indicated that the patient was checked by the RN every 15 minutes until 5:25am. An entry made at 7:07am on the Flowsheet indicated: "The patient has demonstrated behavior requiring restraints (patient is in custody of englewood [sic] PD [police department] procedure to have one hand cuffed to stretcher.)." There ws no indication that the patient was still in 4 point restraint at 7:07am when he/she was documented as having been in a handcuff. There was no evidence in the medical record that an order was obtained from an MD or LIP to release the patient from the restraints prior to the expiration of the order.

Reference #2: The VIOLENT OR SELF-DESTRUCTIVE PATIENT MANAGEMENT (Previously Behavioral Health Care Restraint Management) section of facility policy and procedure titled 'Restraint Management Policy' indicated: ".....COMPETENCIES:
All staff who apply, remove, or care for patients in restraint/seclusion must Complete [sic] the appropriate competency validation. These are done upon orientation and yearly thereafter.
a. Leathers: RN, Security, and PCA (patient care associate) orderly staff of the four units where leather restraints are approved may apply and remove.
....."

1. An entry dated 10/12/2011 at 20:37 (8:37pm) in the 'Clinical Report - Nurses' notes section of Medical Record #35 indicated: "late entry - 8:15 PM (patient placed in restraints by pd [police department]. .....)" Police were not authorized to apply restraints per hospital policy.

Reference #3: The NON-VIOLENT AND NON SELF-DESTRUCTIVE PATIENT RESTRAINT (previously MEDICAL-SURGICAL RESTRAINT MANAGEMENT - Regardless of setting) section of hospital policy titled 'Restraint Management Policy' indicated:
"NOTIFICATION/MD ORDER:
* The use of restraint or seclusion must be in accordance with the order of a physician or other license [sic] independent practitioner who is responsible for the care of the patient.
.....
* The Licensed Physician, other independent licensed health provider, or second-year Resident/Intern (post graduate year 2) who has a permit in New Jersey shall be notified immediately, and a telephone or written order must be obtained within one hour. A face-to-face assessment must occur within one hour.
- The LIP (licensed independent practitioner) must evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral conditions, and the need to continue or terminate restraint. ....."

1. Review of a NON-VIOLENT/NON SELF-DESTRUCTIVE RESTRAINT ORDER SHEET dated 9/7/11 at 11:00pm in Medical Record #33 indicated that the patient be placed in a soft chest restraint, an abdominal belt, and that full side rails on the bed be used. There was no documentation in the medical record that a face-to-face assessment was done within one hour of the application of the restraints.

Reference #4: The VIOLENT OR SELF-DESTRUCTIVE PATIENT MANAGEMENT (Previously Behavioral Health Care Restraint Management) section of facility policy and procedure titled 'Restraint Management Policy' indicated: ".....PATIENT/SIGNIFICANT OTHER EDUCATION:
..... Patient and family members are encouraged to be part of the decision-making process whenever possible, and are given the opportunity to ask questions and seek information. ..... A family member/significant other/guardian identified by the patient should be notified as soon as feasible when a patient is placed in restraints/seclusion, if patient consents, as long as the family agrees to be notified. ....."

1. Review of Medical Record #32 indicated that the patient was placed in 4 point leather restraints for behavior management on 9/7/11. There was no indication in the medical record that the patient was asked if he/she would like family notified of the use of restraints or that any family member was notified of the use of restraints.

2. Review of Medical Record #34 indicated that the patient was placed in 4 point leather restraints for behavior management on 11/24/11. There was no indication in the medical record that the patient was asked if he/she would like family notified of the use of restraints or that any family member was notified of the use of restraints.

3. Review of Medical Record #35 indicated that the patient was placed in 4 point leather restraints for behavior management on 10/12/11. There was no indication in the medical record that the patient was asked if he/she would like family notified of the use of restraints or that any family member was notified of the use of restraints.

Based on review of one of four medical records of patients who were physically restrained in the emergency department for behavior management, it was determined that not all orders were limited to 4 hours for adults 18 years of age or older.

Findings include:

1. Review of a physician order dated 11/2/11 at 5:08am in electronic Medical Record #31 indicated: "TASK: Restrain Patient: Restrain wrists bilaterally with soft limb restraints for fall prevention / patient safety and because of potential for dislodging lines / tubes / dressings." The order was time limited to 24 hours and there were no other restraint orders in the medical record.

An electronic 'Restraint Flowsheet' entry made at 2:43am on 11/02/11 in the same medical record indicated: "late entry - 02:20 (2:20am). The patient has demonstrated violent and self-destructive behavior requiring behavioral restraints including: imminent risk of harm to self or others, agitation and inability to follow directions. ..... Applied double wrist restraints. ..... Assessment: mental status - patient is agitated; ..... ; behavior is self destructive."

The order to restrain the patient should have been limited to a maximum of 4 hours based on the patient's behavior.

Based on review of two of four medical records of patients who were physically restrained in the emergency department for behavioral management, and review of hospital policy and procedure, it was determined that the condition of the patient who was restrained was not always monitored by a physician, other licensed independent practitioner or trained staff at an interval determined by hospital policy.

Findings include:

Reference:

The VIOLENT OR SELF-DESTRUCTIVE PATIENT MANAGEMENT (Previously Behavioral Health Care Restraint Management) section of facility policy and procedure titled 'Restraint Management Policy' indicated: ".....
ASSESSMENT:
4. Nursing staff who are trained and competent in the use of restraint and seclusion (RN's & PCA's) to assess patient q (every) 15 minutes for:
* Visual checks can be performed if patient is too agitated to approach.
* During this time staff assists the patient to meet the criteria for discontinuation of restrain [sic] or seclusion.
a. Changes in behavior or critical condition needed to initiate removal or discontinuation of restraint or seclusion.
b. Level of Consciousness/orientation.
c. Signs of injury associated with use of restraint/seclusion
d. Physical, mental/emotional well being.
e. For color, pulses, movement sensation, skin status of restrained extremities, ROM (range of motion) in extremities
f. Absence of excessive friction/abrasion of skin underneath restraint (q 2 hours and provide skincare [sic] as needed)
g. Evidence of edema of restrained extremity
h. Absence of any respiratory restriction of patients in chest restraints
i. Vital signs as indicated
j. Hygiene and elimination needs
k. Nutrition and hydration needs
l. Patient's dignity and privacy are being maintained. ....."

1. Review of a VIOLENT/SELF DESTRUCTIVE RESTRAINT ORDER SHEET dated 10/12/11 at 8:15pm in Medical Record #35 indicated that the patient be placed in 4 point leather restraints for up to 4 hours. The REASON FOR RESTRAINT section of the order indicated the entries: "Agitated, Combative, Physically Threatening, and Impulsive." There was no documentation in the medical record that the patient was assessed every 15 minutes by nursing staff and that all of the required assessments were done.

2. Review of a BEHAVIORAL HEALTH RESTRAINT ORDER dated 11/24/11 at 4:13am in Medical Record #34 indicated that the patient be placed in 4 point leather restraints for up to 4 hours. The REASON FOR RESTRAINT section of the order indicated the entries: "Agitated, Combative, Danger to Self/Others, Physically Threatening, Impulsive." There was no documentation in the medical record that the patient was assessed every 15 minutes between 5:25am and 6:37am and between 6:37am and 7:07am (when the restraints were discontinued) by nursing staff and that all of the required assessments were done.

Based on review of two of four medical records of patients who were physically restrained for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member, or others, it was determined that patients were not seen face-to-face within 1-hour after the initiation of restraints by, a physician or other licensed independent practitioner; or a registered nurse or physician assistant.

Findings include:

1. A 'Restraint Flowsheet' entry dated 11/2/11 at 2:43am in Medical Record #31 indicated: "late entry - 02:20 (2:20am). The patient has demonstrated violent and self-destructive behavior requiring behavioral restraints including: imminent risk of harm to self or others, agitation and inability to follow directions. ....."

The only order for physical restraint in the medical record was dated 11/2/11 at 4:52am - 2 hours and 32 minutes after the patient was documented as having been placed in restraints. There was no evidence in the medical record of a face-to-face assessment by the ordering physician, or any licensed independent practitioner in the medical record regarding the application of restraints.

Based on review of facility policy and procedure and review of two of six medical records of patients who were physically restrained in the emergency department, it was determined that the medical records were not accurately written.

Findings include:

1. A VIOLENT/SELF DESTRUCTIVE RESTRAINT ORDER SHEET dated 9/7/11 at 2300 (11:00pm) in Medical Record #32 indicated the patient be physically restrained for up to 4 hours in '4 Point Leather' restraints.

The REASON FOR RESTRAINT section of the order sheet indicated the entries: "Agitated, Combative, Danger to Self/Others, Physically Threatening, Damage to Environment, Impulsive." Review of the electronic 'Restraint Flowsheet' entries in the same medical record indicated the following entries: ".....
late entry - 23:20 (11:20pm). Subsequent restraint assessment. The patient has demonstrated behavior requiring non-behavioral restraints including: agitation. .....
late entry - 23:35. Subsequent restraint assessment. The patient has demonstrated behavior requiring non-behavioral restraints including: agitation. .....
late entry - 00:10. Subsequent restraint assessment. The patient has demonstrated behavior requiring non-behavioral restraints including: agitation."

The three entries did not reflect that the patient was in restraints due to violent and/or self destructive behavior, but that he/she was in restraints due to non-behavioral reasons.

Reference: The VIOLENT OR SELF-DESTRUCTIVE PATIENT MANAGEMENT (Previously Behavioral Health Care Restraint Management) section of facility policy and procedure titled 'Restraint Management Policy' indicated: ".....
EXCLUSION CRITERIA: .....
e. Forensic and correction restriction used for security purposes. (At EHMC only done by police officers).
....." The reference indicated that the use of handcuffs on patients by police officers is not considered to be physical restraint.

1. Review of the electronic Restraint Flowsheet entries in Medical Record #34 indicated: ".....
06:37 (7:07am) 11/24/2011. The patient has demonstrated behavior requiring restraints (patient is in custody of englewood [sic] PD procedure to have one hand cuffed to stretcher.). .....
08:35 11/24/11. The patient has demonstrated behavior requiring restraints (patient left hand cuffed per englewood [sic] PD procedure).
....."

The use of handcuffs by police officers is not considered a use of physical restraint per facility policy and should not have been documented as such on the Restraint Flowsheet.

Based upon observations made during a tour of the Emergency Department and Staff interview, it was determined that all drugs and biologicals were not kept in a secure area.

Findings include:

Reference: Facility Policy #5.26, Emergency Medications for Cardiac Arrest Call (CAC), Rapid response and Cardiac Emergency Carts (Date: 2/19/10) states: 4. Maintenance of CAC Carts, 4.1- Each unit with a cart is responsible for maintaining the equipment and supplies. Carts will be locked when not in use. ...

1. During a tour of the Emergency Department, conducted at 10:45 AM on 11/28/11, in the presence of Staff #2 and #4 the Emergency Crash Cart (next to Bay 14) was found with the security tag (#5547037) broken and two drawers open.

a. The cart had last been checked on the 7 PM to 7 AM shift prior to the time of the discovery.

b. Staff could not say when and/or why the cart had been opened.

c. These findings were confirmed by Staff #2 and #4.


2. During the same tour a Urology Cart was found (near Bay #3) that had 6- 250 milliliter bottles of irrigant saline solution and 4-3000 cubic centiliter bags of irrigant solution. The cart and its contents were unsecured.

Based on observation, it was determined that the facility failed to prohibit access to locked areas.

Findings include:

1. On 11/29/11 at 10:50 AM, in the presence of Staff #1, the wall was only 5 feet tall on one side, allowing entry into the pharmacy storage area.

Based on staff interview, document review, lunch meal observation, and a tour of the kitchen conducted in the presence of Staff #11, Staff #12 and Staff #14 on 11/29/11, it was determined that the facility failed to ensure that facility policies and procedures are maintained; and that the facility is in compliance with New Jersey CHAPTER 24 (N.J.A.C. 8:24) Sanitation in Retail Food Establishments and Food and Beverage Vending Machines.

Findings include:

Reference #1: The Director of Food and Nutrition Services job description states, "Directly responsible for the development and execution of an overall program for the procurement, preparation and service of foods to the patients, cafeteria, and catered functions; for the formulation of department policies and procedures and the implementation of these; menu planning, in-service education programs, quality improvement program; hiring, employee evaluations, budget planning, production controls, quality controls, cleaning and sanitation controls (implemented and properly documented). ...PRINCIPAL DUTIES & RESPONSIBILITIES, ...10. Reviews the departments' activities to insure that practices are in keeping with State, Federal and JCAHO standards 100% of the time. ..."

Reference #2: N.J.A.C. 8:24-3.3(d) states, "Working containers holding food or food ingredients that are removed from their original packages for use in the retail food establishment, such as cooking oils, flour, herbs...shall be identified with the common name of the food, except that containers holding food that can be readily and unmistakably recognized..."

1. On 11/29/11 at 10:12 AM near the food and beverage storage rooms, there was a walk-in refrigerator that contained 2 large plastic containers of a brown liquid. There was no identification label on the both items. Staff #14 stated, "it's Miso Soup."

2. On 11/29/11 at 10:20 AM near the food and beverage storage rooms, there was a walk-in freezer with a large container of a frozen white and brown speckled substance. There was no identification label on the item. Staff #14 stated, "it's cannoli cream."

Reference #3: N.J.A.C. 8:24-3.5(f) states, "Potentially hazardous food shall be maintained at refrigeration temperatures (at or below 41°F)."

3. The AM Storeroom Temperature Log for November 2011 evidenced that B3 Refrigerator Standard temperature went above 41°F and there were no corrective actions noted on the log sheet for the following dates:
11/3/11-42°F,
11/5/11-42°F,
11/7/11-44°F,
11/8/11-44°F,
11/9/11-43°F,
11/14/11-42°F,
11/16/11-42°F,
11/17/11-44°F,
11/18/11-43°F.

Reference #4: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

4. On 11/29/11 at 10:05 AM in the food storage room, there was a build-up of dust and debris on the floor underneath the food racks.

5. On 11/29/11 at 10:10 AM in the beverage storage room, there was a puddle of water in the middle of the room.

6. On 11/29/11 from 10:00 AM through 10:20 AM, the flooring outside of the foodservice loading dock area, leading into the hospital and adjacent hallways leading to the food storage, appeared unclean with black marks and stains on the floor surface.

Reference #5. N.J.A.C 8:24-4.6 Cleaning of equipment & utensils (a) Equipment food-contact surfaces and utensils shall be clean to sight and touch.

7. On 11/29/11 at 12:20 PM in the Dean 5 Food Pantry, the Follett Symphony Series water dispenser had pink and brown residue at the water spigot.

a. It should be noted that a facility work order evidenced that maintenance was performed on the Follett Symphony Series water/ice dispenser in Dean 5 Food Pantry on 11/28/11. The document did not specify what cleaning procedures were performed.

Reference #6: The Chief (Clinical) Dietitian, RD job description states, "Under the general supervision of the department director, supervises the nutrition services area. As such, establishes nutrition protocol and polices(sic). Responsible for the provision of high quality nutritional care to patients. Acts as a nutrition resource to hospital professional staff including physicians, residents, interns, nurses and other health care providers; Functions as the departments ' QI coordinator. In carrying out the above programs, participates in providing in-service to the department and hospital employees. Assists in the general supervision of the department and functions as an active member of the management team. Functions as Systems Administrator for Computrition. Demonstrates by example and nurtures in staff the standards of service excellence so that these standards represent minimum behavior. ..."

Reference #7: Facility policy, "Nutrition Risk Screening & Assessment/Reassessment, ...Procedure: 1.0 Nutrition Screening, ...
1.2 Through the Nutrition Screen on the Amission(sic) Assessment,, presence of nutritional risk triggers is identified (See Policy #400-4.4),
1.3 Nursing notifies the Department of Food and Nutrition Services within 24 hours of admission date via the Electronic Medical Record system if one or more nutritional risk triggers are present.
1.4 The Registered Dietitian performs a nutritional assessment within 72 hours of admission date upon receipt of an Admission Referral from EMR or notification via phone.
1.5 Patients at nutritional risk through nutrition screening (see 1.0) will receive a nutrition assessment within 72 hours of admission. ..."

8. Upon review on 11/29/11, 3 of 3 Medical Records (#7, #8, #9) for patients who were determined to be at nutrition risk by the nurse, showed no evidence that a referral was made to Food and Nutrition Services. This was confirmed by Staff
#11 on 11/29/11 at 1:40 PM.

a. In Medical Record #7, the patient was admitted as an in-patient on 11/23/11 and the nursing admission assessment dated 11/23/11 evidenced the following nutrition risk factor, " Nutrition triggers high risk Braden <= 18. " Medical Record #7 showed no evidence that a referral was sent to the Food and Nutrition Department.

i. Medical Record #7 showed no evidence that a nutrition assessment for Patient #7, who was determined to be a high nutrition risk, was performed in accordance with facility policy "Nutrition Risk Screening & Assessment/Reassessment. During an interview on 11/29/11 at 1:40 PM, Staff #11 confirmed this finding.

b. In Medical Record #8, the patient was admitted as an in-patient on 11/17/11 and the nursing admission assessment dated 11/21/11 evidenced the following nutrition risk factor, "Nutrition triggers high risk on hemodialysis/CAPD." Medical Record #8 showed no evidence that there was a referral sent to the Food and Nutrition Department.

c. In Medical Record #9, the patient was admitted as an in-patient on 11/21/11 and the nursing admission assessment dated 11/22/11 evidenced the following nutrition risk factor, " Nutrition triggers high risk Braden <= 18. " Medical Record #9 showed no evidence that there was a referral sent to the Food and Nutrition Department. Staff #11 verified this finding.

9. Patient #9 failed to receive an "Empty cup with handle on tray" so that he/she was able to self feed himself/herself in accordance with the meal tray ticket. The facility failed to promote high quality nutrition care for Patient #9.

a. On 11/29/11 at 12:30 PM during a tour of Dean 5 patient care unit at lunch time, Patient #9 had a meal tray ticket with the following stated, "Dysphagia Stage IV " diet, "...Empty cup with handle on tray..." Patient #9's meal tray did not contain an empty cup with a handle for Patient #9.

Based on observation, it was determined that the facility failed to comply with the Life Safety Code concerning the safety of exit corridors.

Findings include:

1. On 11/29/11 at 10:20 AM, in the presence of Staff #9, in the lab corridor, a construction worker was using a welding torch with only a plastic sheet ICRA barrier.

2. On 11/29/11 at 9:50 AM, in the presence of Staff #9, at the angiography area, a cubical curtain was installed across the exit.

Based on observation, it was determined that the facility failed to ensure implementation of its policy and procedure for isolation precautions.

Findings include:

Reference: Facility policy, "Transmission Based Precautions - Initiating Precautions (Isolation)" states on page 2 under 'Contact Precautions (Isolation),' "Wash or decontaminate hands upon entering and when leaving patient room."

On 11/30/11 at 10:30 AM, in the presence of Staff #4, Staff #21, and Staff #22, the inpatient unit 6 Dean was toured. A Contact Isolation sign was posted outside of Room
#6428. Staff #27 was observed exiting the room, removing his/her gloves in the hallway outside of the patient's room, and disposing of the gloves into the trash located in the hallway. Staff #27 then proceeded to the nurse's station and picked up a patient's medical record without the benefit of hand hygiene.