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Based on observation and staff interview, the facility failed to store refrigerated medication at the manufacturer's recommended temperatures on the West campus. Findings included:

During the tour of the West Campus Pharmacy on 10/12/10 at 1:10 p.m., the surveyor observed the following items stored in the refrigerator:
-Tuberculin Vaccine with the manufacturer's recommended storage temperatures of 35-46? (degrees) F (Farenheit);
-Tetanus Toxoid with the manufacturer's recommended storage temperatures of 35-46? F;
-Risperdal with the manufacturer's recommended storage temperatures of 36-46? F;
-Tetanus Toxoid reduce Diptheria Toxoid, and Acellular Pertussis Vaccine with the manufacturer's recommended storage temperatures of 35-46? F;
-Acetylcysteine with the manufacturer's recommended storage temperatures of 68-77? F;
-Levimir with the manufacturer's recommended storage temperatures of 36-46? F; and
-Methergine 20 ampule with the manufacturer's recommended storage temperatures of 36-46? F.

The surveyor observed the Daily Temperature Log for Medications, which listed temperatures from January 1 to October 11, 2010. The top of the Daily Temperature Log for Medications documented "If temp [temperature] is not between 34-45? F, Adjust temperature control and recheck before calling Facilities for repair. Note maximum/minimum temperatures in date box." The bottom of this form "If temperature outside range complete Date, Time, and Temp. Initials indicate Pharmacy noted and/or Facilities notified and Action taken."

The following discrepancies were noted:
-January: 3 of 19 documented temperatures were below the manufacturers' recommendation for temperature ranges, at 32.7? F to 32.9? F.
-February: 1 documented temperature of 47.7? F and 1 documented temperature of 30.7? F. These temperatures were out of the range of the manufacturers' recommendations. On 2/11 staff member AA, the pharmacist, noted the 47.7? F was out of range and she documented "Will watch."
-March: 4 of 22 documented temperatures were out of range of the manufacturers' recommendations. Staff member AA, the pharmacist, documented "Will watch."
-April: 4 of 20 temperatures were above the manufacturers' recommendations for temperature ranges. Staff member AA, the pharmacist, documented on 2 of 4 temperatures "Will watch," and on 4/1/10 when the temperature was 53.1? F, documented "called maintenance." On 4/2/10, the temperature was 55.6? F. Staff member AA, the pharmacist, stated she had notified the maintenance department regarding the out of range temperatures. The maintenance department staff told her to place the thermometer in different areas, inside the refrigerator. The refrigerator temperatures were not addressed when the staff moved the position of the thermometer as instructed by the maintenance department staff.
-May: 1 of 19 temperatures was above the manufacturers' recommendations for temperature ranges. The Daily Temperature Log For Medication lacked documentation of action taken for the out of range temperatures.
-June: 2 of 20 temperatures were above the manufacturers' recommendations for temperature ranges. The Daily Temperature Log For Medication lacked documentation of action taken for the out of range temperatures.
-July: 4 of 20 temperatures were above the manufacturers' recommendations for temperature ranges. The Daily Temperature Log For Medication lacked documentation of action taken for the out of range temperatures.
-August: 5 of 21 temperatures were above the manufacturers' recommendations for temperature ranges. Staff member AA, the pharmacist, documented on 3 of the out of range temperatures, "Will watch," and for 1 temperature she documented, "called maintenance and moved temp [temperature] gauge further back." On 8/17/10, the temperature in the refrigerator was documented at 50.5? F and on 8/18/10, the temperature was documented at 65.7? F. Eleven of 21 documented temperatures were out of range of the manufacturers' recommendations. The Daily Temperature Log For Medication lacked documentation of action taken for the out of range temperatures.
-September: 21 of 21 documented temperatures were below the manufacturers' recommendations for temperature ranges. The Daily Temperature Log For Medication lacked documentation of action taken for the out of range temperatures.
-October: 7 of 7 documented temperatures were below the manufacturers' recommendations for temperature ranges. The Daily Temperature Log For Medication lacked documentation of action taken for the out of range temperatures.

Staff member AA, the pharmacist, stated, she had been notifying maintenance regarding the above normal temperatures. Maintenance told her to place the thermometer further back in the refrigerator.


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Based on observation, the facility failed to ensure safe practices for food handling, food storage, and kitchen sanitation were followed. Findings include:

1. During the initial tour of the West Campus kitchen on 10/12/10 starting at 1:40 p.m., the surveyor made the following observations:
-a section of the Hobart meat cutter blade edge had meat residue;
-a cupboard contained Carnation Instant Breakfast packages with an expiration date of 7/2010;
-the reach in refrigerator contained 27 - 8 ounce containers of Honey Thick Vanilla Dairy with an expiration date of August 14, 2010 and 30 - 8 ounce Honey Thick orange juice with an expiration date of January 30, 2010.

Staff member LL, dietary manager, stated that the dates on the boxes were difficult to read.

2. On 10/12/10 at 4:55 p.m., the following observations were made in the Occupational Therapy kitchen refrigerator:
-3 sealed Tupperware containers of food were not labeled or dated; and
-1 container of low fat yogurt with a sell by date of 8/10/10.

3. The following handwashing/gloving observations were made on 10/14/10 on the West Campus:
-7:30 a.m., staff member FF, the cook, was observed with gloved hands performing the following activities:
-touched a rolling cart;
-retrieved bread from a bag, dipped the bread into a mixture (French-toast), and placed the bread on the grill;
-removed gloves;
-poured pancake batter;
-placed the French toast and pancakes on plates;
-placed the plates on a tray cart and pushed the tray cart to the tray line;
-pushed the tray cart back to the grill area;
-touched diet menu papers;
-put on 1 glove to retrieve bread from a bag with the gloved hand;
-dipped the piece of bread into the French toast mixture and placed the bread on the grill;
-removed the glove;
-placed hands on the countertop across from the grill;
-retrieved an item from the refrigerator;
-returned to the grill area;
-put on 1 glove to dip French toast; and
-removed the glove.

At no time during this observation did staff member FF wash hands between glove changes.

Staff member C, Food Services Manager, was informed of the observation. At this time, the policy for gloving and hand washing was requested. By the end of the survey, the policy was not provided to the surveyors.


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4. On 10/12/10 at 10:30 a.m., accompanied by staff members C and D, the following unsealed, opened and undated food items were observed in the coolers and freezers.

The freezers contained:
-an unsealed exposed bag of fish nuggets;
-an unsealed exposed bag of fries;
-an unsealed exposed bag of tater tots; and,
-an unsealed exposed bag of corn.

The coolers contained:
-a box of chicken tenderloins unsealed with no open date;
-a box of chicken nuggets unsealed with no open date:
-a box of pork sausage patties unsealed with no open date;
-an unsealed package of ice covered hot dogs with no open date; and,
-an unsealed package of raw chicken breast with no open date.

At 10:30 a.m., staff member C stated that "all food items were to be sealed and dated whether in the dry storage, refrigerators or freezers."


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4. The Medical Floor South wing refrigerator, where patient snacks were kept, was inspected on 10/12/10 at 1:55 p.m. An egg salad sandwich was found in the refrigerator which was undated. The sandwich was discarded immediately by hospital staff.

Based on observations and staff interviews, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

1. During the survey of the West campus laboratory on 10/12/10 at 12:25 p.m., the surveyor observed 75 foil wrapped Clinitest Reagent tablets, for urine sugar testing, located in the Clinitest box with the manufacturer's expiration date of 6/2010.

On 10/12/10 at 12:25 p.m., staff member T, laboratory technician, stated, "[staff member] goes through expired supplies and orders monthly."

2. During the survey of the West campus Cardiopulmonary rehabilitation area on 10/12/10 at 3:40 p.m., the surveyor observed the following:
-11 3 inch by 3 inch Gauze Sponges with the manufacturer's expiration date of 7/2005;
-1 Sterile cotton tipped applicator with the manufacturer's expiration date of 9/2002; and
-1 disposable suture removal kit with the manufacturer's expiration date of 4/2005.

On 10/12/10 at 3:45 p.m., staff member U, quality assurance specialist, stated, "Cardiopulmonary rehabilitation moved into the area within the last few months."