HospitalInspections.org

RECITED
Based on observation, document review, and interview, the director of dietary failed to ensure the safety of the food by not maintaining and monitoring the refrigerator, freezer and food temperature logs per the facility ' s policy for 16 of 16 pantries. The deficient practice affected 1055 patients served at the facility.

Findings include:

Review of the facility's 16 pantry refrigerator temperature logs, freezer logs and food temperature logs was completed on 09/20/12. The review revealed refrigerators, freezers and food were inconsistently monitored for the required temperature parameters, the logs were not being completed per the hospital dietary policy and temperatures were outside of the recommended parameters. Corrective actions were not implemented for recordings that were outside the recommended parameters.
Observations of the refrigerators, freezers and food storage temperature logs in pantries H50, H60, H70 and H80 were completed on 09/20/12.
The temperature log for H50 refrigerator #1 lacked a temperature recording for closing time on 09/19/12. The time of the closing temperatures was not recorded from 09/01/12 through 09/18/12.
The opening time temperature was not recorded from 09/01/12 through 09/08/12.

The closing temperature recording log for the H60 freezer #1 revealed 10 temperatures were recorded that were outside of the hospital dietary policy's acceptable parameters, and no corrective actions were documented. The temperature recording log for H60 freezer # 1 lacked a closing temperature documented on 09/06/12.
The temperature recording log for H60 refrigerator #1 revealed 5 temperature recordings outside of the hospital dietary policy's acceptable parameters with no corrective action documented.
The temperature recording log for H60 refrigerator #1 lacked a closing temperature documented on 09/11/12.
The temperature recording log for H60 refrigerator # 2 lacked an opening temperature recording for the morning of 09/06/12 and lacked closing temperatures recordings for 09/07/12, 09/09/12, 09/11/12 and 09/14/12. There was no documentation for corrective action taken for a temperature outside of the policy's acceptable parameters on 09/06/12.
The temperature recording log for the H60 freezer #3 lacked documentation of corrective actions implemented for 13 temperature recordings that were outside of the hospital dietary policy's acceptable parameters.

The temperature recording log for H70 freezer #4 lacked documentation of a a morning temperature on 09/12/12, and lacked documentation of an implementation of a corrective action for a temperature reading of 60 degrees Fahrenheit on 09/02/12. The temperature recording log for the H70 bottom freezer lacked a temperature recording for the mornings of 09/15/12 and 09/20/12. The bottom freezer log for H70 lacked the recording of a closing temperature on 09/02/12, or documentation of the of corrective actions implemental for 6 readings outside of the hospital dietary policy's acceptable parameters.
The H70 refrigerator log lacked documentation of corrective actions implemented for readings outside of the hospital dietary policy's acceptable parameters on 09/13/12, 09/16/12 and 09/18/12.

The temperature recording log for the H80 freezer #4 lacked documentation of corrective actions implemented for 15 readings outside of the policy's acceptable parameters. The log lacked a morning temperature recording for 09/20/12.
The temperature recording log for the H80 freezer #3 lacked documentation of a corrective action implemental for readings outside of the policy's parameters on 09/12/12, 09/15/12 and 09/16/12.
A morning temperature was not documented on 09/20/12 for H80 freezer #2, #3, #4 and #5.
The H80 freezers #4 and #5 log did not have a closing temperature documented from 09/01/12 through 09/19/12.
The H80 freezer #5 did not have documentation of corrective actions implemented for 17 readings outside of the policy's acceptable parameters.

Review of the hospital dietary policy #205 "Meal Service Procedures" was reviewed on 09/20/12. The policy stated all refrigerator and freezer temperatures were to be checked when opening and closing the pantries. The policy stated corrective action was to be taken and recorded on the temperature log.

Staff W was interviewed on 09/20/12. Staff W stated the pantries are not using the food label guns per the plan of correction due to the guns were difficult to thread. Staff W stated the facility has ordered different label guns that have not yet been delivered.






21893

RE-CITED

Based on tour of the facility, review of facility documentation, and staff interview and verification, the facility failed to ensure that suites of rooms greater than 1,000 sq. ft. had at least two exit access doors remote from each other, and the exit accesses did not exit through an intervening suite, and that chute rooms were used exclusively for accessing the chute openings in accordance with the code at 8.4, and that chute rooms were separated from the service elevator with a one hour fire resistance rated barrier in accordance with the code at Section 18.5.4 and 9.5.1 (A701). This had the potential to affect all those utilizing this facility.






21957

RE-CITED

Based on facility tour, review of facility documentation, and staff interview, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association with regard to suites of rooms greater than 1,000 sq. ft. had at least two exit access doors remote from each other, the exit accesses did not exit through an intervening suite, that chute rooms were used exclusively for accessing the chute openings in accordance with the code at 8.4, and that chute rooms were separated from the service elevator with a one hour fire resistance rated barrier in accordance with the code at Section 18.5.4 and 9.5.1. This had the potential to affect all those utilizing this area of the facility. The facility census was 1,055, at the time of the post survey-revisit. .

Findings include:

Facility tour took place, on 09/18/12 between 9:00 A.M. and 4:00 P.M., with staff members K, M, and N present. Observations of areas designated as suites for pre and post operative care as well as waiting areas were noted to have exit accesses which had egress access through intervening suites.

During the tour observations were made of combination linen chute, trash chute, and service elevator rooms on patient care floors of the J building. Observations of these rooms revealed the linen chute, trash chute, and service elevator were located in the same room, without a one hour fire rated separation between the chutes and the elevator.

Please see the following tags in the life safety code report for more specific details:

K42, which addresses the facility's failure to ensure any suite of rooms greater than 1,000 sq. ft., had at least two exit access doors remote from each other, and the exit accesses did not exit through an intervening suite.

K71, which addresses the facility's failure to ensure chute rooms were used exclusively for accessing the chute openings in accordance with the code at 8.4, and that chute rooms were separated from the service elevator with a one hour fire resistance rated barrier in accordance with the code at Section 18.5.4 and 9.5.1.

Staff verified the above findings remained the same with regard to the suites and the combination chutes/elevator rooms since the life safety code survey completed on 08/03/12.



21957

RECITED
Based on medical record review and interview, the facility failed to ensure informed consent was documented in the patient's chart for one (Patient #13) of 31 patients scheduled for the catheterization lab on 09/18/12, and the facility failed to obtain informed consent by an authorized person for one (Patient #1) of 25 medical records reviewed. The facility's census at the time of the survey was 1055.

Findings include:
The medical record review for Patient #13 was completed on 09/18/12. The facility performed a heart catheterization for the patient on 09/18/12. The patient's record lacked a signed consent for the procedure the facility performed on 09/18/12.
The medical record review for Patient #14 was completed on 09/18/12. The facility performed a heart catheterization on Patient #14 on 09/18/12. The patient's record included 2 signed consents for heart catheterization on 09/18/12. The first consent was signed by Patient #14 for a left heart catheterization with or without invention. The second consent in Patient #14's medical record was signed by Patient #13 for percutaneous coronary intervention to the left anterior descending coronary artery.
Staff #5 was interviewed on 09/18/12. Staff #5 stated that he/she was obtaining consent in the morning and the computer stopped working. He/she stated he/she located a different computer to obtain the consent for the procedure and pulled up the wrong patient's form for Patient #13 to sign.

The medical record review for Patient #1 was completed on 09/17/12. The patient's record contained a durable power of attorney form, effective on the disability of the patient's family member, designated as the durable power of attorney, in case the family member became disabled. There was not a durable power of attorney form signed by the patient in the medical record. The patient's medical record contained three consent forms, signed for surgery. The facility's staff member obtained a telephone consent from the patient's father for two of the surgeries. The facility obtained a telephone consent for a gall bladder surgery from an agent who was not related to the patient or legally authorized to provide consent.
On 09/20/12, the social worker documented the patient's father wanted the patient returned to California to have the surgery. The social worker documented the power of attorney documents presented by the agent were questionable. The social worker documented the ethics (department) needed to be involved because the power of attorney documents appeared to be only partially completed with scribbled out signatures.
On 09/20/12, the facility's policy #R1104 "Informed Consent" and policy #R1104b "Persons Authorized to Consent" was reviewed. The policy stated if a patient cannot provide informed consent, informed consent will be obtained from a person who is legally authorized to consent on behalf of the patient.
On 09/18/12, during an interview, Staff A stated the social worker did not involve the ethics department regarding the durable power of attorney document in the patient's medical record. Staff A stated informed consent was obtained by the social worker from the patient's father, but the facility failed to document that authorization on the informed consent form.





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