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Based on observation, interviews, and review of documentation, it was determined the hospital failed to ensure the physical environment was constructed, arranged, and maintained to ensure patient safety.

Findings:

Observation of the endoscope reprocessing area for Surgical Services on 7/19/2017 at 11:30 AM revealed a ST raising the side rails on an occupied gurney. The ST did not provide the patient on the gurney with a call light prior to leaving the area. The patient was left alone in the Pre-op/Recovery Room without a means to call for assistance.

Observation of the Pre-op/Recovery Room on 7/19/2017 at 11:30 AM revealed a patient call system on the wall panel behind the gurney. Observation revealed two patient call paddles attached to this panel. Both call paddles had electrical cords coiled up and restrained with twist-ties. An RN stated "we don't use those [call paddles], that's why they're dusty."

Observation of the patient call system in the Pre-op/Recovery Room on 7/19/2017 at 3:00 PM revealed the call light located on the wall behind the patient gurney had been activated. Observation revealed an illuminated red light on the wall faceplate that was associated with the patient call paddle. No corresponding audible tone could be heard when the call system had been activated.

During this observation, a clicking sound was heard coming from the speaker on the call system. The red light on the wall faceplate turned off and no staff arrived in the room in response to the activation of the patient call system.

Observation of the patient call system included a random test completed on 7/19/2017 at 3:06 PM. This test included activating the call light. A red light on the wall faceplate illuminated during the test. No corresonding audible tone could be heard when the call system was activated. During this test, a clicking sound was heard coming from the speaker on the call system. The red light on the wall faceplate turned off and no staff arrived in the room to respond to the activation of the patient call system.

The testing determined the call lights were functional, however, there were no corresponding audible alarms to alert staff on the unit that the call system had been activated.

During an interview with an RN in the Pre-op/Recovery area on 7/19/2017 at 3:06 PM at the time of the call light testing, he/she stated, "the call system doesn't ring [into an answering station] on this unit...it rings to the medical side on the other side of the hospital."

During an interview with the OR Manager on 7/19/2017 at 2:15 PM, he/she stated, "The call lights in recovery don't work."

The review of documentation included, "Preventing Falls While in the Hospital," which was undated. This document indicated, "Lower Umpqua [Hospital] is dedicated to providing a safe environment for all our patients. Call light: use your call light and wait for someone to come and assist you before getting out of bed.


37917

Based on observation, interview, and review of documentation, it was determined the hospital had failed to track, inspect, and maintain all patient care equipment to ensure safe operating condition.

Findings:

Observation of the Rehabilitation Unit on 7/19/2017 at 10:45 AM revealed the following:

- 2 "Total Gym 26000" fitness machines; these machines did not have equipment check stickers to indicate that PM had been completed;
- 1 gel warmer; this item did not have an equipment check sticker to indicate that PM had been completed;
- 1 exercise bicycle; this item did not have an equipment check sticker to indicate that PM had been completed;
- 2 CPM machines; the equipment check stickers were faded and unreadable. During an interview, the Rehabilitation Director confirmed the CPM machines were rented by the hospital and there was no evidence to indicate that PM for these machines had been completed for the last year.

Observation of the Cardio/Pulmonary Lab on 7/19/2017 at 11:30 AM with the IPRN revealed the following:

- A treatment bed; the bed did not have an equipment check sticker to indicate that PM had been completed.

Observation of Room 101, used for transfusions and wound care on 7/19/2017 at 12:00 PM with the IPRN revealed the following:

- 3 treatment chairs; these chairs did not have equipment check stickers to indicate that PM had been completed;
- 1 hospital bed; this bed did not have an equipment check sticker to indicate that PM had been completed.

Observation of the hospital's onsite walk-in clinic on 7/19/2017 at 12:30 PM with the IPRN, revealed the following:

- 1 Zoll defibrillator; this defibrillator did not have an equipment check sticker to indicate that PM had been completed;
- 1 infant scale; this scale did not have an equipment check sticker to indicate that PM had been completed;

Observation of the kitchen on 7/19/2017 at 3:30 PM with the IPRN revealed the following:

- 1 Vulcan Steamer; this item did not have an equipment check sticker to indicate that PM had been completed. Review of documentation on the maintenance inventory list revealed the steamer was not included in the hospital's equipment inventory.

Observation of the hospital's onsite walk-in clinic on 7/19/2017 at 12:30 PM with the IPRN revealed the following:

- 2 wall mounted diagnostic transformer units, each unit contained an otoscope and an ophthalmoscope. Documentation on the equipment check stickers on these items indicated the last inspection had occurred on 4/30/2015. Documentation on the stickers indicated the re-inspection of these units was due by 4/30/2016. There was no evidence to reflect that these units had been inspected in 2017.

- 2 treatment beds; the equipment check stickers indicated the last inspection had occurred on 4/30/2015. Documentation on the stickers indicated the re-inspection of these beds was due by 4/30/2016. There was no evidence to reflect that these units had been inspected in 2017.

- 1 VeraTemp+ Scan Thermometer; this item did not have an equipment check sticker to indicate that PM had been completed. Review of documentation on biomedical and maintenance inventory lists revealed the steamer was not included in the hospital's equipment inventory.

Observation of the ED on 7/18/2017 at 10:00 AM with the IPRN revealed the following:

- 1 VeraTemp+ Scan Thermometer; this item did not have an equipment check sticker to indicate that PM had been completed. Review of documentation on biomedical and maintenance inventory lists revealed the steamer was not included in the hospital's equipment inventory.

- 1 Mooney & Co. ring cutter; this item did not have an equipment check sticker to indicate that PM had been completed.

Observation of the Decontamination area on 7/19/2017 at 10:00 AM with the IPRN revealed the following:

- 1 Fuji SPS medical sealer; this item did not have an equipment check sticker to indicate that PM had been completed.

An interview with the POM and the BMT on 7/20/2017 at 11:15 AM included an explanation of the PM process for equipment included in the hospital's biomedical and maintenance inventory lists.

According to the POM and the BMT, equipment items had a "#" sign in parenthesis followed by a description of the equipment. There were additional equipment forms available that included PM instructions for each different type of equipment that required PM. The BMT was expected to pull the appropriate form for the corresponding equipment item and follow the instructions to complete the PM.

The BMT stated during the interview the use of the maintenance instruction forms had been implemented by previous staff and he/she did not know how the forms had been developed. He/she also stated that equipment service manuals were not used to determine how or when PM was done. He/she stated the equipment maintenance forms were the only mechanism in place for evaluating the need for equipment maintenance, determining the type of maintenance that was needed, and determining when or if a piece of equipment needed PM.

The POM and the BMT acknowledged during the interview that PM on hospital equipment was not current.

Additional observation and the review of PM documentation revealed the following:

- 1 Doppler unit in the ED on 7/18/2017 at 10:00 AM. The Doppler was identified on the biomedical inventory list by a hospital equipment number. Documentation on the inventory list failed to indicate a PM interval for the Doppler. Documentation failed to reflect any PM for the Doppler had been done completed.

Documentation presented for review by the BMT for the Doppler included a note dated 9/9/2009. The note indicated, "Tria II not working?...Called factory - the ON button must be held ON button [sic] until unit turns on OK."

- 1 BeliMed washer in the Decontamination area on 7/19/2017 at 12:50 PM. The washer was identified on the maintenance inventory list by a hospital equipment number. Documentation on the inventory list failed to indicate a PM interval for the washer. Documentation failed to reflect any PM for the washer had been done completed.

The POM and the BMT stated during an interview on 7/19/2017 at 12:50 PM that they were unable to locate any PM records to reflect that PM for the BeliMed washer had been completed.

Refer to additional findings cited at Tag C221.

Interviews and the review of documentation revealed the hospital had failed to design, implement, monitor and evaluate a mechanism, including but not limited to written policies and procedures, to ensure that all hospital equipment had PM as required.

Based on observations, interviews, and the review of documentation, it was determined the hospital failed to ensure proper temperature and humidity levels were maintained in the Surgical Services and Sterile Processing areas.

Findings:

Observation of the Surgical Services area on 7/19/2017 at 2:15 PM with the OR Manager revealed there was no documentation to reflect that temperature and humidity levels were being monitored or recorded.

During an interview with the OR Manager he/she stated, "We haven't been tracking humidity or temperatures [in Surgical Services]."

Review of documentation included the hospital policy and procedure titled, "HVAC System Setting in Operating Room" dated, approved and revised on 7/20/2017. Instructions included but were not limited to, "Humidity should be monitored and recorded daily....Temperature should be monitored and recorded daily....Temperature should be maintained between 68 degrees F to 73 degrees F....within the operating room suite and general work areas of sterile processing."

The review of documentation revealed that prior to 7/20/2017, the last day of the survey, the hospital did not have written policies and procedures for monitoring temperature and humidity levels in Surgical Services.

Interviews and the review of documentation revealed the hospital had failed to design, implement, monitor and evaluate a mechanism, including but not limited to written policies and procedures, to ensure the temperature and humidity levels in the Surgical Services and Sterile Processing areas were maintained and recorded as required.

Based on interview and the review of documentation, it was determined that 8 of 8 medical records (Records 1, 2, 3, 9, 10, 11, 12, and 18) failed to have evidence of discharge planning.

Findings:

Record 1: Documentation revealed Patient 1 had been admitted on 7/16/2017 and was currently an inpatient. Patient 1 had medical diagnoses that included acute pancreatitis and a urinary tract infection. Documentation failed to reflect that discharge planning had been initiated for Patient 1.

Record 2: Documentation revealed Patient 2 had been admitted on 7/15/2017 and was currently an inpatient. Patient 2 had diagnoses that included cough, fever, and pneumonia. Documentation failed to reflect that discharge planning had been initiated for Patient 2.

Record 3: Documentation revealed Patient 3 had been admitted on 7/18/2017 with injuries from a physical assault. Documentation failed to reflect that discharge planning had been initiated for Patient 3.

Similar findings were noted in the remaining medical records reviewed (Records 8, 10, 11, 12, and 18).

Review of documentation included the hospital policy and procedure entitled, "Discharge Planning", dated as approved and revised 12/2009. Instructions in the policy and procedure stipulated, "Discharge Planning shall be initiated on admission and continue through discharge, with education and patient planning for the home care environment....All discharge planning....will be documented in the medical record on the patient plan of care and Progress Notes as appropriate."

During an interview with the DON on 7/20/2017 at 9:30 AM he/she confirmed there was no evidence in the medical records reviewed to indicate that discharge planning had been initiated upon admission for Patients 1, 2, 3, 9, 10, 11, 12, and 18.

Based on interview, observation, and review of documentation, it was determined the hospital failed to ensure safe administration of medications and the appropriate storage, handling, and control of medications throughout the facility:

Findings:

Observation of the Surgical Services Pre-Operative/Recovery areas with the DON on 7/19/2017 at 9:20 AM revealed the following:

- A RT entered the pre-op room and asked the RN "Is this [Patient 20]?" The RN responded "Yes." Observation revealed that Patient 20 did not have a patient identification band on either wrist. Observation revealed there was no additional communication between the RT, the RN, or Patient 20 to confirm Patient 20's identification.

Observation revealed the RT then initiated the administration a nebulizer medication to Patient 20. The treatment lasted 15 minutes. Following completion of the nebulizer treatment, the RT left the room. Observation revealed the RN retrieved a patient identification band from a computer stand in the room and placed it on Patient 20's wrist after the nebulizer treatment.

During an interview with the CEO on 7/20/2017 at 9:00 AM he/she confirmed that two methods of identification were required when administering medications to patients.

Review of documentation included the hospital policy and procedure titled, "Medication Administration" dated as approved and revised on 8/2016." Documentation stipulated, "It is the policy of Lower Umpqua Hospital to implement a procedure for the safe and uniform distribution of medication, using the five 'Rights'...Ask patient his/her name and check patient's armband."

Review of documentation included the hospital policy and procedure titled, "Hand Held Nebulizer," dated as approved and revised on 8/7/2016. Documentation stipulated, "Upon entering the room; Introduce yourself to the patient...Identify patient using two patient identifiers."

Observation of the Surgical Services Pre-op/Recovery area with the DON on 7/19/2017 at 9:20 AM revealed a rolling metal supply cart that contained 47 different medication vials in the top drawer. The DON confirmed the drawer was unsecured, unlocked and unattended by staff. Patients were observed in this area waiting for their procedures and could access the contents of the supply cart, including the medications. In addition, following the patients return to the room after their procedures, staff were monitoring the patients recovery and were not attentive to this medication cart.

During an interview with RN for this area on 7/19/2017 at 1:45 PM he/she confirmed patients were often left unattended in the Pre-op/Recovery area prior to their procedures.

Observation of the medical clinic on 7/20/2017 at 8:50 AM with the IPRN revealed the following:

- 6 vials of Xylocaine (local anesthetic); 3 vials expired 5/2017 and 3 vials expired 06/2017. The 6 vials were stored in a tray in an unsecured and unlocked cabinet in a patient treatment room;

- 3 tubes of Grafco Silver Nitrate Applicators (topical cauterization), expired 4/2016;

- 1 tube of Silver Sulfadiazine Cream (topical antibacterial), expired 3/2016;

- 5 bottles of 0.9% Sodium Chloride Irrigation (normal saline), expired 6/01/2017.

Observation of the walk-in clinic on 7/19/2017 at 12:30 PM with the IPRN revealed 1 tube of Grafco Silver Nitrate Applicators in a patient room, expired 3/2017.

Review of documentation included the hospital policy and procedure titled, "Medication Out-Dates," dated as approved and revised on 4/2007. Documentation stipulated, "A regular audit shall be conducted to remove from stock any medications found to be within the expiration date [sic]. Any medications removed from stock for this reason shall be returned to the pharmacy accompanied by a note indicating the medication and the reason for return. Regular audits shall be conducted at least monthly."

Based on observations, interviews, and the review of documentation, it was determined the hospital failed to fully develop and implement policies and procedures to ensure that expired items were not available for use, for infection prevention practices, for safe disinfection processes, and for appropriate nutrition storage for the safety of patients, staff and visitors.

Findings:

Review of personnel records with the HRM on 7/19/2017 at 11:00 AM included documentation of TB risk assessments. Documentation revealed 7 of 34 records (Records 2, 3, 4, 6, 11, 12, and 31) failed to include evidence TB risk assessments had been performed as required.

Record 2: Documentation revealed a DOH for Employee 2 of 5/24/2017. Documentation failed to reflect that Employee 2 had received a TB test within 14 days of hire;

Record 3: Documentation revealed a DOH for Employee 3 of 3/26/2016. Documentation failed to reflect that Employee 3 had received a TB test within 14 days of hire;

Record 31: Documentation revealed a DOH for Employee 31 of 2/10/2017. Documentation failed to reflect that Employee 31 had received a TB test within 14 days of hire.

Similar findings were noted in the remaining personnel records reviewed (Records 4, 6, 11, and 12).

Review of documentation included the hospital policy and procedure titled, "Administration and reading of PPD" dated as approved and revised on 8/2008. Documentation stipulated, "Tuberculin Skin Test (PPD) will be given to eligible employees upon hire, and as required or needed during their employment. PPD will be given upon specific physician orders."

Review of documentation included the undated hospital policy and procedure titled, "Tuberculosis Screening". Documentation stipulated, "Tuberculosis screening shall be completed, on all employees and volunteers, within 14 days of start date."

During an interview with the HRM on 7/19/2017 at 11:00 AM he/she stated the paper documentation in personnel records could be "checked out" or "borrowed" by department managers. He/she stated this practice could result in employee information not being current with the online personnel record system.

Review of documentation on 7/19/2017 at 11:00 AM with the HRM included but was not limited to annual medical staff training.

Documentation revealed 1 of 12 RN's (RN 26) had not completed the annual infection control training for 2016.

During an interview on 07/19/2017 at 11:00 AM with the HRM, he/she stated "I'm unsure what annual infection control training is required. I'm not sure if the hospital has a policy for annual training and what all is required...I know that most of the staff complete a yearly training called 'Safety Storm', but I'm not sure what the content is or who chooses it."

Review of documentation included the hospital policy titled, "Requirements of Exposure Control Plan" dated as approved and revised 10/2008". Documentation stipulated, "Procedures to minimize exposure to bloodborne pathogens...Training requirements - initially and yearly."

Review of documentation included the hospital policy and procedure titled, "Exposure Control Plan: Bloodborne Pathogens" dated as approved and revised 8/2009. Documentation stipulated, "Establish Individual Responsibilities to minimize risk for healthcare workers acquiring bloodborne disease due to occupational exposure. Comply with OSHA Bloodborne Pathogen Directives. Complete yearly online bloodborne pathogen educational sessions annually and as needed."

Review of documentation included a hospital document titled, "Course Syllabus Safety Storm: Alpha 2016," release date 12/31/2015. Document details included the following online training, "Bloodborne Pathogens, Infection Control: Hand Hygiene, PPE, Care of the Environment, Patient Placement and Care, Elements of Respiratory Hygiene and Cough Etiquette, Transmission-based Precautions, Air borne Precautions and responding to Emerging High Infectious Diseases."

Review of documentation included a hospital document titled, "Course Syllabus Safety Storm: Gamma 2016," release date 12/31/2015. Document details included the following online training, "Infections: Magnitude of the Problems of MDRO's, Prevention and Control of MDRO's, Preventing Patient Infections: CAUTI, CLABI's, SSI's."

The review of documentation and interviews revealed the hospital had failed to design, implement, monitor, and evaluation a mechanism to ensure that all staff received annual training relevant to their job duties and responsibilities.

During an interview with the IPRN on 07/20/2017 at 9:00 AM, he/she stated "We don't have a negative pressure room...we had to put a patient with active TB into a regular patient room with a mask on and fans continuously blowing out the windows...[that was] about five or six years ago...our Airborne isolation signs say 'negative pressure' on them, but we don't have one [a negative pressure room]...normally a patient would be transferred to another hospital with negative pressure capabilities."

During an interview with the Facilities Manager on 7/19/2017 at 3:30 PM, he/she stated "There isn't a negative pressure room in the hospital."

Review of documentation included the hospital policy and procedure titled, "Emergency Department Exposure to TB," dated as approved and revised on 6/2/2014. Documentation stipulated, "Exposure to Tuberculosis in the Emergency Department and treatment areas. Encourage Emergency Department staff to recognize the signs and symptoms of active TB, place patient in a separate area apart from other patients and not in the open waiting areas (ideally in a room or enclosure with special ventilation maintained under negative pressure.)"

Review of documentation included the hospital's "Infection Control Policies and Procedures". Review of these policies and procedures revealed the hospital failed to have policies and procedures specific to airborne infection isolation or TB precautions for all hospital units.

The review of documentation failed to reflect the hospital had requested and/or been granted a waiver from having an Airborne Isolation room(s).

- Observation of the Pre-Operative Surgical Services Department on 7/19/2017 at 12:26 PM with the DON revealed an RN put on gloves, pick up a Sani-Cloth HB Germicidal Disposable Wipes container, and remove 2 Sani-Cloths from the container. The RN then cleaned the blood pressure cuff, tubing, and cardiac monitor leads that were still attached to a patient. Further observation revealed the RN removed the blood pressure cuff and cardiac monitor leads while touching the patient's skin with the germicidal wipes without removing and/or changing the gloves that were saturated with germicidal liquid.

Review of documentation on the Sani-Cloth HB Germicidal Disposable Wipes container included but was not limited to, "Precautionary Statement: Hazard to humans and domestic animals...Caution: Harmful if absorbed through skin...Avoid contact with...skin or clothing...Rinse skin immediately with plenty of water for 15-20 minutes...Call poison control center or doctor for treatment advice..."

- Observation of the Surgical Services Endoscopy area with a ST on 7/19/2017 at 11:52 AM, revealed a colonscope storage cabinet with that contained four colonscopes. Observation revealed a white towel with a yellow substance on it that was laying on the bottom of the cabinet, 4 inches below one of the suspended endoscopes. The ST stated the towel was there "to catch any water that drips from the scopes." The ST confirmed he/she could not identify the yellow substance, did not know the source of the yellow substance, or when or if the soiled towel was ever changed.

- Observation of the Surgical Services area with a ST on 7/19/2017 at 12:52 PM included OR1. Observation revealed the door surface was cracked and chipped. Because of the compromised surface integrity of the door, the door could not be cleaned appropriately.

Further observation revealed the door also had a 1/2-inch-wide gap extending the entire length between the two wooden doors. Because of this gap and the lack of air flow monitoring, it was not possible to ensure that appropriate air flow, including temperature and humidity, could be maintained for OR1.

Observation with a ST on 7/19/2017 at 11:45 AM revealed a housekeeping cart located outside of the Environmental Services department. Observation revealed 4 bottles of liquid cleansers, specifically, Hepastat, Heavy-Duty General Purpose Cleaner, Odor Eliminator, and Multi-Use cleaner that were hanging on the cart. The housekeeper stated, "We refill the bottles from the tanks in the closet when they're empty. The bottles are labeled with the manufacturer's label, but the expiration date and the refill dates aren't written on the [individual] bottles."

During an interview with the CEO on 7/18/2017 at 3:35 PM he/she stated, "There is no policy or procedure regarding secondary containers of cleansers."

Observation of the laboratory on 7/18/2017 at 9:30 AM with the IPRN revealed the following:

- 2 boxes of "Blood Grouping Reagent", expired on 5/28/2017 and 6/23/2017, respectively;
- 1 bottle of Sodium Hypochlorite, expired 8/15/2011;
- An open bottle of "Urine Chemistry Control", expired on 6/31/2017;
- 1 vial of "i-Stat cTnl Control Level", expired 1/2017;
- 2 boxes, 24 cartridges per box, "i-Stat cTnl Cartridge" devices, expired 5/28/2017;
- 1 box, 22 cartridges per box, "i-Stat Chem8+ Cartridge" devices, expired 3/28/2017;
- 1 "Calibration Verification Kit for Blood Gases, Oximetry, Electrolytes & Metabolytes [sic]", expired 6/30/2016.

The IPRN and the Laboratory Manager confirmed these items were expired during the observation of the laboratory. They confirmed that items found under a sink were no longer being used and there were expired items "in the process of being transitioned out."

- Observation of the medical clinic on 7/20/2017 at 8:50 AM with the IPRN revealed the following:

- 2 opened bottles of sterile water, no documentation to indicate who had opened the bottles or when they had been opened;
- 1 full box of syringes in the medication room, expired 12/2009;
- 1 bottle of Sodium Hypochlorite in the refridgerator in the medication room, expired 9/2014;
- 1 container of "Cidex OPA" under the sink in the medication room, expired 8/2008;
- A containter with 15 syringes of various sizes in a cabinet in a patient treatment room, expired 1/2016 and 6/2015, respectively;
- 3 "MediChoice Cautery Cordless High Temperature Fine Tip" devices, 1 expired on 7/1/2012, 2 devices were out of the original packaging and there was no indication of the expiration dates;
- 1 bottle of "Activate Bleach", expired 9/2012;
- 2 bottles of "Hibiclens" under the sink in a treatment room, expired 2/2017 and 5/2016, repectively.

During an interview with the IPRN and an RN in the medical clinic on 7/20/2017 at 10:10 AM, the RN stated that containers, "like the Hibiclens are refilled from a larger container but are not dated....the containers under the sinks are not marked as secondary containers and aren't labeled."

- Observation of the Rehabilitation Unit on 7/19/2017 at 1045 with the IPRN revealed the following:

- 1 open container labeled "Kodak...fixer and replenisher" under a sink, expired 6/2007;
- 1 open container of a topical cream labeled "Myogesic Emulsion" with no indication of when it had been opened;
- 1 culture transport tube, expired 8/1999.

During an interview with the IPRN and the Rehabilitation Manager on 7/19/2017 at 10:45 AM, the Manager stated, "I don't know what the container of Myogesic Emulsion is used for or why it's there. The container of fixer and replenisher were used only for water."

- Observation of the Cardio/Pulmonary Lab on 7/19/2017 at 11:30 AM with the IPRN revealed the following:

- 5 tubes of "Nuprep Skin Prep Gel", with expiration dates of 3/2017 and 4/2017.

- Observation of the walk-in medical clinic on 7/19/2017 at 12:30 PM with the IPRN findings revealed the following:

- 1 open container of "Prolystica," an enzymatic cleaner, no documentation to indicate when the container had been opened;
- 1 box, 12 strips per box, of "Baseline Petrolatum Gauze Strips", expired 6/2017;
- 1 "MediChoice Cautery Cordless High Temperature Fine Tip" device, expired 5/1/2017.

- Observation of the room used for transfusion administration and on 7/19/2017 at 12:20 PM revealed the following:

- 1 open package for a "Central Line Dressing Kit" in a drawer. Documentation on the package indicated the contents of the package were "Sterile until opened".

Observation of the kitchen on 7/19/2017 at 2:25 PM with the CEO and the CFO revealed the following:

Dry food storage area:

- 3 cellophane bags that contained cookies. The cookies had been removed from the original package and re-bagged in the cellophane bags. There were no expiration dates or dietary information on the cellophane bags;
- 5 bags that contained croutons. The croutons had been removed from the original package and re-bagged. There were no expiration dates or dietary information on the bags;
- Multiple boxes of "Scalloped Potatoes". There were no expiration dates on the boxes;
- Multiple bottles of chocolate syrup. There were no expiration dates on the bottles;
- Multiple boxes of cake mixes. There were no expiration dates on the boxes;
- A jar of basil pest sauce labeled "Keep Refrigerated";
- An open bag of cornmeal. There was no documentation to indicate when the bag had been opened;
- An open bag of M & M's (chocolate candies). There was no documentation to indicate when the bag had been opened;
- Multiple open bags of pasta. There was no documentation to indicate when the bags had been opened;
- A jar of Pad Thai paste, expired 4/28/2017;
- A jar of "Garlic Chili Pepper Sauce", expired 3/22/2014;
- A jar of "Ponzu" sauce, expired 4/29/2017.

Refrigerator:

- A 5-pound bag of shredded cheese. There was no expiration date on the bag;
- Multiple bags of hotdog buns. There were no expiration dates on the bags;
- Multiple open gallon-size containers of salad dressings and relish. There was no documentation to indicate when the containers had been opened;
- An open container of V8 juice (tomato juice). There was no documentation to indicate when the container had been opened;
- An open 5-pound bag of bleu cheese. There was no expiration date and no documentation to indicate when the bag had been opened;
- An open carton of buttermilk, expired 6/24/2017;
- An open container of garlic, expired 7/16/2017. There was no documentation to indicate when the container had been opened;
- 3 packages of mozzarella cheese, expired 2/20/2017;
- A large piece of meat (salami), expired 11/23/2015;
- Multiple bags of English muffins, pretzel buns and bagles that were expired;
- 2 10-pound boxes of "Pork Sausage Skinless Link[s]". Documentation on the boxes indicated, "Keep Frozen 10 degrees or Below". The boxes were stored in the refrigerator, not in the freezer.

Freezer:

- Numerous boxes of frozen vegetables that were not labeled with "Use by" or "Expiration" dates.

Additional findings:

- Salad dressing containers that were used daily in the salad bar by patients, staff and visitors were refilled from the original containers. There was no documentation on the original containers to indicate when they had been opened;
- An open jar of mustard, with an expiration date of 3/4/2017, was found on a table and available for use by visitors and staff in the dining area.

The review of documentation included the policy and procedure titled, "Food Storage" with an approved/revised date of 8/1/2003. Directions in the policy included, but were not limited to "All unlabeled.....containers....will be removed, marked unacceptable and destroyed."

The review of documentation included the policy and procedure titled, "Patient Nourishments and Floor Stock" with an approved/revised date of 2/2/2003. Directions in the policy included, but were not limited to "Code dates on food items must be observed and food items discarded according to expiration date."

During a tour of the dietary area on 7/19/2017 at 1425, the CEO and CFO confirmed food items were inappropriately stored, that food items were unlabeled, and expired foods were available for patient, staff and visitor use.

Refer to additional findings cited at Tag C276.