HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that blood products were appropriately stored ? to prevent deterioration. Findings include:

On 12/8/10 at 8:00 a.m., during review of the facility lab the surveyor inquired about the blood storage refrigerator. The staff member E, the lab manager, informed the surveyor that the blood products were not being stored in the refrigerator because the alarm system did not work. She stated they had been storing the blood products in the shipping container from the blood services company. The temperatures were being checked daily and documented in a log and were within the recommended range. Ice packs were changed daily, when the temperature was taken.

The Clinical Laboratory Improvement Amendments (CLIA) surveyor was consulted regarding the blood storage. He stated that the temperature of the blood products needed to be checked every four hours while the blood was being stored in the shipping container. He further stated that storing blood in the shipping container should only be done in an emergency situation.

? ?493.1271 (c) Blood and blood products storage. Blood and blood products must be stored under appropriate conditions that include an adequate temperature alarm system that is regularly inspected.
(c)(1) An audible alarm system must monitor proper blood and blood product storage temperature over a 24-hour period.
(c)(2) Inspections of the alarm system must be documented.

Based on observation and staff interview, the facility failed to ensure that safe food handling practices were followed. The findings include:

During the kitchen/food service observation on 12/6/10 at 2:37 p.m., a plate with chocolate cake covered with clear plastic wrap was found in the freezer in the nourishment area. There was no date on the cake. A small chocolate shake, also covered, was found with a date of 11/24/10.

On 12/6/10 at 2:37 p.m., the freezer and refrigerator in the nourishment area were checked for thermometers. No temperature devices were found. On the bottom shelf of the freezer, a cold pack for therapy was found. In the refrigerator, there was an opened gallon of fat free milk and an opened half gallon of 2% milk. Neither container of milk had an open date or discard date.

On 12/7/10 at 8:15 a.m., dietary staff A was observed serving the meals from the off site kitchen. The staff member did not take temperatures of the meals as they were delivered to the patients. When staff member A was asked about temperatures, she stated that they were suppose to be taken before being placed in the heating and cooling containers at the off site kitchen and then again before serving. Dietary staff A then stated that she had forgotten to take the temperatures before taking meals into the patient rooms.

On 12/7/10 at 10:00 a.m., during the initial walk through of the kitchen area, it was noted that there was no separation of the soiled and clean areas in the dish area of the kitchen. The dietary staff, A, B, and C, when asked as a group, stated that the dirty dishes were brought through the clean area of the kitchen. The dirty dishes were stacked to the left of the three compartment sink, on and in the working area for food prep.

Freezers #1 and #2 both had temperature logs on the outside of the doors. the dates for freezer #1 ended on 11/17/10. The dates for freezer #2 ended on 11/16/10. There were no further recordings of temperatures on both logs.

Freezer #1 had clear plastic bags containing sausage patties and fish patties, neither of the bags had open or throw away dates. There was also a clear bag, dated 10/03, identified as vegetable chillie. In freezer #1, ground beef and pot roast were stored on the top shelf with vegetable items stored below that level.

Refrigerator #1, in the kitchen, was noted to have uncooked and thawed bacon and a flat of eggs on the same shelf as celery and lettuce. There were also vegetables and fruit on the shelves under the bacon and eggs.

On 12/7/10 at 10:40 a.m., dietary staff A, B, and C were observed putting away food items that had just arrived. A container of Pace salsa was noted on the wet and muddy floor between the outside door and the doorway into the kitchen. The container of salsa was picked up from the floor by a dietary staff person and placed directly into the refrigerator without washing off the container.

During meal preparation on 12/7/10 at 10:55 a.m., dietary staff B was observed using her bare hands to break a large chunk of ground beef into smaller pieces. The staff member was not observed washing her hands before the task.

On 12/7/10 at 10:56 a.m., dietary staff C was observed cutting vegetables on the cutting board in the kitchen. She did not wash her hands after putting away food items and before starting the process with the vegetables. The prep area was not sanitized before or after the work with the vegetables.

At 11:00 a.m., dietary staff B was observed putting food items away in the kitchen. Without washing her hands, she went back to the stove to tend to the ground beef that was cooking.

Dietary staff member A was observed on 12/7/10 at 11:10 a.m., placing sweet potato fries into the container to be sent to a patient at the hospital. The staff member used her bare hands to brush the fries into the container for transporting the fries. She did not wash her hands before starting the task. One of the fries dropped onto the counter, she picked it up and placed it into the container of fries.

On 12/8/10 at 8:30 a.m., the following problems and concerns were observed:

- In the dish storage area of the kitchen the metal bowls, plates and griddle were stored above the sink area face up exposing the eating surface.
- Two pairs of shoes were noted under the storage shelves for canned goods, located next to the stove. Dietary staff A stated that the shoes were hers.
- The two kitchen refrigerators and the two freezers were observed for cleanliness. The gaskets of the two refrigerators were observed to have dried matter and the door of refrigerator #2 had a dried substance on the inside surface. Freezer #1 had dried food matter that had run down the inside of the door from the top door shelf.
- The surface of the manual can opener had dried food particles that were black in color on the body of the opener and on the blade.
- An electrical cord for the griddle was stored in the same container as the clean cooking/food prep utensils.
- An oven rack was stored on the floor next to the stove.

On 12/8/10, dietary staff A, B, and C were asked about the process of washing produce, and where the process was completed. The staff stated that the produce was washed in the center compartment of the three compartment sink. It was noted that the sink was used as part of the process for washing dishes and processing food without sanitizing the area between uses. There was no notification in place that stated the sink was to be used for washing produce only.

Based on staff interview and review of Medical Staff Bylaws, the facility failed to ensure that discharged patients' medical records were promptly completed. Findings include:

During review of the medical records department on 12/8/10 at 9:00 a.m., staff member D, the health information manager, stated there were incomplete discharged patient records. All of the records were lacking physician signatures. She provided the surveyor with a list of the patient records that were incomplete. The list included the following:
- 15 records that were 30 days after discharge;
- 5 records that were 60 days after discharge;
- 1 record that was 90 days after discharge; and
- 1 record that was 120 days after discharge.

The hospital's Medical Staff Bylaws included the following statement: "The patient's medical record shall be complete at the time of discharge, and shall include progress notes, final diagnosis, and dictated clinical resume. Where this is not possible because final laboratory or other essential reports have not been received at the time of discharge, the patient's chart will be available in a statement area and placed in the medical record room for 48 hours after discharge."

Based on record review, facility policy review, and staff interview, the facility failed to ensure notification of the Organ Procurement Organization (OPO) for 1 (#17) of 4 sampled patients who died in the facility. Findings include:

1. Patient #17 was admitted to the hospital on 5/14/10 with a diagnosis of metastatic prostate carcinoma. On 5/17/10, the patient was pronounced dead. There was no documentation in the patient's medical record that the OPO had been notified.

2. On 12/7/10, the surveyor reviewed the facility's policy for organ and tissue donation. The policy stated, " All hospital death or imminent deaths for Acute Care and Swing Bed patients shall be reported, regardless of age or medical/social to the donor referral line... "

3. On 12/8/10 at 7:25 a.m., staff member F, the DON, stated contact to the OPO was not made and should have been.