HospitalInspections.org

Based on a review of facility documentation and staff interviews, the hospital failed to ensure that the nursing staff implemented a nursing care plan that was consistent with patient nursing care needs and which documented nursing interventions related to the plan in a timely manner for 3 of 3 patient charts reviewed (Patients #3, #8, and #9).

Findings were:

Facility policy entitled Initial Assessment and Reassessment, last review date 10/1/13, included the following:
" ...each patient admitted will receive a complete head-to-toe assessment by a qualified individual so that a plan of care can be developed to best meet the needs of the patient. The assessment of the care or treatment required to meet the needs of the patient will be ongoing ..."

A review of the medical record of Patient #3 revealed the patient was admitted on 5/27/21 with a diagnosis of "strengthening: antibiotic therapy." A nursing assessment which included an incision wound on the patients left lateral knee. There is no description of the incision or any documented treatment. Further review of the patient medical record reflected no physician orders related to the care of the incision.

During an interview on the afternoon of 6/30.21 Staff #2 confirmed that there was no documentation related to the incision. She stated that there should have been a description of the incision including measurements and the prescribed care of the incision in the documentation.

Review of the medical record for Patient #8 revealed the patient was admitted 5/4/21 with a diagnosis of Weakness, Congestive Heart Failure, Stage 3 Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Review of the nursing assessment on 5/4/21 reflected that there is a Skin Abnormality on the Left Middle, Posterior Buttock. There is no description or measurement of the wound located in the medical record.

Review of the medical record for Patient #9 revealed the patient was admitted on 5/17/21 with a diagnosis of "Strengthening for status post Left Arthroplasty." Review of the nursing assessment reflected that the patient had 3 left arm wounds. There was no description or measurements of the wounds. Further review of the Physician History and Physical, dated 5/18/21, revealed "Hip injury and s/p (status post) hemiarthroplasty ...." There were no orders or documentation found related to this wound.

Staff #2 confirmed these findings.

Based on observation, interview, and record review, the facility failed to provide an organized Dietary Services, when food items were not labeled when opened, properly closed and expired foods were made available for use, placing patient at risk for gastrointestinal distress from being served spoilt and contaminated food.

Findings include:

Observation made during a tour of the facility's Dietary Department, on 6/30/21 at 10:00 am revealed the following:
- Unpasteurized eggs, available for use, placing the patients at risk of Salmonella poisoning.
- Opened, 1000 island, Italian, and Greek dressing bottles that had not been labeled when opened, placing patients at risk of being served spoilt food products.
- An opened bag of pancake batter, placing the batter at risk of pest contamination.
- An opened bottle of chicken wing sauce that had been opened; the label read "Refrigerate after opening" The manufacturer's expiration date was 10/2018. A second chicken wing bottle, with the same expiration date, was on the shelf available for use, placing the patients at risk of being served spoilt food products.
- Opened containers of Cocktail sauce, Chicken and Beef Base, and a half and half container, had not been labeled when open, placing the patients at risk of being served spoilt food products.
- Chicken, Waffles, and ground beef where in unlabeled plastic bags in the freezer, placing them at risk for freezer burn and improper identification.

When asked what the eggs were used for, Staff #1, Dietary Director, stated, "We use it for the staff." When asked what if a patient orders an over easy egg, staff #1 stated, "We use the pasteurized eggs, I only order Pasteurized eggs. I don't know why we didn't get Pasteurized eggs."

Staff 1# confirmed the findings and stated, "I thought we had to remove all the freezer items from the boxes ...they are supposed to label opened items."

Review of the facility provided policy Food Storage, Policy #15, (Approved: January 2021) reflected,

"Purpose: The purpose of this policy is to define the procedures for correct food storage.
Policy: food items will be stored, thawed, and prepared in accordance with good sanitary practice to protect it from any and all contamination properly handled.

Procedure:
All products shall be dated upon receipt or when they are prepared. Leftovers shall be dated according to the Leftovers policy ... Eggs, Milk and Cheese
Eggs shall be checked for cracks and any cracked eggs shall be disposed of. store at
temperatures below 4l F. pasteurized shell eggs are used if at all possible.
Dairy items shall be kept under refrigeration until use. store at temperatures below 4l F ... Pasteurized eggs in the shell may be cooked and served individually per patient's preference."

Based on observation and interview, the facility failed to ensure equipment were maintained to ensure an acceptable level of safety and quality.

Findings included:

On a tour of the facility on the morning of 06/30/21, the following items had no initial maintenance check prior to use:
One (1) Olympus ESG 150 placed in use 06/21/21
Three (3) Nihon Kohden Portable Vital Sign Monitors in use 05/21/21
Twelve (12) Air Purifiers placed in use 11/1/2020

During an interview on the afternoon of 06/30/2021 Staff #13 stated that all equipment must be checked for safety prior to use. I have no answer as to why this wasn't completed.

Based on observation, interview, and record review, the facility failed to provide a functional and sanitary environment when,

The facility failed to monitor the humidity and temperatures daily to ensure a safe environment for procedures performed in the treatment room.
Findings include:

Review of the facility provided policy Endoscopy Reprocessing (dated 2/19) reflected,
"Physical Setting: ...Room temperature and humidity levels are recorded every day that endoscopic procedures and reprocessing is scheduled ..."

Review of the facility's room temperature and humidity log and registration- encounters by registration date for OP (out-patient) OP Surgery GI (Gastrointestinal) Lab schedule revealed,
4/7/21, 4/14/21, 4/20/21, 4/27/21, 5/18/21, 5/25/21, 5/28/21, 6/1/21, 6/15/21, and 6/22/21 had procedures performed with no room temperature or humidity testing recorded.

During an interview, on the morning of 6/30/21, in the facility's procedure room, Staff #2, ADON, stated we only check the temperatures once a week.

During an interview, on the afternoon of 6/30/21, in the facility conference room, Staff #8, DON, confirmed the findings.