HospitalInspections.org

Based on record review and interview, the facility failed to ensure emergency department patients
were informed of the patient's rights including the grievance procedure, in advance of furnishing patient
care for 5 of 5 emergency department patients (Patient #16, #17, #18, #19, and #20).

[or when appropriate, the patient's representative as allowed under State law]

Findings

Patient #16's, #17's, #18's, #19's, and #20's record did not document evidence of being informed of their patient rights including the grievance procedure.

During record review and interview on 5/04/2022 ending at 10:30 AM, Personnel #2 navigated five emergency room patient records and confirmed there was no documented evidence of patients informed of their patient rights.

During an interview on 5/04/2022 ending at 11:00 AM, Personnel #2 confirmed the patient rights had not been completed with emergency room patients. Admitted patients were given the rights notice.

Based on observation, interview and record review the Hospital failed to ensure the director of the dietary services was in compliance with food service rules/regulations in the hospital's dietary department; and further failed to ensure the dietary department was managed in a responsible manner in that the following was observed during the survey:

1) Cleanliness issues were observed in the 2 compartment sink and the dishwasher.
2) Two refrigerated food items were not dated and labeled.
3) Bottles of water, a large box holding small boxes of cereal, and a large box holding small boxes of grape juice were stored on the floor.
4) Personnel #9 was the cook and did not have a food handlers certificate as required by state law.

Findings Included:

1) During a tour of the hospital's kitchen on the morning of 05/03/2022 Personnel #7 and Personal #9 were present in the kitchen. Personnel #9 was asked how he washed pots, pans, cooking utensils in the 2 compartment sink. He said he added to the hot water 1/4 cup of bleach and a little Dawn liquid dishwashing detergent. He then rinsed them with a water sprayer and let them air dry on top of the cabinet covered with clean towels. Personnel #9 said he did not test the chlorine levels.

A sign posted above the 2 compartment sink reflected instructions for Hand Dish Washing Procedure. The sign stated to
1) scrape, rinse and stack the dishes. Rinse the silverware and allow to soak in dish pan with approximately one gallon of water and 1/8 cup of bleach.
2) Fill the first sink with water at 110 degree-120 degree Fahrenheit to within 4 inches of top. Add 1 cup of Dawn Dish soap and 1/4 cup of bleach. Check the bleach concentration with chemical strip to achieve 200-600 ppm.
3) Fill the second sink half full with water and add 1/8 cup of bleach. Check bleach concentration as in step #2. Place the washed equipment and utensils in the second sink.
4) Fill a large plastic dish pan with 1 gallon of water. Add 1 Tbsp. of bleach. It should be at 200 ppm. Final rinse everything in this pan and change the water frequently.
5) Drain to dry on clean, sanitized racks. Use the method above to sanitize the racks.
6) Person in the kitchen will remove the dishes from the rack and arrange the dishes on a clean dry towel to air dry for several minutes.

During an interview with Personnel #7 during the kitchen tour on 05/03/2022 Personnel #7 stated the patients were served their meals on disposable containers and plastic utensils. When Personnel #7 and #9 were asked where the dishwashing log was kept, they both said there wasn't one in that they only used the dishwasher for pots and pans and no testing was done.

During the tour of the kitchen the dishwasher was observed to be a ECOLAB single rack. The model number was #ES-2000. The bottle of Chlorine test strips for the pre-wash was observed to have an expiration date of 11/2016. The bottle of LaMotte QAC QR testing strips had an expiration date of 10/2016. The observations were confirmed with Personnel #7 and Personnel #9.

2) During a tour of the hospital's kitchen there were 2 items that were not dated and labeled in the refrigerator. 1) An opened package of deli meat that contained turkey and ham. The expiration date on the package was 03/15/2022. 2) A bowl that contained a red sauce. Personnel #7 said she took the deli meat out of the freezer the day before. The sauce was salsa that had been prepared the day before. She had forgotten to label and date them.

3) During a tour of the hospital kitchen's office/supply room there were 2 large boxes and several purified water bottles in plastic packaging stored directly on the floor. One large box contained many individual Cheerios boxes, and the other large box contained many individual grape juice boxes. Personnel #9 confirmed the observation.

4) Personnel #9 was asked if he had a food handler's certificate during the tour of the kitchen on 05/03/2022. He said he did not. He said he had worked in the kitchen for 5 years and his title was cook. A review of Personnel #9's employee file revealed there was no food handler's certification.

A review of Personnel #7's employee file included a job description for Dietary Supervisor with a review date of 07/01/2022. The job description reflected, "...Monitors the sanitary conditions in food handling and preparation and compliance with infection control procedures... Initiates departmental policies, procedures, and practices consistent with hospital policies... Employee is responsible for ensuring that the employees under their supervision comply with all applicable work rules, perform their jobs in a satisfactory manner..."..."

The hospital's Dietary Infection Control and Sanitation policy dated 09/06/2008 reflected, "...Utilize and reference current FDA Food Code manual for detailed descriptions of practices involving food safety... All food items must be labeled and dated..."

A review of the dishwasher's ECOLAB installation and operational manual issued on 06/18/2009 indicated for the wash and rinse cycle the water should be 120 degrees Fahrenheit. The sanitizing rinse solution should be a minimum of 50 PPM.

Based on observation, interview, and record review, the facility failed to maintain an acceptable level of safety and quality of

A) 5 of 8 germicidal detergent (LpH) spray bottles found in the Medical Surgical and Emergency Room areas on 5/03/2022.

"LpH" was used in various areas of the hospital for cleaning and disinfecting washable, hard, and non-porous surfaces.

B) Crash carts to include crash cart checks every shift for emergency readiness for 3 of 3 crash carts (Emergency Department Adult/Pediatric; Medical Surgical Adult).

C) Patient care equipment to include Biomedical Inspections completed annually.


Findings

A) During a facility tour on 5/03/2022 ending at 2:30 PM in the medical surgical and emergency areas With Personnel #1, multiple spray bottles of "LpH" germicidal detergents were found. Housekeeping closet: One (1) container was not dated or labeled. One container of blue/windex was not dated or labeled. Custodial Closet on Medical Surgical: One (1) container was dated 4/12/2022 - greater than 2 weeks. Soiled Utility Closet on Medical Surgical: Two (2) containers were dated 4/18/2022 and was not labeled - greater than 2 weeks.

During an interview on 5/03/2022 ending at 2:30 PM, Personnel #1 was present and confirmed the findings. Personnel #1 was asked about the 2 week expiration. Personnel #1 confirmed the 2 week expiration.

The facility's undated, "LpH se One Step Germicidal Detergent" Policy required, "Pre-mixed LpH solution has a shelf life of two weeks when stored in a closed container/spray bottle...Solution will be discarded and remixed on the 1st and 15th of each month..."

B) During a facility tour on 5/03/2022 ending at 2:30 PM in the medical surgical and emergency areas with Personnel #1, the April and May 2022 crash cart logs reflected safety checks were no being completed:

Emergency Department Adult Crash Cart: (no check in 2022) the shift
(AM) of 5/3, 5/2, 4/27, 4/18, 4/17, 4/16, 4/15, 4/10, 4/9, 4/6, and 4/4;

(PM) of 5/1, 4/29, 4/24, 4/16, 4/15, 4/12, 4/11, 4/5, 4/3, and 4/2.

Emergency Department Pediatric Cart: (no check in 2022) the shift
(AM) of 5/2, 4/27, 4/24, 4/23, 4/21, 4/20, 4/18, 4/17, 4/16, 4/15, 4/10, 4/9, 4/8, 4/6, and 4/4;

(PM) of 5/2, 5/1, 4/28, 4/24, 4/16, 4/15, 4/12, 4/11, 4/9, 4/5, 4/3, and 4/2.

Medical Surgical Department Adult Crash Cart: (no checks in 2022) the shift
(AM) of 5/3, 4/28, 4/27, 4/25, 4/23, 4/21, 4/20, 4/19, 4/18, 4/17, 4/16, 4/15, 4/12, 4/11, 4/10, 4/9, 4/8, 4/6, 4/5, 4/4, and 4/3;

(PM) of 5/2, 4/14, 4/13, 4/10, and 4/9.

There was no quality monitoring process to identify the nursing issue.

During an interview on 5/03/2022 ending at 2:30 PM, Personnel #1 was present and confirmed the findings.

The facility undated, "Crash Cart Checking" policy required, "charge nurse on each shift will be responsible for checking..."

C) During During a facility tour on 5/03/2022 ending at 2:30 PM with Personnel #1, multiple patient care equipments were found with expired inspection tags including the neonatal monitor and warming bed.

The facility's Biomedical Inspection reports reflected the neonatal monitor and warming bed inspection was out of date 7/2021.

During an interview on 5/03/2022 ending at 2:30 PM, Personnel #1 was present and confirmed the findings.

Based on observation, interview and record review the hospital failed to ensure methods were in place to prevent and/or control the transmission of infections in that:

1) Infection control issues were observed regarding the 2 compartment sink dishwashing process; and there was no testing utilized during the use of the dishwasher .
2) Bottles of water, a large box holding small boxes of cereal, and a large box holding small boxes of grape juice were stored on the floor.

Findings Included:

1) During a tour of the hospital's kitchen on the morning of 05/03/2022 Personnel #7 and Personal #9 were present in the kitchen. Personnel #9 was asked how he washed pots, pans, cooking utensils in the 2 compartment sink. He said he added to the hot water 1/4 cup of bleach and a little Dawn liquid dishwashing detergent. He then rinsed them with a water sprayer and let them air dry on top of the cabinet covered with clean towels. Personnel #9 said he did not test the chlorine levels.

A sign posted above the 2 compartment sink reflected instructions for Hand Dish Washing Procedure. The sign stated:
1) scrape, rinse and stack the dishes. Rinse the silverware and allow to soak in dish pan with approximately one gallon of water and 1/8 cup of bleach.
2) Fill the first sink with water at 110 degree-120 degree Fahrenheit to within 4 inches of top. Add 1 cup of Dawn Dish soap and 1/4 cup of bleach. Check the bleach concentration with chemical strip to achieve 200-600 ppm.
3) Fill the second sink half full with water and add 1/8 cup of bleach. Check bleach concentration as in step #2. Place the washed equipment and utensils in the second sink.
4) Fill a large plastic dish pan with 1 gallon of water. Add 1 Tbsp. of bleach. It should be at 200 ppm. Final rinse everything in this pan and change the water frequently.
5) Drain to dry on clean, sanitized racks. Use the method above to sanitize the racks.
6) Person in the kitchen will remove the dishes from the rack and arrange the dishes on a clean dry towel to air dry for several minutes.

During an interview with Personnel #7 during the kitchen tour on 05/03/2022 Personnel #7 stated the patients were served their meals in disposable containers with plastic utensils. When Personnel #7 and #9 were asked where the dishwashing log was kept, they both said there wasn't one in that they only used the dishwasher for pots and pans and no testing was done.

During the tour of the kitchen the dishwasher was observed to be a ECOLAB single rack. The model number was #ES-2000. The bottle of Chlorine test strips for the pre-wash was observed to have an expiration date of 11/2016. The bottle of LaMotte QAC QR testing strips had an expiration date of 10/2016. The observations were confirmed with Personnel #7 and Personnel #9.

2) During a tour of the hospital kitchen's office/supply room there were 2 large boxes and several purified water bottles in plastic packaging stored directly on the floor. One large box contained many individual Cheerios boxes, and the other large box contained many individual grape juice boxes. Personnel #9 confirmed the observation.

A review of Personnel #7's employee file included a job description for Dietary Supervisor with a review date of 07/01/2022. The job description reflected, "...Monitors the sanitary conditions in food handling and preparation and compliance with infection control procedures... Initiates departmental policies, procedures, and practices consistent with hospital policies... Employee is responsible for ensuring that the employees under their supervision comply with all applicable work rules, perform their jobs in a satisfactory manner..."..."

The hospital's Dietary Infection Control and Sanitation policy dated 09/06/2008 reflected, "...Utilize and reference current FDA Food Code manual for detailed descriptions of practices involving food safety... All food items must be labeled and dated..."

A review of the dishwasher's ECOLAB installation and operational manual issued on 06/18/2009 indicated for the wash and rinse cycle the water should be 120 degrees Fahrenheit. The sanitizing rinse solution should be a minimum of 50 PPM.

Based on observation, record review, and interview, the facility failed to ensure

auditing of adherence by hospital personnel to infection prevention and control policies and procedures for 2021 and 2022.

Findings


During a tour of the facility on 5/03/2022 ending at 2:30 PM with Personnel #1, multiple spray bottles of "LpH" germicidal detergents were found dated (4/12/2022 and 4/18/2022) greater than 2 weeks old in the Emergency and Medical Surgical Departments. Clean supplies were found stored in the soiled utility rooms next to dirty equipment and biohazard in the Emergency and Medical Surgical Departments.

Emergency Department Soiled Utility clean supplies included gloves, gowns, patient drinking cups, laboratory specimen cups, tongue blades, urinals, bedpans, and briefs/diapers.

Medical Surgical Soiled Utility clean supplies included gloves, sharps containers, Sani-Clothes, and 2 hair dryers. Also found 3 bottles of Ruhof Biocide and 4 bottles of LpH.

There were no documented Environmental Infection Control rounds to identify issues for 2021 and 2022.

During an interview on 5/03/2022 ending at 2:30 PM, Personnel #1 confirmed the findings.

The facility's 1/30/2013 reviewed, "Infection Control/Exposure Plan" required, "Design and space shall permit separation of soiled and contaminated items from those that are clean and sterile..."

The facility's undated, "LpH se One Step Germicidal Detergent" Policy required, "Pre-mixed LpH solution has a shelf life of two weeks when stored in a closed container/spray bottle...Solution will be discarded and remixed on the 1st and 15th of each month..."
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