HospitalInspections.org

Based on observation, record review, and staff interview the CAH (Critical Access Hospital) failed to maintain a clean and sanitary Dietary Department. The CAH identified a census of nine patients.

Failure to maintain a clean and sanitary dietary environment could potentially result in a food borne illness outbreak.

I. An observation on 04/19/10 at 12:59 PM, revealed the following:
a. A microwave in the kitchen pantry with greasy yellow food build-up on
the ceiling, meal preparation for the noon meal was completed.
b. A Kitchen-Aid counter mixer with dried on food debris at the area
where the beaters attach. A plastic covering covered the mixer,
indicating that it was clean and ready for use.

A review of the policy/procedures for revealed the following:
a. A policy/procedure for " Cleaning Microwave " with a revised date of
06/08 stated in part ...the microwave will be cleaned after each use ... "
b. A policy/procedure for " Cleaning Mixer " dated 12/00, stated in
part ...the food mixer will be cleaned after each use ... "

An interview with the Dietary Manager on 04/19/10 at 12:29 PM, acknowledged the microwave and the mixer needed additional cleaning.


II. An observation on 04/19/10 at 5:00 PM, revealed Staff A, the dietary aid, serving the evening meal and wearing gloves. Staff A touched the tray cart, the oven door, various serving surfaces, used her gloved finger to push the butter from the spoon to top the mashed potatoes, and de-boned chicken wings and wiped her greasy gloved fingers onto her apron. Staff A pushed the tray cart to the patient care area with her gloves on. Staff A failed to change her gloves during the serving of 7 patient trays, wore the same gloves to the patient care area, and placed various beverages onto patient trays for the evening meal. Staff A contaminated her gloves when she touched the various equipment and the chicken, and continued to serve the evening meal.
An observation on 04/20/10 at 11:45 AM, revealed Staff B serving the noon meal and wearing gloves. Staff B removed the lids from the food items, and touched various serving. Staff B contaminated her gloves, continued serving the noon meal and touched the slices of bread for patient trays.

An interview on 04/20/10 at 12:30 PM, with the Dietary Manager and the Consulting Dietitian verified the incorrect use of gloves during serving of the meals and the lack of a policy/procedure for the use of gloves in the kitchen.

III. An observation on 04/19/10 at 5:20 PM, revealed no recording of temperatures on the rice, mixed vegetables, baked chicken, and mashed potatoes prior to serving of the evening meal. A review of the " Daily Record of Food Temperatures " , revealed numerous evening meals lacking recording of all food temperatures prior to serving.

A review of the policy/procedure titled " Food Temperatures " , with a revised date of 06/08 stated in part ... " the temperature of food items on patient trays shall be taken and recorded before the start of serving " ...

An interview on 04/20/10 at 9:00 AM, with the Dietary Manager acknowledged the inconsistency with recording and measuring all of the food temperatures prior to serving.

Based on closed medical record review, Medical Staff Bylaws review, Health Information Management policy/procedure review, and staff interview, the CAH Administration failed to ensure that medical providers dated and timed all medical record entries in 6 of 12 closed Emergency Department medical records (Patients # 1, 2, 3, 4, 5, and 6).

Failure to authenticate, date and time all entries in a medical record could potentially interrupt the sequence of events and continuity of patient interventions or assessment.

Findings include:

1. Review of closed Emergency Department medical records, on 4/21/10 at 10:00 AM, revealed that medical providers failed to date and time all medical record entries in 6 of 12 closed Emergency Department medical records (Patients # 1, 2, 3, 4, 5, and 6).

2. Review of the CAH's Medical Staff Bylaws, revised on March 2010 and reviewed on 4/21/10, reveals in Section VI, Number 3: "All entries into the Medical Records are authenticated by the attending Practitioner.".

3.. Review of the CAH's Health Information Management Department policy, revised March 2010 and reviewed on 4/21/10, revealed: "Doctor's Orders: All Doctors Orders must be signed, timed and dated by the ordering practitioner.". "Progress Notes: All progress notes must be signed."

4. On interview the Health Information Management Director, on 421/10 at 3:30 PM, acknowledged that medical providers are not required to sign, date and time all entries in medical records.

5. On interview the Quality Improvement Director, on 4/21/10 at 3:30 PM, acknowledged that medical providers are not required to sign, date and time all entries in medical records.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) administration failed to ensure the Activity Coordinator met the educational requirements for the Activity Coordinator. The CAH identified 8 current Skilled Status patients.

Failure to ensure the Activity Coordinator had the required educational background could potentially cause the activity program to not meet the physical and psychosocial needs of the individual patient, impeding the physical and psychological well being of the patient.

Findings include:

1. Review of the policy, "Activities Department Description", revised 6/08, revealed in part, "According to state and Federal Regulations, and in keeping with the policies and procedures within this manual, it is the purpose of this facility to: Hire qualified individuals to meet the patient's activity needs..."

2. During an interview on 4/19/10 at 11:50 AM, the Activity Coordinator stated the Activities Coordinator had not completed the activities training program approved by the state, and did not meet other qualifications for the Activity Coordinator.

3. During an interview on 4/21/10 at 10:30 AM, the Activity Coordinator stated they did not consult with another individual who met the qualifications for the Activity Coordinator.


II. Based on document review and staff interviews, the Critical Access Hospital (CAH) administration failed to ensure the Activity Coordinator performed and documented an initial activity assessment for 2 of 2 open medical records (patient #25 and #26), and 5 of 5 closed medical records (patients #27, 28, 29, 30, and 31). The CAH staff identified 8 current Skilled Status patients.

Failure to perform an initial assessment could potentially lead to the CAH offering activities that fail to meet the physical and psychosocial needs of the individual patient, impeding the physical and psychological well being of the patient.

Findings include:

1. Review of the policy, "Activity Documentation," revised 1/02, revealed in part, "The Activity Coordinator will: Complete in a timely manner the following activity related documents for all Residents: Initial Activity Assessments..."

2. Review of the open medical record for patient #25, admitted to Skilled Status on 4/7/10, revealed activity staff did not complete and document an initial activity assessment.

3. Review of the open medical record for patient #26, admitted to Skilled Status on 3/19/10, revealed activity staff did not complete and document an initial activity assessment.

4. Review of the closed medical record for patient #27, admitted to Skilled Status on 8/25/09 and discharged on 9/3/09, revealed activity staff did not complete and document an initial activity assessment.

5. Review of the closed medical record for patient #28, admitted to Skilled Status on 12/19/09 and discharged on 12/22/09, revealed activity staff did not complete and document an initial activity assessment.

6. Review of the closed medical record for patient #29, admitted to Skilled Status on 3/7/10 and discharged on 3/11/10, revealed activity staff did not complete and document an initial activity assessment.

7. Review of the closed medical record for patient #30, admitted to Skilled Status on 1/11/10 and discharged on 2/3/10, revealed activity staff did not complete and document an initial activity assessment.

8. Review of the closed medical record for patient #31, admitted to Skilled Status on 2/6/10 and discharged on 2/26/10, revealed activity staff did not complete and document an initial activity assessment.

9. During an interview on 4/21/10 at 10:30 AM, the Activity Coordinator acknowledged the open and closed medical records lacked an initial activity assessment. The Activity Coordinator stated, "I document the activities assessment in the acute stay portion of the patient's chart, and don't put [the assessment] in the Skilled Status chart once the patient has changed to Skilled Status."


III. Based on staff interview, the Critical Access Hospital (CAH) administration failed to ensure the Activity Coordinator created a prospective calendar of activities available for patients. The CAH staff identified 8 current Skilled Status patients.

Failure to create a prospective calendar of activities available could potentially result in patients unaware of activities meeting the physical and psychosocial needs of the patient, potentially impeding the physical and psychological well being of the patient.

Findings include:

1. Review of the policy, "Activity Calendar Schedule", revised 6/08, revealed in part, "The Activity Coordinator will: ... [c]reate a monthly activity calendar consisting of planned activities".

2. During an interview on 4/21/10 at 10:30 AM, the Activity Coordinator acknowledged the lack of a prospective monthly activity calendar. "I was informed a week ago that I needed to start keeping a[n activity] calendar, so I've been writing down what I've been doing with patients on a calendar." The Activity Coordinator also acknowledged the Activity Coordinator had not created a calendar of upcoming activities since taking over the activity program in 2008.