HospitalInspections.org

Based on observations during the facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings were:

Refer to the Life Safety Code survey report for findings.

Based on observations, review of the facility's policies and interviews, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner. This had the potential to negatively affect all patients.

Findings include:

Policy:
Effective date: 9/2006
To provide an effective storage program for food and supplies in Dietary.

Procedure:

Perishable Storage:
1. Cool storage facilities must have temperature range of 34 to 45 degrees and freezers should have a temperature range of 0 to -10 degrees.
2. Each unit must be equipped with indicating thermometer accurate to 2 degrees and situated so that it is easy to read.
3. The temperature of all cool storage facilities should be checked and logged daily......

Policy:
Effective date: 1/2008
Prevention of Bacterial overgrowth and Cross Contamination of Foods

Procedure:

Temperature checks are accomplished as follows:
Refrigerators: Daily
Walk-In Refrig (Refrigerator): Daily
Freezers: Daily
3 Compartment Sink: Daily
Dish Machine: Daily
Refrigerators on Floor: Daily....


A tour conducted on 4/16/13 at 1:00 PM with Employee Identifier (EI) # 3, Dietary Manager, revealed the cool storage facilities (refrigerators) and freezer logs were incomplete. Review of the temperature logs revealed there were no signatures or temperatures recorded for the following dates:

April: 4/4/13, 4/7/13, 4/9/13, 4/13/13 and 4/14/13.

Review of the logs for the Pot and Pan Sanitizer Checks for the months of February, March and April revealed there was no documentation the sanitizer checks had been preformed for the following dates:

February: 2/1/13, 2/5/13, 2/6/13, 2/13/13, 2/14/13, 2/15/13, 2/16/13, 2/17/13, 2/19/13, 2/20/13, 2/23/13, 2/24/13, 2/25/13, and 2/26/13.

March: 3/1/13, 3/9/13, 3/11/13, 3/12/13, 3/16/13, 3/17/13, 3/20/13, 3/21/13, 3/22/13, 3/29/13, 3/30/13, and 3/31/13.

April: 4/1/13, 4/3/13, 4/4/13, 4/5/13, 4/9/13, 4/10/13, 4/11/13, 4/12/13, 4/14/13, 4/16/13, and 4/17/13.

Review of the logs for the Dish Machine Temperature for the months of January, February, March, and April revealed there were no signatures or temperatures documented for the following dates:

January: 1/15/13, 1/16/13, 1/17/13, 1/18/13, 1/19/13, 1/20/13, 1/29/13, and 1/31/13.

February: 2/3/13, 2/4/13, 2/7/13, 2/16/13, 2/17/13, and 2/21/13.

March: 3/7/13, 3/26/13, and 3/27/13.

April: 4/4/13.

An interview conducted on 4/17/13 at 1:30 PM with EI # 3 confirmed the aforementioned findings.

Based on observations, review of the facility's policies and procedures and interview, it was determined the infection control officer failed to ensure the Physical Therapy (PT) staff followed the facility's policies for Hand Hygiene and Standard Precautions during 1 of 1 wound care observations. This affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients receiving wound care by the PT staff.

Findings include:

Facility Policy and Procedures

Subject: Hand Hygiene
Effective Date: 2/1/2013

Department: Hospital-wide

Procedure
Indications for Handwashing and Hand-rubbing
A. Indications for Handwashing
3. Handwashing may also be used for routinely decontaminating hands in the following clinical situations:

....After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled...

After removing gloves....

Policy # 6002
Subject: Standard Precautions
Department: Rehabilitation Services
Effective: 01/01/2005

...Standard Precautions include the following:

Handwashing - Hands are to be washed after touching blood, body fluids, secretions, excretions or other contaminated items, whether or not gloves have been worn. Hands must be washed immediately after removal of gloves.....

On 4/17/13 at 8:20 AM the surveyor observed Employee Identifier (EI) # 1, Physical Therapy Assistant, performing wound care on PI # 1, outpatient. EI # 1 cleaned his/her hands and put on clean gloves. EI # 1 measured the wound on the patient's right forearm and proceeded to debride the wound. EI # 1 discarded the sharps used for the debridement, removed his/her gloves and put on clean gloves without cleaning his/her hands. EI # 1 cleansed the wound with wound cleanser, removed his/her gloves and put on clean gloves without cleaning his/her hands. EI # 1 applied ointment to the wounds and covered the wounds with an abdominal pad and wrapped the area with rolled gauze. EI # 1 then removed his/her gloves and washed his/her hands.

An interview on 4/17/13 at 8:45 AM with EI # 2, Physical Therapist/Director Physical Therapy, confirmed that during wound care the hands should be cleaned before putting on gloves and after taking off gloves.