HospitalInspections.org

Based on record review, interview and policy review, the facility failed to inform patients regarding their rights detailed in the Important Message from Medicare IMM for 5 (Patient #s 11, 26, 31, 37 and 49) of 11 patients over the age of 65 years, resulting in the potential for patients to be unaware of the extent of their healthcare rights. Findings include:

On 2/27/12 at approximately 1135 during medical record review for patient #11 revealed that he was admitted on 2/22/12. A copy of the signed Important Message from Medicare was not in the medical record. Interview with staff E revealed that "sometimes they scan the document and it may be available on their 'weblink'". Staff E was unable to provide a signed copy of the IMM for patient #11.

On 2/27/12 at approximately 1135 during medical record review for patient #26 revealed that he was admitted on 2/21/12. A copy of the unsigned Important Message from Medicare was not in the medical record. Interview with staff E revealed that "sometimes they scan the document and it may be available on their 'weblink'". On 2/27/12 at 1330 during continued medical record review for patient #26 a copy of the IMM was found that was signed on 2/27/12. Interview with staff E confirms that this document had just been signed today.

On 2/27/12 at approximately 1335 during medical record review for patient #31 revealed that she was admitted on 2/25/12. A copy of the signed Important Message from Medicare was not in the medical record. Interview with staff E revealed that "sometimes they scan the document and it may be available on their 'weblink'". Staff E was unable to provide a signed copy of the IMM for patient #31.

On 2/29/12 at approximately 0930 a review of facility policy titled "Medicare Important Message" with an effective date of December 15, 2007 revealed that "Patient access staff shall provide the required initial required Medicare "notice" to the patient or patient representative at the time of admission to the facility; Obtain the required dated and timed signature as indicated on the "Notice"; place a copy of the signed "Notice" in the medical record....for cases in which the "Notice" was not completed within forty eight hours of admission, communicate this inability, including the name of the patient representative if known, to the Case Management Department..."


28273

During review of the medical record with staff C for patient #37, admitted to the hospital on 02/17/2012 it revealed an unsigned and undated copy of the IMM. This was confirmed by staff C at the time of the record review.

During review of the medical record for patient #49 on 02/28/2012, admitted to the hospital on 12/28/2012, a signed copy of the IMM was not in the medical record.

During an interview with staff O on 02/28/2012, she confirmed that both patients received medicare. Staff O was unable to locate any signed IMM documents signed within 48 hours of admission for either patient.

Based on document review, policy review, and interview the facility failed to ensure patient complaints and grievances were being accurately recorded, addressed per facility policy, and responded to resulting in the potential to deny patients and patient representatives the right to file a complaint or grievance.

On 2/28/2012 at approximately 1400 it was revealed the patient compliant and grievance log failed to contain all grievances made to the facility. The log failed to include information of grievances from 11/8/2011 to 1/29/2012 of all complaints received.

Two grievances in the grievance file pertaining to lost clothing items were not logged in. Documentation of a grievance filed on 2/14/2012 by a patient rights recipient did not support the appropriate follow up from staff members. The complainant had made a complaint to staff members concerning the care her mother was receiving and the condition in which the patient had been found on "several occasions". The complainant asked for a complaint form and was told a complaint form was not available according to the documentation. The staff failed to allow the complainant to file a complaint. Further review of the grievance log revealed the grievance had been responded to via phone call with no formal documentation to the complainant. Information on the log was also found to be incorrect as the complainant was the daughter of the patient not the "patient's mother".

According to the facility policy "patient complaints and grievances - customer concern processing", current patient concerns the manager of patient's unit will be paged and the nursing administration office will be called during weekdays from 0700 to 1530. On weekends, weekdays from 1530 and 0700 a nursing supervisor is to be paged. Concerns from current or former patients that meet the criteria of alleged quality of care issue that is unable to be resolved at the time the duty manager or nursing supervisor should be notified "immediately". Staff #O and #D confirmed the staff failed to follow complaint policies.

An interview with staff #O and staff #D confirmed the complaint and grievance log was incomplete and missing grievances that may have been handled on the units by the unit managers. According to staff #O and #D complaints received on the weekends and in the evenings may be left for the unit manager to address upon their return. Grievances resolved on the units by unit managers are not recorded by the facility. Both staff #O and #D confirmed not all grievances are recorded.

Based on record review and interview, the facility failed to obtain a physician's order for the use of restraints for 3 of 6 ( #38, #50 and #51) restraint records reviewed, creating the potential for inappropriate restraint of patients. Findings include:

During review of the medical record for patient #38 on 02/28/2012, it revealed documentation for the use of restraints on 12/21/2012 at 2245. The medical record did not contain an order for the restraints. Review of the medical record for patient #50 12/27/2012 at 1800 revealed documentation for the use of restraints but did not contain a physician's order for the restraints.

During an interview with staff O on 02/29/2012 at 0830, she confirmed the findings and was unable to provide physician's orders for the restraint use for the two records.

During review of medical records on 02/28/2012 at 1600, patient #51's record contained documentation of restraint use on a behavioral restraint flow sheet for 12/23/2011 at 2330. The patient's record contain an incomplete physician's order for the restraint. The physician's order for the restraint lacked date, time, reason for the restraint, type/ location of the restraints, notification of the nurse manager of the restraint order. The order contained only the physician's signature and a nurses signature, date and time.

Based on medical record review and interview the facility failed to ensure orders for use of restraints were correctly filled out to meet the need of the restraint, type of the restraint, and the authentication of the order by the physician and/or nurse resulting in the potential to restrict the right of patient to be free of restraint in 4 of 6 patients (patient #5, #6, #11 and #37).


29774

On 2/27/12 at approximately 1030 during record review for patient #37, it revealed that an "order for restraint" was found and the patient was placed in soft bilateral wrist restraints and four side rails on 2/25/12 at approximately 2000 for a "medical indication". The same restraints were reordered on 2/26/12, 2000. The physician signature was present on the above mentioned "orders for restraint" however the date and time of the physician signature was not recorded. Additionally, the "Order for restraint" forms, under the "Duration for restraint" section; "Maximum duration for Med/Surg indication is 24 hours" was checked as was the box in front of "Maximum duration for Behavioral indication is 4 hours".


29955

On 2/27/12 at approximately 1030 during record review for patient #5, it revealed that an "order for restraint" was found and the patient was placed in soft bilateral wrist restraints and four side rails on 2/26/12 at approximately 2000 for a "medical indication". The same restraints were reordered on 2/26/12 at 2200. The physician signature was present on the above mentioned "orders for restraint" however the date and time of the physician signature was not recorded. Additionally, the "Order for restraint" forms, under the "Duration for restraint" section; "Maximum duration for Med/Surg indication is 24 hours" was checked as was the box in front of "Maximum duration for Behavioral indication is 4 hours". An interview with staff #C confirmed the findings.

On 2/27/12 at approximately 1045 during record review for patient #6, it revealed that an "order for restraint" was found and the patient was placed in soft bilateral wrist restraints and four side rails on 2/26/12 at approximately 2000 for a "medical indication". The same restraints were reordered on 2/27/12 at approximately 1400 during record review for patient #11 revealed that an "order for restraint" was found and the patient was placed in soft bilateral wrist restraints and four side rails on the day of admission 2/22/12 at approximately 1830 for a "medical indication". Each day thereafter the same restraints were reordered on 2/23/12, 2/24/12, 2/25/12, and 2/26/12 at 1830. The physician signature was present on the above mentioned "order for restraint" dates however the date and time of the physician signature was not recorded. Additionally, the "Order for restraint" forms, under the "Duration for restraint" section; "Maximum duration for Med/Surg indication is 24 hours" was checked as was the box in front of "Maximum duration for Behavioral indication is 4 hours". ordered on 2/26/12 at 2000. The physician signature was present on the above mentioned "orders for restraint" however the date and time of the physician signature was not recorded. Additionally, the "Order for restraint" forms, under the "Duration for restraint" section; "Maximum duration for Med/Surg indication is 24 hours" was checked as was the box in front of "Maximum duration for Behavioral indication is 4 hours". The form failed to contain the signature date and time of the nurse completing the form. An interview with staff #C confirmed the findings.

Based on record review and interview, it was determined that the facility failed to adequately monitor restrained patients for 2 of 2 records reviewed (#52 and #53), creating the potential for excessive or inappropriate restraint of patients. Findings include:

Review of the medical record on 2/27/12 for patient #52, revealed an order for restraints that contained a date and time of the restraints were initiated but lacked documentation of reason for the restraint, type/ location of the restraints, notification of the nurse manager of the restraint order. The behavioral restraint flow sheet for 12/26/2011 at 1800 contained only a line of times (1800,1815, 1830, etc. to 2100 ) written down the sheet for when the patient should have been observed but contained no documentation of the patient being monitored while in the restraints.

Review of the medical record on 2/27/12 for patient #53, revealed that the order for restraints did not contain a duration for use or a stop time. The record lacked documentation of the patient being monitored during the use of the restraints.

During an interview with staff O on 02/29/2012 at 0830, she reviewed the above records and restraint documentation and was unable to produce any further orders or monitoring for the patients.

Based on observation and interview the facility failed to provide adequate infection control resources to monitor; compliance to maintenance of a sanitary physical environment, compliance to hand hygiene and compliance to isolation protocols resulting in the potential for unrecognized hazards and risk for transmission of infectious agents among patients, visitors and healthcare workers. Findings include:

On 2/27/12 during facility tour found pervasive unsanitary physical environment (refer to tag A-749). On 2/29/12 during interview with the infection preventionist when asked regarding frequency of compliance monitoring, Staff CC replied "I am the only one working in Infection Control and sometimes I don't get to it until every 3- 6 months. The managers will do environmental rounds too." Staff CC indicated that she trains nursing students to be secret observers for monitoring hand hygiene compliance in her facility, where staff CC admitted that there is "room for improvement". When asked regarding availability for data entry for surveillance or help with data collection for surveillance Staff CC replied that " I do data entry for multiple modules for NHSN, Keystone ICU/HAI/SSI, MDSS and the enhanced SCIP measures". Staff CC indicated that her scope of responsibility extends from the 344-bed acute care facility and also includes multiple medical offices as well as the long-term care facility.

During review of the medical record for patient #37 on 02/27 2012 at 1200, it revealed four "verbal orders" written on 02/22/2012 and one "verbal order" written on 02/24/2012 and one "verbal order" written on 02/25/2012 that had not been authenticated by a physician at the time of the chart review.


29314

Based on policy, medical record review and interview the facility failed to authenticate orders for 7 out of 15 patients (#3, #4, #5, #7, #24, #27, #37) medical records reviewed, resulting in the potential for poor patient outcomes. Findings include:

On 2/29/2012 at approximately 1000 during review of the policy titled Orders, Verbal or Telephone it was stated "Verbal Orders 5. The clinician requesting the verbal order must authenticate (sign, date and time) the transcribed verbal order prior to leaving the clinical care unit where the order was accepted." "Telephone Orders 2. For inpatients, the practitioner (or an associate in practice) should sign, date, and time telephone orders within 24 hours of the order."

On 2/27/2012 at approximately 1130 during medical record review of patient #3 it was revealed that 10 of the 10 verbal/telephone orders written had not been signed by the ordering physician. The ordering physician had documented in the progress notes on 2/27/2012 at approximately 0845, however, failed to authenticate his orders.


29774

On 2/27/12 at approximately 1345 during medical record review of Patient #27 found telephone orders from the physician dated 2/22/12 at 1000, 2/22/12 at 2115 and 2/24/12, that were not authenticated. This was confirmed by staff E.


29955

On 2/27/2012 at approximately 1020 during medical record review of patient #5's chart it was revealed the physician failed to authenticate an order for sedation on 2/24/2012. The order contained the signature, date, and time of the resident caring for the patient but failed to contain the date and time of the attending physician's signature. An interview with staff #C confirmed the finding.

On 2/27/2012 at approximately 1100 during medical record review of patient #6's chart it was revealed the physician failed to authenticate an informed consent on 2/22/2012. The order contained the signature of the attending physician's signature but failed to contain the date and time of the signature. An interview with staff #C confirmed the finding.

On 2/27/2012 at approximately 1120 during medical record review of patient #7's chart it was revealed the physician failed to authenticate an informed consent on 1/29/2012. The order contained the signature of the attending physician's signature but failed to contain the date and time of the signature. The form also failed to contain the date and time of the witness' signature. An interview with staff #C confirmed the finding.

On 2/27/2012 at approximately 1125 during medical record review of patient #7's chart it was revealed the physician failed to authenticate an informed consent on 1/14/2012. The order failed to contain the signature, date and time of the physician. An interview with staff #C confirmed the finding.


31054

On 2/27/12 at approximately 13:30, medical record review of Patient #24 revealed telephone orders dated 2/24/12 at 1040 were not yet authenticated by the physician. Findings were confirmed by staff I.

Based on staff interview and policy review, it was determined the facility failed to ensure that all discharged patients' medical records were complete including authentication from the physician within 30 days of patient discharge. Findings include:

On 2/27/12 at approximately 11:00 a.m. an interview with staff J revealed that the facility currently had 564 medical records that were awaiting completion beyond 30 days following the patients' discharge from the hospital. Page 44, number 13 of Medical Staff Rules and Regulations states that "All medical records shall be completed within 30 days of discharge. Records not completed within this timeframe are considered delinquent."

Based on policy review, observation and interview, the facility failed to date IV tubing when initiated or changed for 3 of 3 patients observed (#5,#6, #37). Findings include:

A review of policy 403 titled Intravenous Therapy reads on page 3 in the section titled Replacement of administration sets: "Replace intravenous tubing, including add-on devices, no more frequently than 72-96 hour intervals unless clinically indicated." "Replace secondary tubing every 72-96 hours."

During observation of the ICU on 02/27/2012 between 1030-1200, patient #5 was observed with six (6) different IV lines hanging. Patient #6 and #37 both were observed with six (5) different IV lines hanging.
None of the patient's IV lines were dated as to when they were hung, making it so staff could not determine when the lines required changing. The findings were confirmed by staff C at the time of the observation. She stated that staff are supposed to label the lines so they know when to change them.

During an interview with staff O on 02/28/2012 at 1430, she stated that they "use a different colored piece of tape for each day that staff are supposed to apply to the IV tubing to identify when it went up and when it would need to come down."

Based on observation, interview and policy and procedure review the facility failed to ensure that all drugs and biologicals are kept in a secure area and/or locked when unattended. Findings include:

During observation on 2-28-12 at approximately 1430 it was found in the Baybrooke outpatient facility that the medicine drawers and sample medication closet were left unlocked when unattended.
These findings were confirmed by staff Z.


30988

On 2/27/2 at approximately 1100 during the tour of the facility three of three medication carts were found unlocked and unattended.
During policy and procedure review on 2/8/2 at approximately 0900 it was found in the policy, "Department of Pharmacy Services", states, "All medication storage cabinets will be locked including all medication carts". This finding was verified by staff W.

Based on observation and interview the facility failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use. Findings include:

During observation on 2-27-12 at approximately 1045 it was found on 6 West, in the Respiratory airway box, one 15 ml bottle of Chlorhexidine 0.12% that expired on 1-7-12.
This finding was confirmed by Staff W.

During observation on 2-28-12 at approximately 1430 it was found at the outpatient Baybrooke center the following drugs were outdated or unusable:
1. Four 30 ml bottles of Sensorcaine labeled for single use only, in the drawer, open and ready for re-use.
2. One 30 ml bottle of 1% Lidocaine labeled for single use only, in the drawer, open and ready for re-use.
3. One 20 ml bottle of Lidocaine/Epinephrine opened 11/30/11, no expiration and only useable for 28 days after opening.
4. One 30 ml bottle of Bacteriostatic water with no open or expiration date.
These findings were confirmed by staff W.


29774

On 2/27/12 at approximately 1025 during facility tour found on 6 East in the clean storage room in the medication refrigerator, NovoLog (insulin) with an open date of 1/13/12 and discard after date of 2/13/12. This was confirmed by Staff E.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-709.

The overall physical environment was not being maintained so as to ensure patient safety as evidenced by:

1. The automated chemical dispensing unit in the housekeeping closet on 9 East (ICU) was connected to the water supply in a manner that compromises the integrity of the atmospheric vacuum breaker on the mop sink as observed on 2/27/12 at 10:30 AM. The dispensing unit effectively creates a shutoff valve downstream of the atmospheric vacuum breaker (AVB) which can permanently damage the AVB. Note: This was observed throughout the facility.

2. The drywall at the mop sink in the housekeeping closet on 9 West had a hole in the wall as observed during the facility tour on 2/27/12 at 10:50 AM.

3. The flat courtyard/roof terrace for Geriatric Psych in the 1962 Building was observed on 2/28/12 at 2:30 PM to be in very poor condition with many broken pavers, heavy moss growth between the pavers and with roof material deteriorated and coming loose by the north end of the courtyard allowing for water intrusion which could cause material damage and foster mold growth inside the building adversely affecting the indoor air quality and health of building occupants.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated February 29, 2012 for Life Safety Code.

An acceptable level of quality of the patient care environment was not provided as evidenced by the following observations:

1. Laminated sink substrate was severley deteriorated at the backsplash and the portion where the material contacts the floor in the 9th floor nourishment room on 2/27/12 at 10:45 AM.

2. Approximately six floor tiles in the Nourishment room on 9 East were water damaged and coming loose. This was observed during the facility tour on 2/27/12 at approximately 10:30 AM.

2. The backsplash for the sink in the emergency department xray room had deteriorated and was missing caulk as observed on 2/28/12 at 9:45 AM.

3. The countertop CocaCola dispensing machine in the dining area was leaking, creating a puddle of water on the floor in front of the counter as observed on 2/27/12 at 2:00 PM. Also, the cabinet and countertop had experienced significant water damage over time.

4. The paper towel dispenser serving the hand washing sink in the dishwashing area was not functioning at the time of the facility tour, approximately 2:10 PM on 2/27/12.

5. The cabinetry for the sink in the Geriatric Psych Dining area was observed to be severely water damaged on 2/28/12 at approximately 2:00 PM. The back of the wall as seen from the adjacent room was also severely water damaged. These wet and deteriorated conditions make it difficult to clean the area and promote hazardous mold growth which could adversely affect patients in the area.

6. The shower wall by the shower controls in Room 145 Substance Abuse was water damaged and deteriorated as observed on 2/28/12 at approximately 3:00 PM.

7. The wall in the old x-ray dark room (3054L) was damaged and in need of repair. This was observed during the facility tour on 2/18/12 at approximately 11:50 AM.

Based on policy review, observation and interview the facility failed to monitor refrigeration temperatures resulting in the potential to promote bacterial growth and spread of infection. Findings include:

On 2/27/2012 at approximately 1145 during review of the policy titled Specific Cleaning and Maintenance Policies it is stated under G. "Maintenance and Temperature Monitoring 1. A temperature record chart will be posted on the door of each refrigeration unit that contains Medications, Patient Food, or Laboratory Specimens." During review of the HACCP Refrigerator Temperature Log it is stated "Check and record temperature once a day."

On 2/27/2012 at approximately 1040 on the rehabilitation unit it was revealed that the medication refrigerator temperature was not documented 6 out of 27 days on the refrigerator log. The patient nutrition refrigerator temperature was not documented 10 out of 27 days on the refrigerator log.

On 2/27/2012 at approximately 1040 staff B confirmed that the logs were not completed.


19647

The facility failed to provide adequate ventilation and lighting as evidenced by the following observations:

1. At approximately 3:30 PM on 2/28/12 the illumination at the scrub sinks by ORs 1 and 5 measured 43 and 55 foot-candles respectively. This is over 20 foot-candles less than the accepted standard of minimum 75 foot-candles to facilitate effective handwashing.

2. The exhaust for the shower room adjacent to the isolation room in Geriatric Psych was not working as observed during the building tour on 2/28/12 at 1:20 PM. Later that afternoon this surveyor also observed that the rooftop Exhaust Fan 41 was not working; however, the facility director did not know if EF 41 served the shower room. The lack of exhuast causes excessive moisture in the area which has contributed to the observed growth of mold/mildew in the shower area tile grout.

3. At 11:10 AM on 2/27/12, the negative pressure airborne isolation room (Rm 9030) was found to NOT be under negative pressure as required.

4. At 3:30 PM on 2/27/12, the chemotherapy hood was found to not be exhausted to the outside. There was an exhaust duct directly above the hood, but it was not connected to the hood via a thimble connection, and the volume damper on the exhaust duct was in the fully closed position. This creates a risk for room occupants to be exposed to hazardous chemotherapy agents that can vaporize and pass through the hood filters into the room.




29313

During the observational tour on 2-27-12 at approximately 1530 it was found that the outpatient physical rehabilitation and occupational therapy refrigerator didn't have a daily temperature log. Staff EE confirmed this finding.


30562

During the 7 West unit tour on 02/27/2012 at approximately 1010 it was noted that the Medication Room Refrigerator Log for February 2012 was missing. The January 2012 log showed no documentation of temperature checks after January 10, 2012.

Staff A confirmed that the January log was not complete, and provided a February temperature log that appeared to be up to date.


28273

During observation of the emergency department on 02/27/2011 with staff N, it was revealed that the medication refrigerator log, the food refrigerator log and the freezer log temperatures were not documented on 22 of the 27 days of the month. This was confirmed by staff N at the time of the observation.

Based on observation, interview and policy review the facility failed to provide a clean and sanitary environment resulting in the potential for transmission of infectious agents among patients, visitors and healthcare workers. Findings include:

On 2/27/12 starting at approximately 1010 until 1100, during a tour of 6 East found the following areas:
Clean patient care supplies storage
a). patient labeled skin cream barrier kit and a limb sling stored in a drawer with other clean patient care supplies
b). Culturette tube with a manufacturers expiration date of 6/2011
c). an overstuffed drawer (storage) of a sterile packaged thoracic catheter whose package integrity was non-intact with reddish stains on the outside of the package

Pantry
d). Ice machine that leaked (water?) into the overflow tray which was soiled with a reddish white material and whose tray contained a broken up Styrofoam cup
e). food refrigerator has residual reddish sticky accumulation on the bottom of the refrigerator which was also soiled with accumulated crumb debris
f). the food refrigerator's freezer had an accumulation of about one inch of ice
g). the food refrigerator had an opened milk carton without specification of a date opened with an expiration date of 2/27/12
h). a bagged box of toaster strudel that was not marked with a patient name

Patient-ready room # 6020-B
i). in the patient storage cabinet found; a roll of tape, an opened package of IV tubing and opened package of (EKG) chest lead buttons

Soiled utility room
j). two used commode buckets stored in the water inside of the hopper sink
k). floor storage of bagged trash around the trash hopper bin

At the nurses station
l). the blood glucose monitoring machine containing one each of the high and low control solutions with an open date of 11/10 and a discard after date of 2/10, solutions, which may support bacterial growth if kept in use beyond manufacturers' recommendations
m). the blood glucose monitoring machine that according to staff E is "cleaned daily and not between patients unless it is used in an isolation room". Staff E collected the undated test strips and high/low control test tubes and discarded them.

Interview with staff E regarding the items found in the clean storage area reveals that:
"the patient labeled care items should have been discarded "
"expired culture tube should have been discarded",
"the catheter should have been discarded and would not be used on a patient"

Interview with staff E regarding the items found in the Pantry area reveals that;
"housekeeping cleans the ice machine daily"
she "wasn't sure how often the maintenance people cleaned the internal components of the ice machine"
"housekeeping cleans and defrosts the food refrigerator monthly"
"the opened milk carton should be discarded and the toaster strudel should be labeled with the patients name"

Interview with staff E regarding the items found in the patient-ready room reveal that "those items should have been discarded after the (previous) patient left the room"

Interview with staff E regarding the soiled utility reveal that "we rarely use the hopper sink however those commode bucket should not be left there". Additionally staff E indicated that "somebody missed the trash bin and left the trash (bag) on the floor around the bin".

A review of facility policy titled "Environmental Services Infection Control" revised August 2008 on 2/29/12 at approximately 0900 revealed that "refrigerators are cleaned monthly by the RN, LPN, PCA using disinfectant wipes noting the cleaning includes defrosting"..."Ice machine exterior is cleaned daily by environmental services using a germicide wipe, the internal components are cleaned by B & G (Buildings and Grounds)" with an unspecified frequency. The "Accucheck/blood Glucose machine is cleaned Q shift by the RN, LPNM-PCA using a germicidal wipe". "IV pumps are clean while in use daily and between patients using a germicide wipe by the RN/LPNM IV poles are cleaned by environmental services in use and between use using a germicide".

A review of facility policy titled "Refrigerator and Freezer Maintenance" with a revised date of 10/20/05 reveals that "The unit manager of each nursing unit will ensure compliance with the following policy"..."Unit manager shall ensure refrigeration units are kept cleaned and spills are (to) be wiped up immediately as they are an excellent media for bacterial growth...If ice accumulation in the freezer is greater than 1/4 inch, it should be defrosted and cleaned".


31054

On 2/27/12 at approximately 10:30 while touring 8 West the following observations were noted:
1. The refrigerator containing patient food was soiled with sticky liquid rings and particles on shelves.
2. Access to the handwashing sink was blocked by a biohazard container and dirty linen cart.
3. IV pumps being stored in an alcove and ready for patient use were soiled at the bases and horizontal surfaces.
4. Vital sign monitoring equipment stands were soiled at the bases and horizontal surfaces.
During the tour, findings were confirmed with staff O.

In was noted on 2/27/12 at approximately 14:00 during review of facility policy "Floor Stock/Food Storage in Patient Care Areas For After Hours" under Responsibility - Food and Nutrition Services Department, #9: "Food Service employee routinely cleans and sanitizes patient refrigerators including freezer units. Refrigerators are cleaned and sanitized weekly."


19647

Based upon observation the facility failed to provide a clean and sanitary environment resulting in the potential for transmission of infectious agents among all building occupants. Findings include:

1. On 2/27/12 at 10:40 AM, the Equipment Room 9032 was observed to ahe a significant amount of dust and debris under the storage carts. Also boxes were being stored on the floor which can become soiled during routine mopping/cleaning.

2. On 2/27/12 at 11:15 AM, the Nursing Report and Conference Room 9017, had an accumulation of dust and debris under and on the side of the Pyxis units as well as an accumulation of dust on top of the employee lockers.

3. On 2/27/12 at 11:43 AM, it was observed that there was a spare dialysis machine being stored in the patient toilet room for the inpatient dialysis treatment room (Room 9062). In this location there is a significant risk for the dialysis machine to become contaminated.

4. On 2//27/12 at 11:45 AM, a large cart full of dialysis supplies was found stored within the dialysis treatment cubicle. All the supplies on this cart are at risk for contamination.

5. On 2/27/12 at 1:58 PM, it was observed that the temperature of the pass through refrigerator in the kitchen for the serving area measured 48 F (well over the limit of 41 F as established by the Food Code). Food stored above 41 F for more than 4 hours can become hazardous due to the growth of bacteria at these elevated temperatures. This could affect staff and visitors eating in the dining area.

6. On 2/27/12 at 1:50 PM, the Dietary dry storage area had some debris on the floor and had so much storage that it was difficult to move around the room which would make cleaning and doing any work in the room difficult as well. There is an overall lack of adequate storage space in the Kitchen area.

7. On 2/27/12 at 2:37 PM, the PACU area Omnicell was found to have an accumulation of dust and debris under it.

8. On 2/27/12 at 2:40 PM, the patient refrigerator in PACU was found to have staff food in it. The use of patient refrigerators for staff food is inappropriate since the staff food can potentially contaminate patient food items.

9. On 2/28/12 at 11:30 AM, the old X-ray processor area still had water supply piping along the wall that has been capped off, creating several dead ends. These dead ends creat a potential for bacteria growth in the stagnant water that could contaminate the water supply.



28273

During observation of the ICU on 02/27/2012 at approximately 1100, room #9012 was observed to have a feeding pump in the room if needed when a patient was admitted to the room. The front of the feeding pump was observed to have several spots of a brownish color on the dial and screen of the pump. Staff C was present during the observation and she stated that the room was "clean and set up for the next patient" she also confirmed that the feeding pump contained the brown substance on the front and needed to be cleaned.



29313

During observation on 2-27-12 at approximately 1015 it was observed that the medication drawer cabinet on 6 West was right up next to the hand washing sink and was within splashing distance with potential of cross contamination of the medications for patients.
During observation on 2-27-12 at approximately 1030 it was observed in the 6 West dietary pantry that the ice machine had a white film in the catch basin and around the edges and up into the actual ice dispenser.
During observation on 2-27-12 at approximately 1035 it was found at the 6 West nursing station that the accucheck control hi/lo bottles expired on 2-10-11.
These findings were all confirmed by staff W.
During observation on 2-27-12 at approximately 1530 it was observed in the outpatient occupational therapy use room that the drawers, cabinets, refrigerator and countertops were stained, cluttered and had debris scattered about.
These findings were confirmed by staff EE.
During observation on 2-28-12 at approximately 1430 it was found that at the Baybrooke outpatient office the Hemoglobin control bottles had expired on 1/11 and 11/10. The urine test controls expired 6-19-10. These findings were confirmed by staff EE.


29314

On 2/27/2012 at approximately 1145 during review of the policy titled Expiration Of Supplies it is stated under Procedure: "4. The supplies that have reached their expiration date on the package will be discarded in the appropriate manner. Paper and plastic can be disposed in general waste, while sharp objects will go in sharps containers."

On 2/27/2012 at approximately 1030 it was observed on the Rehabilitation Unit that the following supplies were out dated in the Treatment Cart:
1. Thoracic Catheter expired 5-2011.
2. Four Super Sheath Catheters expired 8/2009, 12/2011, 4/2011 and 8/2010.
3. One Pressure Monitoring Kit expired 11/2012.

On 2/27/2012 at approximately 1145 during review of the policy titled Floor Stock/Food Storage in Patient Care Areas under Patient Care Services "1. Patient food should be labeled with patient name, room number and expiration date."

On 2/27/2012 at approximately 1035 it was observed on the Rehabilitation Unit in the patient nutrition refrigerator there were three bottles of pop, one carton of milk and one bottle of ensure opened and not dated with the open date. Staff B confirmed this finding.





30988

On 2-27-12 at approximately 1100 during the tour of the facility the clean storage room on 6 West was found to have a rolling cart that was dirty, and dusty, with debris. There was equipment for patient use lying in the bottom of the cart in a dried crusted brown substance. There were also condiments: creamer, butter, and ketchup, sitting on top next to the shampoo that had no lid. There were 2 trash baskets with discarded blue pads. These findings were confirmed by staff W.