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Based on observations and interviews, the hospital failed to ensure that its foods on its salad bar was maintained at 41 degrees Fahrenheit or below. Failure to maintain cold food temperatures within an acceptable of 41 degrees Fahrenheit or below has the potential to create an environment for food borne illnesses within the patient, staff, and visitor population. The hospital failed to ensure its dietary staff followed it own policies and procedures and acceptable principles for disinfection of its 3 compartment sink which could have the potential to not achieve acceptable sanitization of its dish ware.


The findings are:


On 09/18/2017 at 11:30 a.m., observations of Dietary Manager and Dietary Staff Member 1 obtaining the temperatures of the cold foods placed on the salad bar revealed:
a) Ten pimento cheese sandwiches had temperatures between 47 degrees Fahrenheit and 55 degrees Fahrenheit;
b) Sliced Tomatoes had a temperature at 45 degrees Fahrenheit;
c) Water melon had a temperature at 44 degrees Fahrenheit; and
f) Broccoli had a temperature of 55 degrees Fahrenheit.

Observations of the cold bar on 09/20/2017 at 11:20 a.m. revealed:
a) Lettuce had a temperature of 59 degrees Fahrenheit;
b) Carrots had a temperature of 44 degrees Fahrenheit;
c) Okra had a temperature of 44 degrees Fahrenheit; and
d) Pimento Cheese had a temperature of 50 degrees Fahrenheit.
Foods on the cold salad bar were served to patients, employees, and visitors.

On 09/18/2017 at 12:00 p.m., the Dietary Manager who was present during all observations stated the cold bar wasn't working like it should to keep the foods cold.

Observations of the three compartment sink on 09/18/2017 at 12:15 p.m. revealed the third sink was filled to the top with water. A Thermometer was sticking out of the top of the water and registered 160 degrees Fahrenheit. Beneath the sink, a heater in the on position was located. The water in the sink was a light bluish color. On the side of the first sink, a bottle of testing strips was observed. On a ledge beside the third sink was a bottle of disinfectant tablets. The label on the bottle with the test strips was yellow and appeared old. Upon opening the bottle, four test strips were revealed. The test strips had a yellow appearance and look old. There was no expiration date on the bottle. The label on the bottle with the disinfectant tablets appeared old with no expiration date. When the Dietary Manager was asked to explain the third compartment sink set up, he/she stated " we were told by the state that if we filled the sink with water, turned a heater on, and placed a thermometer in the sink and it was 160 degrees that it was okay to do it that way. It was like this when I came to work here." When asked to test the water with the testing strip, the Dietary Manager swished the strip though the water in the sink and compared the strip with the color strip on the bottle that measures the parts per minute(ppm). The color on the water testing strip did not change indicating the disinfectant level was low. When asked how the disinfectant tablets were used, the Dietary Manager stated, " I put one or two tablets in the sink of water." Review of the manufacturer's directions for use (DFU), the label stated to use 1 to 2 tablets per gallon of water. When the Dietary Manager was asked how many gallons of water it would take to fill the sink, the Dietary Manager stated, " I don't know." The sink was not marked to show how many gallons of water it could hold or to give guidance on the number of gallons of water in the sink so the accurate amount of disinfectant tablets required could be assured. The Dietary Manager stated the hospital had no more testing strips to assure the accurate level of disinfectant was being used. The Dietary also used a testing strip for the disinfectant solution for cleaning cloths and the strip did not change color in that solution either.

The hospital failed to ensure a system was in place to determine the efficacy of the disinfectant used in its three compartment sink.

Hospital policy and procedure, titled, "Cleaning Dishes - Manual Dishwashing" effective date 12/5/2012, reads, "Policy: Dishes and cookware will be washed after each meal to assure that all dishes are clean and sanitary. Procedure: ....3. Prepare the sinks according to the chart below. All sinks should be cleaned and sanitized prior to beginning. 4. Place a few dishes at a time into the sink. Wash thoroughly with a clean cloth or sponge. Scrub Items as needed using a scouring pad. Rinse in sink 2, and sanitize in sink 3 following the directions below. 6. Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate.. Sink 3: Sanitize. Sanitize dishes: 1. Measure the appropriate amount of sanitizing chemical into the appropriate amount of water (following the manufacturer's guidelines). 2. Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level. 3. Place the dishes in the sanitizing sink. Allow to stand according to the manufacturer's guidelines for sanitizer ( or see chart below). 4. Allow dishes to air dry. Invert dishes in a single layer to air dry......".

Based on observations of the hospital's cold salad bar, review of the manufacturer's labels for the disinfectant tablets and water testing strips for the 3 compartment sink, and interview, the hospital's governance failed to ensure its dietary kitchen staff ensure the cold foods held on its salad bar was 40 degrees Fahrenheit or less and failed to ensure staff was knowledgeable and followed the hospital's own policies and procedures and the manufacturer's procedures and acceptable practices in the disinfectant procedures for the three compartment sink.


The findings are:

Cross Reference to C 0270: The hospital's dietary kitchen failed to ensure the cold foods held on its salad bar was 40 degrees Fahrenheit or less and failed to ensure staff was knowledgeable in the disinfectant procedures for the three compartment sink.

Based on observations of the hospital's cold salad bar, review of the manufacturer's labels for the disinfectant tablets and water testing strips for the 3 compartment sink, and interview, the hospital's dietary kitchen failed to ensure the cold foods held on its salad bar was 40 degrees Fahrenheit or less and failed to ensure staff was knowledgeable in the disinfectant procedures for the three compartment sink.

The findings are:

Cross Reference to C 0226: The hospital failed to ensure that its foods on its salad bar was maintained at 41 degrees Fahrenheit or below. Failure to maintain cold food temperatures within an acceptable of 41 degrees Fahrenheit or below has the potential to create an environment for food borne illnesses within the patient, staff, and visitor population. The hospital failed to ensure its dietary staff followed it own policies and procedures and acceptable principles for disinfection of its 3 compartment sink which could have the potential to not achieve acceptable sanitization of its dish ware.


Cross Reference to C 0279: The hospital failed to ensure that its foods on its salad bar was maintained at 41 degrees Fahrenheit or below. Failure to maintain cold food temperatures within an acceptable of 41 degrees Fahrenheit or below has the potential to create an environment for food borne illnesses within the patient, staff, and visitor population. The hospital failed to ensure its dietary staff followed it own policies and procedures and acceptable principles for disinfection of its 3 compartment sink which could have the potential to not achieve acceptable sanitization of its dish ware.

Based on observations, interviews, and review of the hospital's policy and procedures, the Critical Access Hospital (CAH) staff failed to discard expired medications.

The findings are:

On 9/19/17 at 2:30 p.m., observations in the operating room (OR) revealed two (2) Nitrous Oxide tanks with expiration dates of 3/12/14 and 2/16/2016. The findings were verified with Registered Nurse (RN) 2 at the time of the observation. RN 2 stated," I didn't realize these had expired. We only probably use them like one time a year. I will have them taken out of here."




39208

Observations on 9/18/17 at 11:45 a.m. revealed a bag of 100 milliliters (ml) of 0.9%(percent) NaCL(Sodium Chloride) in the hospital's medication room expired August 2017. The finding was verified by Director Of Nurses at 11:45 a.m. on 9/20/17.

Hospital Policy and Procedure, titled, "Expiration Dates", reads, "....in departments where medications are administered, before giving the medication(s), the employee must check the expiration date....all hospital employees are responsible for checking expiration dates....".

Based on observations, interview, and review of the hospital's policy and procedures, the hospital staff failed to minimize the potential cross transmission of infectious agents in the hospital setting for 2 of 8 Registered Nurses(RN). (RN 6 and 5)

The findings are:

On 9/20/17 at 9:00 a.m., observations in Patient 2's room revealed RN 6 transported the medication cart into the patient's room, but failed to clean the medication cart after exiting the patient's room. On 9/20/2017 at 09:00 a.m., RN 6 stated "We only clean the cart if it's taken in a room where the patient has an infectious disease."

On 9/20/17 at 10:00 a.m., observations in a random patient's room revealed RN 5 transported the medication cart in the the patient's room, but failed to clean the medication cart after exiting the patient's room.






39208

On 9/20/17 at 9:12 a.m., RN 5 entered a patient's room to check a beeping intravenous (IV) machine, but failed to perform hand hygiene upon entering the patient's room. The findings were verified with RN 5 at 9:15 a.m. on 9/20/17. On 9/20/17 at 9:14 a.m., RN 5 returned the medication cart to the medication room without performing sanitation procedures after taking the medication cart into a patient room. The findings were verified with RN 5 at 9:25 a.m. on 9/20/17.

Hospital Policy and Procedure, titled, "Clean Equipment Management", reads, "A .... C. Ideally, individual equipment should be provided for each patient. When equipment is shared, disinfection of equipment should take place prior to next patient use ... ...".

Based on observations and interviews, the hospital failed to ensure that its foods on its salad bar was maintained at 41 degrees Fahrenheit or below. Failure to maintain cold food temperatures within an acceptable of 41 degrees Fahrenheit or below has the potential to create an environment for food borne illnesses within the patient, staff, and visitor population. The hospital failed to ensure its dietary staff followed it own policies and procedures and acceptable principles for disinfection of its 3 compartment sink which could have the potential to not achieve acceptable sanitization of its dish ware.


The findings are:


On 09/18/2017 at 11:30 a.m., observations of Dietary Manager and Dietary Staff Member 1 obtaining the temperatures of the cold foods placed on the salad bar revealed:
a) Ten pimento cheese sandwiches had temperatures between 47 degrees Fahrenheit and 55 degrees Fahrenheit;
b) Sliced Tomatoes had a temperature at 45 degrees Fahrenheit;
c) Water melon had a temperature at 44 degrees Fahrenheit; and
f) Broccoli had a temperature of 55 degrees Fahrenheit.

Observations of the cold bar on 09/20/2017 at 11:20 a.m. revealed:
a) Lettuce had a temperature of 59 degrees Fahrenheit;
b) Carrots had a temperature of 44 degrees Fahrenheit;
c) Okra had a temperature of 44 degrees Fahrenheit; and
d) Pimento Cheese had a temperature of 50 degrees Fahrenheit.
Foods on the cold salad bar were served to patients, employees, and visitors.

On 09/18/2017 at 12:00 p.m., the Dietary Manager who was present during all observations stated the cold bar wasn't working like it should to keep the foods cold.

Observations of the three compartment sink on 09/18/2017 at 12:15 p.m. revealed the third sink was filled to the top with water. A Thermometer was sticking out of the top of the water and registered 160 degrees Fahrenheit. Beneath the sink, a heater in the on position was located. The water in the sink was a light bluish color. On the side of the first sink, a bottle of testing strips was observed. On a ledge beside the third sink was a bottle of disinfectant tablets. The label on the bottle with the test strips was yellow and appeared old. Upon opening the bottle, four test strips were revealed. The test strips had a yellow appearance and look old. There was no expiration date on the bottle. The label on the bottle with the disinfectant tablets appeared old with no expiration date. When the Dietary Manager was asked to explain the third compartment sink set up, he/she stated " we were told by the state that if we filled the sink with water, turned a heater on, and placed a thermometer in the sink and it was 160 degrees that it was okay to do it that way. It was like this when I came to work here." When asked to test the water with the testing strip, the Dietary Manager swished the strip though the water in the sink and compared the strip with the color strip on the bottle that measures the parts per minute(ppm). The color on the water testing strip did not change indicating the disinfectant level was low. When asked how the disinfectant tablets were used, the Dietary Manager stated, " I put one or two tablets in the sink of water." Review of the manufacturer's directions for use (DFU), the label stated to use 1 to 2 tablets per gallon of water. When the Dietary Manager was asked how many gallons of water it would take to fill the sink, the Dietary Manager stated, " I don't know." The sink was not marked to show how many gallons of water it could hold or to give guidance on the number of gallons of water in the sink so the accurate amount of disinfectant tablets required could be assured. The Dietary Manager stated the hospital had no more testing strips to assure the accurate level of disinfectant was being used. The Dietary also used a testing strip for the disinfectant solution for cleaning cloths and the strip did not change color in that solution either.

The hospital failed to ensure a system was in place to determine the efficacy of the disinfectant used in its three compartment sink.

Hospital policy and procedure, titled, "Cleaning Dishes - Manual Dishwashing" effective date 12/5/2012, reads, "Policy: Dishes and cookware will be washed after each meal to assure that all dishes are clean and sanitary. Procedure: ....3. Prepare the sinks according to the chart below. All sinks should be cleaned and sanitized prior to beginning. 4. Place a few dishes at a time into the sink. Wash thoroughly with a clean cloth or sponge. Scrub Items as needed using a scouring pad. Rinse in sink 2, and sanitize in sink 3 following the directions below. 6. Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate.. Sink 3: Sanitize. Sanitize dishes: 1. Measure the appropriate amount of sanitizing chemical into the appropriate amount of water (following the manufacturer's guidelines). 2. Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level. 3. Place the dishes in the sanitizing sink. Allow to stand according to the manufacturer's guidelines for sanitizer ( or see chart below). 4. Allow dishes to air dry. Invert dishes in a single layer to air dry......".

Based on patient chart review, interview, and review of the hospital's policy and procedure, the staff failed to document pain assessments and reassessments for 9 of 20 closed patient charts reviewed. (Patient 2, 4, 6, 7, 10, 11, 12, 13, and 15)

The findings are:

On 9/20/17 from 2:00 to 2:10 p.m., review of Closed Patient 2's record revealed the patient was administered Acetaminophen 650 milligrams (mg) by mouth on 7/16/2017 at 11:19 p.m.. His/her pre-pain was assessed as 4/10. There was no post pain reassessment documented.

On 9/20/17 from 2:20 to 2:30 p.m., review of Closed Patient 4's record revealed the patient was administered Morphine Sulfate 2 mgs intravenous push (IVP) at 1:09 a.m. on 6/23/17 . There was no pre or post pain assessment documented. On 6/23/17 at 8:58 p.m., the patient was administered Morphine Sulfate 2 mgs intravenous push (IVP). There was no pre or post pain assessment documented.

On 9/20/17 from 2:40 to 2:50 p.m., review of Closed Patient 6's record revealed the patient was administered Tylenol 500 mgs by mouth at 8:33 p.m. on 8/23/17. There was no pre or post pain assessment documented.

On 9/20/17 from 2:55 to 3:00 p.m., review of Closed Patient 7's record revealed the patient was administered Motrin 600 mgs by mouth at 4:09 p.m. on 8/21/17. There was no pre or post pain assessment documented. On 8/22/17 at 12:35 p.m., the patient was administered Motrin 600 mgs by mouth. There was no pre or post pain assessment documented.

On 9/20/17 from 3:10 to 3:15 p.m., review of Closed Patient 10's record revealed the patient was administered Lortab 5/325 mg tabs(Tablets) x(times) 2 by mouth at 12:02 a.m. on 7/24/17. There was no pre or post pain assessment documented. On 7/25/17 at 2:56 p.m., the patient was administered Lortab 5/325 mg tab x 1 by mouth. There was no pre or post pain assessment documented.

On 9/20/17 from 3:20 to 3:25 p.m., review of Closed Patient 11's record revealed the patient was administered Ultram 50 mg by mouth with a documented pain scale of 4/10 at 5:03 a.m. on 7/29/17. There was no post pain reassessment documented. On 7/30/17 at 9:31 p.m., the patient was administered Ultram 50 mg by mouth with a documented pain scale of 5/10. There was no post pain reassessment documented.

On 9/20/17 from 3:30 to 3:35 p.m., review for Closed Patient 12's record revealed the patient was administered Dilaudid 2 mg IVP(Intravenous Push) at 1:16 p.m. on 6/22/17. There was no pre or post pain assessment documented. On 6/23/17 at 4:39 a.m., the patient was administered Dilaudid 2 mg IVP. The pre-pain assessment was documented as 5/10. There was no post pain assessment documented. On 6/23/17 at 8:15 p.m., the patient was administered Lortab 5/325 mg tab x 1 by mouth. The pre-pain assessment was documented as 5/10. There was no post pain assessment documented.

On 9/20/17 from 3:40 to 3:45 p.m., review of Closed Patient 13's record revealed the patient was administered Motrin 800 mg by mouth at 7:22 p.m. on 7/28/17. There was no pre or post pain assessment documented.

On 9/20/17 from 3:55 to 4:05 p.m., record review for closed patient 15's record revealed the patient was administered Acetaminophen 650 mg by mouth at 4:58 on 7/10/17. The pre-pain assessment was documented as 4/10. There was no post pain assessment documented.

On 9/21/17 at 9:15 a.m., the findings were verified with the Director of Nursing who stated "a pre and post pain assessment is supposed to be documented within an hour of administration."

Hospital Policy and Procedure, titled, "Hospital Wide Clinical Policies and Procedures Patient Pain Assessment", reads, "....pain assessment is ongoing....reassessment will occur thirty to sixty (30-60) minutes after any pain intervention or at discharge if under thirty (30) minutes....".

Based on record reviews, observations, and review of hospital policy, the Hospital (CAH) failed to ensure a transcription system was in place to verify nursing orders are transcribed to prevent errors or missed medications for 1 of 20 closed patient charts reviewed for care and services. (Closed Patient Chart 10)

The findings are:

On 9/20/17 at 3:15 p.m., review of Closed Patient 10's chart revealed a physician order was not transcribed by staff and resulted in an ordered medication was not administered to the patient. The finding was verified by RN 1 at 10:19 a.m. on 9/21/17.

On 9/21/17 at 11:05 a.m., review of the hospital's Policy and Procedure, titled, (Medication Procedure), reads, "....the RN or LPN will verify the accuracy and completion...." of the physician orders.

Based on record reviews, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure the patient's nursing care plan was reviewed daily for 1 of 20 closed patient records. (Closed Patient 4 )

The findings are:


On 9/19/17 at 1:50 p.m., review of Closed Patient 4's chart revealed the patient was admitted on 6/20/17 with a Urinary Tract Infection and Sepsis and was discharged on 6/24/17. The patient's plan of care was implemented on 6/20/17 at 6:44 p.m. with updates on 6/21/17 at 7:23 a.m., 6/22/17 at 7:09 a.m., and 6/24/17 at 12:37 a.m. There was no review or update charted on 6/23/17 by the nursing staff. The finding was verified with RN 1 on 9/19/17 at 2:22 p.m.

Hospital Policy and Procedure, titled, "Care Plan Policy", reads, "The plan of care will be reviewed daily and kept current by ongoing assessments of the patient's needs and responses to interventions and will be revised based on patient's response to interventions....".

Based on record reviews, interview, and review of the hospital's policy, the Hospital (CAH) failed to follow ensure its staff responsible for the transcription of physician orders specifically the verification of medication orders during the Internet downtime for its electronic medical records to assure safe medication delivery.


The findings are:

On 9/18/17 at 12:15 p.m., review of Open Patient #2's chart revealed the patient's medication record had physician orders for medications with no documentation of verification of the medication orders. The findings were verified by the Director Of Nursing on 9/18/17 at 3:00 p.m. and on 9/19/17 at 9:55 a.m. by the Pharmacist 2 (PHM2).

On 9/18/17 at 4:00 p.m., review of the hospital's policy, titled, "Internet/HMS/MedHost(EDIS) Downtime Policy", states, "....MedHost (EDIS) will not work in the event the Internet is down. When this happens you must resort back to paper charting....".

Based on record review and interview, the hospital failed to ensure the Conditions of Admission and Authorization for Medical Treatment form was witnessed and dated for 12 of 20 closed patient records and for 1 of 2 open patient records. (Closed Patient 1, 2, 3, 6, 7, 8, 10, 11, 12,14, 15, 17) and 1 of 2 Open Patient records (Patient 1)


The findings are:


On 9/20/17 at 10:00 a.m., review of Closed Patient 3's chart revealed the patient was admitted on 7/16/17 for a diagnosis of Hypertension and the Condition of Admission and Authorization for Medical Treatment form was not witnessed and dated.

On 9/20/17 at 10:20 a.m., review of Closed Patient 6's chart revealed the patient was admitted on 8/22/17 for a diagnosis of Diverticulitis, and the Condition of Admission and Authorization for Medical Treatment page 2 form was not present in the chart.

On 9/20/17 at 10:40 a.m., review of Closed Patient 7's chart revealed the patient was admitted on 8/20/17 for a diagnosis of Diabetes, and the Condition of Admission and Authorization for Medical Treatment form was not witnessed and dated.

On 9/20/17 at 11:00 a.m., review of Closed Patient 8's chart revealed the patient was admitted on 8/17/17 for a diagnosis of shortness of breath, and the Condition of Admission and Authorization for Medical Treatment form was not witnessed and dated.

On 9/20/17 at 11:10 a.m., review of Closed Patient 12's chart revealed the patient was admitted on 6/22/17 for a diagnosis of acute Pancreatitis, and the Condition of Admission and Authorization for Medical Treatment form was not witnessed and dated.

On 9/21/17 at 10:45 a.m., the Director of Nursing (DON) revealed the Conditions of Admission and Authorization for Medical Treatment forms are to be witnessed and dated when the patient and/or their representative signs the form.



31672

On 9/20/17 at 11:30 a.m., review of Closed Patient 1's medical record revealed the patient was admitted on 9/15/17 for rehab and weakness and discharged on 9/18/17. There was no consent to treat the patient in the chart. The findings were verified with the Director of Nursing at 09:00 a.m. on 9/21/17.


39208

On 9/20/17 at 2:00 p.m., review of Closed Patient #17's chart revealed the Authorization for Medical Treatment Form was missing the signature of the witness. The finding was verified by Registered Nurse(RN) 1 at 10:45 a.m. on 9/21/17.

On 9/20/17 at 2:30 p.m., review of Closed Patient #14's chart revealed the Authorization for Medical Treatment Form was missing the signature of the witness. The finding was verified by RN1 at 10:48 a.m. on 9/21/17.

On 9/20/17 at 2:55 p.m., review of Closed Patient #15's chart revealed the Authorization for Medical Treatment Form was missing the signature of the witness as well as the Notice of Privacy Practices and Advanced Directive/Living Will information. The Patient Rights and Responsibilities Form was missing. The findings were verified by RN1 at 10:36 a.m. on 9/21/17.

On 9/20/17 at 3:15 p.m., review of Closed Patient #10's chart revealed the Authorization for Medical Treatment Form was missing the signature of the witness as well as the Notice to Privacy Practices and Advanced Directive/Living Will information. The finding was verified by RN1 at 10:19 a.m. on 9/21/17.

On 9/20/17 at 4:10 p.m., review of Closed Patient #11's chart revealed the Patient Rights and Responsibilities Form was missing the date of the patient representative's signature. The finding was verified by RN1 at 09:39 a.m. on 9/21/17.

On 9/20/17 at 1:30 p.m., review of Open Patient #1's chart revealed incomplete consent forms for: Patient Rights Form, Notice of Privacy Practices Form, and Authorization for Medical Treatment Form. The findings were verified by RN1 at 09:32 a.m. on 9/21/17.

On 9/20/17 at 3:50 p.m., review of Closed Patient #2's chart revealed four physician orders with signatures that had no dates or times. The findings were verified by RN1 at 10:00 a.m. on 9/21/17.

Based on record reviews and interview, the Hospital (CAH) failed to ensure a system was in place to verify that physician documentation was complete for 1 ( Patient #17) in 20 closed charts.

The findings are:

On 9/20/17 at 2:00 p.m., review Closed Patient #17's chart revealed a progress note dated August 16, 2017 was not signed by the physician. The finding was verified by Registered Nurse 1 on 9/21/17 at 10:45 a.m..

Based on record reviews, interview, and review of the hospital's policies and procedures, the hospital failed to ensure each patient's medical record was signed and timed and dated by the physician for 1 of 20 closed patient records. (Closed Patient 4)

The findings are:

On 9/19/17 at 1:50 p.m., review of Closed Patient 4's record revealed the patient was admitted on 6/20/17 for a Urinary Tract Infection and Sepsis. On 6/21/17 at 0100 a.m., a physician verbal order was written by the nursing staff, but the verbal order was not authenticated by the physician. The finding was verified with the Director of Nursing(DON) on 9/19/17 at 2:05 p.m. in an interview, and the DON stated, "Any verbal must be signed as soon as possible by the providers within forty eight hours."

Hospital policy and procedure, titled, "Verbal Records", reads, "....verbal orders (direct or telephone) are to be written immediately, read back for accuracy, then signed with name of the prescriber and the name of the transcriber....orders must be cosigned by the physician ordering the medication within 48 hours....".