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Based on observation, interview, and record review it was determined that the hospital failed to incorporate the kitchen into the hospital wide infection control surveillance program.

Findings include:

1) On 12/13/2010 at approximately 12:00 PM a tour of the kitchen was conducted with the hospital's Risk Manager and the Certified Dietary Manager ( CDM) and the following was observed:

Walk in cooler-pool of bloody juice on floor from ground beef that had been defrosted earlier in the day and an opened carton of whipped cream without an opened date

Plastic bin of items stored under a counter containing Yellow and Green food dye, container of Balsamic Vinegar, container of cooking oil, bottle of honey, bottle of vanilla flavoring, bottle of lemon juice, container of dry seasoning salt. The bin and the containers were soiled with grease-like and dried food-like debris. The containers, bottles, and bin were all sticky. The food dye containers had "open date" labels that had not been filled out.

Dry storage area floor was noted to be gritty and with visible dirt.

The hand washing sink behind the steam table and register was soiled with grease like debris and the drain had some type of milky film.

The wall and surrounding floor behind the fryer were noted to have significant greasy debris.

The high temperature dishwasher was observed and the corresponding log for December 2010. The dishwasher logs for the entire year of 2010 were obtained and reviewed. The CDM was interviewed at this time and indicated that the kitchen staff were to measure and record the wash and rinse temperatures twice daily and that weekly a lime solution was to run through the dishwasher and the staff were to sign and date that event as well on the "Dish Machine Temperature Monitoring Log."

a) January 2010-2 days missing 3 measurements and no weekly cleaning documented
b) February 2010-4 days missing measurements and no weekly cleaning documented
c) March 2010-28 days missing measurements and no weekly cleaning documented
d) April 2010-28 days missing measurements and no weekly cleaning documented
e) May 2010- 28 days missing measurements and no weekly cleaning documented
f) June 2010- 7 days missing measurements and no weekly cleaning documented
g) July 2010-3 days missing measurements and no weekly cleaning documented
h) August 2010-28 days missing measurements and no weekly cleaning documented
i) September 2010- 30 days missing measurements and no weekly cleaning documented
j) October 2010-No weekly cleaning documented
k) November 2010-only one day of temperatures were performed and no weekly cleaning documented
l) December 2010- no weekly cleaning documented for the first 2 weeks of the month.

2) An interview was conducted with the CDM during the tour. She stated the opened items did not need to be dated when opened. However, she produced a policy titled "Food and Nutrition" (#6.08) that instructed staff that "all food items stored in the cooler must be covered and dated." She also produced a "Quality Monitoring Indicators" audit dated October 28, 2010 that listed "kitchen-Items labeled, lids secured and dated if opened (all areas). The CDM documented this indicator as "Met."

3) An interview was conducted with the Risk Manager/Director of Quality on 12/15/2010 at approximately 10:30 AM. She produced an "Infection Control Risk Assessment for 2009-2010" that included all of the areas of the hospital except the kitchen. She stated the dietary department has "been off limits" for her to review regarding infection control or quality.

Based on observation, interview and record review it was determined that the hospital failed to follow their policy for Grievance Reporting by not providing complete information to patients regarding their right to report a complaint to the Agency for Health Care Administration (AHCA).

Findings include:

1) On 12/13/2010 at approximately 9:40 AM, a tour of the lobby area was conducted. Posted in the lobby was a notice of Patient Rights and the address of AHCA to report any complaints. The notice did not include the AHCA phone number.

2) A review of the hospital's policy for "Complaint and Grievance Process" (#C06-A-revised 7/1/2010) revealed "The grievance procedure is posted in a public area of the hospital and provides the name of the Hospital's Director of Quality Management or Director of Clinical Services and his/her phone number. The patient is also notified of the state survey agency, phone number, and address."

A sample patient and family admission/information packet was reviewed and also lacked AHCA's phone number.

3) On 12/13/2010 at approximately 3:00 PM and interview was conducted with the hospital's Director of Quality (also Risk Manager). She verified the postings did not include AHCA's number.

Based on interview, record review and policy review the facility failed to ensure nursing staff develop and maintain a nursing care plan for 1 of 20 sampled patients. (#1)

The findings include:

1. Review of resident #1 record revealed a physician order for Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure (CPAP/BIPAP) as tolerated on 12/7/10. Resident #1's 24 hour patient record and plan of care dated 12/11/2010 and 12/12/2010 failed to include the use of CPAP/BIPAP as tolerated.

2. An interview with the Risk Manager was conducted on 12/13/10 at approximately 4:00PM. The Risk Manager stated, "you would think they would include the use of the BIPAP/CPAP on the plan of care." An interview with the Registered Nurse was conducted at the same time and the nurse stated the night shift plan of care should mention the use of BIPAP/CPAP since it is used at night. An interview was conducted with the Respiratory Therapist (RT) on 12/15/10 at approximately 2:50PM. The RT stated monitoring the use of BIPAP/CPAP is a dual responsibility between RT and nursing.

3. The facility policy for Nursing Care Plan (N02-N) was reviewed on 12/15/10. The policy indicates A-205 482.23 (b) (4) The hospital must ensure that the nursing staff develop, and keep current, a nursing care plan for each patient.

Based on observation, interview, record review and policy review the facility failed to ensure orders for drugs and biologicals were documented and signed by a practitioner who is authorized to write orders by hospital policy and in accordance with State law, and who is responsible for the care of the patient as specified under ?482.12(c) for 1 of 20 sampled patients. (#13)

The findings include:

1. Observation of medication administration conducted on 12/13/10 at approximately 4:30PM revealed the nurse administered Novolog insulin 2 units subcutaneously to patient #13.

2. Record review of resident #13 revealed a physician order dated 12/10/10 for low dose scale before meals and at bedtime. The order does not indicate a drug or route for administration. The Medication Administration Record dated 12/14/10 for resident #13 lists Novolog insulin to be administered subcutaneously.

3. An interview was conducted with the Chief Nursing Officer (CNO) on 12/14/10 at approximately 11:45AM. The CNO stated they do not have a standing order for Novolg insulin and he has revised the order to include a check box including the type of insulin to be administered.

4. The facility policy for medication order transcription was reviewed and #1 stated a complete medication order consists of name of medication, dose, frequency and route.

Based on observation and interview, the facility failed to ensure that outdated drugs were not available for patient use.

The findings include:
On December 13, 2010 at approximately 09:45 AM a facility tour was conducted. Accompanied by the Risk Manager, an inspection of the North wing Medication Room was done. An expired box of FluMist, with an expiration date of 11/22/2010 was found in the medication refrigerator. The expired medication was also confirmed with the pharmacist at this time. He had no explanation why the FluMist was missed and not removed.
On December 13, 2010 at approximately 3:00 PM, an interview was conducted with the Pharmacy Director. He stated that pharmaceuticals expiration dates are checked monthly and a log is maintained within the pharmacy, medications on the units are checked when restocked. Medications are stocked when PAR levels are low or as needed.

Based on interview and record review it was determined that the hospital's consultant Dietitian failed to perform required nutritional assessments and reassessments that were accurate and timely for 5 of 20 sampled patients (#5, #7, #9, #15, #19). The Dietitian failed to approve the menus, and failed to evaluate the over all hospital dietetic services.

Findings include:

1) On 12/14/2010 at approximately 2:36 PM and interview was conducted with the hospital's consultant Registered Dietitian (RD), Certified Dietary Manager (CDM), and Chief Executive Officer (CEO). The RD stated she provided services to the hospital 6-7 hours weekly. She stated she conducted nutritional assessments and would occasionally verify a patient's diet with the actual menu, however she stated she did not approve any menus, did not provide any evaluation of the dietetic department, and did not review or approve the dietary policies. She also stated she typically does not conduct Nutritional Reassessments unless contacted by the Physician. She stated she did not evaluate the sanitary conditions of the kitchen or participate in any quality assurance activity.

The CDM stated at this time that the hospital purchased their menus from Sysco systems and that those menus were approved by a Sysco Dietitian in 2007. The CDM unaware of the requirement for annual approval of menus.

2) The hospital's policy and procedure for Nutritional Assessments (A03-G) "Scope of Assessment Performed by Dietitian" revealed, "Since the vast majority of patients are typically at significant nutritional risk, the Dietitian assesses all patients within 72 hours of admission. Changes in nutritional status trigger a Reassessment of the patient with the review of data every 7 to 10 days."

3) During the 3 day survey a sample of 20 patients was selected for review.

The following documentation was noted regarding Nutritional Assessments :

a) Patient #5 was admitted on 11/12/2010 with a diagnosis of Respiratory Failure, Renal Failure requiring Dialysis 3 times weekly, enteral feedings, and a right heel wound (eschar/unstageable). The RD performed a Nutritional Assessment on 11/15/2010 but the assessment lacked any mention of the patient's wound.

b) Patient #7 was admitted 11/24/2010 with a diagnosis of Respiratory Failure, large abdominal wound with a wound vacuum, Stage III pressure ulcer to left buttock, and morbid obesity (302 lbs 5'4"). The RD performed a Nutritional Assessment on 11/29/2010 that reflected the patient was receiving Pivot enteral formula via nasogastric tube. However, the patient developed abdominal distention (12/11/2010) and poor tolerance of the enteral feedings which were put on hold (12/13/2010) and the NGT was connected to suction. The RD was not contacted and did not perform a reassessment.

c) Patient #9 was admitted on 10/21/2010 with a diagnosis of status post Cardiac Arrest, large sacral wound requiring a wound vacuum, and several areas of unstageable eschar to bilateral lower extremities. The RD performed a Nutritional Assessment on 10/24/2010 that reflected the patient was 154.4 lbs and 5'5 inches, receiving Glucerna via percutaneous gastric feeding tube, and a goal to "promote weight maintenance," however the assessment lacked documentation regarding the patient's wounds. The nursing notes dated 12/13/2010 revealed to patient's current weight was 111.4 lbs (33 lb weight loss)
The RD did not perform any reassessment.

d) Patient # 15 was admitted on 8/6/2010 with a diagnosis of Sepsis and an infected wound. The RD performed a Nutritional Assessment 8/16/2010 which is outside the 72 hour required time frame per the hospital policy.

e) Patient #19 was admitted on 10/15/2010 with a diagnosis of status post Wound Closure. The RD performed a Nutritional Assessment 10/21/2010 which is outside the 72 hours required time frame per the hospital's policy.

Based on observations, record review and interviews, the facility failed to ensure that outdated medical supplies were not available for patient use and that patient medical equipment was stored in an acceptable manner.
Finding include:
1. On December 13, 2010 at approximately 09:45 AM a facility tour was conducted. During this tour, the South wing tour was guided by the CNO and the North wing tour was guided by the Risk Manager. An inspection of the contents of each unit ' s crash cart was conducted. The following observations were made:
The South wing crash cart contained -(1)Bard Lubri-Sil latex free Foley catheter tray - expired 08/2009, (1) Arrow Clark Pleura Seal Thoracentesis Kit - expired 06/2009, (1) MediChoice Sterile Disposable Scalpel - expired 01/2009, (1) 500 ml bottle of 0.9% Sodium Chloride Irrigation, USP - expired 12/2009, (1) Medline General Purpose Tray - expired 11/2009, (2) packages Aplicare Povidone -Iodine swabsticks - expired 02/2009.
The North wing crash carts contained - Cart #1 - (3) Medichoice IV start Kits - expired 02/2009, (1) 500ml bottle of 0.9% Sodium Chloride Irrigation, USP - expired 12/2009, (1) Bard Lubri-Sil Latex Foley Tray - expired 08/2009. Cart #2 - (4) 18 gauge IV Angio-caths - expired 03/2010, (4) 20 gauge IV Angio-caths - expired 03/2010, (4) 22 gauge IV Angio-caths - expired 03/2010.
2. On December 13, 2010 at approximately 10:10 AM an interview was conducted with the Risk Manager, she stated the pharmacy department was responsible for replacing the medications and the unit staff was responsible for checking the crash cart daily.
On December 13, 2010 at approximately 10:25 AM an interview was conducted with the pharmacist, he stated that the crash carts are inspected every month by a pharmacist or tech. and that only the medications are checked, not the supplies.
On December 13, 2010 at approximately 10:27 AM an interview was conducted with the CNO, who stated that the House Supervisor is responsible for supplies in the crash cart. They are inspected quarterly. He stated that it looked like " we need a better process. "
On December 13, 2010 at 03:10 PM and interview was conducted with the CNO. He stated the facility had no previous process to check for expired supplies in the crash carts.

3. On December 13, 2010 the hospital ' s policy #E02-N entitled " Emergency Equipment (Code Cart and Defibrillator) Checking Procedure " was received and reviewed.
PROCEDURE:
RNS and RTs with demonstrated competency will check the Emergency Equipment/Crash Cart daily for:
- A locked intubation box
- All drawers locked on the crash cart
- No expired medications
- Presence of Quik Combo/Defibrillator Pads
- Backboard
- Testing of defibrillator per manufactures recommendations (details on Emergency Equipment/Code Cart Check List)
This procedure will be completed daily and documented on the Emergency Equipment/Code Cart Check List. If any items are found to be out of compliance, the charge nurse will be notified and the Code Cart/Intubation Box or Defibrillator will be replaced.

There is no policy or procedure for checking the supplies in the crash cart.

4. On December 13, 2010 while on initial hospital tour, at approximately 09:45 AM observations made in the ICU of several patients with respiratory masks draped over equipment uncovered; Foley catheter bags on the floor; and wound vacuums on the floor. CNO confirmed these findings.
On December 13, 2010 at approximately 3:30 PM an observation on the South Wing revealed a Foley catheter bag touching floor, but hung from bed.
On December 14, 2010 at approximately 11:20 AM an observation on the North Wing revealed a Foley catheter bag touching floor, but hung from bed.

5. On December 13, 2010 an interview was conducted with the CNO regarding infection control concerns regarding uncovered respirator equipment, Foley catheter bags and wound vac's. Policies were requested addressing infection control practices in relation to patient medical equipment, the CNO stated he could not find a specific policy for covering face masks or nebulizer items between patient use, but that was a standard practice for Infection Control and should be in place. He then stated he had instructed staff to place all items in a bag and remove catheter bags from touching the floor.

6. Hospital Policies requested and received entitled M01-R "Metered Dose Inhaler / Hand-held Nebulizer", IC IV-4 "Reducing Risk of Urinary Tract Infections", W12(2)-N "Negative Pressure Wound Therapy Using Svedman Pump". These policies fail to address storage and handling.
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