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On the days of the Validation Survey based on observations, interviews, record reviews, review of hospital policies and procedures, and other data submitted for review, the hospital failed to ensure that patients received Hemodialysis in a responsible manner to ensure the safety of those patients receiving hemodialysis.


The findings include:


Cross Reference to A 0084: The governing body in accordance with hospital policy failed to ensure that specific patient care requirements of Hemodialysis patients were met.

Cross Reference to A 0144: The facility failed to ensure the patient's right to receive care in a safe setting for hemodialysis patients, patients requiring restraint, and patients identified as a high risk for falls.

Cross Reference to A 0347: The hospital failed to ensure the physician provided complete written orders for patient care prior to initiation of dialysis treatments for 13 of 14 closed patient records reviewed and 1 of 1 concurrent patient record reviewed .

On the days of the Validation Survey based on record review and interview, the hospital failed to ensure that the contractural services of the Hemodialysis Unit operated in a responsible manner to ensure the safety of those patients.
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The findings are:


Cross Reference to A 0385: The hospital failed to ensure that patients received care and services in accordance with the hospital's policies and procedures and Standards of Practice.

Cross Reference to A 0395: The hospital failed to ensure that Registered Nurses followed physician orders for administering medications in the dialysis unit and obtained physician orders prior to initiating dialysis treatment for patients receiving dialysis.

Cross Reference to A 0398: The hospital failed to ensure adequate supervision and oversight for the contract dialysis service.

On the days of the Validation Survey based on observations, hospital policy review, record review, and interview, the hospital failed to ensure the rights of patients requiring restraint, nursing interventions appropriate to the patient assessments that identify the patient as a high risk for falls, the Hemodialysis patient's right to receive care in a safe setting, and failure to have pediatric emergency equipment available to meet the potential emergency needs of the pediatric patient presenting for care in the outpatient diagnostic center.


The findings include:


Cross Reference A 386: The facility failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care for those patients receiving hemodialysis services.

Cross Reference A 392: The hospital failed to ensure that contractual dialysis staff obtained physician orders for the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) for patient dialysis prescriptions and treatment, Dialysis staff failed to follow Physician Orders for the administration of Heparin, and failed to ensure that nursing interventions were appropriate to the nursing assessment for patients identified as high risk for falls on the medical surgical units and progressive care unit.






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On 12/14/11 at 1120, observation in the Outpatient Radiology Diagnostic Center revealed an Automated Electric Defibrillator(AED) with adult pads only. During an interview on 12/14/11 at 1120, Radiology Technician #1 revealed there were no pediatric pads for the AED device even though the diagnostic department services children.





30011

On 12/13/11 at 1355, random observation of the crash cart shared by the Pulmonary Medicine Department and the Dialysis Treatment Unit revealed a safety check log that had no documentation of daily defibrillator and crash cart checks on:
11/17/11, 11/19/11, 11/21/11, 11/24/11, 11/28/11, 11/29/11, 11/30/11, 10/29/11, 8/10/11, 8/17/11, 8/23/11, 8/25/11, 8/28/11, 8/30/11, 7/1/11, 7/2/11, 7/3/11, 7/4/11, 7/5/11, 7/17/11, 7/19/11, 7/21/11, 7/27/11, 7/28/11, 7/29/11, 7/30/11, 5/1/11, 5/27/11, 4/26/11, 4/27/11, 4/28/11, 4/30/11, 3/6/11, 3/7/11, 3/8/11, 3/15/11, 3/18/11, 3/29/11, 2/1/11, 2/2/11, 1/29/11. The finding was verified by the Pulmonary Medicine Director at 1400 on 12/13/11.

Facility policy, reads, "Purpose: To ensure proper equipment operation and patient safety, Procedure: Resuscitation equipment must be maintained to be ready for immediate use. The following operation check should be performed daily when the Nursing unit is open to ensure proper equipment operation and patient safety....".

On the days of the Validation Survey based on observation, interview, and concurrent patient record reviews, the hospital failed to ensure the documentation and implementation of the least restrictive method of restraint was used for 1 of 1 concurrent patient records reviewed for care and services related to restraint use. (Patient #57).

The findings include:


Concurrent record review conducted on 12/15/11 at 1425 revealed Patient #57 was admitted to the hospital on 12/14/11 with Pneumonia and Dehydration. A physician verbal order dated 12/15/11 at 2400, read, "Ok (Okay) for pt (patient) to have 4 side rails ^ (up)". Review of the hospital's "Restraint Flowsheet for Non-Violent or Non-Self Destructive" dated 12/15/11 at 2400 showed "Side rails" and under the section labeled "Other", staff recorded, "Per daughter request" in the section of the form identified as "Interventions attempted to modify behavior prior to initiation of restraints". On 12/15/11 at 1435, Registered Nurse #1 stated, "We rarely use restraints up here, and usually to prevent patients from pulling lines (catheters, IV's [intravenous]). The order was written per the patient's daughter's request. The patient is a resident of a nursing home, and I think the rails are up (all 4) over there."

Facility Policy QSP-NSG-0103, titled, "Restraint Policy", revised 7/11, states, "...Use: Assessment, implementation, and monitoring of restraint/seclusion will only be done by a trained registered nurse (RN) and used only when less restrictive interventions are deemed ineffective in ensuring the immediate physical safety of the patient, staff, or others. The type or technique of restraint/seclusion used will be the least restrictive intervention necessary and will be discontinued at the earliest possible time (regardless of the length of time identified in the order) or modified if less restrictive methods become adequate. Restraint/seclusion may not be used as a means of coercion, discipline, convenience, or retaliation...".

On the days of the Validation Survey based on closed patient record review, hospital policy review, and interview, hospital staff failed to ensure that all physician orders for restraint are obtained, documented, and authenticated by the physician within a reasonable amount of time for 1 of 3 closed patient records reviewed for care and services related to restraints. (Patient #7).


The findings include:


Closed record review on 12/14/11 at 1624 revealed Patient #7 was admitted to the hospital on 11/7/11 with the diagnosis of Schizophrenia. Review of a nurse note dated 11/7/11 showed the patient was placed in restraints on 11/7/11 at 0915. The patient's medical record had no documentation of a physician's order until 12/3/11 as an addendum. The findings were verified by the Chief Nursing Officer on 12/15/11 at 1630.

Facility Policy QSP-NSG-0103, titled, "Restraint Policy", revised 7/11 states, "...Orders: Restraint/seclusion will be ordered by a physician and cannot be written as a standing or 'as needed' (PRN) order. Pre-printed orders are available on Medex...".

On the days of the Validation Survey based on interview, hospital policy review, and closed medical record review, the hospital failed to ensure orders for restraint are not written as PRN (as needed basis; as circumstances require) including "trial release" for 1 of 3 closed patient records reviewed for care and services related to restraints (Patient #3).


The findings include:


Closed record review conducted on 12/15/11 at 0920 revealed Patient #3 was admitted to the hospital on 12/5/11 and transferred on 12/6/11 with the diagnosis Violent/Threatening to Self/Others. Review of a physician order dated 12/6/11 at 1058, reads, "...restraint criteria to remove: when patient is calm and cooperative;.... restraint type: 4 point, leathers as needed...". Review of the nurse notes showed staff documented, ".... RESTRAINTS:...1055 Removal: Restraints were removed due to decreased agitation/hostility, right wrist only at this time until pt (patient) displays further cooperation. Pt verbalizes understanding. 1105: Removal: Restraints were removed due to decreased agitation/hostility, patient's verbal contract to do no harm, patient's ability to follow instructions, remaining three restraints. Pt moved to a room with a tv (television) and given activity book and crayons...". On 12/15/11 at 1305, Nursing Director #3 stated, "Sometimes, we will release one restraint and explain to the patient that if you are calm, because we don't like the restraints any more than you do, we will let you out of all of the restraints."

Facility Policy QSP-NSG-0103, titled, "Restraint Policy", revised 7/11 states, "...Use: Assessment, implementation, and monitoring of restraint/seclusion will only be done by a trained registered nurse (RN) and used only when less restrictive interventions are deemed ineffective in ensuring the immediate physical safety of the patient, staff, or others. The type or technique of restraint/seclusion used will be the least restrictive intervention necessary and will be discontinued at the earliest possible time (regardless of the length of time identified in the order) or modified if less restrictive methods become adequate. Restraint/seclusion may not be used as a means of coercion, discipline, convenience, or retaliation. Orders: Restraint/seclusion will be ordered by a physician and cannot be written as a standing or 'as needed' (PRN) order. Pre-printed orders are available on Medex...".

On the days of the Validation Survey based on interview, patient record review, and hospital policy review, hospital staff failed to ensure physician documentation of the one hour face-to-face of medical and behavioral evaluation of the patient for violent behavior following the initiation of restraints for 2 of 3 closed patient records reviewed for restraints (Patient #3 and 7).


The findings include:


Closed record review conducted on 12/15/11 at 0920 revealed Patient #3 was admitted to the hospital on 12/5/11 and transferred on 12/6/11 with the diagnosis Violent/Threatening to Self/Others. Documentation in the nurse notes showed the patient was placed in restraints on 12/6/11 at 1020. Review of the patient's medical record failed to show the physician's documentation that a one hour face-to-face assessment was conducted within 1 hour of initiation of patient's restraints.


Closed record review on 12/14/11 at 1624 revealed Patient #7 was admitted to the hospital on 11/7/11 with the diagnosis of Schizophrenia. Documentation in the patient's nurse notes showed the patient was placed in restraints on 11/7/11 at 0915. Review of the documentation in the patient's chart failed to show the physician documented a one hour face-to-face assessment within 1 hour of initiation of the patient's restraints.

On 12/15/11 at 1630, the Chief Nursing Officer revealed, "The one hour face to face must be completed by the physician, but the evaluation may not be documented in the patient's chart, but an ED (Emergency Department) physician is always in the department to evaluate the patient".

Facility Policy QSP-NSG-0103, titled, "Restraint Policy", revised 7/11 states, "...Orders:...In the event that the immediate physical safety of the patient, staff, or others is in jeopardy, restraint or seclusion may be initiated by trained RN staff without an order, however the physician will be notified as soon as possible. In this case, a face-to-face evaluation of the patient's physical and psychological condition will be done within 1 hour by the physician...".

On the days of Validation Survey based on interview and record review, the hospital failed to ensure the physician provided complete written orders for patient care prior to dialysis treatment for 13 of 14 closed patient records reviewed (Patient #4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19)and 1 of 1 concurrent records reviewed. (Patient #4)


The findings are:


On 12/12/11 at 1600, review of patient charts revealed that 13 of 14 closed patient charts and 1 of 1 concurrent patient Charts had no BFR (Blood Flow Rate) and/or DFR(Dialysate Flow Rate) for the patient's dialysis prescription prior to treatment. On 12/12 11 at 1630, Registered Nurse #3 revealed "BFR and DFR is very subjective. The doctor is usually present during dialysis and will address in his progress notes where the patient is pertaining to the BFR and DFR, but this is usually not written prior to the patient having dialysis. Fresenius policy and protocol is used for starting patients up."

Facility Policy, "QSP-NSG-0079, revision May 2011, Policy/Procedure: Orders, Providers, Policy: Prior to providing care, treatment and services, the hospital obtains or renews orders (verbal or written) from a licensed independent practitioner in accordance with professional standards of practice and law and regulation. Care, treatment and services will be provided using the most recent patient order. All therapeutic and diagnostic orders shall be in writing. An order shall be considered to be in writing when dictated to, and written by an authorized person (RN, Licensed Practical Nurse, Physical Therapist, Respiratory Therapist, Physician Assistant or Pharmacist) and signed by the ordering or attending physician....".

On the days of the Validation Survey based on observation, record review, and interview, the facility failed to ensure that patients received care and services in accordance with the hospital's policies and procedures and Standards of Practice.


The findings are:


Cross Reference to A 0386: The facility failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care in the hemodialysis unit.

Cross Reference to A 0392: The hospital failed to ensure that (contractual) dialysis staff obtained physician orders for the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) for patient dialysis prescriptions and treatment, that Dialysis Staff failed to follow Physician Orders for administration of Heparin, and failed to ensure that nursing interventions were appropriate to the nursing assessment for patients identified as high risk for falls on the medical surgical units, and followed hospital policies and procedures for patients requiring restraints.

Cross Reference to A 0395: The hospital failed to ensure that Registered Nurses followed physician orders for administering medications in the dialysis unit, obtained physician orders for the blood flow rate and dialysate flow rate prior to initiating dialysis treatment for patients, used the most appropriate interventions for patient's identified as high risk for falls on the medical surgical units, and followed the hospital's policies and procedures for patients requiring restraints.

Cross Reference to A 0398: The hospital failed to ensure adequate supervision and oversight for the contract dialysis services for the hospital.

On the days of the Validation Survey through observation, facility policy review, record review, personnel file review, and interview, the facility failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care in the contractural hemodialysis unit, patients identified as high risk for falls on the medical surgical units, and patients requiring restraints.

The findings include:

On On 12/14/11 at 1100, a review of the hospital's personnel files revealed that the Director of the Hemodialysis Unit had no previous dialysis experience.

Cross Reference A 392: The hospital failed to ensure that contractual dialysis staff obtained physician orders for the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) for patient dialysis prescriptions and treatment, staff failed to follow Physician Orders for administration of Heparin, and staff failed to ensure that nursing interventions were appropriate to the nursing assessment for patients identified as high risk for falls on the medical surgical units, and failed to follow hospital policies and procedures for patients requiring restraints.

Cross Reference to A 398: The hospital failed to ensure adequate supervision and oversight for the contract dialysis services for the hospital

On the days of the Validation Survey based on interview, record review, review of contractual facility policy, and review of the hospital's policies and procedures, the hospital failed to ensure that (contractual) dialysis staff obtained physician orders for the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) for patient dialysis prescriptions and treatment prior to the initiation of dialysis for 1 of 1 concurrent patient records reviewed (Patient #4), and 13 of 14 closed patient records reviewed (Patient #4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 58). Dialysis contractural staff failed to follow Physician Orders for accurate administration of Heparin for 5 of 14 closed patient charts (Patient #9, 11, 13, 14, and 58) reviewed for care and services related to Dialysis. Hospital nursing staff failed to ensure that nursing interventions were appropriate to the nursing assessment for patients identified as high risk for falls on the medical surgical units for 12 of 15 patient records reviewed. (Patient #8, 44, 45, 47, 48, 49, 50, 51, 52, 53, 55, and 56)


The findings are:


On 12/12/11 at 1600, survey of the hospital's dialysis unit showed only one active patient (Patient #4) undergoing dialysis. Review of Patient #4's chart showed the patient had Endstage Renal Disease, Systemic Inflammatory Response Syndrome, Hypertension, Cerebrovascular accidents, Diabetes Type 2, Bradycardia and Anemia. Review of the physician orders dated 12/12/11 showed the patient's Dialysis Prescription for 12/12/11 was "Hemodialysis 3 hours, Dialysate bath 2 k (potassium), Mini Heparin "Tight", Dialyzer F160 and 2 L (liter) UF (ultrafiltration)". There was no Blood Flow Rate or Dialysate Flow Rate on the physician order. Although there was no BFR or DFR documented on the physician orders, a review of the the documentation on the patient's Inpatient Hemodialysis Treatment dated 12/12/11 showed nursing staff documented the patient's Blood Flow Rate as 250-300 and the Dialysate Flow Rate as 500.

Review of thirteen (14) closed patient records revealed there were no physician orders for blood flow rate or dialysate flow rates for 13 patient charts. Facility Policy, "FMS-CS-IS-I-500-040A, 21-May-2008, The FMS (Fresenius Medical Services) Inpatient Services or apheresis services must be ordered by an appropriately credentialed physician. Orders must be appropriately communicated and written on the medical record prior to treatment....".

Staff failed to follow the physician's orders for Heparin administration for 5 of 14 closed patient charts. (Patient #9, 11, 13, 14 and 58) Facility Policy, FMS-CS-IS-I-525-025A, "Heparin Administration Policy, 28-Apr-2010, reads, "Tight heparin, Use the heparin pump on the arterial bloodline to continuously pump heparin during the treatment (500 unit/hour-recommended dose). Stop the heparin pump one hour before the end of the treatment, or per policy....".

Review of Patient #4's closed medical record revealed the patient had Endstage Renal Disease, Coronary Artery Disease, Hypertension, Type 1 Diabetes and Gastroesophageal reflux disease. The patient's chart showed the physician order dated 11/15/11 for the patient's Dialysis Prescription, read, "Hemodialysis 3 hours, Dialysate bath O k, Mini Heparin "Tight", Dialyzer F160 and 3 L UF". There was no Blood Flow Rate or Dialysate Flow Rate on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the the documentation of the patient's Inpatient Hemodialysis Treatment dated 11/15/11 showed staff documented Blood Flow Rates of 450 and Dialysate Flow Rates of 700.

Review of the closed patient chart for Patient #9 showed the patient had Acute Metabolic Encephalopathy, Endstage Renal Disease, Chronic Obstructive Pulmonary Disease and Chronic Thrombocytopenia. Review of the physician order dated 10/25/11 for the patient's Dialysis Prescription, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini Heparin "Tight", Dialyzer 160 and 3 L UF". The physician order had no BFR or DFR. Although there was no BFR or DFR documented on the physician orders, review of the documentation of the patient's Inpatient Hemodialysis Treatment on 10/25/11 showed staff documented a BFR of 450 and a DFR of 700. Review of the patient's dialysis treatment sheet dated 10/25/11 showed no heparin was administered during the patient's treatment. Review of the patient's Dialysis Prescription dated 10/27/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini Heparin "Tight", Dialyzer 160 and 2 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/27/11 showed staff documented a BFR of 400 and a DFR 600. There was no documentation that the heparin was given during the dialysis treatment on 10/27/11. The patient's Dialysis Prescription dated 10/29/11, read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini Heparin "Tight", Dialyzer 160 and 3 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 10/29/11 showed staff documented a BFR of 400 and a DFR of 600. There was no documentation that the heparin dose was administered during the dialysis treatment on 10/29/11.

Review of Patient #10's closed medical record showed the patient had Sepsis with cellulitis and history of Methicillin-resistant Staphylococcus Aureus sepsis and bacteremia, Endstage renal Disease, Insulin-dependent Diabetes Mellitus Type 1 and Hypothyroidism. Review of the patient's Dialysis Prescription dated 10/31/11, read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini Heparin "Tight", Dialyzer F160 and 2 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 10/31/11 showed staff documented a BFR 300 and a DFR of 500-600.

Review of Patient #11's closed medical chart showed the patient had Acute Renal Failure, Hypertension and Acute Respiratory failure. Review of the patient's Dialysis Prescription dated 9/29/11, read, "Hemodialysis 6 hours, Dialysate bath 2 k, Mini heparin 500 units/hour via dialysis pump, Dialyzer F160 and no UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 9/29/11 showed staff documented a BFR of 375-400 and a DFR of 600. Review of the patient's Dialysis Prescription dated 10/3/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3 L UF." There was no BFR or DFR on the physician order sheet. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment Sheet dated 10/3/11 showed staff documented a BFR 400 and DFR 600. Heparin was documented as administered at 1000 units/hour on 10/3/11. The patient's Dialysis Prescription dated 10/6/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 4 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 10/6/11 showed staff documented a BFR of 450 and a DFR of 700. Staff documented the Heparin was administered at 1000 units/hour on 10/6/11.

Review of the closed medical record for Patient #12 showed the patient had Acute Renal Failure, Accelerated Hypertension, Congestive Heart Failure and Thrombocytopenia. The patient's Dialysis Prescription dated 10/4/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 2 L UF". Although there was no BFR or DFR documented on the physician orders, there was no BFR or DFR on the physician order. Review of the patient's Inpatient Hemodialysis Treatment sheet dated 10/4/11 showed staff documented a BFR 400 and a DFR 600. Review of the patient's Dialysis Prescription dated 10/6/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3 L UF". There was no BFR or DFR on the physician's order. Although there was no BFR or DFR documented on the physician orders, the patient's Inpatient Hemodialysis Treatment sheet dated 10/6/11 showed staff documented a BFR 450 and a DFR 700.

Review of the closed medical record for Patient #13 revealed the patient had Congestive Heart Failure, Endstage Renal Disease, Respiratory Failure and Type 2 Diabetes Mellitus. Review of the patient's Dialysis Prescription dated 9/27/11, read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 9/27/11 showed staff documented a BFR 400 and a DFR 600. Staff documented the Heparin was administered at 1000 units/hour on 9/27/11. Review of the patient's Dialysis Prescription dated 9/29/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3 L UF". There was no BFR or DFR on the physician's order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 9/29/11 showed staff documented a BFR 300-400 and a DFR 600. Review of the patient's Dialysis Prescription dated 9/30/11, read, "Hemodialysis 2 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 2 L UF". There was no BFR or DFR on the physician's order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 9/30/11 showed staff documented a BFR 400 and a DFR 600.

Review of the closed medical record for Patient #14 revealed the patient had Acute-on-chronic renal failure, Diabetes, Hypertension and Sepsis. Review of the patient's Dialysis Prescription dated 10/17/11, read, "Hemodialysis 4 hours, Dialysate bath 0 k, Mini heparin "Tight", Dialyzer F160 and no UF". There was no BFR or DFR on the physician's order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/17/11 showed staff documented a BFR of 400 and a DFR of 600. Staff documented the Heparin was administered at 1000 units/hour. Review of the Dialysis Prescription dated 10/19/11, read, "Hemodialysis 3 hours, Dialysate bath 3 k, Mini heparin "Tight", Dialyzer F160 and 1 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 10/19/11 showed staff documented a BFR of 400 and a DFR of 600. Review of the Dialysis Prescription dated 10/21/11, read, "Hemodialysis 3 hours, Dialysate bath 3 k, Mini heparin "Tight", Dialyzer F160 and 2 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 10/21/11 showed staff documented a BFR 400 and a DFR 600.

Review of the closed medical record for Patient #15 showed the patient had Acute Respiratory failure secondary to Pneumonia, Sepsis, Pulmonary Hypertension and Endstage Renal Disease. Review of the patient's Dialysis Prescription dated 10/17/11, read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and no UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/17/11 showed staff documented a BFR of 400 and a DFR of 600. Review of the patient's Dialysis Prescription dated 10/19/11 read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/19/11 showed staff documented a BFR of 400 and a DFR of 600. Review of the patient's Dialysis Prescription dated 10/21/11 read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/21/11 showed staff documented a BFR of 400 and a DFR of 600.

Review of the closed medical record for Patient #16 showed the patient had Endstage Renal Disease, Hyperkalemia, Hyperparathyroidism and Congestive Heart Failure. Review of the patient's Dialysis Prescription dated 10/20/11 read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/20/11 showed staff documented a BFR of 300-330 and a DFR of 500-600. Review of the patient's Dialysis Prescription dated 10/22/11 read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 2 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/22/11 showed staff documented a BFR of 305-320 and a DFR of 600. Review of the patient's Dialysis Prescription dated 10/24/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 2 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/24/11 showed staff documented a BFR of 255-300 and a DFR of 500.

Review of the closed record of Patient #17 showed the patient had Endstage Renal Disease, Acute Respiratory Failure, Endstage Liver Disease and Portal Hypertension. Review of the patient's Dialysis Prescription dated 10/18/11, read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 4 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 10/18/11 showed staff documented a BFR of 450 and a DFR of 700. Review of the Dialysis Prescription dated 10/20/11 read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 4 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet showed staff documented a BFR of 450 and a DFR of 700.

Review of the closed medical record for Patient #18 showed the patient had Endstage Renal Disease, Hypertension, Coronary Artery Disease and Type 2 Diabetes. Review of the patient's Dialysis Prescription dated 11/14/11 read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3 L UF". There was no BFR or DFR on the physician's order. Although there was no BFR or DFR documented on the physician orders, review of the Inpatient Hemodialysis Treatment sheet dated 11/14/11 showed staff documented a BFR of 450 and a DFR of 700. Review of the patient's Dialysis Prescription dated 11/16/11 read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 3 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 11/16/11 showed staff documented a BFR of 300 and a DFR of 500.

Review of the closed medical record for Patient #19 showed the patient had Chronic Renal Failure, Hypertension, Atrial Fibrillation and Syncope. Review of the patient's Dialysis Prescription dated 11/28/11 read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 2 L UF". There was no BFR or DFR on the physician's order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 11/28/11 showed staff documented a BFR of 300 and a DFR of 500. Review of the patient's Dialysis Prescription dated 11/30/11 read, "Hemodialysis 3 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160 and 2-3 L UF". There was no BFR or DFR on the physician order. Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 11/30/11 showed staff documented a BFR of 300 and a DFR of 500.

Review of the closed medical record for Patient #58 showed the patient had Diabetes Mellitus Type 1, Endstage Renal Disease, Malignant Hypertension and Peripheral Vascular Disease. Review of the patient's Dialysis Prescription dated 12/15/11 read, "Hemodialysis 4 hours, Dialysate bath 2 k, Mini heparin "Tight", Dialyzer F160, 4 L UF, BFR 400 and DFR 800". Although there was no BFR or DFR documented on the physician orders, review of the patient's Inpatient Hemodialysis Treatment sheet dated 12/15/11 showed staff documented a BFR of 475 and a DFR of 800. Documentation on the dialysis treatment sheet dated 12/15/11 showed staff administered the Heparin at 1000 units/hour.
The findings were verified by ICU/PCU/Dialysis Nurse Manager on 12/12/11 at 1620.

During an interview with Registered Nurse #3 on 12/16/11 from 0900-0920, the registered nurse stated that the patient's "BFR and DFR is very subjective". Registered Nurse #3 reported that the doctor is usually present during dialysis treatments and addresses the patient's BFR and DFR in his progress notes, but the patient's progress notes are usually not written prior to the patient having dialysis. Registered Nurse #3 stated, "We use Fresenius policy and protocol for starting patients up."

Facility Policy, "FMS-CS-IS-I-500-040A, 21-May-2008, The FMS (Fresenius Medical Services) Inpatient Services or apheresis services must be ordered by an appropriately credentialed physician. Orders must be appropriately communicated and written on the medical record prior to treatment....".

Facility Policy, QSP-NSG-0079, revision date: May 2011, Policy/Procedure: Orders, Providers, Scope: This policy applies to persons who are authorized to give and receive orders, Policy: All therapeutic and diagnostic orders shall be in writing...."

Facility Policy, FMS-CS-IS-I-525-025A, "Heparin Administration Policy, 28-Apr-2010, Tight heparin, Use the heparin pump on the arterial bloodline to continuously pump heparin during the treatment (500 unit/hour-recommended dose). Stop the heparin pump one hour before the end of the treatment, or per policy...."






















18581

On 12/13/11 at approximately 1445, random observation of Patient #8 revealed the patient's legs were over the side of the bed below the raised right upper side rail, and the patient's right hand was positioned on the raised side rail. The head of the patient's bed was at an approximately 45 degree angle and the patient was leaning forward. The patient had a nasal canula in the his nares and intravenous fluids flowing through a cannula in the lower right arm. The patient looked straight ahead and did not respond to conversation initiated by Staff Member #1 who was present in the patient's room when the observation occurred. When queried about the bed alarm not sounding, Staff Member #1 reported that the bed had a bed alarm but she did not know why the bed alarm was not alarming. Staff Member #1 exited the patient's room and returned a few minutes later with the Head Nurse. On the bed alarm system's digital screen was the word "OFF". The Head Nurse initially reported that the bed alarm was turned off, but then reported that she did not really know how the device operated. The Head Nurse exited the patient's room and returned a few minutes later with Registered Nurse #1. Registered Nurse #1 reported that the patient's bed alarm was on but the bed alarm had been set at a level three(3). When asked why the bed alarm was not auditory, Registered Nurse #1 reported that a bed alarm set at a level three (3) was not activated until the patient actually exited the bed and was standing on the floor. The Head Nurse stated that a level three (3) was the least sensitive level and was an out of bed mode. Registered Nurse #3 reported that each patient is assessed each shift by the nurse, and the bed alarm is set according to that nurse's assessment of the patient's potential for fall. The Head Nurse stated that the bed alarm at level one (1) was the most sensitive and least used because of so many false positive calls invoked due to patient movement in bed. Registered Nurse #1 revealed a form identified as a High Fall Risk Patient Hourly Rounding Log used by nursing staff to document the Bed Exit Level. Employee #1 and the Head Nurse verified that the bed alarm for this patient based on the nursing assessment should have been at least a level two(2).

Review of the hospital form identified as "High Fall Risk Patient Hourly Rounding Log" showed "Bed Exit Levels (1-3). Level 1: Patient Position Movement Most Sensitive, Level 2: Bed Exiting Mode, and Level 3" Out - of - Bed Mode Least Sensitive".

On 12/13/11 at 1515, a review of Patient #8"s chart showed the 75 year old patient was admitted from a skilled nursing facility on 12/7/11 with Respiratory Failure. Review of the transfer form from the Skilled Nursing facility dated 12/7/11 showed the patient had a diagnosis of Dementia. Review of the initial nursing assessment dated 12/7/11 at 0540 showed the patient was admitted via the Emergency Room with Respiratory Failure, was non - ambulatory, confused, very limited bed mobility and required the assistance of two people for transfers. In the section labeled Neurological, staff checked Dementia, Alzheimer's, and disoriented to place and time. Review of the Fall Risk Assessment showed a score of eight(8) related to confusion/disorientation, poor mobility/ generalized weakness, and altered elimination. Notations in this section show a high risk patient as having a score equal to or greater than five (5). In the section labeled, Respiratory, staff documented the patient had Oxygen at 4 liters via a non-re-breather mask. In the section labeled, Musculoskeletal, staff documented the system as abnormal related to general weakness and the use of a Merriwalker.

Review of Patient #8's medication administration record showed the patient was ordered Aricept (Donepezil) 10 milligrams (mg) 2 tablets oral every night at bedtime, Namenda (Memantine) 10 mg 2 tablets oral every day at 0800, and Risperidone ) 0.5 mg 2 tablets oral every night at bedtime.

Review of the Fall Risk/Safety assessments documented by staff dated 12/07/ 11 through 12/14/11 revealed Patient #8 was high risk patient for falls equal to or greater than 5. Review of the hospital forms labeled "High Fall Risk Patient Hourly Rounding Log" dated 12/9/11 through 12/ 13/11 in Patient #8's chart showed that although the patient was assessed by nursing staff as a high risk for falls, the bed alarm was set for a level 3. Level 3 was identified as the least sensitive mode and required the patient to have gotten out of the bed and standing on the floor before the bed alarm would be activated.

On 12/16/11 from 1400 to 1515, an interview was conducted with the Performance Improvement Leader revealed that Fall Assessments are conducted by staff when the patient is admitted. The Performance Improvement Leader reported that staff use the falls assessment data to determine the patient's appropriate risk level and the appropriate bed alarm setting if needed.

Review of hospital policy, QSP-NSG-0048, Revision level:9, Revision Date: Sep 2011, Page 2 of 4, Falls Risk Assessment, reads, "Important consideration when using the Fall Risk Assessment Tool:
-Patient's medication regimen as a causative factor and should be incorporated in the patient's specific interventions. Examples: anti-depressant, antipsychotic, benzodiazepines, sedatives/ hypnotics, diuretics, laxatives, bowel preps, etc.
Interventions should be specifically targeted to the individual's case of each patient while considering the benefits and risks for maintaining the highest degree of functionality possible.
-The Fall Risk Assessment Tool is only a guide and should be used in conjunction with the individual assessment and the nurse's professional judgement. ....The Registered Nurse is responsible for implementation and oversight of individualized patient's fall prevention care as follows: -Assessing fall risk, - Determining and setting the bed exit alarm level appropriate for the patient. ....".





27175

Review of Patient #44's chart showed the patient was admitted to the hospital on 12/13/11 with the diagnoses of Atrial Fibrillation and Syncope. The Nursing Admission Assessment dated 12/13/11 showed staff documented the patient's falls risk at 10 (High Risk = 5 or greater). On 12/14/11, documentation showed the patient's bed alarm exit level was set at level 2 until 0500 to 0600, and then changed to a level 3 (least sensitive) without a documented change in the assessment score for high risk for falls.

Review of Patient #45's chart revealed the patient was admitted to the hospital on 12/13/11 with the diagnoses of Congestive Heart Failure (CHF), Hypoxia, and Shortness Of Breath (SOB). The Nursing Admission Assessment dated 12/13/11 showed staff documented the patient's falls risk at 5 (High Risk = 5 or greater). On 12/13/11 and 12/14/11, documentation showed the patient's bed alarm exit level was set at level 3(least sensitive).

Review of Patient #47's chart showed the patient was admitted to the hospital on 12/13/11 with the diagnosis of Cardiovascular Accident (CVA). The Nursing Admission Assessment dated 12/13/11 showed staff documented the patient's falls risk at 5 (High Risk = 5 or greater). On 12/14/11, the patient's bed alarm exit level was set at level 3(least sensitive).

Review of Patient #48's chart showed the patient was admitted to the hospital on 12/11/11 with the diagnoses of Pneumonia and Respiratory Failure. The Nursing Admission Assessment dated 12/11/11 showed staff documented the patient's falls risk at 18 (High Risk = 5 or greater). On 12/14/11, documentation showed the patient's bed alarm exit level was set at level 3 (least sensitive).

Review of Patient #49's chart revealed the patient was admitted to the hospital on 12/13/11 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) exacerbation, and Pneumonia. The Nursing Admission Assessment dated 12/13/11 showed staff documented the patient's falls risk at 5 (High Risk = 5 or greater). On 12/13/11 and 12/14/11, documentation showed the bed alarm exit level was set at level 3 (least sensitive).

Review of Patient #50's chart revealed the patient was admitted to the hospital on 12/11/11 with the diagnosis of Pneumonia. The Nursing Admission Assessment dated 12/11/11 showed staff documented the patient's falls risk at 19 (High Risk = 5 or greater). On 12/12/11 and 12/13/11, documentation showed the bed exit alarm was set at level 2 and then, on 12/13/11 and 12/14/11, the patient's bed alarm exit level was set at level 3 (least sensitive) with no change to the patient's falls risk assessment documented.

Review of Patient #51's chart showed the patient was admitted to the hospital on 12/13/11 with the diagnosis of CVA. The Nursing Admission Assessment dated 12/13/11 showed staff documented the patient's falls risk at 22 (High Risk = 5 or greater). On 12/13/11 and 12/14/11, documentation showed the patient's bed alarm exit level was set at level 3 (least sensitive).

Review of Patient #52's chart revealed the patient was admitted to the hospital on 12/12/11 with the diagnoses of Chest Pain (CP), Pleural Effusion, Pneumonia, and CHF. The Nursing Admission Assessment dated 12/13/11 showed staff documented the patient's falls risk at 5 (High Risk = 5 or greater). On 12/12/11 through 12/14/11, documentation showed the patient's bed alarm exit level was set at level 3(least sensitive).

Review of Patient #53's chart revealed the patient was admitted to the hospital on 12/12/11 with the diagnoses of Stridor, and Respiratory Distress. The Nursing Admission Assessment dated 12/12/11 documented the patient's falls risk at 16 (High Risk = 5 or greater). On 12/12/11 through 12/14/11, documentation showed the patient's bed alarm exit level was set at level 3(least sensitive).

Review of Patient #55's chart showed the patient was admitted to the hospital on 12/12/11 with the diagnoses of Bacterial Pneumonia and Aspiration. The Nursing Admission Assessment dated 12/12/11 showed staff documented the patient's falls risk at 5 (High Risk = 5 or greater). On 12/12/11 through 12/14/11, documentation showed the patient's bed alarm exit level was set at level 3(least sensitive).

A review of Patient #56's chart admitted to the hospital on 12/13/11, with the diagnosis of Syncope. The Nursing Admission Assessment dated 12/13/11 documented the patient's falls risk at 5 (High Risk = 5 or greater), on 12/14/11 the bed alarm exit level was set at level 3 (least sensitive).

On 12/16/11, a review of the hospital's quality data revealed a graph identified as "Patient Falls Per 1000 Patient Days" that showed the hospital had exceeded it's identified threshold for falls in November 2010, December 2010, February 2011, March 2011, August 2011 and September 2011. It met or slightly exceeded its identified falls threshold in January 2011 and June 2011.


Medical record review conducted on 12/15/11 at 1425 revealed Patient #57 was admitted to the hospital on 12/14/11 with Pneumonia and Dehydration. A physician verbal order dated 12/15/11 at 2400, read, "Ok (Okay) for pt (patient) to have 4 side rails ^ (up)". Review of the hospital's "Restraint Flowsheet for Non-Violent or Non-Self Destructive" dated 12/15/11 at 2400 showed "Side rails" and under the section labeled "Other", staff recorded, "Per daughter request" in the section of the form identified as "Interventions attempted to modify behavior prior to initiation of restraints". On 12/15/11 at 1435, Registered Nurse #1 stated, "We rarely use restraints up here, and usually to prevent patients from pulling lines (catheters, IV's [intravenous]). The order was written per the patient's daughter's request. The patient is a resident of a nursing home, and I think the rails are up (all 4) over there."

Closed record review on 12/14/11 at 1624 revealed Patient #7 was admitted to the hospital on 11/7/11 with the diagnosis of Schizophrenia. Review of a nurse note dated 11/7/11 showed the patient was placed in restraints on 11/7/11 at 0915. The patient's medical record had no documentation of a physician's order until 12/3/11 as an addendum. The findings were verified by the Chief Nursing Officer on 12/15/11 at 1630.

Closed medical record review conducted on 12/15/11 at 0920 revealed Patient #3 was admitted to the hospital on 12/5/11 and transferred on 12/6/11 with the diagnosis Violent/Threatening to Self/Others. Review of a physician order dated 12/6/11 at 1058, reads, "...restraint criteria to remove: when patient is calm and cooperative;.... restraint type: 4 point, leathers as needed...". Review of the nurse notes showed staff documented, ".... RESTRAINTS:...1055 Removal: Restraints were removed due to decreased agitation/hostility, right wrist only at this time until pt (patient) displays further cooperation. Pt verbalizes understanding. 1105: Removal: Restraints were removed due to decreased agitation/hostility, patient's verbal contract to do no harm, patient's ability to follow instructions, remaining three restraints. Pt moved to a room with a tv (television) and given activity book and crayons...". On 12/15/11 at 1305, Nursing Director #3 stated, "Sometimes, we will release one restraint and explain to the patient that if you are calm, because

On the days of the Validation Survey based on observation, record review, interview, review of facility policy and procedures, and other data submitted by the hospital for review, the hospital failed to ensure that Registered Nurses followed physian orders for administering medications in the dialysis unit, obtained physician orders prior to initiating dialysis treatment for patients, used the most appropriate interventions for patient's identified as high risk for falls, and followed the hospital's policies and procedures for patient restraints.

The findings are:

Cross Reference to A 0392: The hospital failed to ensure that contractual dialysis staff *Registered Nurses) obtained physician orders for the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) for patient dialysis prescriptions and treatment, Dialysis contractural staff failed to follow Physician Orders for administration of Heparin, Registered Nurses failed to ensure that nursing interventions were appropriate to the nursing assessment for patients identified as high risk for falls, and failed to follow the hospital's policies and procedures for the care and safety of patients of patient's in restraint.

On the days of the Validation Survey based on interview, personnel record review, and annual competency review for Department Directors, the hospital failed to ensure adequate supervision and oversight for the contract dialysis services for the hospital. (Director of Nursing #4)

The findings are:

On 12/14/11 at 1100, a review of hospital personnel files for Nurse Director #4 revealed no documentation of qualifications in Dialysis or competency skills for dialysis in the Director's personnel file. On 12/15/11 from 1640-1655, Nurse Director #4 verified he/she had responsibility for the oversight of the hospital's dialysis services and revealed that contract dialysis had been instituted at the hospital in 2009.

Cross Reference to A 0392: Based on interview, record review, review of contractual facility policy, and review of the hospital's policies and procedures, the hospital failed to provide the supervision and oversight to ensure that contractual dialysis staff obtained physician orders for the Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR) for the dialysis prescription and treatment for 1 of 1 concurrent patient records (Patient #4) and 13 of 14 closed patient records (Patient #4, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 58), and dialysis contractural staff failed to follow Physician Orders for administration of Heparin for 5 of 14 closed patient charts (Patient #9, 11, 13, 14, and 58) reviewed for care and services related to Dialysis,

On the days of the Validation Survey based on random observation, hospital policy review, and interviews with staff, the Hospital failed to ensure that outdated or unusable medications and medication supplies were removed from the treatment areas. (Surgery, Emergency Room, Clinical Decision Unit, and Women's Services)


The findings include:


On 12/13/2011 at 1025, an inspection of the Omnicell located within the Surgical Services Department revealed three (3) opened Sterile Surgi Lube lubricant tubes without dates indicating when they were opened. The tubes of opened lubricants had been placed back in the Omnicell where unopened medications are kept. Further inspection of the Omnicell in the Surgical Services Department revealed five (5) Gentamicin 80 milligram(mg)/2 milliliter(ml) vials with expiration dates of 11/2011. The findings were verified with the Surgical Services Director and the Out Patient Services Director on 12/13/2011 at 1045.

Hospital policy, titled, Expiration Date Checking and Removal Process, reads, " ....Purpose....To insure all medications have not reached expiration and are pulled prior to expiration dates.... Scope.... All areas that store medications". .... Responsibility....Pharmacy Department... "All outdated, contaminated, improperly stored, or illegibly labeled medications will be considered outdated and stored in a separate area, so designated for outdates, until they can be returned to the manufacturer... Check the Omnicells on the floors and pull expired medications monthly".




27175

On 12/12/11 at 1430, random observations during a tour of the Women's Services (2 Tower) showed the respiratory box that was located on top of the crash cart had 3- 5 ml (milliliter) vials of sterile (not for injection) 0.09% Sodium Chloride Solution an expiration date of 03/04.



30011

On 12/13/11 at 0935, random observation of Clinical Decision Unit (CDU) at 0935 revealed one (1) respiratory vial expired 11/07 and one (1) respiratory vial expired 09/05 in the red box on the crash cart. The finding was verified by CDU Nurse Manager. On 12/13/11, random observation of the Emergency Room at 1400 showed two (2) Cuffed Tracheal Tubes Murphy Eye Oral/Nasal 16 mm (millimeter) expired 11/11, (2) Cuffed Tracheal Tubes Murphy Eye Oral/Nasal 24 mm expired 11/11, and (1) Cuffed Tracheal Tube Murphy Eye Oral/Nasal 11 mm expired 10/11. The findings were verified by Emergency Room Nurse Manager on 12/13/11 at 1400.

On the days of the Validation Survey based on observations and interview, the Director of the hospital's Dietary Services failed to ensure compliance with the Dietary Department's safety practices for food storage and handling by way of unsanitary work environment and improper storage in the kitchen preparation area.


The findings are:


On 12/12/11 at 1430, random observations of the kitchen's freezer showed brown and black debris on and around the seal of the freezer door. Observation of an oven that the Director stated was no longer used for cooking revealed black layers of substance coating the oven interior and door and food crumbs and debris on the floor of the oven The finding was verified by the Director of Dietary on 12/12/2011 during this tour.

Observation of the cook top area at 1445 showed the oven had a broken handle and an accumulation of brown to black substance coated the oven door and interior. Observations of the food serving line on 12/12/2011 at 1500 showed food debris in a removable sink area. Observation of a toaster used for food preparation showed the toaster had multiple food crumbs and layers of a black - brown substance and brown debris. An unlocked cabinet contained another toaster with food crumbs and layers of a brown black substance and dust particles. Observations of the warmer revealed the warmer lid was broken and a bolt was missing on the handle. The seal around the warmer had layers of accumulated brown debris. In this area, the milk cooler and ice cooler were located. The door seals of the milk cooler and ice cooler had layers of accumulated black debris and brown sludge. The findings were verified by the Dietary Director on 12/12/2011 at 1500.

Observations of the food preparation area on 12/12/2011 at 1515 showed a container of fudge frosting sitting on the counter with frosting located on the lip of the container and down the side of the container. The receive date was documented on the frosting container, but no open date or discard date was documented on the label. Observation showed a metal cabinet with open boxes of muffin mix that did not have an open date, and an uncovered plastic bin filled with assorted ladles, spoons, and other preparation utensils that appeared to have just been thrown into the bin. The findings were verified by the Dietary Director on 12/12/2011 at 1515.

Observation of the dry storage areas on 12/12/2011 at 1535 revealed the bin for the flour was not closed completely. The finding was verified by the Dietary Director on 12/12/2011 at 1535.

Random observation on 12/12/2011 at 1550 revealed the kitchen's dirty linen was not in a closed container and some items were thrown over the top of the linen container. The kitchen's clean linen containers with clean linen were directly adjacent to the dirty linen containers and some clean linen was observed in a plastic bag sitting in the floor. The finding was verified by the Dietary Director on 12/12/2011 at 1550.

Observation of the kitchen ovens that are currently used on 12/12/2011 at 1555 revealed a large amount of accumulated greasy brown sludge on the interior as well as on all of the doors of the ovens. On the counter area was a bin with blackened bananas in it. The Director stated that the bananas would be used for baking. The finding was verified by the Dietary Director on 12/12/2011 at 1555.

On the days of the Validation Survey based on observations and interview, the facility failed to ensure the industrial trash containers and loading dock were maintained to ensure the proper storage of and disposal of trash and storage of supplies.


The findings are:


Random observations of the dock area on 12/14/2011 at 1115 revealed the hospital's industrial trash containers for discarding of trash from the kitchen area were overflowing with trash and cardboard boxes. The industrial trash containers had doors that were not or could not close due to the accumulation of garbage in the containers. The dock area was cluttered with an accumulation of empty cardboard boxes, undelivered supplies in boxes for Materials Management, and open boxes of urinary supplies awaiting pickup by Materials Management. The findings were verified by the Plant Operations Director on 12/14/2011 at 1115.

On the days of the Validation Survey based on observations and interview, the hospital failed to ensure a system was in place to determine if oxygen extension tubing and other respiratory equipment in a radiology patient treatment area had been changed. (radiology)

The findings are:


On 12/13/11 at 1250, random observations of the Radiology Department revealed oxygen extension tubing with a Christmas Tree Adaptor wrapped around the Oxygen flow meter in Patient Treatment Room #2 and #3. There was no labeling on the oxygen extension tubing or the Christmas Tree that identified when the set up occurred. On 12/13/11 at 1400, the Assistant Director of Radiology reported the Oxygen tubing was wrapped around the meter because sometimes patients come to the Radiology Department on portable Oxygen. The Radiology Director stated that the Radiology Technician who was responsible for cleaning the room after the procedure was to discard the oxygen tubing and prepare a new setup. The Assistant Director confirmed there was no system in place such as labeling to identify if the oxygen tubing had been disposed of and/or how long the oxygen tubing presently in the treatment room had been placed there. On 12/13/11 at 1455, Radiology Technician #2 revealed that a new cannula or mask was used but the oxygen extension tubing was never discarded.