HospitalInspections.org

Based on observation, staff interview and review of dietary policy and procedures, the Food Service Director did not ensure that the daily operation of the food service department is maintained in a sanitary manner.

Findings include:

A tour of the hospital kitchen was conducted on 5/12/15 at approximately 11:00 AM. The surveyor was accompanied by the Director and Senior Assistant Director of Food Service. The Food and Nutrition Department is self-operated. It is not contracted. Examples of issues observed, included, but were not limited to, the following:

A. 1- A reach-in freezer containing a case of sausages and a case of omelets was inspected. This reach in freezer had two termometers; an internal temperature that read 15 degrees Fahrenheit and a second thermometer located outside of the freezer that read 45 degrees Fahrenheit. Both temperatures were out of range for a freezer. Note: A freezer should have a temperature of 0 degrees and below Fahrenheit.

2- The Food Service Director placed his bare hands into the case of sausages and pulled out a sausage to show the Surveyor that the food in the freezer was still frozen. Afterwards, the Director threw the sausage back into the case of sausages. The Food Service Director's actions were not in keeping with safe food handling practice. The case of sausages and omelets were removed from the freezer by a food service employee. The Director of Food Service informed the surveyor that the freezer would not be used, and that a sign would be posted indicating that the freezer is out of order. The freezer remained out of order during the survey.

3- There was no Master Menu posted in the kitchen as required by regulation. A Master Menu contains all approved hospital diets for all meals for the number of days contained in a cycle.
The kitchen had no Master menu. Instead it had a cheat sheet. This cheat sheet listed a nameless seven day menu. Beneath each menu were three non prescriptive or inconplete diets. This cheat sheet had the following deficits:
1- The cheat Sheet contained one nameless menu.
2- This nameless menu had no food portion size on the food items.
3- The cheat sheet listed only five diets below the nameless menu. Example of these diets are: Regular Renal Diabetic and Regular Puree Diabetic . These diets contained only one food item beneath their name. Example: Regular Puree Diabetic Diet only had one food item listed, a "Tropical Fruit Cup". This food item cannot be provided to a pureed diet nor can it be provided if it is not sugar free.
4- The diets listed on the sheet sheet were not specific to the amount of the restriction. Example: Renal Diabetic (the amount of protein, sodium, potassiun and calories).
5- The cheat sheet listed only 5 diets out of 29 diets in the physician diet formulary.

4- Two hand washing sinks were obesrved to have no wastebaskets for paper towel disposal.

B. Review of the Emergency Preparedness Manual was conducted on 5/12/15 at approximately 1:00 PM. The manual was reviewed with the Assistant Director of Food Service and the Clinical Nutrition Manager. This manual was incomplete.
1- The manual contain four menus without food portions beside the food item.
2- The menus failed to indicate if the food item is boxed, canned or in a container.
3- The menu did not list the hospital diets it would cover.
4- There was no diagram where the food, water and equipment would be found.
5- The entree for all four days at lunch and dinner were repeated.
6- The manual did not state if the menu would be provided in bulk and if so how much of each item would be sent to each patient unit.
7- Non food items such as can openers, hairnets etc. was not listed.
8- Paper goods and utensils were also missing in this manual.
9- There was no mentioned in the manual how much food to be sent for staff on the units.
10- The menu was not nutritionally balanced. This menu is prepared in advanced therefore it should meet the expectations of a hospital menu.

Based on hospital nutrition screen, staff interview and other documents, it was determined that the facility did not ensure that all patients at nutritional risk for malnutrition are identified by the facility nutrition screen.

Findings include:

A review of the hospital policy on nutrition screening was conducted on 5/13/15 at approximately 11:00 AM. Present at the review was the Clinical Nutrition Manager.

The surveyor interviewed the Clinical Nutrition Manager on the point system utilized in the hospital nutrition screen . The hospital policy titled, " Nutrition Screening and Assessment Timeline" Revised 3/15 does not refer to the point system utilized for the identification of patient who may be at risk for malnutrition. The Clinical Nutrition Manager was unable to provide the number of points that is required to identify a patient at high or moderate nutritional risk for malnutrition. She informed the surveyor that the computer software does the adding of points hence she is unaware of the weight of each trigger in terms of points. Note: The surveyor informed the Clinical Nutrition Manager that there were two columns in the nutrition screen. One column consist of (10) triggers which identify diseases/conditions (except for the trigger of blood albumin), with each trigger afforded a weight of 2 points. The other (or second) column contains (12) triggers (varied), with each trigger afforded a weight of 1 point.

The nutrition screen noted that patient's identified as High Risk required 11 points and patient's identified as Moderate Risk had 2-11 points. To identify patients at high risk meant that the patient, for example, requires five triggers be selected in the first column and 1 trigger selected in the second column, for a total of 11 points.

Due to the nutrition screen process and the high number of points required for a patient to be identified as high risk or moderate risks; may result in that patient with less point yet are at high risk may not be identified by this point system .
In addition, anticoagulant was a trigger on the nutrition screen with a weight of 1 point. The use of anticoagulant is not a nutritional risk for malnutrition.
The current nutrition screen is flawed due to its inadequate classification system of points.

Based on review of hospital master menus, physician diet formulary and staff interview, it was determined the Food and Dietetic Department failed to ensure that hospital menus are nutritionally balanced and meet the needs of patients. This finding was noted in 24 of 29 menus.

Findings include:

A review of hospital menus was done on 12/13/15 at approximately 1:00 PM. Present during the review was the Clinical Nutrition Manager and the Senior Assistant Food Service Director. The surveyor requested to see the hospital master menu. Instead of a master menu the surveyor received a cheat sheet with a seven day menu and 5 diets listed. The five diets listed on the menu did not have complete menus (See A 620). There are 29 diets in the physician diet formulary yet there are only five diets listed on the hospital master menu (cheat sheet). Therefore, 24 out of 29 physician's diet orders do not have menus.

Based on menu review, nutrient analysis of menu and staff interview, it was determine that that the Food and Nutrition Department did not ensure that physician's prescribed diets met the therapeutic nutritional needs of the patients. This finding was noted in 25 of 29 diets.

Findings include:

A review of nutrient analysis of hospital menus was conducted on 5/13/15 at approximately 2:00 PM. Present at the review was the Clinical Nutrition Manager.

1- The Clinical Nutrition Manager provided a nutrient analysis for 6 diets out of 29 diets. The hospital physician's diet formulary consist of 29 diets. Therefore 23 prescribed diet orders did not have a nutrient analysis. Due to the absence of a nutrient analysis for these diets; the physician diet orders cannot be validated for nutrient adequacy nor for diet restriction. In addition, two of the six nutrient analysis submitted did not meet patient's caloric needs.

2- The Physician's diet formulary was not updated to meet the approved hospital diet manual. Diets included in the formulary did not match the diets in the manual.

a) The physician's diet formulary contained 4 pediatric diets. The hospital does not have a pediatric unit.

b) Seven diets in the physician's diet formulary did not specify the total amount of the restriction for each therapeutic diet. Examples are: Low Cholesterol (200mgs or 300 mgs) , Consistent Carbohydrate (number of grams of carbohydrate per day) , High Fiber (25 or 30 gms), and Renal Consistent Carbohydrate (amount of protein restriction ).

Based on observations and staff interview, the facility failed to maintain the physical plant in a manner to provide a safe and sanitary environment for the treatment of patients.

Findings include:


The Operating Room (OR) Suite:

1- During the tour of the Operating Room suite on 05/12/15 at approximately 11:15 AM, the surveyors observed the operating room had tiled walls with grout filling in between. This type and condition of the tiled walls in the Operating Rooms is an infection control issue as it may promote microbial growth.

2- The cove molding of OR #8 was observed to be chipped, and rusted and in disrepair.

3- The water temperatures of the scrub sinks outside the ORs were found to be outside the proper temperature range as per CDC Guidelines. The temperatures were measured at 10 faucets of the scrub sinks by the hospital staff and the temperature ranged between 82 to 101 Fahrenheit (F). It should be noted that the acceptable temperature range by CDC guidelines is from 110 F to 120 F.

4- The water at the scrub sinks was found to be turbid and discolored. When asked, the Hospital staff did not know that the water was discolored and turbid and did not provide any explanation or reason.

5- The floor of the recovery area was found to be dirty.


The Emergency Department (ED):

1- The corridor outside the ED was found to be totally blocked by stretchers, chairs and IV fluids.

2- Many patients were observed receiving their treatment on both sides of the corridor.

3- The corridor was overcrowded with patients on stretchers and chairs receiving treatment, and there was no privacy what so ever. The nurses and physicians were talking and seeing patients on the corridor without providing privacy to any of those patients.

4- The airborne isolation room (Room E) did not have a negative air pressure as required for this type of room.

5- The patient men and women bathrooms did not have nurse call bells.

6- The women's bathroom was found to have broken tiles and the floor was dirty.

7- An unattended food cart was observed on the corridor outside room A and it was partly obstructing the corridor and the exit way, which is a fire hazard.

8- The floor of the trauma room (Room 7) was very dirty.

9- The nurses desks at the nurse station were broken and had chipped Formica at different parts of their surfaces. Additionally, the surfaces of the desks were found to have black stains and marks of plaster.

10- The hand washing sink on the main area of the ED was blocked by Computers on Wheel (COW), crash cart, chairs and two sharps containers.


Psychiatric Unit:

During the tour of the Psychiatric Unit on the second floor on the morning of 05/13/15, the surveyors observed the following:

1- The doors of the seclusion room and its adjacent bathroom had regular hinges instead of piano hinges, which are required in the psychiatric units.

2- The mechanical access panels on the ceilings of all the rooms and other areas of the psychiatric unit had gaps around them, which is a potential looping hazard.

3- All the patient beds were captain beds that had metal hooks on them, which is a potential looping hazard.

4- The phone cabinet on the corridor had chipped Formica and sharp edges where the Formica is chipped, which is a potential safety risk.

5- There were three (3) of the shower heads in the psychiatric unit that had metal ridges at or near the end of the shower heads, which are a potential looping hazard.

6- The patient bathrooms were observed to have three rusted exhaust vents.

7- There was a pad lock observed on the electric panel across from room 207, which is a potential looping hazard.

8- The door frames of all the patient rooms and other rooms were observed to have a protruded metal door latch plate, which are a potential safety risk.

9- The strobes of the fire alarm in the dining room had metal plates, which are a potential looping hazard.

10- All the air diffusers on the units were not of the security type, which are a potential looping hazard.

11- The door handles of the doors on the corridor at the back of the unit are regular type handles, which are a potential looping hazard.

12- The electric panel at the back of the unit near the rear exit door had a pad lock, which is a potential looping hazard.

13- The laundry room was found to have a fire extinguisher that was mounted to the wall without limiting patients' access to the fire extinguisher, which is a potential safety risk.

14- The hoses and wiring for the washing machine were exposed and not secured, which is a potential looping hazard.

15- There was an opening around the drain pipes that needs to be repaired / sealed.

16- The door handles of the housekeeping room are the regular type - not the safety type - which is a potential looping hazard.

17- The door handles and hinges of the seclusion room were the regular type, which are a potential looping hazard.

Based on review of the Organ, Tissue and Eye Procurement Program Manual and staff interview, it was determined that the facility failed to ensure that this program was integrated into the Hospital Wide Quality Assurance Performance Improvement Program (QAPI).

Findings include:

A review of the hospital's Organ, Tissue and Eye Procurement Program Manual was conducted on 5/15/15 at approximately 11:30 AM. Tracking data concerning compliance with Time Notification was reviewed.

The definition of Time Notification is when the hospital contacts the Organ Procurement Organization by telephone after an individual or patient has died. The ideal turnaround time should be one hour.

A review of this Time Notification data revealed that the compliance rate for Time Notification was at 65% in 2014.

The surveyor interviewed the Director of Nursing who is in charge of the program. The Director of Quality Management provided the surveyor with the 2014 data provided by the Organ Procurement Organization. There was no formal report showing what the facility had done to improve 2014- 65% rate of compliance for time notification. The Director of Quality Management informed the surveyor that there was no quality assurance program for the Organ, Tissue and Eye Procurement Program.