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Based on record reviews, interviews, and review of the hospital's policy and procedures, the hospital failed to provide evidence that Advance Directives were addressed for 6 of 17 closed patient records reviewed for care and services. (Closed Patient 3, 5, 7, 9, 11, and 14)


The findings are:


On 9/27/17 at 9:30 a.m., review of (Closed)Patient 9's chart revealed the patient was admitted on 9/9/17 for Pyelonephritis and Advance Directives were not addressed with the patient on admission.

On 9/27/17 at 10:23 a.m., review of (Closed) Patient 11's chart revealed the patient was admitted on 6/25/17 for a diagnosis of Gastroparesis, and Advance Directives were not addressed with the patient on admission.

On 9/27/17 at 10:53 a.m., review of (Closed) Patient 14"s chart revealed the patient was admitted on 9/6/17 for a diagnosis of bilateral Pneumonia, and Advance Directives were not addressed with the patient on admission.

The findings were verified with the Chief Nursing Officer at 2:55 p.m. on 9/27/17.

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On 9/26/17 at 1:45 p.m., review of (Closed) Patient 3's chart revealed the patient was admitted on 7/24/17 and discharged on 7/25/17, and there was no documentation for Advanced Directives on the patient's admission paperwork.

On 9/26/17 at 2:45 p.m., review of (Closed) Patient 5's chart revealed the patient was admitted on 9/6/17 and discharged on 9/7/17, and there was no documentation for Advanced Directives on the patient's admission paperwork.

On 9/26/17 at 1:45 p.m., review of (Closed) Patient 7's chart revealed the patient was admitted on 7/29/17 and discharged on 7/31/17, and there was no documentation for Advanced Directives on the patient's admission paperwork.

The findings were verified on 9/27/17 at 3:20 p.m. with the Chief Nursing Officer.

Review of the hospital's policy and procedure, titled, "Advance Directives", reads, "....1. all patients/residents will be asked on admission if he/she has an advanced directive...this will be documented on the Consent and Conditions of Treatment....".

Based on record reviews and interview, the Critical Access Hospital's (CAH) Human Resource Department failed to ensure employees completed annual mandatory training for two (2) of the fifteen (15) employee files reviewed. (Registered Dietitian- RD 1 and 2)


The findings are:


On 9/26/17 at 2:00 p.m., review of the hospital's personnel files revealed there was no documentation of annual training for RD#1 and RD#2. The findings were verified by the HR Manager at 2:17 p.m. on 9/26/17.

Based on observations and interview, the Critical Access Hospital's (CAH) Maintenance Department failed to ensure all essential essential mechanical, electrical, and patient care equipment was maintained in safe operating condition in the dietary kitchen's 3 compartment sink, for the automatic door in the radiology department, and other public areas.


The findings are:


On 9/25/17 at 1:35 p.m., during a tour with the Manager, observations of one of the automatic doors located at the entrance to the Radiology Department revealed the automatic door would not open when the door pad was pressed. The finding was verified by the Manager at 1:35 p.m. on 9/25/17.

On 9/25/17 at 1:55 p.m., during a tour with the Manager, observations in Patient Room 59 revealed the red electrical outlet was painted over with the color of the wall paint. The finding was verified by the Manager at 1:55 p.m. on 9/25/17.

On 9/25/17 at 2:10 p.m., during a tour with the Manager, observations revealed a light was not operative in a step down hallway to an exit door. The finding was verified by the Manager at 2:20 p.m. on 9/25/17.

On 9/25/17 at 4:06 p.m., observations in a step down hallway to an exit door showed the step down had no handrails. The finding was verified by the Facility Manager at 12:46 p.m. on 9/26/17.





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Based on observations and interview, the hospital failed to maintain kitchen sanitation equipment to ensure the sanitizer in the third compartment of the 3- compartment sink registered appropriately. The quaternary (quat) sanitizer concentration registered too strong between 400-500 parts per million (ppm). The effective range for sanitation is between 150-400 ppm. This had the potential to affect all patients eating out of the kitchen.


The findings included:

Observations with the Certified Dietary Managers (CDMs) on 9/25/17 at approximately 2:08 p.m. revealed Dietary Aide #3 washing pots and pans in the 3- compartment sink. When Dietary Aide #3 tested the third compartment sink for appropriate sanitizer concentration, there was confusion over which test strips to use and how long to dip the test strip in the water. Dietary Aide #3 dipped the Hydrion quat test strip in the sanitizer solution for 15 seconds instead of 10 seconds as directed by instructions on the test strip package. After dipping the quaternary test strip in the sanitizer solution, the test strip registered a concentration of 400-500 ppm. CDM #1 acknowledged this reading was too strong and turned on the water faucet. Using another test strip, the solution still registered an immediate dark green once dipped in the water prior to the 10 second mark which corresponded to a concentration of 400-500 ppm. Observations of the sanitizer bottle under the sink revealed the hospital uses Oasis 146 multi-quat sanitizer. There was a question brought up by the CDM as to whether the test strips may have been wet prior to the test so new test strips were obtained and the test strips continued to register 400-500 ppm when tested. According to CDM #1, the water and the quat sanitizer come out of the faucet together in the adequate concentration for sanitation as per Ecolab who set up the system. CDM #1 provided an Ecolab service inspection of the kitchen dated 9/6/17 which documented a quat sanitizer concentration of 300 (ppm) on 9/6/17 which is in range for appropriate sanitation.

During an interview on 9/26/17 at approximately 9:05 a.m., CDM #2 stated that an Ecolab representative had come the previous evening to check the system and post instructions on how to fill the 3- compartment sink. The newly posted instructions included information that the acceptable amount of quat sanitizer was between 150-400 ppm. According to CDM #2, the reason the quat sanitizer concentration had been too strong because of the water pressure in the sinks. They had been instructed by Ecolab to run only one sink faucet at a time when filling the 3 compartment sinks (to allow the chemicals to mix properly and test correctly). The surveyor asked for documentation from Eco-lab that this had been the problem. On 9/26/17 at 1:27 p.m., CDM #2 provided an Ecolab inspection of the kitchen, dated 9/26/17 at 7:00 p.m., that documented those recommendations. According to an observation listed on the form, the quat sanitizer condition was too high, caused by equipment; and adjusted to ensure proper product usage. The "Service Area Readings" area of the form indicated the quat sanitizer had been observed "Today" at 400 ppm, adjusted by 200, with a water hardness of 10 gpg. "Last Visit" quat was noted at 300 ppm with a water hardness of 4 gpg., and "Prior Visit" at 300 ppm with a water hardness of 4 gpg.

Based on observation, interviews, and review of the Critical Access Hospital's (CAH) policy and procedures, the hospital failed to ensure emergency life saving medications and equipment was properly secured.

The findings are:

On 9/25/17 at 1:45 p.m., observations in Emergency Department (ED) Room 2 revealed an adult crash cart that did not have a secure lock to keep non-medical staff from entering the cart. On 9/25/17 at 1:55 p.m., observations in ED Room 2 revealed the pediatric emergency crash cart did not have a seal to lock and secure the cart. On 9/25/17 at 1:55 p.m., in an interview with the Chief Nursing Officer (CNO), the CNO revealed, "Our pharmacist is going to be getting new locks for the adult carts. We have discussed this and were aware that they didn't secure the contents. With the Peds cart, our staff checked it off this morning and replaced some expired meds, and she just hasn't replaced the seal yet."

On 9/25/17 at 3:45 p.m., observations of the cash cart on the medical nursing unit revealed the same type of lock. The crash cart was easily accessed when pushing down on the dummy lock. At 3:45 p.m., the finding was verified with the CNO at the time of the observation.

Hospital policy and procedure, titled, "Medications", reads, "....drugs shall be kept in locked storage when unattended and shall be inaccessible to unauthorized individuals....".

Hospital policy and procedure, titled, "Crash Cart- Adult and Pediatric", reads, "....To establish criteria for maintaining Adult and Pediatric Crash Carts located in Room 2 of the Emergency Department....check if cart is locked....all medications on the Emergency Crash Carts are to be kept locked, unless the cart is in use, or is being checked by Nursing or Pharmacy....".

Based on observations and interviews, the hospital failed to ensure its maintenance department monitored and maintained the interior of the hospital patient rooms and bathrooms randomly observed. (Patient Room 53)

The findings are:


Observations of Room 53 on 9/26/17 at approximately 9:30 a.m. revealed paint peeling from the wall over the headboard of the bed. In the bathroom of Room 53, the vinyl was peeling off from an area covering the left side entrance to the shower from the floor up about a foot. The inside part of the vinyl was spotted with a black substance as was the exposed cement block the vinyl was covering. The findings were verified with Registered Nurse #1 and #3 on 9/26/17 at 2:32 p.m. Registered Nurse (RN) #3 stated nursing sends a maintenance request for any concerns they identify and provided maintenance requests for Room 53 dated 3/22/17 documenting chipped paint behind the bed and water damage outside of the shower, and a request dated 8/22/17 for peeling wall paper behind the bed. During observation/interview on 9/26/17 at approximately 3:00 p.m., the Manager verified the findings. At that time, when the surveyor pulled the vinyl back to show the Manager the black substance on the block, a brown water bug/roach was noted inside the vinyl. When asked how repairs for water damage and painting were provided, the Manager stated the county will send a worker to provide repairs on the vinyl or paint at the request of the hospital. The Manager stated that the hospital will request the work to be done when there is enough work to be done to validate a call for them to come over.

Based on observations and interview, the Critical Access Hospital (CAH) failed to ensure the emergency food supply for the patients was within date and stored properly.


The findings are:


On 9/26/17 from 4:15 to 4:40 p.m., observations in the Certified Dietary Manager's (CDM) office revealed numerous cans of emergency food supply on the floor, on shelves, and stacked to the top of the shelf to the ceiling with no ventilation space noted. Eleven (11) cans of carrots- six (6) pounds (lbs) 9 ounces (oz) sitting on the shelf with a hand written date of "received 8/5/13". There was no expiration date found.
1 can of sliced pineapples with a hand written date of "received 2/1". The best use by date read July 2, 2015.
5 cans of tomato soup 50 oz. expired 5/3/2017.
8 cans of Chicken and dumplings 48 oz. with no expiration date noted.
11 cans of Libby Chili 108 oz. with no expiration date noted.
1 can of Home Tastee Chili con Carne delivered "8/5/12". No expiration date noted.
1 can of Chunk Light Tuna delivered " 4/8/12". No expiration date noted.
2 cans of Fancy Applesauce Unsweet 6 lb. 8 oz. with no expiration date noted.
7 boxes of Zataran's Creole Seasoning 17 oz. expired 5/2015.
12 containers of Medpass (Nutritional shakes) 32 oz. on the floor with an expiration date of 8/27/17.
1 case of Reese's cups containing 25 found under the desk of the CDM.
2 cases of 16 oz.(ounces) bottles of water located on the floor under the shelf.
2 cases of hinged containers, 2 cases of cup lids, and 2 cases of 16 oz. cups located on the floor.
On 9/26/17 at 4:15 p.m., in an interview with CDM 1, he/she revealed, "This is actually my office, and I know it's cluttered, but we haven't gone through this food back here in a very long time. Most of it is probably out of date. We will remove it and make sure there is nothing on the floor and touching the ceiling."

Based on observations, interview, and review of the hospital's policy and procedures,the Critical Access Hospital's (CAH) Emergency Room failed to ensure safety of their patients in non-medical emergencies.


The findings are:

On 9/25/17 at 1:30 p.m., observations in the emergency room revealed there was no back-up lighting (flashlights) if the electrical system failed. The finding was verified by the Manager.

Hospital policy, titled, "Utilities Systems Failure Management Plan", reads, "....c. ensure flashlights and batteries are on hand in adequate supply....".

Based on observations, interview, and review of the hospital's policy and procedures, the hospital staff failed to discard expired medications from the patient area.


The findings are:


On 9/25/17 at 2:06 p.m., observations in the radiology control room cabinet revealed an expired bottle of ED-HD Barium Sulfate for suspension that had an expiration date of 3/2015. The findings were verified with Director 1 in an interview on 9/25/17 at 2:06 p.m., and he/she stated," We don't use these anymore. I bet she probably had that in here to order by."

Hospital policy, titled, "Oral Contrast for CT", reads, "....if a full bottle of Gastrografin is not used at time of procedure, the remaining Gastrografin must be recapped properly, dated and used within a three day period or the remaining bottle will be discarded and replaced with a new bottle....".

Based on observations, interviews, and review of the hospital's policies, entitled, "Hand Washing and Personal Hygiene", "Left Over Policy, and "Manual Pot and Pan Washing", the hospital failed to ensure a sanitary environment to prevent the risk of potential food borne illnesses for 3 of 3 hospital patients who ate from the hospital's kitchen. (Swing Bed Residents #1 and #2, and Patient #1)

The findings are:


Observations revealed a red sanitizer bucket in use for cleaning purposes that did not have a sufficient amount of sanitizer in it to register on a test strip. In interviews with the random dietary staff actively dish/pot-washing revealed the staff were not knowledgeable on the appropriate test strips to use to test the red sanitizer bucket or 3- compartment sink. Instructions on filling the 3- compartment sink were not posted as per policy, and the CDM was unable to provide documentation that the dietary aides had been educated relative to these concerns. Observations of the walk- in refrigerator revealed raw meats stored over and beside cooked or ready to eat food and food that had been opened but were not labeled with date opened or had labels that showed the foods had passed the use by date. Observations of random dietary staff revealed the dietary staff removed gloves and donned new gloves without handwashing in between gloving episodes, including multiple observations of the dietary aide in charge of the tray line, plating food, and cutting up food with gloved hands without washing his/her hands between the removal of soiled gloves and the donning of clean gloves. During 2 days of the survey, the hospital's ice machine was observed with a black substance along the top of the white insulator strip above the ice and visible when the ice machine door was opened.
One observation was made of 9 burgundy warming plate lids on the drying rack which had water droplets on them when separated.
The vents on the exhaust hood were dirty/dusty along with a grease/sticky substance noted on the bottom rectangular surfaces of the hood. Four of four random male dietary aides had facial hair that was not covered with a facial hair restraint to prevent the possibility of facial hair falling onto food contact surfaces while walking through the kitchen during food preparation and service.

Observations of the walk-in refrigerator on 9/25/17 at approximately 1:30 p.m. revealed raw meats stored over and next to fully cooked meats and/or ready to eat food. On the top shelf of the refrigerator shelving were boxes and bags of uncooked breakfast sausage, polska kielbasa, bacon, and country pudding. Directly below the raw meats on the second shelf from the top were 2 pans of cooked turkey. Next to the cooked turkey was a bag of raw hamburger meat along with bags of bologna, boxes of uncooked pork sausage, and 2 packages of deli meat. On the third shelf from the top were boxes of raw turkey wings next to 2 pans of cooked turkey. On a separate area of shelving just to the left as you enter the walk- in refrigerator, there was a bag of raw chicken next to a single serve container of fruit salad and other ready to eat food items. All the food was covered with aluminum foil or plastic wrap and/or were contained in boxes/bags, but there was a potential for cross contamination of the raw meats with the already
prepared cooked or ready to eat foods due to the storage and proximity of the items. Also noted in the walk-in refrigerator was a butter pound cake and whipped topping that had been opened but not dated; and an opened bag of prunes with a use by date that had passed (8/22/17). There was a potential for food borne illness if the food items had been used, without knowing how long the items had been stored since they weren't dated or had passed the use by date. The findings were verified by Certified Dietary Managers #1 and #2 who were present during the observation. A review of the hospital's policy provided by the hospital, entitled, "Left Over Policy ', revealed that all leftover foods must be properly dated with the date of preparation and discarded if not used within 72 hours of the preparation date.

Observations of the ice machine on 9/25/17 at 1:58 p.m. with Certified Dietary Manager (CDM) #1 revealed a black substance on the white insulation seal noted over the ice when the ice machine door was lifted up. When asked about the black substance, CDM #1 wiped the seal with a white towel and some of the black substance came off onto the towel. A second check of the ice machine on 9/26/17 at 9:12 a.m. revealed the white seal had not been cleaned and still contained the black substance present the day before. The finding was verified by CDM #1 who stated that maintenance was coming to fix the strip. Observations later that day on 9/26/17 revealed the black substance on the strip had been cleaned.

Observations on 9/25/17 at 2:00 p.m. revealed a drying rack where coffee cups and stacked plate covers were drying. When un-stacked, it was noted that 9 of the burgundy plate covers had small droplets of water on them. Having been stacked together, the lids were prevented from being able to completely air dry. The finding was verified by CDM #2 at the time of the observation.

Observations on 9/25/17 at 2:15 p.m. of the kitchen's exhaust hood revealed vents on the exhaust hood were dirty/dusty along with some grease droplets/sticky substance noted on the bottom rectangular surfaces of the hood. According to CDM #2, the hood is deep cleaned monthly by a contracted company and was last cleaned the first week of September 2017. CDM #2 stated they did not have an interim cleaning schedule in place to clean the hood in between the monthly deep cleanings.

Observations and interviews revealed dietary staff were not knowledgeable on the appropriate test strips to use to test for adequate sanitizer concentrations or the correct way to use them. On 9/25/17 at approximately 2:08 p.m., observations revealed Dietary Aide #3 washing pots and pans in the 3- compartment sink. When asked to test the third compartment for the appropriate amount of sanitizer solution, the dietary aide grabbed a container of Chlorine test strips to test the water. One of the CDMs present told him to use the Quaternary (quat) test strips instead. The facility was using a Quat sanitizer in the 3- compartment sink and not Chlorine. The dietary aide dipped the Quat test strip in the water for 3 seconds and removed it. When asked by the surveyor how long s/he should keep the test strip in the water, the dietary aide was unsure. The CDM instructed the dietary aide to put it in the water for 15 seconds. During the observation, Dietary Aide #3 was asked and stated that s/he had been employed as a dietary aide for 6 years. When asked if s/he had received any training on using the 3 -compartment sink, s/he stated that initially on hire s/he had received training, but could not recall any additional training. When asked how long s/he dipped the pots and pan in the sanitizing solution before removing them to dry, s/he hesitated, and then said they are dipped or left sitting for 3-4 minutes. A review of the hospital's policy at approximately on 9/25/17 3:30 p.m. indicated that the pots are to be dipped in the sanitizing solution for 1 minute.

The undated policy, entitled, "Manual Pot and Pan Washing", included information that reads, " ...5. The third sink should contain hot water with adequate chemical solution. All items should be completely submersed in the water and be allowed to soak for one minute. A test strip should be used to determine if the sanitizer is appropriate. Each type of sanitizer contains its own test strip and a representative of the company should provide information for testing. The sanitizer used at this facility is Quat and the test strips are located at the end of the 3-compartment sink ...7. The procedure for proper cleaning and sanitizing should be posted in the area of the 3 compartment sink. The instructions should include what sanitizer should be used and how much to add when filling the sink with water to a line on the third sink ...". The policy did not address the appropriate Quat concentration level to be obtained for appropriate sanitation or the length of time the test strips were to be dipped into the water.

During an interview on 9/25/17 at 3:20 p.m., CDM #1 verified s/he had to instruct Dietary Aide #3 on what test strips to use and how long to keep the strip dipped in the water. S/he verified s/he had told him/her to keep the strip in the water for 15 seconds. Observations of the facility's "Hydrion" Quat test strips with both CDMs revealed a dip time of 10 seconds listed on the strips and not 15 seconds as had been told to Dietary Aide #3. When asked how dietary aides/staff would know how many parts per million concentration the test strips would register to indicate adequate sanitizing concentration; or the length of dipping time for the strips and to dip the pots and pans, the CDM verified this information was not posted. S/he could not provide staff training for this. Observations of the kitchen revealed the instructions for using the 3-compartment sink had not been posted as per policy. According to CDM #1, the water and the Quat sanitizer come out of the faucet together in the adequate concentration for sanitation as per Ecolab, who set up the system. CDM #1 provided an Ecolab service inspection of the kitchen dated 9/6/17, which documented a quat sanitizer concentration of 300 (ppm) on 9/6/17, in range for appropriate sanitation.

Observations in the kitchen on 9/26/17 at 9:00 a.m. revealed a red sanitizer bucket on the sink counter(where dirty dishes are pre-rinsed before being placed in the dish machine. Water and what appeared to be old suds were noted in the bucket. When asked to test the red bucket for the appropriate amount of sanitizer, Dietary Aide #5 conducted the test with a Quaternary (quat) test strip appropriately, but the test strip did not register any sanitizer concentration in the water. When asked what the solution in the red bucket was used for, s/he stated it was used to clean/wipe the sink down. Dietary Aide #5 stated s/he had filled the red bucket about an hour ago. When asked how the bucket had been filled with the sanitizer and water, s/he shook his/her head and stated s/he was unsure and then, pointed to the recently posted signage that demonstrated how staff were to fill the 3- compartment sink.

Observations on 9/26/17 at 1:07 p.m. revealed Dietary Aide #7 washing pots in the 3- compartment sink. When asked to check the 3rd compartment sink for appropriate sanitizer concentration, Dietary Aide #7 asked the surveyor to wait a moment. Dietary aide #7 went to wash his/her hands and asked Dietary Aide #2 to come help him/her. Dietary Aide #2 came and handed Dietary Aide #7 a Chlorine test strip bottle. Dietary Aide #7 removed a Chlorine test strip and dipped it in the water, but the strip did not register any sanitizer. Dietary Aide #5 told them they were using the wrong test strips. Dietary Aide #2 then handed Dietary Aide #7 the Quat test strips; and Dietary Aide #7 stated, "What do I do, stick it in the water?" After testing, the sanitizer concentration was appropriate. During an interview immediately after the observation, Dietary Aide #2 stated it was his/her fault that s/he had given Dietary Aide #2 the test strips that were to be used for the dish machine instead of the 3- compartment sink. Dietary Aide #7 stated s/he had received training in September 2016 of last year.

Observations on 9/26/17 at 1:12 p.m. revealed Dietary Aide #5 pre-rinsing and loading dishes into the dish machine. When asked to check the red sanitizer bucket for the appropriate sanitizer concentration, s/he took a Chlorine test strip and dipped it in the sanitizer bucket. When it did not register any sanitizer concentration, s/he stated that s/he didn't ' know s/he was using the wrong ones (strips). When tested with the Quat test strip, there was an appropriate concentration of sanitizer in the bucket.

Observations of the lunch service in the kitchen on 9/26/17 from 11:17 a.m. - 12:18 p.m. revealed multiple instances of male dietary staff with unrestrained facial hair performing their duties throughout the kitchen. The male dietary aides were in and around active food service preparations and service during lunch; taking utensils to the tray line, stocking, serving food, transporting food, and washing dishes. The following aides were observed walking through the kitchen at the following times: Dietary Aide #5- 11:17 a.m., Dietary Aides #1, #2, and #3- 11:35 a.m., Dietary Aides # 2 and #3- 11:50 a.m., Dietary Aide #1- 11:58 a.m., Dietary Aides #1, #2, and #3- 12:07 p.m., Dietary Aides #2, #3, and #5- 12:18 p.m.

During interviews on 9/26/17 from 12:52 p.m. - 12:57 p.m., the dietary aides were asked if they knew they were supposed to wear beard or mustache restraints to prevent hairs from getting into food or food service items. Dietary Aide #1, who had a mustache and goatee, stated that he did not know a facial hair restraint was needed. Dietary Aide #2 who had a mustache and beard, stated he knew of the rule and stated they normally kept the facial hair restraints in the office. When asked, he brought back a few to show they were available. Dietary Aide #3 who had a mustache and beard, stated that the CDM had told him before that a facial hair restraint was needed. Dietary Aide #5 who had a mustache, stated he had never heard of needing a facial hair restraint.

Observations of the tray line service on 9/26/17 from 11:13 a.m. - 12:18 p.m. revealed multiple instances where Dietary Aide #4, who was plating food for the tray line, failed to wash his/her hands after removing gloves and donning clean gloves. A box of gloves was noted behind the steam table in easy access to Dietary Aide #4. During the observation, Dietary Aide #4 was noted to leave some of the soiled gloves s/he had removed on the table next to the box of clean gloves.

At approximately 11:30 a.m., Dietary Aide #4 removed gloves after checking food temperatures and donned new gloves without handwashing. After plating food/touching food utensils and plates at 11:43 a.m., s/he removed gloves and put on a new pair of gloves without handwashing to check food temperatures again. At approximately 11:55 a.m., Dietary Aide #4 was observed to use the same gloves to plate food, then used a knife and gloved hands to cut up a turkey wing into pieces, and plated the chopped meat. S/he changed gloves without handwashing, and plated more food. At about 12:00 noon, Dietary Aide #4 went to the employee/public access serving line, got a barbecued pork chop with a utensil, came back to the hospital tray line, changed gloves without handwashing in between, held the pork chop with his/her gloved hand, and used a knife to cut the meat off the pork chop and put it on a plate. S/he then removed his/her gloves, got a towel, wiped the BBQ sauce from the handle of the knife, and put on a new pair of gloves without handwashing.

At 12:02 p.m. during the same lunch tray service, Dietary Aide #6 was observed to walk to the hot box, remove his/her gloves, ball it up in his/her hand, open the hot box, and reach in and grab a bowl of food with the same hand s/he was using to hold the gloves that he/she just removed. S/he then went to the stove where s/he stated s/he was going to heat up the grits when asked what s/he was doing with the bowl. During an interview at 12:57 p.m., Dietary Aide #6 verified the findings, and stated that s/he usually did wash his/her hands.

At 12:04 p.m., Dietary Aide #4 was observed holding a pork chop with gloved hands, and cutting the meat off it with a knife. S/he then removed gloves and put on a new pair without handwashing, and plated food. At 12:08 p.m., s/he was observed plating food, getting clean bowls out of the hot box and touching the inside of the bowls with gloved hands. S/he then removed his/her gloves and put new ones on without handwashing. At 12:12 p.m., Dietary Aide #4 was observed using the same gloves to plate food and to hold a pork chop with his/her gloved hands and use a knife to cut the meat off. S/he then changed his/her gloves without handwashing. At 12:18 p.m., s/he was observed to remove gloves and put on a new pair without handwashing in between, take a knife and chop up a pork chop holding it with his/her gloved hands. S/he then removed 1 glove (right) and put on a new right hand glove without handwashing. During an interview on 9/26/17 at 1:00 p.m., Dietary Aide #4 stated that if s/he left the steam table and came back s/he would wash his/her hands before resuming the tray line; but if s/he stayed at the steam table, s/he normally did not wash hands in between glove changes.

A review on 9/26/17 of the undated hospital policy, entitled, "Hand Washing and Personal Hygiene", revealed, " ...2. Hand washing is the most important aspect of personal hygiene. Hand washing sinks shall have hot water, soap, and paper towels. Hands shall be washed accordingly: Hands must be washed: Before starting work...After touching anything that can be a source of contamination ...". The policy did not include information on what to do after removing soiled gloves, and prior to putting on clean gloves. During an interview on 9/26/17, the RD stated staff should be washing hands after removing soiled gloves prior to putting on a clean pair.

A review of information on 9/28/17 at 3:47 p.m., from SC DHEC (South Carolina Department of Health and Environmental Control) found on the website www.scdhec.gov/library/CR-01153.pdf, revealed information related to Retail Food Establishments, No Bare Hand Contact Guidelines, Regulation 61-25. The information included, "Guidelines for Single use Gloves", which stated to ..."always wash your hands before putting gloves on and when changing to a new pair; you should change gloves at the following times; As soon as they become soiled or torn, Before beginning a different task, and ...before handling ready-to-eat food ...". According to the information, gloves and other barriers do not replace handwashing.


31672

(THIS IS MARY RUETER'S REPORT)

Based on observations, interviews, and review of facility policies entitled "Hand Washing and Personal Hygiene", "Left Over Policy", and "Manual Pot and Pan Washing", the facility failed to ensure a sanitary environment to prevent the risk of potential food borne illnesses for 3 of 3 hospital patients who ate from the facility ' s kitchen. (Swing Bed Residents #1 and #2, and Patient #1)

Observation revealed a red sanitizer bucket in use for cleaning purposes did not have a sufficient amount of sanitizer in it to register on a test strip. Interviews with some of the dietary staff actively dish/pot-washing revealed they were not knowledgeable on the appropriate test strips to use to test the red sanitizer bucket or 3- compartment sink. Instructions on filling the 3- compartment sink were not posted as per policy, and the CDM was unable to provide documentation that the dietary aides had been educated relative to these concerns.

Observation of the walk- in refrigerator revealed raw meats stored over and beside cooked or ready to eat food; and food that had been opened but not dated or had passed the use by date.

Observations were made of dietary staff removing gloves and placing new gloves on without handwashing in between, including multiple observations of the dietary aide in charge of the tray line, plating food and cutting up food with gloved hands without washing his/her hands between the removal of soiled gloves and the placement of clean gloves.

On 2 days of the survey, the facility ' s ice machine was observed with a black substance along the top white insulator strip above the ice and visible when the ice machine door was opened.

One observation was made of 9 burgundy warming plate lids on the drying rack which had water droplets on them when separated (presumably stacked wet).

The vents on the exhaust hood were dirty/dusty along with a grease/sticky substance noted on the bottom rectangular surfaces of the hood.

Four of four male dietary aides with facial hair did not use facial hair restraints to prevent the possibility of facial hair falling onto food contact surfaces while walking through the kitchen during food preparation and service.

The findings included:

Observation of the walk-in refrigerator on 9/25/17 at approximately 1:30 p.m. revealed raw meats stored over and next to fully cooked meats and/or ready to eat food. On the top shelf of the refrigerator shelving were boxes and bags of uncooked breakfast sausage, polska kielbasa, bacon, and country pudding. Directly below the raw meats on the 2nd shelf from the top were 2 pans of cooked turkey. Next to the cooked turkey was a bag of raw hamburger meat along with bags of bologna, boxes of uncooked pork sausage, and 2 packages of deli meat. On the 3rd shelf from the top were boxes of raw turkey wings next to 2 pans of cooked turkey. On a separate area of shelving just to the left as you enter the walk- in refrigerator, there was a bag of raw chicken next to a single serve container of fruit salad and other ready to eat food items. All the food was covered (with aluminum foil or plastic wrap) and/or contained (boxed/bagged), but there was a potential for cross contamination of the raw meats with the already

prepared cooked or ready to eat foods due to the storage and proximity of the items. Also noted in the walk-in refrigerator was a butter pound cake and whipped topping that had been opened but not dated; and an opened bag of prunes with a use by date that had passed (8/22/17). There was a potential for food borne illness if the food items had been used, without knowing how long the items had been stored (since they weren ' t dated) or had passed the use by date. These findings were verified by Certified Dietary Managers #1 and #2 who were present during the observation. A review of the policy provided by the facility entitled "Left Over Policy ' , revealed that all leftover foods must be properly dated with the date of preparation and discarded if not used within 72 hours of the preparation date.

A check of the ice machine on 9/25/17 at 1:58 p.m. with Certified Dietary Manager (CDM) #1 revealed a black substance on the white insulation seal (noted over the ice when the ice machine door was lifted up). When asked about the black substance, CDM #1 wiped the seal with a white towel and some of the black substance came off onto the towel. A second check of the ice machine on 9/26/17 at 9:12 a.m. revealed the white seal had not been cleaned and still contained the black substance present the day before. This was verified by CDM #1 who stated that maintenance was coming to fix the strip. Observation later that day on 9/26/17 revealed the black substance on the strip had been cleaned.

Observation on 9/25/17 at 2:00 p.m. revealed a drying rack where coffee cups and stacked plate covers were drying out. When unstacked, it was noted that 9 of the burgundy plate covers had small droplets of water on them. Having been stacked together, the lids were prevented from being able to completely air dry. This was verified by CDM #2 at the time of the observation.

Observation on 9/25/17 at 2:15 p.m. of the kitchen ' s exhaust hood revealed vents on the exhaust hood were dirty/dusty along with some grease droplets/sticky substance noted on the bottom rectangular surfaces of the hood. According to CDM #2, the hood is deep cleaned monthly by a contracted company and was last cleaned the first week of September. CDM #2 stated they did not have an interim cleaning schedule in place to clean the hood in between the monthly deep cleanings.

Observations and interviews revealed dietary staff were not knowledgeable on the appropriate test strips to use to test for adequate sanitizer concentrations or the correct way to use them. On 9/25/17 at approximately 2:08 p.m., observation revealed Dietary Aide #3 washing pots and pans in the 3- compartment sink. When asked to test the third compartment for the appropriate amount of sanitizer solution, the dietary aide grabbed a container of chlorine test strips to test the water. One of the CDMs present told him to use the quaternary (quat) test strips instead. (The facility was using a quat sanitizer in the 3- compartment sink and not chlorine.) The dietary aide dipped the quat test strip in the water for 3 seconds and removed it. When asked by the surveyor how long s/he should keep the test strip in the water, the dietary aide was unsure. The CDM instructed the dietary aide to put it in the water for 15 seconds. During the observation, Dietary Aide #3 was asked and stated that s/he had been employed as a dietary aide for 6 years. When asked if s/he had received any training on using the 3 -compartment sink, s/he stated that initially on hire s/he had received training, but could not recall any additional training. When asked how long s/he dipped the pots and pan in the sanitizing solution before removing them to dry, s/he hesitated then said they are dipped or left sitting for 3-4 minutes. A review of the policy provided by the facility later at approximately 3:30 p.m. indicated that the pots are to be dipped in the sanitizing solution for 1 minute.

The undated policy, entitled "Manual Pot and Pan Washing", included information that " ...5. The third sink should contain hot water with adequate chemical solution. All items should be completely

submersed in the water and be allowed to soak for one minute. A test strip should be used to determine if the sanitizer is appropriate. Each type of sanitizer contains its own test strip and a representative of the company should provide information for testing. The sanitizer used at this facility is Quat and the test strips are located at the end of the 3-compartment sink ...7. The procedure for proper cleaning and sanitizing should be posted in the area of the 3 compartment sink. The instructions should include what sanitizer should be used and how much to add when filling the sink with water to a line on the third sink ...". The policy did not address the appropriate quat concentration level to be obtained for appropriate sanitation or the length of time the test strips were to be dipped into the water.

During an interview on 9/25/17 at 3:20 p.m., CDM #1 verified s/he had to instruct Dietary Aide #3 on what test strips to use and how long to keep the strip dipped in the water. S/he verified s/he had told him/her to keep the strip in the water for 15 seconds. Observation of the facility ' s "Hydrion" quat test strips (with both CDMs) revealed a dip time of 10 seconds listed on the strips (not 15 seconds as had been told to Dietary Aide #3). When asked how dietary aides/staff would know how many parts per million concentration the test strips would register to indicate adequate sanitizing concentration; or the length of dipping time for the strips and to dip the pots and pans, the CDM verified this information was not posted. S/he could not provide staff training for this. Observation of the kitchen revealed the instructions for using the 3-compartment sink had not been posted as per policy. According to CDM #1, the water and the quat sanitizer come out of the faucet together in the adequate concentration for sanitation as per Ecolab, who set up the system. CDM #1 provided an Ecolab service inspection of the kitchen dated 9/6/17, which documented a quat sanitizer concentration of 300 (ppm) on 9/6/17, (In range for appropriate sanitation).

Observation in the kitchen on 9/26/17 at 9:00 a.m. revealed a red sanitizer bucket on the sink counter (where dirty dishes are pre-rinsed before being placed in the dish machine). Water and what appeared to be old suds were noted in the bucket. When asked to test the red bucket for the appropriate amount of sanitizer, Dietary Aide #5 conducted the test with a quaternary (quat) test strip (appropriately), but the test strip did not register any sanitizer concentration in the water. When asked what the solution in the red bucket was used for, s/he stated it was used to clean/wipe the sink down. Dietary Aide #5 stated s/he had filled the red bucket about an hour ago. When asked how the bucket had been filled with the sanitizer and water, s/he shook his/her head and stated s/he was unsure; then pointed to the recently posted signage that demonstrated how staff were to fill the 3- compartment sink.

Observation on 9/26/17 at 1:07 p.m. revealed Dietary Aide #7 washing pots in the 3- compartment sink. When asked to check the 3rd compartment sink for appropriate sanitizer concentration, Dietary Aide #7 asked the surveyor to wait a moment. Dietary aide #7 went to wash his/her hands and asked Dietary Aide #2 to come help him/her. Dietary Aide #2 came and handed Dietary Aide #7 a chlorine test strip bottle. Dietary Aide #7 removed a chlorine test strip and dipped it in the water, but the strip did not register any sanitizer. Dietary Aide #5 told them they were using the wrong test strips. Dietary Aide #2 then handed Dietary Aide #7 the quat test strips; and Dietary Aide #7 stated, "What do I do, stick it in the water?" After testing, the sanitizer concentration was appropriate. During an interview immediately after the observation, Dietary Aide #2 stated it was his/her fault, that s/he had given Dietary Aide #2 the test strips that were to be used for the dish machine (instead of the 3- compartment sink). Dietary Aide #7 stated s/he had received training in September of last year.

Observation on 9/26/17 at 1:12 p.m. revealed Dietary Aide #5 pre-rinsing and loading dishes into the dish machine. When asked to check the red sanitizer bucket for the appropriate sanitizer concentration, s/he took a chlorine test strip and dipped it in the sanitizer bucket. When it did not register any sanitizer concentration, s/he stated that s/he didn ' t know s/he was using the wrong ones (strips). When tested with the quat test strip, there was an appropriate concentration of sanitizer in the bucket.

Observation of the lunch service in the kitchen on 9/26/17 from 11:17 a.m. - 12:18 p.m. revealed multiple instances of male dietary staff with unrestrained facial hair performing their duties throughout the kitchen. These male dietary aides were in and around active food service preparations and service during lunch; taking utensils to the tray line, stocking, serving food, transporting food, and washing dishes. The following aides were observed walking through the kitchen at the following times: Dietary Aide #5- 11:17 a.m., Dietary Aides #1, #2, and #3- 11:35 a.m., Dietary Aides # 2 and #3- 11:50 a.m., Dietary Aide #1- 11:58 a.m., Dietary Aides #1, #2, and #3- 12:07 p.m., Dietary Aides #2, #3, and #5- 12:18 p.m.

During interviews on 9/26/17 from 12:52 p.m. - 12:57 p.m., the dietary aides were asked if they knew they were supposed to wear beard or mustache restraints (to prevent hairs from getting into food or food service items). Dietary Aide #1 who had a mustache and goatee, stated that he did not know a facial hair restraint was needed. Dietary Aide #2 who had a mustache and beard, stated he knew of the rule and stated they normally kept the facial hair restraints in the office. When asked, he brought back a few to show they were available. Dietary Aide #3 who had a mustache and beard, stated that the CDM had told him before that a facial hair restraint was needed. Dietary Aide #5 who had a mustache, stated he had never heard of needing a facial hair restraint.

Observation of the tray line service on 9/26/17 from 11:13 a.m. - 12:18 p.m. revealed multiple instances where Dietary Aide #4, who was plating food for the tray line, failed to wash his/her hands after removing gloves and putting on clean gloves. A box of gloves was noted behind the steam table in easy access to Dietary Aide #4. During the observation, Dietary Aide #4 was noted to leave some of the soiled gloves s/he had removed on the table next to the box of clean gloves.

At approximately 11:30 a.m., Dietary Aide #4 removed gloves after checking food temperatures and applied new gloves without handwashing. After plating food/touching food utensils and plates at 11:43 a.m., s/he removed gloves and put on a new pair without handwashing to check food temperatures again. At approximately 11:55 a.m., Dietary Aide #4 was observed to use the same gloves to plate food, then used a knife and gloved hands to cut up a turkey wing into pieces, and plated the chopped meat. S/he then changed glov

Based on a review of the hospital's current diet manual, entitled, "Simplified Diet Manual Nutrition Care Guide", and interviews, the hospital failed to follow proper procedures to update and review their dietary manual to prevent potential nutritional problems for patients served. The manual did not contain information relative to the Low Concentrated Sweets (LCS) diet listed on the menu spreadsheets.


The findings included:


During an interview on 9/25/17 at 2:50 p.m., the surveyor and Certified Dietary Manager (CDM) #1 reviewed the hospital's current in use dietary manual, entitled, "Simplified Diet Manual Nutrition Care Guide", copyrighted 2011. CDM #1 verified the manual was more than 5 years old with no revisions noted, and that the RD (Registered Dietician) and Medical Director had failed to sign the annual review of the manual. A form located in the diet manual binder, entitled, "Diet Manual Review and Approval", stated, " ...The diet manual should be reviewed and approved annually by the registered dietician, director of nursing, medical director, and the administrator. The therapeutic diet prescriptions generally utilized are described in this manual. The diet manual should be revised at least every three years. Diet manuals should be accessible to both the food service and nursing staff ...". The last time the RD and Medical Director signed the review was in June/July of 2016.

A continued review revealed the dietary manual did not contain information corresponding with the Low Concentrated Sweets (LCS) therapeutic diet listed on the hospital's menu spreadsheets and policy. According to CDM #1, the LCS diet the facility used included the use of smaller portions of sweets or items that contain sugars. The diet manual included information related to a consistent carbohydrate diet, but did not include a LCS diet. During an interview on 9/26/17, the Registered Dietician was notified the manual was not in date within 5 years as per regulation, and had not been signed by the Medical Director or RD indicating the annual review for the current year. When asked, s/he indicated the LCS diet was different than a consistent carbohydrate diet.

Based on record review and interview, the hospital failed to ensure physician orders for Intravenous (IV) catheter was obtained for 2 of 17 closed patient records. (Patient 1 and 11)

The findings are:

On 9/27/17 at 10:23 a.m., review of closed Patient 11's record revealed the patient was admitted on 6/25/17 with a diagnosis of Gastroparesis and an IV catheter was in place during the patient's hospital stay, but there was no physician order for the IV catheter. The findings were verified at 1:35 p.m. on 9/27/17 with the Chief Nursing Officer (CNO).


39208

On 9/26/17 at 11:30 a.m., review of the closed record for Patient #1 revealed the patient had an intravenous catheter in lace but no physician order for the intravenous (IV) catheter was in the patient's chart. The finding was verified by Chief Nursing Officer (CNO) at 10:30 a.m. on 9/27/17.

Based on record reviews and review of the hospital's policy and procedures, the hospital failed to ensure the nursing care plan was reviewed and/or revised the patient's plan of care daily for 3 of 17 closed patient's records for care and services. (Patient 4, 9, and 15)

The findings are:

On 9/27/17 at 9:30 a.m., review of closed Patient 9's chart revealed the patient was admitted on 9/9/17 for Pyelonephritis and the patient's plan of care was initiated on 9/9/17. The patient's plan of care was not addressed on 9/10/17 or 9/11/17. On 9/27/17 at 1:40 p.m., the findings were verified with the Chief Nursing Officer.



39208

On 9/26/17 at 1:30 p.m., review of (closed)Patient #4's chart revealed the patient's plan of care was not updated on 7/15/17 by nursing. The finding was verified by the Chief Nursing Officer (CNO) at 2:40 p.m. on 9/27/17.

On 9/27/17 at 9:30 a.m., review of (closed)Patient #15's chart revealed the plan of care was not updated on 6/27/17 by nursing. The finding was verified by the CNO at 2:46 p.m. on 9/27/17.

Based on record reviews and interview, the Critical Access Hospital's (CAH) Medical Record Department failed to ensure completed medical records on one (1) closed patient record of twenty (20) patient charts. (Closed Patient 17)


The findings are:


On 9/27/17 at 12:06 p.m., review of closed Patient #17's chart revealed a History and Physical (H & P) was dictated by the physician on 7/20/17 and signed by the physician on 7/21/17. The patient was admitted on 7/18/17 at 14:48. The finding was verified by the Chief Nursing Officer (CNO) on 9/27/17 at 2:57 p.m.

Hospital policy and procedure, titled, "Completion and Requirements and Time Frames for Dictation and Transcription of Documents and Content of the Medical Record for Completed Record", reads, "....History and Physical- Written or Dictated- within 48 hours of admission and authenticated by dictating physician or partner....".

Based on record reviews and interview, the Critical Access Hospital's (CAH) Medical Record Department failed to maintain completed medical records for four (4) of 17 closed patient records.


The findings are:


On 9/26/17 at 12:35 p.m., review of closed Patient #2's chart revealed a missing physician progress note for 7/16/17. The finding was verified on 9/27/17 at 2:52 p.m. by the Chief Nursing Officer (CNO).

On 9/26/17 at 1:30 p.m., review of closed Patient #4's chart revealed a missing physician progress note for 7/15/17. The finding was verified on 9/27/17 at 2:40 p.m. by the CNO.

On 9/27/17 at 10:40 a.m., review of closed Patient #13's chart revealed a missing physician progress note for 7/16/17. The finding was verified on 9/27/17 at 2:55 p.m. by the CNO.

On 9/27/17 at 12:06 p.m., review of closed Patient #17's chart revealed a missing physician progress note for 7/19/17. The finding was verified on 9/27/17 at 2:57 p.m. by the CNO.

Hospital policy and procedure, titled, "Completion and Requirements and Time Frames for Dictation and Transcription of Documents and Content of the Medical Record for Completed Record", reads, "....Progress Notes- written or dictated daily or prn as patient's condition warrants....".

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 authenticated in a timely manner by the physician for 3 of 17 closed patient records. (Patient 10, 12, and 15)

The findings are:


On 9/27/17 at 9:50 a.m., review of closed Patient 10's record revealed the patient was admitted on 8/18/17 for COPD(Chronic Obstructive Pulmonary Disease) Exacerbation. On 8/18/17 at 9:40 a.m., a verbal physician order was written by the nursing staff for a CT (computerized axial tomography scan) of the head, but the physician didn't authenticate the order until 8/29/17 at 12:32 p.m.

On 9/27/17 at 10:30 a.m., review of closed Patient 12's record revealed the patient was admitted on 7/27/17 for Acute Pancreatitis. On 8/01/17 at 10:39 a.m., a verbal physician order was written by the nursing staff for Hydromorphone (Dilaudid) 2 milligrams (mg) intravenously (IV) as needed every 4 hours for pain. The physician didn't authenticate the order until 8/06/17 at 12:43 p.m.

The findings were verified in a record review with Licensed Practical Nurse (LPN) 1 at 3:10 p.m. on 9/27/17.

Review of the facility Policy and Procedure, "Verbal Orders", reads "....all verbal orders for narcotic medications and restraints will be electronically signed by the ordering physician within 24 hours of giving the verbal order....".



39208

On 9/27/17 at 9:30 a.m., review of Patient #15's chart revealed two (2) physician telephone orders dated 6/26/17 that were signed by the physician on 6/30/17. The findings were verified by the Chief Nursing Officer (CNO) at 2:46 p.m. on 9/27/17.

Based on record review, interview, and review of hospital policy and procedures, the hospital staff failed to obtain written order for 2 of 17 closed patient charts. (Patient 10 and 14)

The findings are:

On 9/27/17 at 11:55 a.m., review of closed Patient 14's record revealed the patient was admitted on 8/8/17 for a diagnosis of Pancreatitis. A physician order for a Posey restraint was obtained on 9/7/17 at 12:40 p.m., but the physician order was not authenticated by the physician until 9/9/17 at 8:18 p.m. The physician order was renewed on 9/8/17 at 1:01 p.m., but was not authenticated by the physician until 9/9/17 at 8:18 p.m. On 9/27/17 at 1:40 p.m., the findings were verified with Chief Nursing Officer.


31672

On 9/27/17 at 9:50 a.m., review of closed Patient 10's record revealed the patient was admitted on 8/18/17 for COPD(Chronic Obstructive Pulmonary Disease) Exacerbation. On 8/18/17 at 9:51 a.m., an order was obtained from the physician for a Posey vest restraint for patient safety to be renewed every twenty four (24) hours. The physician didn't authenticate the order until 8/29/17 at 12:32 p.m. The findings were verified with the Chief Nursing Officer on 9/27/17 at 3:15 p.m.

Review of the hospital's policy and procedure, titled, "Verbal Orders", reads, "....all verbal orders for narcotic medications and restraints will be electronically signed by the ordering physician within 24 hours of giving the verbal order....".