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Based on interview, record review, and policy review, the facility failed to ensure that patients received information regarding their patient rights. This had the potential to affect all patients in the facility, including outpatients and emergency room patients. The facility census was 53.

Findings included:

1. Record review of the facility policy titled, "Rights & Responsibilities of Patients" reviewed 03/01/08 stated the patient, family, and/or legal representative shall receive a written, concise copy of his/her right and responsibilities upon admittance to the hospital.

2. During an interview on 09/13/11 at 10:50 AM, Staff M, Admissions Clerk, stated that patients are not given "Patient Rights" in the Emergency Department .

3. During an interview on 09/13/11 at 11:00 AM, Staff OO, Registered Nurse (RN), stated that the Admitting Department staff give patients their Patient Rights.

4. During an interview on 09/13/11 at 11:00 AM, Staff II, Admitting Department Supervisor could not find "Patient Rights" material and stated, "We don't give (Patient Rights) out to the patients anymore".

5. During an interview on 09/13/11 at 11:10 AM, Staff D, Medical/Surgical (M/S) Director stated that the electronic medical record contained a checkbox titled "all info". Staff check this box when they reviewed the rights with the patient. A copy of the patient rights are located in the patient rooms in a blue folder, hanging on the wall.

6. Record review of Patient #12's current electronic medical record showed that Staff FF, Graduate Nurse (GN), had documented that he/she had reviewed "all info" with the patient.

During an interview on 09/13/11 at 11:00 AM, Staff FF, GN stated that the Admitting Department staff reviewed patient rights with the patients, not the nurses.

7. Record review of Patient #14 current electronic medical record showed that staff checked the "all info"box, indicating staff had reviewed the "Patient Rights" information reviewed with the patient.

8. During an interview on 09/13/11 at 1:45 PM, Patient #14 stated that:
-He/she did not know what his/her Patient Rights were;
-No one had reviewed the blue folder with him/her (which was hanging in the patient's room);
-He/she did not know what was in the blue folder.


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Based on interview, record review, and policy review, the facility failed:
-To ensure grievances were promptly resolved for ten (#37, #38, #39, #40, #41, #50, #51, #52, #53 & #54) of 12 patient grievances reviewed. This had the potential to affect all who filed a grievance. The facility census was 53.

Findings included:

1. Record review of the facility's policy titled, "Patient Grievance Procedure" revised on 03/01/08, showed the following:
-A patient grievance is a written or verbal complaint by a patient or patient representative, regarding the patient's care;
-Whenever a complainant requests a written response from the hospital, the complaint must be treated as a grievance;
-If a verbal patient care complaint cannot be resolved at the time of the complaint and requires further actions for resolution, the complaint is a grievance;
-The goal is to respond to each complaint/grievance within two business days;
-If the grievance cannot be resolved within seven days, the patient or patient representative must be contacted by the hospital and informed that the hospital is still working to resolve the grievance and the hospital will follow-up with a written response within a stated number of days and;
-The hospital must attempt to resolve all grievances as soon as possible.

2. During an interview on 09/14/11 at 9:25 AM, Staff HH, Emergency Department (ED) Director stated that complaints and grievances about physicians or their care are managed by the ED Medical Director.

3. Record review of Patient #37's grievance dated 06/16/11, showed the patient complained that a physician had ripped a bandage off of a wound, which made the wound larger. There was no additional information related to the grievance other than a note stating that the physician involved had not been followed-up with, indicating the grievance was still not resolved.

3. Record review of Patient #38's grievance dated 03/23/11, showed that the patient complained he/she was misdiagnosed and required hospitalization and surgery at another hospital. Attached to the grievance was an email dated 04/15/11, which showed that the patient had called several times about his/her complaint, and that no one ever called the patient back, indicating the grievance was still not resolved..

5. Record review of Patient #39's grievance dated 07/28/11, showed that the patient complained he/she was misdiagnosed. There was no investigation of follow-up documented on the grievance, indicating the grievance was still not resolved.

6. Record review of Patient #40's grievance dated 08/12/11, showed that a patient complained a physician made a rude comment to him/her and wanted a letter of apology.
There was no investigation of follow-up documented on the grievance, indicating the grievance was still not resolved.

7. Record review of Patient #41's grievance dated 07/25/11, showed that the patient's representative complained the patient was treated in the ED and released, went to another facility, and required four days of hospitalization for two infections, and operative care. There was no investigation of follow-up documented on the grievance, indicating the grievance was still not resolved.

8. During an interview on 09/14/11 at 1:45 PM, Staff HH stated that he/she was not working as director prior to the end of July, 2011 and found a stack of complaints and grievances in the previous directors office that had not been addressed. Staff HH added that:
-He/she did forward both of the physician related grievances to the ED Medical Director;
-The ED Medical Director forwards the grievances to the ED contract group's Risk Management;
-He/she was not sure where the grievances were currently in the process or if they had been resolved.

9. During an interview on 09/14/11 at 2:50 PM, Staff A, Director of Patient Care Services stated that grievances which dated back to the previous ED Medical Director (July 2011 and prior) were not addressed and that Patient #39, #40, and #41's grievances should be in process with the current ED Medical Director.

10. During an interview on 09/15/11 at 9:27 AM, Staff LL, ED Medical Director stated the following:
-The facility expected complaints and grievances to be followed up on in 48 hours;
-Some of the complaint and grievances that were "stumbled upon" were old and needed to be addressed immediately;
-He/she has been the ED Medical Director since July, 2011;
-The oldest complaint or grievance he/she received was dated 07/17/11 (58 days old), which was provided to him/her this morning (09/15/11);
-He/she had never seen Patient #41's grievance (50 days old);
-He/she received Patient #40's grievance one week ago (34 days old), but had not followed-up with the physician involved;
-He/she had reviewed the chart for Patient #39's grievance (48 days old), but had not followed up.


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11. Record review of "the Patient/Customer Complaint Form" of discharged Patient #50's grievance dated 09/06/11 at 9:10 AM by email, showed the patient complained of waiting time and delay of service. There was no check mark indicating if the patient complained in person, letter, telephone, hot line or survey The form showed the patient expected a response by phone. A response is documented as given by phone on 09/06/11 at 10:30 PM. There was no letter documented as being sent to the patient.

12. Record review of the "Patient/Customer Complaint Form" of discharged Patient #51's grievance dated 07/18/11 at 8:30 AM showed the patient complained of unfriendly staff and discrimination due to being a Medicaid patient. There was no check mark indicating if the patient complained in person, letter, telephone, hot line or survey. The form does not indicated if this was determined to be a complaint or a grievance. There was no letter documented as being sent to the patient.

13. Record review of the "Patient/Customer Complaint Form" of discharged Patient #52's grievance dated 07/30/11 at 7:45 PM showed the patient's daughter complained in person stating no staff checked on the patient for an hour after taking blood. The form does not indicated if this was determined to be a complaint or a grievance. The form also did not indicate if the patient's daughter was satisfied with the facility phone call. There was no letter documented as sent to the patient.

14. Record review of the "Patient/Customer Complaint Form" of discharged Patient #53's grievance dated 7/28/11 at 9:00 AM showed the patient had telephoned the facility complaining of poor treatment in the ED. Patient stated he/she was sent for an x ray and suffered a fall. The form stated that the customer expects response by a letter. The Investigative Follow Up stated the patient was called on 08/01/11 and the patient asked that he/she be called back on 08/04/11 and a message was left at 11:20 AM. No further calls were received by the patient. There was no letter documented as sent to the patient.

15. Record review of a typed plain 8 x 12 paper titled "Patient Complaint" of Patient # 54 with a visit date of 12/22/10 showed a communication (date unknown) from unknown staff regarding a complaint (unknown how it was made) regarding the timeline of care in the ED. The concern was addressed, according to this letter, by a phone call to the patient's spouse. There were no specifics as to the resolution of these concerns except "some changes occurring here that were not in place during their visit". There was no letter documented as sent to the patient.

16. Record review of a typed plain 8 x 12 paper titled "Complaint" stated the facility staff (no name) had called the complainant on 05/02/11 at 4:00 PM concerning the lack of care and caring from the physician in the ED for Patient #55. The facility staff stated in the letter of the "process charges that were coming". There was no letter documented as being sent to the complainant.

17. During an interview on 09/15/11 at 9:00 AM Staff C, Director of Quality, stated that the process for grievances and complaints were as follows: The staff from Customer Care Line is for you to report any concern, suggestion, compliment or complaint related to patient care at our hospital form and the form is sent to the manager of the affected department with a copy going to Staff C. The manager is to then investigate the concern and respond to the complainant. Staff C stated that responses were supposed to be within two days of receiving the concern. Staff C stated that there was no education given to unit managers as to what was supposed to be contained in the letter a complainant was sent. Staff C confirmed the above grievance forms and responses or lack of responses did not fulfill the regulatory requirement.

Based on interview, record review, and policy review, the facility failed to ensure that a patient or patient representative received a written response to their grievance which included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for five (#37, #38, #39, #40, and #41) of twelve patient grievances reviewed. This had the potential to affect all patients with a filed grievance, or grievance filed on their behalf. The facility census was 53.

Findings included:

1. Record review of the facility's policy titled, "Patient Grievance Procedure" revised on 03/01/08, showed that all grievances will receive a written response within seven business days, which will include:
-The steps taken on behalf of the patient to investigate the grievance;
-The results of the grievance process;
-The date of completion;
-That if the grievance cannot be resolved within the seven day time frame, the patient or patient representative must be contacted by the hospital and informed that the hospital is still working to resolve the grievance and the hospital will follow-up with a written response within a stated number of days.

2. Record review of Patient #38's grievance dated 03/23/11, showed that the patient complained he/she was misdiagnosed and required hospitalization and surgery at another hospital. Attached to the grievance was a typed letter dated 04/20/11, addressed to the patient. The letter acknowledged the patient's complaint, but did not include the steps taken to investigate the complaint or the outcome of the investigation.

4. Record review of Patient #37's grievance dated 06/16/11, showed the patient complained that a physician had ripped a bandage off of a wound, which made the wound larger. There was no indication that a written response to the grievance had been sent to the patient.

5. Record review of Patient #39's grievance dated 07/28/11, showed that the patient complained he/she was misdiagnosed. There was no indication that a written notice had been sent to the patient.

6. Record review of Patient #40's grievance dated 08/12/11, showed that a patient complained a physician made a rude comment to him/her and wanted a letter of apology.
There was no indication that a written response to the grievance had been sent to the patient.

7. Record review of Patient #41's grievance dated 07/25/11, showed that the patient's representative complained the patient was treated in the ED and released, went to another facility, and required four days of hospitalization for two infections, and operative care. There was no indication that a written response to the grievance had been sent to the patient's representative.

8. During an interview on 09/14/11 at 1:45 PM, Staff HH stated that:
-Patient #37 and Patient #41's grievances did not receive a written response;
-He/she did forward the physician related grievances to the ED Medical Director;
-He/she was responsible for sending response letters to patients or patient representatives that involved non-physician, ED care, but was not sure about the physician related grievances;
-He/She had not sent any response letters since he/she assumed role as ED Director in July 2011.

9. During an interview on 09/14/11 at 2:50 PM, Staff A, Director of Patient Care Services stated that when he/she sends a response letter to a patient grievance, he/she does not include the resolution or outcome of the investigation in the letter.

Based on interview and record review the facility failed to identify performance improvement/quality assessment issues related to patient care and services provided by Materials Management Services (MMS) and Contracted service providers (for linen, for positron emission tomography (PET) and computer tomography (CT), for laboratory services, for speech language pathology and for preventive maintenance) by collecting pertinent data to measure, analyze and implement any necessary corrective systems. The facility census was 53.

Findings included:

1. During an interview on 09/14/11 at 9:58 AM Staff C, Director of Quality Management (QM) stated the following:
-He/she received the reports from most of the department's performance improvement (PI)/ quality assessment (QA) projects.
-MMS maintained a (PI) project that measured the number of "out of stock items" with a goal of less than five items "out" per day.

Record review of the MMS PI/QA report showed the following:
-The department had provided data for the last fifteen months.
-Graphed data showed rates of outages ranged from nineteen to eighty-six percent in some months.
-The stated goal was "less than five (no higher than one hundred percent)"

During the same interview on 09/14/11 at 10:00 AM Staff C reviewed the MMS report and stated he/she did not understand the numbers reported and the related graphing and could not explain the MMS PI study.

During an interview on 09/15/11 at 9:40 AM Staff NN, Director of MMS stated the following:
-MMS maintained a PI/QA project counting "out of stock" items.
-The PI/QA project measured and reported "out of stocks" (which was when those items were requisitioned but not on the shelves).
-All of the over three thousand items in MMS were counted in the study in an equal manner (patient care and non-patient care items were counted the same for the PI/QA report).
-He/she gave an example of a requisition for a pencil (and not on the MMS shelf) as being equal to a requisitioned direct patient care supply item.
-He/she had decided on the PI/QA study topic and parameters.
-He/she has studied the same topic for a "couple of years".
-He/she reported the study results to the QA program director and reported annually to the Quality Council.
-The study was not a measure of the negative impact of lack of patient care supply items because MMS would get any of those items "as soon as possible".

2. During an interview on 09/14/11 at 9:58 AM, Staff C, Director of Quality Management (QM) stated the program areas not reporting for the last fiscal year were:
-The contractor providing patient linen services.
-The contractor providing positron emission tomography (PET, an imaging test that produces three-dimensional images) and computer tomography (CT, cross-sectional images of body structures processed through a computer, producing a three-dimensional image or tomogram).
-The contractor providing some laboratory services.
-The contractor providing speech language pathology services (speech and swallowing problems).
-The contractor providing preventive maintenance services for patient care equipment.

3. During an interview on 09/14/11 at 9:58 AM Staff Z, Assistant Administrator for Professional Services stated assessments of each individual contractor was done but not reported through the PI/QA program or through Staff C.

4. Record review of documents titled "Contracted Services Evaluation" provided by Staff Z as PI/QA assessments showed the following:
-An undated check sheet (satisfactory or unsatisfactory) of the linen services contractor outlining requirements including relations with others, communication skills, attitudes and performance/competence factors including use of time, level of understanding of the facility, commitment to safety, participation in PI activities and meets facility expectations.
-The same undated form for the PET/CT scanning contractor.
-The same form check marked for the laboratory testing contractor dated 07/26/11.
-The same form check marked for the speech language pathology contractor dated 07/20/11.
-The same undated form for the preventive maintenance contractor.

5. During an interview on 09/15/11 at 11:50 AM Staff Z stated the Contracted Services Evaluations were the only assessments done on the contractors and the evaluations were not quality assessments of work provided by the contractors (such as cleanliness of the sheets and towels).

Based on interview, record review, and policy review, the facility failed to ensure that Patient Controlled Analgesic (PCA - large syringes of pain medication in which the administration of the medication is controlled by a pump and the patient) was documented according to policy for one (#44) of three patient records reviewed. This had the potential to affect any patient with a PCA, which could lead to possible diversion of the medication, overdosing, or underdosing errors. The facility census was 53.

Findings included:

1. Record review of the facility's policy titled "Patient Controlled Analgesic Infusion" revised on 05/12/10, showed direction for nursing to document the dosage amount infused every four hours.

2. Record review of Patient #44's current electronic medical record showed missing PCA dosage documentation for the following times:
-between 09/08/11 at 9:41 AM and 2:47 PM (greater than five hours);
-between 09/09/11 at 2:07 PM and 9:20 PM (greater than six hours);
-between 09/09/11 at 9:20 PM and 09/10/11 6:47 AM (greater than nine hours);
-between 09/10/11 at 10:38 AM and 6:00 PM (greater than seven hours);
-between 09/10/11 at 10:00 PM and 09/11/11 at 6:28 AM (greater than eight hours).

During an interview on 09/13/11 at 2:07 PM, Staff D, (M/S) Medical/Surgical Director stated that the PCA amount infused should be documented every four hours.

Based on interview, record review, and policy review, the facility failed to ensure that physician orders were signed, dated, and timed according to policy for three (#1, #45, and #46) of five patient charts reviewed for authentication. This had the potential to affect all patients in the facility. The facility census was 53.

Findings included:

1. Record review of the facility's policy titled "Physician's Orders" revised on 07/01/09, showed the following:
-Orders will be signed, dated, and timed by a physician within 24 hours;
-An order will be reviewed and verified for completeness by a licensed provider every 24 hours, signed, timed, and dated as a 24-hour chart review;
-Written orders by a physician, verbal order by a physician, telephone orders by a physician, and standing orders will all be signed by the physician within 24 hours;
-Verbal or phone orders require the person to document on the physician order sheet "verbal orders read back".

2. Record review of the facility's policy titled, "Physician Orders: Written, Faxed, or Verbal" revised on 08/11/10, showed the following:
-The responsible practitioner will countersign, date, and time telephone orders for medication within 24 hours;
-The staff member receiving the order (verbal or telephone) will sign the transcribed order, including date and time of transcription;
-It is the responsibility of the prescribing physician to review and countersign the telephone or verbal order as soon as possible and no later than 24 hours after the event;
-During daily rounds the physician will sign any unsigned order, thus indicating a review of the order for appropriateness;
-Nursing will review physician orders each day and will bring unsigned verbal order to the attention of the attending physician.

3. Record review of the facility's undated Rules and Regulations showed that all orders will be signed by the attending physician or his designee within 48 hours (which differed from the policy's allotted time for a physician's signature).

4. Record review of Patient #1's current medical record on 09/12/11 at 1:45 PM showed the following:
-A 09/10/11 telephone order for wound care did not have a time the order was written when obtained by the nurse;
-A 09/10/11 order for a Peripherally Inserted Central Catheter (PICC - vein access), written by a nurse, did not specify if the physician's order was a verbal order, a telephone order, or a standing order, and was not signed, dated, or timed by the physician;
-The ICU (Intensive Care Unit) Admission Orders, which were initiated by a nurse, did not include the date or time the orders were initiated and did not include a physician's signature;
-The Oxygen Protocol (pre-written, physician approved orders), which were initiated by a nurse, did not include the date or time the orders were initiated and did not include a physician's signature.

During an interview on 09/12/11 at 2:20 PM, Staff EE, ICU Director made the following statements about Patient #1's physician orders:
-The 09/10/11 telephone order for wound care did not have a time the order was written when obtained by the nurse;
-The 09/10/11 order for a Peripherally Inserted Central Catheter (PICC - vein access), written by a nurse did not specify if the physician's order was a verbal order, a telephone order, or a standing order, and was not signed, dated, or timed by the physician;
-The ICU Admission Orders, which were initiated by a nurse, did not include the date or time the orders were initiated and did not include a physician's signature;
-The Oxygen Protocol which were initiated by a nurse, did not include the date or time the orders were initiated and did not include a physician's signature.

5. Review of Patient #45's current medical record showed a physician's order dated 09/14 (without year), was signed (indicating it had been reviewed for completeness), but was timed "AM".

6. Review of Patient #46's current medical record showed a Standing Order for Patient Controlled Analgesic. The signature line showed that the order was initiated as a phone order, but did not include a date and time of initiation.

7. During an interview on 09/12/11 at 2:20 PM, Staff EE, Intensive Care Unit (ICU) Director stated that physicians are required to sign all orders within 24 hours.

Based on observation, interview and record review, Rehabilitation Services and Engineering Services staff failed to ensure patient care equipment was checked periodically and maintained to ensure safe patient use. This failure had the potential to effect all inpatients and out patients treated in the Rehabilitation gyms. The facility census was 53.

Findings included:

1. Record review of the facility's policy titled "Equipment Management", dated 04/30/10, showed the following:
-An equipment management program and safety testing schedule shall be maintained for equipment related directly and indirectly to patient care, both electrical and non-electrical.
-The equipment management program included an inventory list of all fixed and portable mechanical and electrical patient care equipment.
-Equipment listed on the inventory must be tested for safety and performance and undergo preventive maintenance periodically (maximum testing interval was annually).

Record review of the facility's policy titled "Patient Care Equipment, Testing and Inspection", dated 04/30/10, showed the following:
-All patient care equipment will be checked before use to insure proper performance and safety.
-An independent contract company performed the initial patient care equipment checks.
-Testing and preventive maintenance were performed according to manufacturer's recommendations by the contractor.

Record review of the current contract agreement (provided during the survey by Staff X, Director of Engineering) showed the following:
-The contractor provided the facility with safety inspection and preventive maintenance of equipment.
-All patient care equipment will be serviced at least once a year.

2. Observation on 09/13/11 at 2:00 in the Rehabilitation and Wellness outpatient clinic location showed the following:
-Gel warmer without a PM sticker.
-"Game Ready", (exercise machine with electric monitoring equipment) with a PM sticker dated 04/10.
-Freezer unit for ice packs without a PM sticker.
-Paraffin bath (heated wax) without a PM sticker.
-Two treadmills, two exercise bicycles, arm bicycle, stepper (stair climber) all with PM stickers dated 10/09.
-Traction table with a PM sticker dated 10/07.

3. During an interview on 09/13/11 at 2:00 PM Staff Y, Director of Rehabilitation Services (RS) stated the following:
-The facility Engineering department maintained a listing of RS equipment for preventive maintenance (PM) checks.
-Engineering and a contracted service checked only the electrically operated equipment.
-Staff Y relied on Engineering to maintain the process of checking electrical equipment for safety.
-All electrically operated RS equipment was stickered (adhesive sticker placed on the equipment) with a hand written next date due for re-checking.

During an interview on 09/13/11 at 2:53 PM Staff Z, Assistant Administrator for Professional Services, examined the PM stickers and confirmed all were past the scheduled PM check dates.

4. Observation on 09/13/11 at 3:23 PM in the facility RS gym showed two electrical stimulation machines with PM stickers dated 08/09.

Observation on 09/13/11 at 3:25 PM in the facility Cardiac Rehabilitation gym showed the following:
-Exercise equipment labeled #9 with a PM sticker dated 08/10.
-Exercise equipment labeled #7 without a PM sticker.
-Two treadmills labeled #2 and #5 both with PM stickers dated 08/10.

During an interview on 09/13/11 at 3:25 PM Staff Z examined the PM stickers and confirmed all were past the scheduled PM check dates.

5. During an interview on 09/15/11 at 9:15 AM, Staff X, Director of Engineering stated the following:
-All patient care equipment should undergo an preventive maintenance check for safety.
-The current contracted company came to the facility every week.
-The current contractor should be making routine on-site visits to the Rehabilitation and Wellness outpatient clinic location to perform preventive maintenance checks on the patient care equipment used there.
-The contractor should also routinely check the RS patient care equipment in the facility gyms.
-Staff Z had informed Staff X (on 09/13/11 after the surveyor discovered the outdated PM stickers) of the multiple pieces of RS equipment that had not received preventive maintenance checks.
-Staff X felt the contractor needed to improve their performance.

Based on observation, interview and record review the facility failed to ensure:

-Food and Nutrition Services (FANS) staff washed hands when required.
-FANS staff used disposable gloves appropriately.
-FANS removed jewelry when working with foods.
-FANS stored foods used in patient meal service to protect against possible cross contamination.
-Nursing staff cleansed their hands when entering and leaving a patient's room,
-Nursing staff cleansed their hands before and after removing gloves,
-Nursing staff cleansed their hands between removing a dirty dressing and before applying a clean dressing to a wound.
This has the potential to affect all patients. The facility census was 53.

Findings included:

1. Record review of the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed the following direction for FANS staff:
-Chapter 2-301.14 When to Wash; After touching bare human body parts other than clean hands and clean, exposed portions of arms; After handling soiled equipment or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; Before donning gloves for working with food; and After engaging in other activities that contaminate the hands.
-Chapter 2-303.11 Jewelry prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.
-Chapter 3-304.15 Gloves, Use Limitation-If used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.
-Chapter 3-305.11 Food Storage food shall be protected from contamination by storing the food in a clean, dry location; where it is not exposed to splash, dust, or other contamination.

Record review of the FANS orientation booklet, dated 08/11 showed the following direction for FANS staff:
-Personnel Policies, Paragraph #2. Jewelry was limited to a wedding ring for FANS staff on duty. Other jewelry should not be worn.
-Sanitation, Infection Control and HACCP {hazard analysis, critical control point, a system used in food service to identify possible chances for food contamination} Guidelines, Paragraph #5. Good hand washing and proper glove use is essential for infection control. The times when it is most important for the employee to wash hands {included} after handling soiled equipment and utensils.
-Sanitation, Infection Control and HACCP Guidelines, Paragraph #6. Disposable gloves should be used {during specific food preparation activities}. Change gloves often.
-Sanitation, Infection Control and HACCP Guidelines, Paragraph #21. Keep food service areas spotless by cleaning up messes made, doing assigned cleaning and document.

2. Observation on 09/13/11 at 11:50 AM in the facility kitchen showed Staff S, Diet aide spoke into a small walkie-talkie, placed it on top of the food tray delivery cart then, without performing hand hygiene continued to assemble foods for a patient tray.

During an interview on 09/13/11 at 11:50 AM Staff Q, Food Production Manager, stated FANS staff used four walkie-talkies to communicate with each other, the devices were usually kept on top of the food tray carts, were used frequently and were cleaned weekly.

3. Observations on 09/13/11 in the facility kitchen showed the following:
-At 11:52 AM showed Staff R Cook, gloved without hand washing, then prepared foods for a patient meal tray.
-At 12:02 PM showed Staff S gloved without hand washing then, placed foods on a meal tray.
-At 12:31 PM showed Staff T, Dietary aide used a walkie-talkie, placed it on the top of a food tray cart then without removing soiled gloves and hand washing carried a patient meal tray to the tray elevator.

4. Observation on 09/13/11 at 12:10 PM, in the facility kitchen showed Staff S prepared trays for patient meal service and wore a finger ring with raised settings.

During an interview at 09/13/11 at 12:10 PM Staff S stated he/she had received in-service education prohibiting certain jewelry, and forgot to remove the finger ring prior to working in the kitchen.

During an interview on 09/13/11 at 12:11 PM Staff U, Dietary Supervisor stated he/she forgot to check the dietary staff for jewelry prior the staff working in food preparation.

5. Observation on 09/13/11 at 11:30 AM in the dry food storeroom showed staff failed to clean a stainless steel canned food rack covered with dust and unknown debris.

During an interview on 09/13/11 at 11:30 AM Staff Q looked at the can rack and confirmed the nine level canned food rack looked like it needed cleaning.

6. Observation on 09/13/11 at 11:40 AM in the cook's area showed staff failed to clean a table mounted can opener, covered with blackened, gummy food spills and metal can shavings.

During an interview on 09/13/11 at 11:40 AM Staff E, Director of FANS examined the table mounted can opener and confirmed it needed to be cleaned.

7. During an interview on 09/15/11 at 10:02 AM Staff MM Infection Control Nurse stated the following:
-He/she had done in-service education in the FANS but, not recently.
-Currently there was no specific surveillance performed in the FANS.
-Topics covered during sessions were isolation patient contact, hand hygiene before and after patient contact but not regarding hand hygiene and gloving in the kitchen.
-Proper infection control practices in the FANS should be discussed.
-The FANS walkie-talkies should be wiped down (sanitized) daily.
-FANS staff should remove gloves and use the walkie-talkies.


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7. Record review of the facility policy "Standard and Enhanced Precaution Guidelines", revised 07/28/2011 showed the following direction:
PROCEDURE:
Perform hand hygiene before and after patient contact and immediately upon removing gloves.
Gloves
-The patient's room is considered contaminated by the patient's body substances, therefore, gloves will be worn whenever a caregiver is touching the patient or the patient's environment.
-Always perform Hand Hygiene immediately after removing gloves.
-Remove gloves when the task is finished or if touching public items or areas that others may contact. Handling medical equipment and devices with contaminated gloves is not acceptable.

8. Observation on 09/13/11 at 9:25 AM showed Staff FF, Graduate Nurse (GN), lifted a dirty trash can lid with his/her hands, pushed a medication cart to a patient's room, lifted the patient's arm in order to scan the patient's identification wrist band, typed on the computer and used the mouse without hand washing or hand sanitizing.

9. Observation on 09/13/11 at 10:35 AM showed Staff GG, Registered Nurse (RN), put gloves on to remove a patient's intravenous (IV - in the vein) catheter (flexible tubing) without first washing or sanitizing his/her hands.


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10. Observation on 09/12/11 at 2:45 PM showed Staff H, Licensed Practical Nurse (LPN), entered Patient #5's room without performing hand hygiene. Staff H put on gloves, without performing hand hygiene, to handle the the urinary catheter bag (a container which holds urine) while examining the bag. Staff H wore the same gloves to turn the patient; adjusted the IV pump settings; documented on paper; and again adjusted the pump settings.

11. Observation on 09/13/11 at 8:35 AM showed Staff I, RN, entered Patient #5's room without performing hand hygiene and put on non sterile gloves to flush the heparin lock (intermittent intravenous device for the administration of heparin, a blood thinner medication to keep the IV access patent) with normal saline (salt water solution) and then administered a subcutaneous injection (given in the fatty layer of tissue just under the skin) to the patient's abdomen. Staff I did not change gloves or perform hand hygiene between tasks.

12. Observation on 09/13/11 at 9:39 AM showed Staff G, LPN, entered Patient #44's room without performing hand hygiene. Staff G put on non sterile gloves and using scissors from her pocket [with cleaning them] cut the kerlex (sterile, self adherent gauze roll bandage) dressing from the right foot. Staff G wore the same gloves to adjusted the IV pump settings and then proceeded to cleanse the right heel wound with Normal Saline, and without changing his/her gloves or performing hand hygiene, applied a dressing and taped the dressing to the foot.

During an interview on 09/13/11 at 9:45 AM Staff MM, RN, Charge Nurse stated that Staff G should have changed gloves and used hand hygiene between the dirty dressing and the clean dressing.

13. Observation on 09/13/11 at 10:10 AM showed Staff K and Staff L, Certified Nurse Assistants (CNA), completing a bath for Patient #8. Staff L cleansed the meatus (the opening at the end of the penis) and penis, then applied lotion to the penis. While wearing the same gloves, Staff L picked up several items in a stack of clean linen to remove a wash cloth, picked up a pillow and put it on the right side of the patient and snapped the patient's gown. Staff L continued to wear the same gloves to lower the right rail and raise the bed and then repositioned the patient. Staff K wore gloves to apply lotion to the patient's buttocks and continued to wear the same gloves to reposition the patient.