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Based on unit tour, staff and patients interviews, the review of medical records and other documents, it was determined that the facility did not effectively inform each patient of his or her rights in advance of furnishing or discontinuing patient care. This deficiency was noted in ten of twenty two applicable medical records reviewed (MR#s 10-19).

Findings include:

The review of MR #10 on 12/7/10 during the tour of 7N, noted the patient was admitted to the hospital on 11/18/10. The Admission Data Base & Clinical Assessment Psychiatry form indicated the information was obtained from the patient. There was no evidence that Patients' Rights were discussed and Patients' Rights package provided to the patient. The Patients' Rights section of the form was not completed; the section titled Patient Bill of Rights that requires staff to indicate whether or not the Patients' Rights information was given to the patient or explained to the patient was left blank.

-This 69 year-old patient was sent from a nursing home for evaluation due to violent behavior. It was noted that appropriate legal documents were given to the patient and retained in the medical record. However, a copy of An Important Message for Medicare patients (IM) was not in the record. There was no evidence that the Important Message from Medicare was discussed with the patient. The reason for not providing the patient with the instruction was not documented.

-Based on the review of the list of patients with Medicare Insurance and their medical records, it was noted that four of six medical records did not have a copy of IM notice - MR #s 10, 12, 13 & 14.

The patient in MR #12 was admitted on 11/30/10. This patient on interview on 12/7/10 reported that she did not receive a Patients' Rights package or IM notice on admission.

Similarly, the patient in MR #11 reported not to have received a Patient's Rights package.

-Two registered nurses, a physician and a rehabilitation therapist were interviewed on the unit (7N) on 12/7/10, in an attempt to determine how patients are informed of their rights. The staff reported that Patients' Rights information is either given in the ED or on the unit at admission. The information is reinforced during group meetings (therapy group). The staff was unable to determine if patients interviewed were provided with patients' rights information.

During the tour of 4N on 12/8/10, the patient in MR # 18 was interviewed regarding patient ' s rights. The patient reported that he did not remember obtaining a Patients' Rights package or having a discussion with any staff regarding Patients' Rights.

Review of MR #18 noted that this 53 year- old- patient was brought to the Emergency Department (ED) by ambulance on 12/5/10. The presenting problem was ETOH abuse. It was documented that the patient was unable to sign legal or medical consent forms while he was in the ED. There was no documentation that once the patient was alert and oriented the patient ' s rights were discussed with the patient.

The patient in MR # 19 is a 44- year old who was admitted on 12/5/10 to be evaluated for left sided abdominal pain. This patient also stated that she did not receive a Patient's Rights package.

Review of a copy of Medical Surgical and Critical Care Patient Admission Database and Flow sheet record form noted that there was no section on this form for documenting how Patient Rights package is given to a patient.

A registered nurse (RN) assigned to patients on 4N was interviewed on 12/8/10; the focus of the interview was on the provision of Patients' Rights information to patients in the unit. This staff reported that Patient Rights package is given in the ED and reinforced in the unit. She also stated that the documentation is found on the Orientation to Service form at the patient' s bedside. However, she was unable to verify that the patients actually received the Patients' Rights Package. Another nurse reported that the Patients' Rights booklet is placed in the slot outside patients' doors. This is a Geriatric unit and thirty-four of the thirty-six patients on the unit were elderly and the majority of them were bed bound.

During the tour of 4S on 12/8/10, it was noted that MR #15, an 81 year old patient came to the ED on 12/2/10 accompanied by her husband and daughter. A copy of the IM (An Important Message from Medicare about Rights) dated 12/2/10 indicated that the patient was unable to sign. There was no documentation why the patient was unable to sign and why the patient's rights information was not given to the patient's representatives.
On 12/6/10, telephone consent was obtained from the patient's son for AV Fistula placement. There was no documentation that the IM notice was discussed with the family member or the reason why this was not done.

MR #16 is an 83- year- patient, admitted to the hospital on 12/2/10. A copy of the IM form indicated that the patient was unable to sign because she was confused. The patient had family involvement as a copy of DNR order dated 4/26/10 was signed by the patient's son. Additionally, on 12/6/10 at 2:45 PM, the social work spoke to the son concerning discharge issues. There was no documentation that a copy of IM was given to the patient ' s son and patients' rights discussed with her family member.

-Similar finding was noted in MR # 17, this patient was confused and the IM indicated that the patient was unable to sign. This patient had family involvement but there was no documentation that the IM form was given to the patient's representative.

In MR #20, the patient's family member filed a complaint alleging that the patient was admitted on 6/3/09 and the Patients' Rights manual was not provided until there was a discussion with the staff about discharge plan on 08/4/09.

Based on staff interview, the review of Patients'/Patients' Representatives Complaint and Grievance files, facility's policy and other documents, it was determined that although the facility has a grievance process, there was no evidence of analysis of trends and implementation of actions necessary to correct identified problems.

Findings include:

The Quality Assurance Data for Patient Grievances for 12 months was submitted. The staff who submitted this document stated that the data was for all sites. The facility has four sites Moses, CHAM 8, Weiler and North Division. The staff was unable to provide a breakdown for the North Division. Therefore, it could not be determined if the facility was adequately addressing and analyzing grievances for the North Division.

The facility's Patient Grievance Mechanism policy indicated that Acute Executive Leadership Group is delegated by the governing body as the Patient Grievance Committee, whose responsibility is to regularly review complaints and grievances and acts to revolve them when indicated.

- The staff interviewed reported that the Director of Customer Services have weekly meetings with the Vice Present of Operations who presents the outcome of their discussions at Leadership meetings. If there are no issues, then nothing is written down during these meetings. The specific topics discussed during the weekly meetings were not submitted for review.

-A written statement was submitted by the Director of Customer Service, the document indicated that there is a weekly Leadership Meeting that is chaired by the Senior Vice President of Operations. Attendees of this meeting include Vice Presidents of each Care Center, VP of Finance, Chief Nurse and representatives from facilities including Human Resources, and Customer Service. Customer Service items, including grievances, complaints, etc are discussed on a monthly basis. The sign-in sheets for these monthly meeting was not submitted.

- The Clinical Delivery System Care Center Meeting for May 11, 2010, July 13, 2010, and September 2010 were submitted. The May 11, 2010 and July 13, 2010 meetings indicated the Grievance Report was reviewed and there was no question. The September 21, 2010 minutes indicated that each divisional PI project Plan highlighted would be discussed at year-end meeting.

Review of patients' complaints and grievances submitted for the eighteen months requested noted that there were thirty-three complaints/grievances. The bulk of the complaints were from Labor & Delivery/OB (13) unit and ED North (12). There was no documentation that issues of these complaints were addressed during grievance meetings.

On 8/4/09, a patient family filed a complaint alleging that the patient was admitted on 6/3/09 and Patients' Rights Manual was not given on admission. During the survey, it was determined that patients'/patients' representatives were not consistently provided with Patients' Rights information. There was no documented evidence that the facility identified the problem and discussed it in the Grievance and Leadership meetings.

Based on review of Patients Complaints/Grievances files, it was determined that the facility did not consistently provide patients/patient's representatives with prompt resolution of their grievances. This deficiency was noted in 1 of 13 files reviewed.

Findings Include:

Review of complaint file # 18632 noted that on 11/6/2009, the patient in MR #21 filed a complaint with the facility alleging she was physically assaulted by a PCA. A review of a copy of the response letter to the complainant dated 11/27/2009 noted that the complainant was informed that the case was forwarded to the Human Resources Department for further review and investigation. There was no evidence that the complainant was provided with the outcome of the investigation.

Based on medical record review, it was determined that the facility did not consistently ensure that patients/patients' representatives were involved in treatment plans.

Findings include:

MR #22
This patient was brought to the ED by EMS and the police on 11/14/10. The patient was an involuntary admission with diagnosis of bipolar disorder. The nurse ' s admission progress note indicated that this 24- year-old female was brought to the ED by family after she threatened the family member with a knife.
- The treatment plans dated 11/15/10, 11/23/10 & 11/30/10 noted that the problem and goals were completed by the physician, nurse, social worker and rehabilitation therapist. Although there was a section for the patient to sign and date the treatment plan, the patient's signature was missing. The reason why the patient was not involved in her treatment plan was not documented. It was noted that this patient had family involvement but the treatment plans were not signed by the patient's family/representative. The reason for the lack of family involvement in the patient's care plan was not documented. It was not until 11/22/10 that the physician documented in the progress note that the patient's mother was involved.
- It was noted that goals and problems were completed but the nurse, social work and rehabilitation therapist did not document the steps taken to assist the patient in achieving the set goals.
- The social work completed an admission assessment dated 11/16/10 but there were no follow up notes in the medical record. The first progress note by the rehabilitation staff was dated 12/7/10, the day of the survey.

Based on staff interviews, the review of medical records, hospital ' s internal occurrence reports and other documents, it was determined that the facility did not effectively monitor patients to ensure their safety and provide a safe discharge that meet patients needs.

Findings include:

Review of MR #22 on 11/19/10 at 1:15 PM revealed the nurse noted the patient was visible in the unit hallway, very angry, irritable, and disruptive. The patient was not responding to her oral medication. The nurse noted the patient was banging in her room and was a danger to self and others. The patient was evaluated and medicated with Haldol 5 mg, Ativan 1 mg and Benadryl 50 mg at noon with security assistance. The patient was only calm briefly; she remained very labile, angry and unpredictable. Nurse notes she will reassess patient as needed. There was no documentation of a nursing reassessment. On 11/19/10 at 10:00 PM, the patient had an altercation with another patient and bit the patient ' s finger.

-The " Shift Rounds " record dated 11/19/10 indicated the patient was observed every 30 minutes. The form also documented the patient ' s physical location in the unit; however, a description of the patient ' s behavior was not noted. Therefore, the patient was inadequately monitored.

-The review of medical record shows the patient had a history of violent behavior resulting in her admission. It was noted that earlier, the patient showed aggressive behavior and should have been closely monitored. There was no documentation in the medical record to show why the patient did not require closer monitoring.

The physician and nurse interviewed reported that although the patient had violent behavior at home, there was no evidence of this behavior while she was on the unit. This explanation was unacceptable because it was documented in the record on 11/19/10 at 1:15 PM that the patient displayed angry and disruptive behavior. This patient was not properly monitored resulting in harm to another patient.

Review of MR # 23 on 12/8/10 noted a 16 year old female who was brought to the ED by ambulance from home on 06/26/10 for suicidal thoughts. The patient attempted to cut her wrist. The patient had a psychiatric evaluation and it was determined that she required hospitalization. The plan was to transfer the patient to another facility since the hospital does not have an inpatient adolescent unit. The patient was placed on 1:1 security watch pending transfer. On 6/27/10 at 12:30 PM, the nurse noted that the patient eloped. The patient was not found in the waiting room of the emergency department or the immediate vicinity. The nurse noted that the patient was on 1:1 observation but the officer stepped away to assist another patient who tried to elope. A police report was filled.

-Review of the hospital ' s Internal Occurrence Report form noted that although the patient was under security 1:1 watch, the patient was able to elope from the facility.

-The Security incident/offence report noted that the officer assigned to the patient reported that on 6/27/10 at 0957, the patient was asleep; " Post 3 " called for help in his section. " I stepped to the hall to see if he was ok, when I stepped back to the room; the patient was not in bed. "

The Director of security was interviewed on 12/8/10. This staff reported that the investigation found that the officer assigned to the patient fell asleep. The officer was suspended for three days. The Disciplinary notice dated 7/6/10 was reviewed which verified that this staff was suspended for three days. However, the plan put in place to ensure this incident does not reoccur was not submitted for review.

Review of MR #24 on 12/8/10 noted that this 29- year- old patient with a history of alcohol and opiate dependence went to the facility on 9/18/10 to seek detoxification. The patient was admitted for alcohol withdrawal. She was administratively discharged on 9/18/10 because she was found having sex with another patient. It was documented in the record that the patient was homeless and was interested in rehabilitation. There was no evidence that staff provided a safe discharge for this homeless patient. The discharge summary did not include where the patient was discharged to.

The facility ' s staff interviewed, reported that the patient was administratively discharged because she violated hospital rules and regulation. The patient signed " MMC 4-East Rules and Regulations " form on 09/18/10. It was noted that the patient arrived in the unit on 9/17/10 and the " Orientation to Service " form dated 9/17/10 at 11:30 PM was signed by the patient. However, the Rules and Regulations form was not signed by the patient until 9/18/10, the day of the administrative discharge. The review of the form noted that rule # 4. " Sexual acting out will not be tolerated and will result in a possible legal action. " This rule did not clearly describe " sexual acting out behavior " . It was also noted that this event was not documented in the progress notes.

Based on the review of medical record, nursing staff did not employ the use of appropriate device to ensure patients' safety and did not obtain appropriate restrait orders prior to or immediately following the application of restraints. This finding was noted in 1 of 6 applicable records.

MR #9, an elderly patient with multiple medical conditions was admitted on 11/20/10. Physician orders were noted for bilateral wrist restraints on 12/2 and 12/3/10. The review of patient's medical record noted there was no corresponding restraint monitoring record for 12/2 and 12/3 in accordance with the facility's policy. There was no physician order for the application of restraint on 12/1/10; however, a Restraint Flow Sheet dated 12/1/10 revealed the patient had a left wrist restraint application from 7:00 AM to 10:00 PM.

Based on interview with the patient's nurse on 12/7/10, the patient was only restrained on 12/1 and was not in restraint on 12/2 and 12/3. The nurse could not explain the rationale for the renewal of wrist restraints on both days. During unit tour in the ICU, the patient was observed wearing a sock to her left hand. The nurse explained the sock prevent the patient from scratching her self because her nails are sharp. While mittens are generally not considered a restraint except when they are secured, the use of sock was inappropriate as it limits the movement of the patient's fingers and does not have adequate room compared to the hospital approved mittens.

Based on unit tour, the review of medical record and other documents, it was determined that nursing staff failed to develop care plan for each patient that includes an adequate assessment and treatment of patient's skin condition, timely referrals of patients to appropriate medical and other clinical staff; the development of a discharge plan that assures continuity of care post discharge.

Findings include:

MR #1
The patient is a 68-year-old nursing home resident who was initially admitted on 5/24/10 for evaluation of left heel ulcer secondary to gangrene. Past medical history includes Hypertension, Congestive heart failure, diabetes type II, multiple myeloma, CVA, breast cancer, peripheral vascular disease, GERD, chronic constipation, GI bleed and DVTs. The initial nursing assessment documented in the Patient Admission Database and Flow Sheet on 5/25/10 revealed edema to bilateral lower extremities and a gangrenous left lower extremity. The skin was intact and skin turgor was fair. On 6/8, a sacral stage II pressure ulcer was documented in a progress note. The Pressure Ulcer Flow Sheet was not updated in accordance with the facility policy. There was no indication that the patient's skin condition was brought to the attention of the physician and the care plan revised to ensure appropriate treatment of the pressure ulcer. The patient was discharged to the Nursing Home on 6/9/10. The Discharge Plan/ Instructions did not indicate the presence of a sacral ulcer and did not include a plan for the care of the patient's surgical wounds and the pressure ulcer post discharge. The PRI completed on 6/9/10 was inaccurate; the Decubitus Level entered was "0", which meant patient had no pressure ulcer. The nursing staff failed to communicate the patient's skin condition through available means to ensure continuity of care.

On the second admission on 6/14/10, nursing identified on the Pressure Ulcer Flow sheet, three open blisters on the right and left buttocks measuring 4cm x 4cm, 3cm x 2cm and 1cm x 0.5 cm. The next day on 6/15, two of the open blisters were identified as a stage II pressure ulcer 4cm x 4cm and 3cm x2cm, the third ulcer was not documented. There was no treatment plan indicated on the Flow Sheet in accordance with facility's policy. There was no indication the nursing staff confer with the patient's physician relative to the care of the pressure ulcers. There were no dressing orders noted on admission.

Nursing assessment from 6/16 to 6/21 notes a sacral, unstagable ulcer. The Pressure Ulcer Flow Sheet was not updated to reflect the patient's deteriorating skin condition. Significant changes in the condition of the pressure ulcer were not brought to the attention of the medical staff. There was no integrated care plan for the management of the pressure ulcers during hospitalization. Although, the sacral ulcer was unstagable, the nursing staff failed to document in accordance with the skin care policy, the size of the ulcer, tissue type, exudates type, exudates amount, odor and the type of dressing applied to the wound. Several instances, nursing noted that dressing was applied to the sacral ulcer as ordered, whereas, there were no orders for treatment until 6/21/10 at 7:45 AM. The patient was discharged on the same day to the Nursing Home. The physician ordered a wet to dry dressing to sacral area on 6/21/10; there was indication that the physician was aware that the sacral pressure ulcer was unstagable. Based on the facility's definition, "Unstagable" is a pressure ulcer which is totally or partially covered with necrotic tissue. Such pressure ulcer cannot be staged until the deepest viable tissue layer is exposed. The treatment plan for the sacral ulcer was inappropriate as no debridement of the necrotic tissue occurred before discharge.

The Discharge Plan/ Instructions completed on 6/21/10 noted a stage IV sacral ulcer which was inconsistent with repeated assessments indicating an unstagable pressure ulcer. There was no plan noted for post discharge management of the sacral ulcer. The PRI completed on 6/21/10 did not reflect the status of the patient's skin condition; Decubitus Level "2" was documented on the Medical Events session, instead of "5", the most severe level as defined in the PRI instructions. Again, nursing staff failed to conduct an appropriate assessment of the patient's pressure ulcer, formulate an integrated care plan for the treatment of the ulcer and communicate a post discharge care plan to the Nursing Home to ensure continuity of care.

MR #2
This patient is a Nursing Home resident admitted on 11/28/10 for treatment of sepsis secondary to aspiration pneumonia. The patient had multiple medical conditions including hypoxic encephalopathy, chronic pancreatitis diabetes type II, and chronic respiratory failure, ventilator dependent. The initial nursing assessment noted in the Pressure Ulcer Flow Sheet revealed 10 pressure ulcers at various stages - stage I to bilateral heels; stage II to multiple sites, left ischium, left arm, coccyx, two sites on right hip, right arm; unstagable ulcers on right and left tibia. A reassessment of the pressure ulcers on 12/6/10 showed no changes in the condition of the ulcers. The physician orders on 11/30/10 did not address the treatment of all the pressure ulcers and was not appropriate for the treatment of pressure ulcers described in the Pressure Ulcer Flow Sheet. Physician ordered Collagenese ointment every 12 hours for the sacral ulcer which the nurse documented as a coccyx ulcer, stage II, 5cm x 7.5 cm with epithelial tissue (silvery pink). Allevyn dressing was ordered to bilateral hips every 3 days; there was no pressure ulcer on the left hip, the right hip had two sites, 4cm x 3.5cm and 1cm x 1cm respectively; the bigger site was necrotic. There was no order for collagenese application on the four pressure ulcer sites with necrotic tissue; the left ischium, left tibia, right hip and right tibia. Nursing staff documented "Y" for the type of dressing application on 11/29 and Hydrogel dressing "HG" for all the sites on 12/6; these dressings were not reflective of the standing order. The four sites with necrotic tissue required a different treatment plan. Also, two sites, the left ischium and left arm were necrotic and were not accurately staged. Nursing staff did not appropriately assess each pressure ulcer and develop an appropriate plan with the medical staff that addresses the patient ' s skin condition.

MR #3
The patient is a 63-year-old, nursing home resident with multiple comobidities. The patient was admitted on 12/3/10 to rule out sepsis. The initial nursing assessment on 12/4 noted a Braden score of 17. A stage II pressure ulcer, 1cm x 1cm was noted on patient's left great toe. The tissue type was epithelial with no exudates and no odor. There was no evidence of physician involvement in the management of the pressure ulcer; no treatment order was noted. Nursing initiated Bacitracin application with dry dressing on 12/4/10. The frequency of the dressing change could not be determined. A reassessment of the pressure ulcer on 12/7 showed a 1cm x 1cm, dry scab with necrotic tissue. Although, necrosis was noted, the tissue type was documented as epithelial (Silvery pink) and there was no change in the patient's treatment plan.

MR #26
This is an elderly patient who was admitted to the hospital on 12/2/10 from a nursing home for evaluation of suicidal ideation. Medical Surgical and Critical Care Patient Admission Database and Flowsheet on 12/3/10 noted the patient ' s skin was not intact. Patient had a right upper extremity skin tear, ecchymotic areas and sacral redness. He was at risk for pressure sores evidenced by a Braden Score of 11. Although, the Pressure Ulcer Flow Sheet on 12/3 noted the patient had a stage I sacral ulcer, his nutrition risk was not identified and no nutrition triggers were documented. The patient did not have nutrition referral and was not assessed by the Dietitian.

MR #27
This patient, a nursing home resident was admitted to the hospital on 12/5/10 for evaluation of bloody stool.The patient has a colostomy. Medical Surgical and Critical Care Patient Admission Database and Flowsheet on 12/6/10 noted skin was not intact. The Braden Score was 7 on 12/6 which revealed the patient was at risk for pressure sore. Pressure Ulcer Flow Sheet on 12/6/10 showed four pressure ulcers; two pressure ulcers on the right hip, one was unstageable, 4.5cm x 5 cm, and the other was a stage II, 2cm x 5cm. Also, noted was a sacral ulcer stage IV, 6cm x 7cm and a left hip stage I, 2.4cm x1.5cm. The patient nutrition risk was not identified though he had multiple triggers including NPO status, tube feeding and colostomy. Nursing assessment did not trigger nutrition consultation therefore; nutrition assessment was not done by the Dietitian.


Based on review of medical records and tours conducted on inpatient units, it was determined that nursing staff did not ensure appropriate monitoring of a patient on intravenous therapy. This finding was noted in 1 of 15 applicable records.

Findings include:

MR #4 is a nursing home resident with multiple medical conditions including respiratory failure, status post tracheostomy and ventilator dependent. On 8/1810, the patient was observed with large infiltration resulting in multiple blisters on the dorsum of left hand around the heplock site. The physician notes the blisters covered an area of about 10cm x 15cm. Based on record review, there was no evidence the infusion site was monitored frequently to ensure safe administration of intravenous fluid.

MR #5
This elderly patient was admitted on 7/18/10 for evaluation of tachycardia and tachypnea. The patient's medical history included hypertension, left hemiparesis, status post CVA, respiratory failure and acute renal failure. The initial nursing assessment on 7/18 noted a Braden score of 11 and a sacral stage IV ulcer. Nursing staff did not document any skin changes prior to discharge of the patient to a Skilled Nursing Facility on 7/22/10. Based on interview with the Director of Nursing at Bronx Park Nursing Home on 8/5/10, the patient upon arrival to the Nursing Home on 7/22/10 was observed with multiple abrasions to the right side of his face and forehead. The incident was reported to the hospital for investigation.


Based on observations and record reviews, the nursing staff failed to promptly implement physician orders to ensure adequate care for patients. This finding was noted in 2 of 3 applicable records.

Findings include:
MR #6 is a 56 year-old patient who was status post left Total Knee Replacement on 12/7/10. Post surgery orders at 1:00pm included deep vein thrombosis prophylaxis; Fragmin 5000 units subcutaneously daily and Intermittent Compression Device. During the tour of 6E on 12/8 at 4:15 PM, the patient did not have an Intermittent Compression Device to bilateral extremities as ordered by the physician. Based on interview with nursing staff, compression device is in short supply and not readily available on request. While the surveyor was still on the unit, a nursing staff was seen applying a Compression Device to the patient's lower extremities.

Similarly, another patient, MR #7, a 42 year-old, status post myomectomy. A post op order was written at 10:00 AM on 12/8/10 for Sequential Compression Device to be used while in bed. During the tour at 4:15 PM, the patient was observed in bed with no Compression Device. Based on interview with the patient's nurse, the patient arrived on the unit at about 12:00 noon. There was no Compression Device available for the patient at the time of the unit tour.

MR #3 was admitted from the nursing home on 12/3/10 to rule out sepsis. The physician orders on admission indicated activity as tolerated. The Inter-Institutional Patient Transfer Form noted the patient is ambulatory with assistance. Nursing staff did not develop a care plan to include routine activity as tolerated. The review of the patient's flow sheet on 12/8/10 revealed the patient had been on bed rest since admission and had vest restraint applied to prevent fall. Nursing notes indicated the patient is confused and attempting to climb over the bed rails. Based on interview with the Assistant Nurse Manager, some patients are not taken out of bed because of their medical condition on admission. However, based on review of restraint orders, vest restraint had been renewed daily because the patient had been active and had made several attempts to climb out of bed.

Based on tour, interview and review of hospital policy, the facility failed to ensure food are stored properly and in appropriate sanitary condition.

Findings include:

1- Surveyor observed on 12/7/10 at 11:50AM a food truck containing food trays parked next to a wall in the intensive care unit. The food truck did not have doors or a protective shield to prevent tampering during transportation from the kitchen and to protect the tray from gathering dust. The covers on the food items were not tightly secured and could move during transportation exposing the food to the environment.

2- The Thermal Food Truck observed in the ICU unit was not connected to an electrical outlet to maintain appropriate food temperature. Surveyor observed the food truck was parked next to a wall in the corridor at 11:50AM. The truck with patients ' food trays was still stationed at the ICU at 1:00 PM. Food temperatures dropped since the truck had no doors and was not connected to a power source to maintain the temperature in the hot/cold plate. Based on observation on the unit trays were delivered sporadically in the ICU.

3- Patients refrigerators were not located in a clean area and were accessible to all staff. Based on unit tour of the ICU, 4S and 3E, refrigerators designated for patients use were located in employee lounges. Two employee lounges had employee lockers in the same room with the patients ' refrigerators and one lounge had an employee bathroom in close proximity with the refrigerator.

4- Refrigerator logs in the ICU, 4S and 3E were observed not to have freezer temperature recorded in the " Temperature Control Chart " located in a plastic sleeve attached to the refrigerator. Patients' refrigerators had no thermometer in the freezer despite ice cream and sorbet served on a liquid diet. Pediatric (3E) refrigerator contained ice cream and sorbet items in their freezer without a thermometer in the freezer. Refrigerator temperatures throughout these units were documented inconsistently.

5- Patients ' refrigerator at the ICU did not have a door attached to the freezer to maintain freezer temperature. One of the shelves of the refrigerator was found dirty with food encrusted on it lying on the floor between the refrigerator and the locker.
Two microwaves located in 4S in the employee lounge which is used for heating patient food had black residue inside both microwaves. The dry residue makes the food unsafe for consumption.

6- Cans containing enteral feedings were found on a table adjacent to the microwaves in 4S; these cans were not labeled. The cans were also observed in bags labeled with room numbers only. Some bags were unlabeled and others were labeled with a name and room number. The date on some of the bags were not current. The bags with the enteral feedings were stored in a dirty, dusty cabinet above two microwaves.