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Based on interview, record review, and policy review, the facility failed to ensure all components of a face to face evaluation following a restraint episode are addressed for three (#10, #11 and #12) of three patient restraint records reviewed. The facility census was 29.

Findings included:

1. Review of the facility's policy titled, "Restraint/Seclusion" revised July 2011, showed if a face to face evaluation was not done prior to the initial physician order, the physician or a trained Registered Nurse (RN) must conduct a face to face evaluation of the patient within one (1) hour of restraint initiation. The physician or trained RN will evaluate:
-The patient's immediate situation;
-The patient's reaction to the intervention;
-The patient's medical and behavioral condition, and;
-The need to continue or terminate the restraint or seclusion.

2. Review of physician's order for current Patient #10, dated 08/27/11 at 12:00 PM showed an order for a physical restraint due to the patient being physically assaultive and an imminent danger to self/others. The face to face evaluation dated 08/27/11 at 11:50 AM (ten minutes prior to the physical hold) showed the RN failed to document the patient's reaction to the restraint and the need to continue or terminate the restraint.

3. Review of physician's orders for discharged Patient #11 showed the following:
- An order dated 08/05/11 at 6:50 AM for seclusion due to pounding on doors, yelling and running down the hall. The face to face evaluation dated 08/05/11 at 6:55 AM showed the RN failed to document the patient's reaction to the restraint and the need to continue or terminate the restraint.
- An order dated 08/07/11 at 5:00 AM for seclusion for four hours due to threats of harm to staff and other patients. The face to face evaluation dated 08/07/11 at 5:50 AM showed the RN failed to document the patient's reaction to the restraint and the need to continue or terminate the restraint.
- An order dated 08/08/11 at 6:15 AM for seclusion for four hours due to the patient being physically assaultive and being an imminent danger to self/others. The face to face evaluation dated 08/08/11 at 6:15 AM showed the RN failed to document the patient's reaction to the restraint and the need to continue or terminate the restraint.
- A preprinted order sheet titled "Orders for seclusion/restraint for behavioral" dated 08/12/11 at 4:15 AM for seclusion due to the patient being physically and verbally aggressive. The face to face evaluation dated 08/12/11 at 4:15 AM showed the RN failed to document the need to continue or terminate the restraint.

4. Review of physician's order for discharged Patient #12, dated 07/01/11 at 11:25 AM showed an order for a physical restraint due to the patient's verbal/physical threats of harm, being physically assaultive and an imminent danger to self/others. The face to face evaluation dated 07/01/11 at 12:02 PM showed the RN failed to document the patient's reaction to the restraint and the need to continue or terminate the restraint.

5. During an interview on 8/30/11 at 10:00 AM, Staff Y, Psychiatrist, confirmed that not all elements of the one hour face to face evaluation are documented 100% of the time.

Based on interview, record review, and policy review the facility failed to notify and consult with the physician regarding a one hour face to face evaluation for three (#10, #11 and #12) patients of three restraint records reviewed. The facility census was 29.

Findings included:

1. Review of the facility's policy titled, "Restraint/Seclusion" revised July 2011, showed if a face to face evaluation was not done prior to the initial physician order, the physician or a trained Registered Nurse (RN) must conduct a face to face evaluation of the patient within one (1) hour of restraint initiation. The physician or trained RN will evaluate:
-The patient's immediate situation
-The patient's reaction to the intervention
-The patient's medical and behavioral condition, and
-The need to continue or terminate the restraint or seclusion
-The patient's attending physician is notified, through direct contact, of the restraint within 60 minutes.

The facility policy did not address consultation with the physician regarding the findings of the one hour face to face evaluation, the need for other interventions or treatments and the need to continue or discontinue the use of restraint when the one hour face to face evaluation was conducted by a trained Registered Nurse.

2. Review of physician's order for current Patient #10, dated 08/27/11 at 12:00 PM showed an order for a physical restraint due to the patient being physically assaultive and an imminent danger to self/others.

Review of the one hour face to face evaluation dated 08/27/11 at 11:50 AM (ten minutes prior to the physical hold) showed the RN failed to consult with the physician regarding the face to face evaluation.

3. Review of physician's orders for discharged Patient #11 showed the following:
- An order dated 08/05/11 at 6:50 AM for seclusion due to pounding on doors, yelling and running down the hall. The face to face evaluation dated 08/05/11 at 6:55 AM showed the RN failed to consult with the physician regarding the face to face evaluation.
- An order dated 08/07/11 at 5:00 AM for seclusion for four hours due to threats of harm to staff and other patients. The face to face evaluation dated 08/07/11 at 5:50 AM showed the RN failed to consult with the physician regarding the face to face evaluation.
- An order dated 08/08/11 at 6:15 AM for seclusion for four hours due to the patient being physically assaultive and being an imminent danger to self/others. The face to face evaluation dated 08/08/11 at 6:15 AM showed the RN failed to consult with the physician regarding the face to face evaluation.
- A preprinted order sheet titled "Orders for seclusion/restraint for behavioral" dated 08/12/11 at 4:15 AM for seclusion due to the patient being physically and verbally aggressive. The face to face evaluation dated 08/12/11 at 4:15 AM showed the RN failed to consult with the physician regarding the face to face evaluation.

4. Review of physician's order for discharged Patient #12, dated 07/01/11 at 11:25 AM showed an order for a physical restraint due to the patient's verbal/physical threats of harm, being physically assaultive and an imminent danger to self/others. The face to face evaluation dated 07/01/11 at 12:02 PM showed the RN failed to consult with the physician regarding the face to face evaluation.

5. During an interview on 8/30/11 at 10:00 AM, Staff Y, Psychiatrist, stated that nursing staff did not contact him/her regarding the face to face evaluations.

Based on observation, interview and policy review, the facility failed to ensure two of two staff members (Z and BB ) on the behavioral health unit were educated, trained and competent on the use of the emergency crash cart (an organized, self contained method for delivery and administration of medications, fluids and respiratory equipment during an emergency situation.) This potentially impacts all behavioral health patients. The behavioral health unit census was 21 and the facility census was 29.

Findings included:

1. Review of the facility's policy titled, "Resuscitation Services (Crash Cart Emergency Medications)" dated 02/10, showed the following direction:
- The professional staff will provide cardiopulmonary resuscitation to patients with cardiac, pulmonary or cardiopulmonary arrest as effectively as possible.
- Clinical personnel are to immediately initiate Code Blue Procedures when a patient or visitor appears unresponsive.
- Call for help: Help may be called from any telephone by dialing 3333. Start cardio-pulmonary resuscitation with Ambu bag (a hand-held device used to provide ventilation to a patient who is not breathing or who is breathing inadequately.) Bring Emergency Crash Cart into room.
- Code Blue Participants include the team nurse of patient involved.
The policy further documents the following:
- The crash cart will be locked with a disposable red numbered lock that is easily broken when the crash cart is needed.
- The disposable red lock is numbered and will be accounted for and maintained by the Department of Pharmacy and stored in the narcotic vault.
- The crash cart will be checked to assure that the lock is intact by the titled nurse each morning.
- The defibrillator (a machine capable of delivering a therapeutic dose of electrical energy to the heart) will be checked according to manufacturer's suggested procedure (unplugged and with recommended joules [unit of energy] per unit) daily by the titled nurse or Radiology Technologist.
- On a daily basis, the crash cart will be checked and documented according to the Crash Cart Daily Log.
- Nursing will indicate by initialing the Crash Cart Check Sheet that the lock is intact, the defibrillator is working and all drawers are within the expiration date.

2. Observation of the behavioral health unit on 08/29/11 at 2:10 PM showed a locked 22 bed patient care unit composed of a patient population with diagnosis of hallucinations (visual, auditory or olfactory experiences that are not real), delusions (fixed false belief), agitation, anxiety attacks and potential harm to self or others. Patients may be admitted who have current medical issues or a history of medical problems.

Observation of the behavioral health unit on 08/31/11 at 10:55 AM showed a hallway with a locked storage room, which contained the unit crash cart.

3. During an interview on 08/31/11 at 10:55 AM, Staff Z, behavioral health Clinical Manager stated that he/she does not check the crash cart and could not demonstrate how to check the cart but would ask another nurse to check the cart with this surveyor.

During an interview on 08/31/11 at 11:00 AM, Staff BB, Registered Nurse (RN) stated that he/she checked the crash cart when assigned and agreed his/her signature on the crash cart check sheet indicated he/she did the cart check. When asked to show this surveyor if the defibrillator battery was charged, Staff BB stated, "The green light is on so it's ok." Staff BB did not unplug the defibrillator from the wall and test the battery. When asked to show this surveyor if the suction machine was working, Staff BB was unable to turn on the suction machine without assistance. When asked to show this surveyor how the oxygen tank worked, Staff BB pointed to an oxygen concentrator sitting on the floor and asked this surveyor if that was the oxygen tank. When asked by this surveyor what number he/she would call for a code, Staff BB pointed to the red disposable crash cart lock and stated that he/she would call the number on the lock.

Staff BB stated that the nursing staff on the floor does not need to know how to work anything on the crash cart because Respiratory Therapy comes to the unit for a code and runs the code. Staff BB stated that he/she would not start a code or use the suction machine on a patient while waiting for Respiratory Therapy.

Based on interview and record review, facility staff failed to ensure medical record entries had dated and timed signatures for one (Patient #32) of one current patient medical records and for two (Patient #27, #28) of seven discharged patient medical records reviewed for complete medical records entries. The facility census was 29.

Findings included:

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 11/08/10, Part 7.4 Progress Notes, 7.4.1 Generally: Pertinent progress notes must be recorded at the time of observation and must be sufficient to permit continuity of care and transferability of the patient.

2. Record review of current Patient #32's physician's progress notes dated 08/31/11 showed an undated, untimed signature.

3. Record review of discharged Patient #27's physician's progress notes showed the following:
-Untimed progress notes dated 08/01/11, 08/02/11 and 08/03/11.
-Two untimed notes on each date for 08/05/11, 08/06/11 and 08/07/11.
-An untimed note dated 08/08/11 that was also unsigned.
-An untimed noted dated 08/08/11.

During an interview on 09/01/11 at 9:30 AM, Staff J, Director of Health Information Services (HIS) reviewed Patient #27's physician's progress notes and confirmed the notes were untimed, or unsigned and untimed.

4. Record review of discharged Patient #28's progress notes showed an untimed note for each date 08/10/11 and 08/11/11.

During an interview on 09/01/11 at 10:00 AM, Staff J reviewed the patient's progress notes and confirmed the notes dated 08/10/11 and 08/11/11 were untimed.

Based on review of the Rules and Regulations of the Medical Staff, interview and record review facility staff failed to ensure physician's orders were dated, timed and/or signed for one (Patient #32) of one current and for three (Patient #26, #30 and #11) of seven discharged patient medical records reviewed for complete physician's orders. The facility census was 29.

Findings included:

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 11/08/10, Part VI: Orders, 6.1 General Requirement All orders for treatment or diagnostic tests must be written clearly, legibly and completely, and signed by the practitioner responsible for them.

During an interview on 08/29/11 at 2:44 PM Staff J, Director of Health Information Services (HIS) stated complete physicians orders should be timed, dated and signed.

2. Record review of current Patient #32's physician's orders on 09/01/11 at 1:15 PM showed an order dated 08/30/11, signed without a date and time.

3. Record review of discharged Patient #26's admission orders dated 07/02/11 showed the orders were untimed.

During an interview on 09/01/11 at 9:10 AM, Staff J reviewed the patient's admission orders dated 07/02/11 and confirmed the orders were untimed.

4. Record review of discharged Patient #30's physician's orders showed an overprinted order sheet (a pre-printed set of orders on a blank form) without time or date of the orders.

During an interview on 09/01/11 at 10:25 AM, Staff J reviewed the order sheet and confirmed the orders were not timed and dated.


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5. Record review of discharged Patient #11's physician's orders showed admission orders dated 08/02/11. The order sheet was untimed.

Based on interview, review of the Rules and Regulations of the Medical Staff and record review facility staff failed to ensure physician's verbal and telephone orders for three (Patient
#32, #9 and #6) of three current and for six (Patient #18, #26, #27, #28, #30 and #11) of seven discharged patient's orders were authenticated (signed, dated and timed) by the physician within twenty- four hours as required. The facility census was 29.

Findings included:

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 11/08/10, Part VI: Orders, 6.3 Verbal orders showed verbal orders shall be countersigned by the prescribing physician within twenty-four hours.

2. During an interview on 08/29/11 at 2:55 PM Staff J, Director of Health Information Services (HIS) confirmed all physician's verbal orders should be signed within twenty-four hours.

3. Record review on 09/01/11 at 1:15 PM of current Patient #32's physician's orders showed an unsigned telephone order for admission dated 08/30/11.

4. Record review of discharged Patient #18's physician's orders showed six telephone orders dated 08/04/11, two telephone orders dated 08/06/11 and three telephone orders dated 08/07/11, each without timed and dated signatures.

During an interview on 09/01/11 at 8:30 AM, Staff J reviewed the Patient #18's physician's orders and confirmed the eleven telephone orders were signed without a time and date (showing authentication within twenty-four hours).

5. Record review of discharged Patient 26's physician's orders showed a telephone order dated 07/02/11 with an untimed, undated signature.

During an interview on 09/01/11 at 9:10 AM, Staff J reviewed the Patient #26's physician's orders and confirmed the telephone order was signed without a time and date.

6. Record review of discharged Patient #27's physician's orders showed the following:
-An unsigned telephone order for admission dated 08/01/11.
-Two unsigned verbal orders dated 08/01/11.
-Two unsigned verbal orders dated 08/02/11.
-An unsigned verbal order dated 08/03/11.
-A page of telephone orders dated 08/04/11 with an untimed, undated signature.
-A page of telephone orders dated 08/05/11 with an untimed, undated signature.
-A telephone order dated 08/05/11 with an untimed, undated signature.
-A page of orders dated 08/05/11 without signature.
-A verbal order dated 08/05/11 with an untimed, undated signature.
-A verbal order dated 08/06/11 with an untimed, undated signature.
-Three verbal orders dated 08/07/11 each with untimed, undated signatures.
-Four unsigned verbal orders each dated 08/08/11.
-An unsigned verbal order dated 08/09/11.

During an interview on 09/01/11 at 9:30 AM, Staff J reviewed the Patient #27's physician's orders and confirmed the telephone orders were unsigned, or signed without dates and times.

7. Record review of discharged Patient #28's physician's orders showed a telephone order for admission signed without a time or date.

During an interview on 09/01/11 at 10:00 AM, Staff J reviewed the Patient #28's admission orders and confirmed the signature was without a date and time.

8. Record review of discharged Patient #30's physician's orders showed eight telephone orders dated 05/31/11, eight telephone orders dated 06/01/11, three telephone orders dated 06/02/11, two telephone orders dated 06/03/11 and a telephone order dated 06/04/11 each without a time or date of the signature.

During an interview on 09/01/11 at 10:25 AM, Staff J reviewed the Patient #30's physician's telephone orders and confirmed the signatures were without a time and date.


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9. Record review on 8/30/11 at 10:30 AM of current Patient # 6's physician orders showed on 8/26/11 at 8:00 AM the physician gave a telephone order for eight medications, one IV (intravenous) solution and tube feeding (nourishment delivered directly to stomach via an indwelling tube). The physician failed to authenticate the telephone order within 24 hours.

10. Record review on 8/30/11 at 10:35 AM of current Patient # 9's physician orders showed on 8/27/11 at 3:10 PM the physician gave a telephone order for two medications and to "hold" (don't give) one medication. The physician failed to authenticate the telephone order.

During an interview on 8/30/11 at 10:45 AM Staff B, Regulatory Coordinator, stated that physicians had 24 hours to authenticate telephone orders and the physician had not authenticated Patient #6 or #9's orders yet.


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11. Record review on 08/30/11 at 11:05 AM of discharged Patient #11's physician orders showed the following telephone orders:
-An order taken on 08/05/11 at 11:00 AM to place patient on a 1:1 (one staff member with patient at all times) lacked a date and time of the physician's signature.
- An order taken on 08/07/11 at 6:00 PM to take the patient's temperature Q 1 h (every hour) until 9:00 PM. The telephone order lacked a date and time of the physician's signature.

Based on interview and record review, facility staff failed to ensure each patient admitted had a completed history and physical within twenty four hours of admission for three (Patient #6, #7, #32) of three current and for four (Patient #26, #27, #28 and #19) of seven discharged patient medical records reviewed for completed history and physical. The facility census was 29.

Findings included:

1. Review of the Rules and Regulations of the Medical Staff of the facility, approved 11/08/10, Part 7.2 History and Physical Examination, 7.2.1 Generally: The attending physician will complete a history and physical examination to be recorded in the chart or dictated within twenty-four hours after admission of the patient.

2. During an interview on 08/29/11 at 2:44 PM Staff J, Director of Health Information Services (HIS) stated the history and physical should be on the medical records within twenty-four hours of admission.

3. Record review on 09/01/11 at 1:15 PM of current Patient #32's medical record showed the patient was admitted on 08/30/11 and there was no completed, authenticated history and physical in the medical record.

4. Record review of discharged Patient #26's admission history and physical showed staff admitted the patient on 07/02/11 but, the physician completed and authenticated the history and physical on 07/28/11.

During an interview on 09/01/11 at 9:10 AM, Staff J, reviewed the Patient #26's history and physical and confirmed the history and physical was not completed within twenty-four hours of admission.

5. Record review of discharged Patient #27's admission history and physical showed staff admitted the patient on 08/01/11 and the physician failed to complete and authenticate the history and physical.

During an interview on 09/01/11 at 9:30 AM, Staff J, reviewed the patient's history and physical and confirmed the physician was expected to complete and authenticate the document within twenty-four hours of admission.

6. Record review of discharged Patient #28's admission history and physical showed staff admitted the patient on 08/10/11, but the physician completed and authenticated the history and physical on 08/23/11.

During an interview on 09/01/11 at 10:00 AM, Staff J reviewed the patient's history and physical and confirmed the document was not completed and authenticated within twenty-four hours of admission.


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7. Record review of discharged Patient #19's admission History and Physical showed the physician admitted the patient on 05/27/11. The physician did not complete the history and physical until 05/30/11, three days after admission.


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8. Record review on 08/30/11 of current Patient #6's History and Physical showed the physician admitted the patient on 8/26/11. The History and Physical was dictated and transcribed on 8/26/11 but was not authenticated by the physician.

9. Record review on 08/30/11 of current Patient #7's History and physical showed the physician admitted the patient on 08/28/11. The History and Physical was dictated and transcribed on 8/28/11 but was not authenticated by the physician.

During an interview on 8/30/11 at 10:45 AM Staff B, Regulatory Coordinator, stated that he/she was not sure how long physicians had to authenticate History and Physicals.

Based on observation, interview, and policy review the facility failed to label anesthetic medications that had been drawn up into syringes, and label surgical scrub solutions with the proper information in two of four operating rooms. The facility census was 29.

Findings Included:

1. Record review of the facility's policy titled, "Dispensing Labels" dated 12/07, showed the following direction:
-All drug containers shall be labeled and drug labels must be clear, consistent, legible and in compliance with state and federal requirements
-Drug labeling must be consistent among all preparation areas throughout the facility.

2. Record review of the Health and Human Services website titled, "Labeling guidelines for Drugs" showed direction that all practitioners must label all medication dispensed to patients with the following information:
-Date of dispensing;
-Name of drug;
-Dosage of drug;
-Date the medication will expire.

3. Observation on 08/31/11 at 3:00 PM of the top drawer of the anesthesia cart in Operating Room #4 showed a syringe with five milliliters (ml) of a clear fluid secured with a capped needle labeled Anectine (a drug used in conjunction with general anesthesia that helps paralyze the patient) and dated 08/18.

4. Observation on 08/31/11 at 3:30 PM of the top drawer of the anesthesia cart in Operating Room #3 showed a syringe with five ml of a clear fluid secured with a capped needle labeled Anectine and dated 08/26.

During an interview on 08/31/11 at 3:30 PM, Staff CC, Director of Surgical Services, stated that he/she was not sure if the date on the labels of the Anectine syringes were when the medication was drawn up or if it was the expiration date. He/she was unsure who drew up the medication, and confirmed the syringe was not labeled correctly.

5. Observation on 08/31/11 at 1:15 PM of the nurse cart in Operating Room # 4 showed:
-Two opened bottles of Provodine Surgical Scrub Solutions (solution for cleansing area of patients skin prior to surgery) without a label as to when opened and when it should expire.
-One bottle of Chlorhexidine Gluconate Antiseptic Solution (solution for cleansing area of patients skin prior to surgery) opened without a label as to when opened and when it should expire.

During an interview on 08/31/11 at 1:15 PM, Staff CC, Director of Surgical Services, stated that the solutions were not labeled correctly and should be labeled with the date opened, the initials of the person opening and the date when they will expire after opening.

Based on interview and record review the facility failed to ensure Nutrition Services had a qualified, full time director who was responsible for the daily management of the department. The facility census was 29.

Findings included:

1. Review of the facility Nutritional Services organizational chart, dated 05/10/11, showed the Director of Nutritional Services (NS) was administratively responsible to the Director of Integrated Services (IS).

2. During an interview on 08/30/11 at 3:15 PM, Staff O, Dietitian stated the following:
-He/she was not the Director of NS.
-He/she had been in position since 06/20/11.
-He/she had recently become a Registered Dietitian (RD).

3. During an interview on 08/31/11 at 9:48 AM Staff N, Director of IS stated the following:
-He/she was administratively responsible for multiple departments including Nutrition Services.
-The position of Director of NS had been vacant a number of months (vacant since 01/01/11).
-The facility was not actively recruiting for a NS director.
-In the interim, he/she was serving as the Director of NS.
-The facility may recruit for a person to fill the position sometime in the future.

4. Review of the personnel folder for the Director of IS/Director of NS showed the following:
-An associate's degree in general technology.
-A certification in plant maintenance management.
-There was no evidence of specialized training in food, nutrition or management of a dietary service with responsibility for meal service to medical, surgical, obstetrical patients who required a variety of modified diets.

During an interview on 09/01/11 at 1:40 PM, Staff K, Director of Human Resources reviewed the education listed in Staff N's personnel file and confirmed there was no evidence of specialized education, training or experience in food, nutrition or management of a dietary service.

Based on observation, interview, record review and policy review the facility staff failed to ensure acceptable levels of safety and quality for equipment, nourishment and supplies including:
-Storing previously sterilized laryngoscopes with legible expiration dates on a shelf in the Respiratory Services supply room. .
-Not performing preventative maintenance checks on Pulmonary Function Testing (PFT, measurements of how well the lungs take in and release air) equipment, including an EKG (electrocardiogram, equipment recording the electrical activity of the heart) machine and a treadmill in the Respiratory Department.
-Not storing foods,disposable dishes and cups on the floor or on shelving uncovered in the Nutrition Services storeroom
-Not storing foods with appropriate labeling and dating in the Nutrition Services storeroom.
-Not storing and serving foods on dust and unknown debris covered kitchen equipment.
-Not removing expired foods including, commercially prepared canned tube feeding stored in the Nutrition Services dry food store room and and juice stored in the Emergency Department patient nourishment refrigerator.
-Not removing expired medical supplies use for patient care in the Medical/Surgical Unit, Emergency Department, and the Operating Room.
-Removing or cleaning rusted and dusty equipment in the Operating Room.

The facility census was 29.

Findings included:

1. Observation on 08/30/11 at approximately 2:00 PM in the Respiratory Services (RS) supply storeroom showed fifteen previously sterilized adult and five pediatric laryngoscopes with illegible expiration dates on the sticker labels.

During an interview on 08/30/11 at approximately 2:00 PM, Staff L, Director of RS examined the laryngoscopes and stated that the expiration dates on the labels were illegible.

During an interview on 09/01/11 at 2:38 PM Staff II, Infection Control Nurse stated that if the expiration dates on any supplies were illegible he/she would expect the staff to find the appropriate expiration date and hand write it on the package.

2. Observation on 08/30/11 at 2:05 PM in the RS Pulmonary Function Testing (PFT) room showed electrocardiogram equipment and a treadmill.

Review of the preventive maintenance (PM) check date stickers on the EKG machine and the treadmill showed the "next due date" on both pieces of equipment was 07/11.

During an interview on 08/30/11 at 2:05 PM Staff L examined the PM stickers on both pieces of equipment and confirmed both were past due for preventive maintenance checks, needed to be re-checked and re-stickered.

3. Record review of the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed direction for facility Nutrition Services (NS) staff including:
-Chapter 3-302.12 Food Storage Containers. Food or food ingredients, removed from their original packages such as flour and sugar shall be identified with the common name of the food.
-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 and at least 15 cm (6 inches) above the floor.

4. Observation on 08/31/11 from 9:45 AM through 10:02 AM in the NS dry food storeroom showed the following:
-Five cans of a commercially prepared tube feeding labeled with a manufacturer's expiration date of 05/11.
-One and a half cases (approximately thirty individual units) of a second brand of commercially prepared tube feeding labeled with a manufacturer's expiration date of 05/11.
-Seven metal canned food storage racks heavily soiled with black unknown powdery debris and a dried reddish food spill on some of the rungs of the racks (rims of the cans resting in the black debris and red food spill).
-An unlabeled, opened five pound sack of powder (later identified as milk powder) loosely stored in an unsealed clear plastic bag with spilled powder in the bottom of the plastic bag.
-A case of disposable drinking cups stored on the soiled floor.
-Several stacks of uncovered (exposed to air) disposable plates, bowls and cups stored on an unknown debris covered shelf.
-Six cases of flavored beverages stored on the floor.

During an interview on 08/31/11 from 9:45 AM through 10:02 AM in the NS dry food storeroom, Staff P, Dietary supervisor stated the following:
-The can racks needed cleaning.
-The powdered food (milk) was not stored correctly.
-Cases of disposable cups and flavored beverages were routinely stored on the floor.
-Disposable plates, bowls and cups were stored uncovered on shelving.

5. Observation on 08/31/11 at 10:02 AM in the walk-in refrigerator showed a refrigerator condenser fan blade guard covered with black fuzzy debris (the condenser fan was on and blowing air and the black debris onto foods and food containers in the walk-in).

During an interview on 08/31/11 at 10:04 AM, Staff N, Director of NS/Director of Integrated Services stated the refrigerator condenser fan blade guard was on a quarterly cleaning/preventive maintenance schedule and should be clean.

6. Observation on 08/31/11 at 10:05 AM in the cook's preparation area showed staff stored bulk flour, cornstarch and rice in unlabeled bins.

7. Observation on 08/31/11 at 10:06 AM in the tray preparation area showed the tray assembly line equipment (used in patient meal tray assembly) was covered with blackened, sticky food spills, dried food splashes and browned food crumbs on the metal slides and rollers.


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8. Record review of the facility's policy titled, "Cleaning Procedures for the OR Suite" dated October 2002 showed direction for the following:
-Cleaning routines include diagnostic imaging and other equipment brought into the surgery for cases;
-Each day, seven days per week and before the first scheduled procedure of the day, all horizontal surfaces within the operating room must be damp dusted with a clean lint free cloth and hospital approved disinfectant;
-Particular attention is given to all surfaces of the OR bed, mattress, and positioning aids where contamination with blood or other fluids may have taken place.

9. Observation on 08/31/11 at 1:15 PM of Operating Room #4 showed the following:
-A rusted can opener in the top drawer of the nurses prep cart;
-One gel leg stabilizer that had a large broken area and several areas with sticky tape residue;
-Two non-cleanable rusted oxygen tanks located on the back of the anesthesia machine.

10. Observation on 08/31/11 at 1:44 PM of the Procedure Room during current Patient #20 endoscopy procedure showed the following:
- Staff EE, Registered Nurse (RN) preparing medication for administration on an over-the-bed table that had non-cleanable rusted areas on the base and;
-A Cauterizing Machine with non-cleanable rust on the base of the machine.

11. Observation on 08/31/11 at 3:30 PM of Operating Room #3 showed the following:
- Top of the Cauterizing Machine dusty and sticky from tape residue;
-Dental X-ray machine with non-cleanable rusted base;
-Two non-cleanable rusted oxygen tanks located on the back of the anesthesia machine and;
-Nerve Stimulator (used to stimulate patients who are having difficulty arousing after surgery) maintenance check was due 05/11, three months late.

12. Observation on 08/31/11 at 3:45 PM of Operating Room #2 showed the following:
-Two packages of tonsil sponges with an expiration date of 05/11;
-Two non-cleanable rusted oxygen tanks located on the back of the anesthesia machine.

13. Observation on 08/31/11 at 4:00 PM of the Operating Room #1 showed two non-cleanable rusted oxygen tanks located on the back of the anesthesia machine.

During an interview on 08/31/11 at 4:00 PM, Staff CC, Director of Surgical Services confirmed the rusted table bases, the rusted equipment in the operating room, the dusty equipment and the sticky tape residue. He/she confirmed that rusted surfaces were not cleanable and needed to be removed or replaced.


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14. Observation on 08/29/11 at 2:40 PM in the Medical/Surgical supply room showed the following expired supplies:
-26 lavender top blood specimen tubes, manufacturers' expiration date 1/2011;
-37 red top blood specimen tubes, manufacturers' expiration date 2/2011;
-37 blue top blood specimen tubes, manufacturers' expiration date 9/2010;
-34 green top blood specimen tubes, manufacturers' expiration date 3/2011;

15. Observation on 08/30/11 at 3:00 PM of the crash cart (emergency supply cart) located on the Medical/Surgical Unit showed the following expired supplies:
-One endotracheal tube, size 8.5 with a manufacturers' expiration date of 7/2002;
-One endotracheal tube, size 6.0, with a manufacturers' expiration date 2/2004;

16. Observation on 08/30/11 at 3:15 PM in the Medical/surgical Unit Nurses Station showed a glucometer control solution with a hand written expiration date of 07/05/11.

During an interview on 08/30/11 at 3:20 PM Staff B, Regulatory Coordinator, stated that these items should not be on the Nursing Unit and will be removed immediately.

17. Observation on 08/31/11 at 10:15 AM, in the Emergency Room (ER) showed:
-In Trauma Room: a Chest Tube Tray with one (1) Xeroform dressing with manufacturer's expiration date of 11/10 and one pack of silk suture size 4.0 with a manufacturer's date of 07/10.
-In ER room 4: one occult blood test (test to check for hidden blood) slide with manufacturer's expiration date of 01/11 and nine occult blood test slides with manufacturer's expiration date of 07/11.

-In ER room 8: one transducer cover with manufacturer's expiration date of 03/11 and two specimen collection kits with manufacturer's expiration date of 05/11.

-In the ER patient nourishment refrigerator: one carton of grape juice with a manufacturer's expiration date of 08/27/11 and two cartons of apple juice with a manufacturer's expiration date of 08/22/11.

During an interview 08/30/11 at 11:00 AM Staff KK, Emergency Department Director, stated that these expired items should not be in the department and would be removed immediately.

Failure to remove expired supplies and nourishment from stock has the potential to expose patients to unsterile, unstable supplies which could cause infection or spoiled food which could cause illness.

Based on observation, interview and record review, facility staff failed to ensure:
-The facility dish washing machine was operated and maintained so the final sanitizing rinse water temperature consistently reached 180 degrees Fahrenheit.
-Effective sanitizing solutions were used on food contact surfaces (use a sanitizer not a degreaser) and solutions used were applied appropriately (rinse the product off the surface).
-Effective hair restraints were used in the Nutrition Services department.
-Hand washing and appropriate disposable glove use was done in the Nutrition Services at required intervals.
-Mask were worn during a sterile procedure of one patient (#20).
-Staff performed hand hygiene (washed hands with soap and water or used hand sanitizer) between patients when administering medications to three patients (#10, #13, #14).

The facility census was 29.

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 facility dietary staff:
-Chapter 2-103.22 Person in Charge, paragraph (I) The person in charge shall ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused through routine monitoring of solution temperature and exposure time for hot water sanitizing.
-Chapter 4-501.112 Mechanical ware washing equipment, hot water sanitization temperatures shall be eighty two degree Centigrade (180 degree Fahrenheit).

Record review of the facility Nutrition Services (NS) policy titled, "Ware Washing in Dish Machine", #01914.017, effective 05/17/10 showed the following direction:
-Check temperature of the dish machine and record on the temperature chart before the first wash cycle.
-The machine must show 180 degrees F {Fahrenheit} at the gauge before beginning a wash cycle.
-When rinse water does not reach the 180 degrees F at the gauge, run three empty racks through the machine to bring up temperature.
-If this fails to show water at correct temperature, you may not use the machine.
-Advise the supervisor.

Record review of the facility Dish washer temperature log dated 08/11, showed the following:
-Staff recorded the final rinse temperature three times a day.
-Of the ninety one temperature recordings, twenty seven of the final rinse temperatures were below the required 180 degree F (two as low as 155 degrees F, one at 160 degrees F and twenty four at or between 170 to 175 degrees F).
-The over printed form had instruction "if temperature are not acceptable, tell supervisor".

During an interview on 08/31/11 at 10:15 AM Staff P, Dietary supervisor stated the following:
-The NS department served patients in isolation (due to diagnosis of communicable infectious disease) on regular non-disposable dishes and silverware and those dishes and silverware were washed in the NS department dish washing machine with all other dishes, silverware and utensils.
-He/she was not aware the final rinse water temperature had not consistently been reaching the required 180 degrees F during 08/11.
-He/she did not routinely review the temperature log notations on a daily basis.
-He/she usually collected the form at the end of the month and just filed it.

2. 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 facility dietary staff:
-Chapter 2-103.22 Person in Charge, paragraph (I) The person in charge shall ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused through routine monitoring of solution temperature and exposure time for hot water sanitizing.
-Chapter 4-702.11 Before use after cleaning utensils and food contact surfaces of equipment shall be sanitized before use after cleaning.
-Chapter 4-703.11 Hot water and chemical, After being cleaned, equipment and food contact surfaces and utensils shall be sanitized in chemical manual or mechanical operations, including the application of sanitizing chemicals by immersion, manual
swabbing, brushing, or pressure spraying methods, using a solution with an exposure time of at least ten seconds for a chlorine solution or an exposure time of at least thirty seconds for other chemical sanitizing solutions.

Record review of the facility NS policy titled, Sanitizing Food Contact Surfaces, #01914.014, effective 05/17/10 showed the following direction:
-Solutions in "sani-buckets" were prepared with a commercially prepared product called Oasis-146 and cool water.
-Wash {equipment surface} in a solution of detergent and hot water.
-Rinse the surface and air dry.
-Wipe surface with sanitizer solution from the sani-bucket and allow to air dry.

Observation on 08/31/11 at approximately 11:25 AM showed Staff R, Diet aide sprayed a preparation table with an orange colored solution in a plastic bottle, wiping without rinse or application of other solutions then, placed foods and equipment on the newly wiped table top.

During an interview on 08/31/11 at approximately 11:25 AM, Staff R stated the following:
-The spray bottle contained a solution called Orange Force.
-Orange Force could be used to wipe food contact surfaces.
-The NS department did not use bleach anymore because the former department director banned the use of bleach in the department. {Staff could not use bleach in an emergency as directed in the policy}.
-Orange Force was drawn from a bulk container in the mop closet.

Review of the Material Safety Data Sheet (MSDS) for Orange Forcer dated 02/09/07 and provided during the survey by the Director of NS/Director of Integrated Services showed the following direction:
-Full name of the product was Oasis 137 Orange Force {not Oasis 146 as indicated in the facility policy. Oasis 146 is a different product.}.
-May cause allergic skin reactions.
-May cause eye irritation.

Review of the bulk dispensing container for Oasis 137 Orange Force directed, after use on food contact surfaces, rinse {the surface} with potable {drinkable} water.

During an interview on 09/01/11 at 10:00 AM Staff P, Dietary supervisor stated that staff might use the Orange Force on table tops in the kitchen.

During an interview on 09/01/11 at 10:00 AM Staff W, Dietary aide stated that staff never used Orange Force on tables but did use the product around the fryers as a degreaser.

Review of the product descriptions on the manufacturer's web site showed the following:
-Oasis 137 Orange Force was described as a degreaser, not a sanitizer (staff was using inappropriately).
-Oasis 146 Orange Force was a no rinse, food contact surface sanitizer concentrate (Identified in the policy but not dispensed from the manufacturer's bulk dispenser in the dietary mop closet. Also the policy inaccurately directed staff to rinse this no rinse sanitizer).

3. 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 facility dietary staff in Chapter 2-402 .11 Effective hair restraints. Food employees shall wear hair restraints such as hats, hair coverings, nets that are designed and worn to effectively keep their hair from contacting food, clean equipment, utensils and linen.

Review of the facility NS policy titled, "Good Hygiene", #01914.008, dated 05/17/10,
showed directions included to dietary staff to keep hair clean and wear a bonnet or hair net in food preparation.

Observation on 08/31/11 showed the following:
-At 11:10 AM Staff R Dietary aide, prepared foods in the cook's area and wore a baseball cap with approximately two inches of hair extending out of the rim of the back of the cap.
-At 11:20 AM Staff Q, Dietary aide, prepared foods and ineffectively wore a bonnet with strands of hair extending from the elastic edge of the bonnet.
-At 11:30 AM Staff S, Dietary aide, walked through the entire length of the kitchen, past the tray assembly area, through the cook's area with long (extended half way down the back), unrestrained hair.

During an interview on 08/31/11, Staff S stated he/she always entered the kitchen through the same door, walked through the tray assembly area and the cook's area to retrieve a hair net.

4. 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 facility dietary staff:
-Chapter 2-103.11 Person in Charge, paragraph (D), The person in charge shall ensure employees are effectively cleaning their hands by routinely monitoring the employee's hand washing.
-Chapter 2-301.14 When to Wash {hands}; 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 3-304.15 Gloves, Use Limitation-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.

Review of the facility NS policy titled, "Hand Washing Procedure", #01914.009, effective date 05/17/10 showed the following direction for NS staff:
-Food handlers must wash their hands before starting work.
-After touching hair, face or body.
-After touching clothes or aprons.
-Touching anything else that may contaminate hands, such as unsanitized equipment, work surfaces or wash cloths.

Observation on 08/31/11 in the facility kitchen showed the following:
-At 11:16 AM Staff Q, Dietary aide gloved without hand washing then, prepared foods for noon meal.
-At 11:16 AM Staff R, Dietary aide gloved without hand washing then, prepared foods for noon meal.
-At 11:29 AM Staff W, Dietary aide gloved without hand washing then, prepared salads for meal service.
-At 11:35 AM Staff T, Dietary aide used his/her apron to shield a hand to remove the cover from a steam table pan then, took temperatures of foods all without hand washing.
-At 11:45 AM Staff U, Dietary aide gloved without hand washing then, handled a spoon to portion individual servings of peaches for patient meal service.
-At 11:58 AM Staff W, touched his/her eyeglasses then without hand washing touched items on each patient meal tray.
-At 12:05 PM Staff W, answered the telephone then without hand washing touched items on each patient meal tray.
-At 12:06 PM, Staff V, Dietary aide touched his/her eyeglasses then without hand washing placed each meal tray in a cart for delivery to the patients.
-At 12:20 PM, Staff W, again answered the telephone then without hand washing touched items on each patient meal tray.
-At 12:20 PM, Staff T, removed soiled gloves then, without hand washing retrieved a pen and multiple slips of paper and wrote "we ran out of your food selection" messages to patients who ordered specific food for noon meal.
-At 12:25 PM Staff W, retrieved a thermometer from the floor then, without hand washing returned to handling items on each patient meal tray.
-At 12:31 PM, Staff T, placed both gloved hands on hips then, without removing soiled gloves and hand washing and re-gloving used a knife to remove a plate wedged in a plate base on the tray assembly line.

5. During an interview on 09/01/11 at 2:00 PM, Staff II Infection Control Nurse stated the following:
-He/she was responsible for the Infection Control practices in all facility departments.
-He/she should be involved with infection control practices in the Nutrition Services department.
-Infection Control hand washing surveillance and monitoring had declined recently.
-No infection Control training or surveillance of temperatures had been done in the Nutrition Services department.
-He/she was on the facility product standards committee and was able to determine the appropriateness of cleaning solutions purchased in each department.


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6. Observation on 8/30/11 at 9:45 AM of dressing change on Patient # 8's foot showed Staff F, RN, applied Santyl, wound ointment medication, to area. Patient # 8 asked for additional medication to be applied to site. Staff F stated that he/she would need to go get more. Staff F wore sterile gloves for the procedure, left the room without removing gloves or washing hands, obtained additional ointment from medication room, returned to Patient #8's room and applied additional medication and new dressing without removing gloves or washing hands upon reentry.

During an interview on 8/30/11 at 9:50 AM Staff B, Regulatory Coordinator, stated that the RN should have washed hands and changed gloves during this process.


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7. Record review of the CDC (Centers for Disease Control and Prevention) guidelines states that employees must wear masks to prevent respiratory protection during sterile procedures and patient care that may cause splashes of blood, body fluids and secretion (saliva expelled from mouth through talking).

8. Observation on 09/01/11 at 9:00 AM showed Staff OO, RN accessing current Patient #20's port (device implanted under the skin for Intravenous (IV) access) using sterile gloves but failed to wear a face mask

During an interview on 09/01/11 at 2:30 PM, Staff JJ, RN, Infection Prevention Nurse and Staff II, RN, Case Management Manager, stated that a mask should be worn by the staff performing the port access, as well as the patient. It is a sterile procedure.


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9. Observation on 08/30/11 from 9:10 AM to 9:30 AM showed Staff I, RN, lifted Patient
#10'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. Staff I then handed Patient #10 his/her medication.

Further observation showed Staff I failed to perform hand hygiene before or after medication administration for Patients #13 and #14.

During an interview on 08/30/11 at 9:35 AM, Staff C, Chief Nursing Officer confirmed RN Staff I did not perform hand hygiene between patient contact. Staff C stated that it is an expectation that staff clean their hands between patients and before patient contact after using the computer.