HospitalInspections.org

Based on observation and interview the facility failed to provide patients with their Patient Rights in a second language in the patient's admission area. The facility provides care to a large Hispanic population. The Patient Rights was not being provided in a second language in the Radiology Department where patients present to register for services.
While touring the area where patients were interviewed and provided the admission information, patient's rights were not being provided in a second language.
An interview at the time of the findings on 03/19/2013 at approximately 9:00 am, staff #11 agreed and substantiated the findings of no Patient Rights were provided to patients in a second language.
While touring the Radiology Department on 3/18/2013 at 1:30 pm the Patient Rights was not being provided to patients in a second language.
An interview at the time of the findings on 03/18/2013 at approximately 1:30 pm with staff #5 and staff #7 agreed and substantiated the findings of no Patient Rights was being provided to patients in a second language.

Based on record review and interview the facility failed to ensure written documentation of patient and/or family involvement in the development and implementation of his/her plan of care. Citing 15 of 15 patient charts reviewed. (Patient chart #11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26).

Review of medical records on 3/19/2013 at 1:30 pm on the patient care unit revealed the following: (Patient chart #11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26).
1. No documentation found to ensure patient and/or family involvement in the development of patient's Plan of Care.

Interview with staff #11 on 3/19/2013 at 3:00 pm confirmed the findings.

Based on record review and interview the facility failed to ensure emergency room physician physical examination sheet was dated and timed by physician. Citing 5 of 10 emergency room records reviewed. (Patient #1, 3, 4, 5, and 9).

While reviewing records on 3/19/2013 at 11:00 am the following was revealed:
1. Patient #1- no date and/or time per physician on emergency room physical examination sheet.
2. Patient #3- no date and/or time per physician on emergency room physical examination sheet.
3. Patient #4- no date and/or time per physician on emergency room physical examination sheet.
4. Patient #5- no date and/or time per physician on emergency room physical examination sheet.
5. Patient #9- no date and/or time per physician on emergency room physical examination sheet.

Interview with staff #29 on 3/20/2013 at 9:00 am confirmed the findings.

Based on record review, the facility failed to ensure verbal orders were authenticated within 48 hours in 8 of 31 charts (#23, 25, 26, 27, 28, 29, 30, and 31).

Findings include:

Review of Medical Staff Rules and Regulations revealed the following: "Verbal orders must be in accordance with Federal and State law and authenticated within forty-eight (48) hours or earlier, if required by State law."

Review of medical records revealed 8 charts where verbal orders had not been authenticated within 48 hours. Findings were as follows (Chart# x number of verbal orders without authentication within 48 hours):
-Chart #23 x 4
-Chart #25 x 1
-Chart #26 x 2
-Chart #27 x 1
-Chart #28 x 4
-Chart #29 x 4
-Chart #30 x 4
-Chart #31 x 8

During an interview on 3/20/13 at 9:30am in the conference room, staff #8 confirmed these findings.

Based on observation, interview and document review the facility failed to insure supervision of the day to day operations of the dietary department evidenced by dry can goods and stock rotations with out a date system observed, 3 of 3 bulk storage containers with loose fitting lids, 5 of 5 one gallon dressing and sauce containers not dated or labeled once they were opened, foods not labeled in the cooler and labeled foods "left over" in the cooler past their safe time limit and incomplete temperatures logs for 3 months (January, February and March) on the dish washing machine.

On 3/19/2013, at 8:30 am, during the tour of the dry stock room in the dietary department no dates were observed on any stock can good or dry good. When staff # 27 was questioned about the rotation of stock he confirmed "yes we do first in, first out rotation", however no dates were observed to identify the first items in from any other item placed in the stock room.

Further observations included a sack of bulk bread crumbs observed in a large white plastic rolling bin. The sack containing the bread crumbs had been placed inside the white container. The sack was open and a scoop was sticking out of the sack, handle up. The lid being used to seal the container was smaller than the bin. It did not fit and simply covered the opening of the container resting on the rim. There was no label identified on the bin or on the lid. This was confirmed by staff #3 who was present during the tour.

Further observations of the dry stock room revealed, bulk sugar was also stored in a rolling bin. The sugar had been emptied from the sack. The container appeared half full of sugar. Observed on the surface of the white sugar was a light brown substance. The substance was not identified as sugar. The lid on the sugar bin did not seal and rattled around the rim. Bulk corn meal was also observed being stored in a large capacity storage bin. The sack of corn meal was setting inside the bin. The paper sack was open and had a scoop, handle side up, sticking out of the sack. The lid did not seal round the rim of the bin. Both of these observations were also observed by staff #3 who was present.

During the same tour the walk in refrigerator was observed with fruit glaze dated "3/6" and gravy that was dated "3/12".upon observation of the 3/6 and 3/12 dates staff #27 stated "That's not going to be used, it's going to be thrown away". A large metal bowl of what appeared to be salad was observed on a cart inside the cooler. The bowl was covered with plastic wrap but had no use by date identity. Staff #27 stated "that will be used today". Gallon containers, 1 each, mayonnaise, 3 different salad dressings and 1 barbeque sauce were observed with partial contents removed. There was no date opened or use by date identified on the label, lid or bottle. This was confirmed by staff #27 and staff #3 who were both present.

During the tour of the prep tables seasonings were observed on the shelf with no use by date or date opened identified. Staff #27 revealed "the staff were really not thinking about spices as needing a use by date".

Further observation during the tour revealed dish washer temperature logs from March 1-March 19, with 9 days identified as not reflecting a recorded temperature or staff initial. March 2 and 3 recorded "didn't use" with no further explanation. A review of dish washer temperature logs for the previous two months revealed January had 6/31 days without temperatures recorded or staff initials for use, February recorded 8/28 days without temperatures recorded or staff initials for use. Interview with Dietary supervisor, staff #27 revealed "It looks like some one forgot to fill this in".

On 3/19/2013 in the conference room at 10:00 revealed the following: Policy # BOO3 revised October 2012 Dry Storage, Date and rotate items: First in and First out. Store foods in their original packages when possible. Open foods must be stored in NSF (National Safe Food) approved containers that have tight fitting lids. Label both the bin and the lid
Refrigerator storage Date and rotate items: first in first out. Discard unused portions not utilized within 48 hours.
Food and Supply storage procedures Unused portions: cover, label, date and store above raw foods.
Frozen storage: Date and rotate items; first in first out.

Policy #BOO4 revised October of 2012. Production, Purchase, Storage. Storage time and temperature. Number of days past sell by date that product may be used in recipe.

Condiments (except Mayonnaise) 60 days
Mayonnaise, salad dressings 30 days.
Juice 7 days
Cobbler and pie fillings 4 days
Honey 6 months
spices ground 6 months
Spices whole 12 months
Syrup 2 months
Vanilla/extracts with vinegar 12 months

The facility failed to supervise staff and insure the established policies of the facility were followed relating to the rotation of food stocks, dating and labeling of foods stocks and safety measures for the sanitation of non disposable eating utensils and cook ware.

Based on observation and interview the facility failed to dispose of 6 expired nasal trumpets, (a tube that is designed to be inserted into the nasal passageway to secure an open airway making them available for patient use.

While touring the Surgical Department on 03/18/2013 at approximately 2:00 pm with staff #4 and staff #30 it was observed in the airway cart, six expired packages, containing nasal airway trumpets. Over the expiration date was a label placed by the facility that read, Clean, Non-sterile.

An interview at the time of the findings 03/18/2013 at approximately 2:00 pm with staff #4 and staff #30, agreed and substantiated the findings. Both staff #4 and staff #30 were in agreement that the placement of sticker over the expiration date was not an accepted practice. Both staff #4 and staff #30 were unaware of a policy that would support the practice of covering over the manufactures expiration date. Staff #30 state he would research the origin of the practice and for any supporting policies.

A later interview with staff #30 on 03/19/2013 at approximately 10:00 am revealed there was no evidence or policy supporting the practice of placing stickers over the manufactures expiration date.

Based on observation and interview the facility failed to ensure sterile and/or clean supplies were protected from possible contamination in respiratory supply room in intensive care unit.

While touring the intensive care unit on 3/19/2013 at 1:30 pm the following observations were made:
1. Respiratory supplies stored in a storage room on wire racks. One wire rack was sitting on the floor with no barrier to prevent contamination from cleaning solution and/or dirt or dust on floor. Second wire rack was off the floor, but still contained no barrier to prevent contamination from cleaning solution and/or dirt and dust on floor.

Interview with staff #28 on 3/10/2013 at 1:45 pm confirmed the findings.