HospitalInspections.org

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A0048
A0057

Cross refer to:

A0432
A0438
A0458

Cross refer to:

A0621

Cross refer to:

A0701
A0726

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A0748

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A1124
A1125

Based on a review of clinical records and facility documentation, the governing body failed to enforce the medical staff rules and regulations. Failure to do so can result in a lack of continuity in patient care.

Findings were:


During a review of Swing Bed clinical records (patients #4, #5, #6 and #7) on 3-31-15, the following was noted:
· 4 of the 4 Swing Bed clinical records contained History(s) & Physical(s) performed greater than 7 days prior to admission.

Page 4 of the Medical Staff Rules & Regulations titled "Medical Records" states, in part:
"7. A complete history and physical examination shall be done on all patients no more than seven (7) days before admission ..."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on a review of documentation, a tour of the facility and interviews with staff, the governing body failed to appoint a chief executive officer who is responsible for the management of the hospital. Failure to appropriately manage the hospital can result in potential harm to patients and staff.

Findings were:


During a tour of the kitchen on 3-31-15, the following was noted:
· During a demonstration of the automatic dishwasher, the temperature gauge indicated the wash temperature to be 100 degrees Fahrenheit during the wash cycle. When the wash cycle had finished, the temperature gauge continued to read 100 degrees Fahrenheit. In an interview with staff #14, staff #14 indicated that the water should be at least 125 degrees Fahrenheit during the wash cycle and should drop quickly after the wash cycle is complete.
· A review of the document titled "Dishmachine Log" revealed that no temperature check had been performed for March 16th, 1 of the 30 days recorded.
· A document dated March 2015 appeared to be a document on which to record the temperatures of the kitchen refrigerator, chest freezer and upright freezer. The document stated no target temperature ranges for any of the three appliances listed, nor steps to take in the event that an appliance's temperature was outside the target range. In an interview with staff #14, staff #14 was asked to state the proper temperature range for both refrigerator and freezer. Staff #14 stated the proper temperature range for the refrigerator was "33-40 degrees" and the proper temperature range for the freezer was "0-20 degrees." A review of the temperature log for March 2015 revealed that the chest freezer temperature had registered outside the acceptable temperature range for 1 of the 30 days recorded and that the upright freezer temperature had registered outside the acceptable temperature range for 14 of the 30 days recorded.

Facility Dietary policy titled "Sanitation - Dishwashing" stated, in part:
"2.c. Make sure that wash-water temperature is at least 125 degrees F (Fahrenheit) for 52 seconds, and rinse water is at least 125 degrees F (Fahrenheit) for 25 seconds.
3. Check the following areas of the dish machine daily: ...b. Washing, rinsing and sanitizing temperatures."

Facility Dietary policy titled "Purchasing and Storage" stated, in part:
"2. A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
a. Refrigerated perishable foods: 33 degrees to 40 degrees F (Fahrenheit)
b. Frozen Foods: -10 degrees to 0 degrees F (Fahrenheit)"

During a tour of the cardiac rehabilitation area on 3-31-15, the following was noted:
· In the department crash cart, 1 of 1 bottle of nitroglycerin 0.4 mg tablets had expired 2-2015 but was available for patient use.
· In the department crash cart, 2 of 2 vials of verapamil had expired 3-1-15 but were available for patient use.
· In the department crash cart, no documentation of periodic testing of the defibrillator was available.

Facility Pharmacy & Therapeutic policy titled "EXPIRED (OUTDATED) AND OTHER UNUSABLE DRUGS" states, in part:
"Drugs are considered expired according to manufacturer's labeled date or an expiration date assigned by pharmacy prior to manufacturer's expiration dating is in accord with USP labeling guidelines."

Facility documentation titled "Cardiac Rehabilitation Equipment" stated, in part:
"Standard equipment options include;
Defibrillator which is portable and charge-tested prior to program operation."

In an interview with staff #16 on 3-31-15 at 3:45 pm, staff #16 was unable to produce documentation of testing prior to program operation and stated that a monitor strip was only run once or twice a month. Based on a review of the Cardiac Rehabilitation Schedule (provided by staff #16), Cardiac Rehabilitation services were being provided and had been provided 3 times per week during the months of February 2015 and March 2015.

During a review of Swing Bed clinical records (patients #4, #5, #6 and #7) on 3-31-15, the following was noted:
· 4 of the 4 Swing Bed clinical records contained History(s) & Physical(s) performed greater than 7 days prior to admission.

Page 4 of the Medical Staff Rules & Regulations titled "Medical Records" states, in part:
"7. A complete history and physical examination shall be done on all patients no more than seven (7) days before admission..."

Based on a review of documentation, the facility failed to conduct the required number of fire drills (12) during the review period of 2014, only conducting drills on 1-23-14 and 8-26-14. The facility was unable to provide documentation that the drills included communication of alarms, simulation of evacuation of patients and other occupants and use of fire-fighting equipment. Failure to perform necessary drills can leave staff members unprepared in case of a true emergency.

Facility document titled "FIRE PLAN" states, in part:
"...To assist with this preparedness, the District shall conduct at least 12 fire drills per hear, one drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and the use of firefighting equipment."

During an interview with staff #16 on 3-31-15 at 4:19 pm, staff #16 stated that his/her ACLS certification had expired "in the last few months" and that s/he was not scheduled to be recertified.

Facility documentation titled "Job Description, Cardiac Rehabilitation Program Director" states, in part:
"Requirements
Current CPR and ACLS certification."

During an interview with staff #16 on 3-31-15 at 4:30 pm, staff #16 stated that the cardiac rehabilitation services were performed by three paramedics but that none of the 3 paramedics who provided patient care in the Cardiac Rehabilitation Program held any current competencies in the provision of patient care for that program. Documentation was provided that indicated that the facility had provided cardiac rehabilitation services 3 times weekly during the months of February 2015 and March 2015.

Facility documentation titled "Staffing Policy" states, in part:
"Purpose
To establish guidelines for the staffing of the Cardiac Rehabilitation Program.
Policy
Only licensed and/or certified health care professionals who are qualified by relevant education, experience, and current competency shall provide patient care in the Cardiac Rehabilitation Program."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on a review of documentation and an interview with staff, the medical record service was not appropriate to the scope and complexity of the services performed, allowing the facility to comply with Federal and State regulations such as Histories & Physicals performed within 24 hours of the patient's admission and completion of medical records within 30 days following the patient's discharge.

Findings were:


In an interview with staff #15 on 3-31-15, staff #15 stated that s/he performs all transcription services for the facility. Staff #15 also stated that transcription is usually performed the same day it is dictated into the electronic system or on the Monday following any weekend dictation, but that the date of the dictation is never placed on the item transcribed. Staff #15 confirmed that the date of the dictation was of utmost importance in determining compliance with State and Federal regulations regarding Medical Record Content.

The above was verified in an interview with the Chief Executive Officer and the Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on a review of clinical records, the hospital failed to maintain a promptly completed medical record for each patient. Failure to do so can affect patient continuity of care.

Findings were:


During a review of Inpatient clinical records (patients #1, #2 and #3) on 3-31-15, the following was noted:
· 1 of the 3 inpatient clinical records (patient #2) contained a Discharge Summary that had not been completed within 30 days following the patient's discharge from the facility.

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on a review of clinical documentation, all records did not contain a medical History and Physical completed and documented within 24 hours of admission or no more than 7 days prior to admission, as per facility guidelines.

Findings were:


During a review of Inpatient clinical records (patients #1, #2 and #3) on 3-31-15, the following was noted:
· 2 of the 3 inpatient clinical records (patients #1 and #2) contained History(s) & Physical(s) not performed within 24 hours of admission.


During a review of Swing Bed clinical records (patients #4, #5, #6 and #7) on 3-31-15, the following was noted:
· 4 of the 4 Swing Bed clinical records contained History(s) & Physical(s) performed greater than 7 days prior to admission.

Page 4 of the Medical Staff Rules & Regulations titled "Medical Records" states, in part:
"7. A complete history and physical examination shall be done on all patients no more than seven (7) days before admission..."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on a tour of the facility, outdated or otherwise unusable drugs were available for patient use. The avaibility of these items has the potential to cause patient harm.

Findings were:


During a tour of the Emergency Department on 3-31-15, the following was noted:
· In ER #1, a 500 ml bottle of 0.9% sodium chloride irrigation had been opened and dated 3-30-15. Approximately 100 ml remained in the bottle and the bottle was available for patient use. The label stated "discard unused portion." Failure to discard the solution according to directions on the label can result in contamination and possible illness.

During a tour of the Cardiac Rehabilitation department on 3-31-15, the following was noted:
· In the department crash cart, 1 of 1 bottle of nitroglycerin 0.4 mg tablets had expired 2-2015 but was available for patient use.
· In the department crash cart, 2 of 2 vials of verapamil had expired 3-1-15 but were available for patient use.

Facility Pharmacy & Therapeutic policy titled "EXPIRED (OUTDATED) AND OTHER UNUSABLE DRUGS" states, in part:
"Drugs are considered expired according to manufacturer's labeled date or an expiration date assigned by pharmacy prior to manufacturer's expiration dating is in accord with USP labeling guidelines."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on observation, interviews and a tour of the facility, the facility failed to employ a qualified dietitian that observed and adhered to professional standards of practice regarding food storage and sanitation. Failure to adhere to these professional standards compromises patient safety and increases the likelihood of infections caused by improper sanitation and improper food storage.

Findings were:

During a tour of the kitchen on 3-31-15, the following was noted:
· A pair of eyeglasses was noted hanging above measuring cups and spoons on a rack over the food preparation area. In an interview with staff #14 at the time of the tour, staff #14 confirmed that the eyeglasses belonged to staff #14. Personal items transmit bacteria onto food preparation surfaces.
· 3 of 4 corners of the food preparation table were being held in place with transparent tape, preventing proper cleaning of the area.
· The surface of the food preparation table was marred with numerous holes in the formica finish, preventing the surface from being properly cleaned and creating an environment for bacterial growth.
· During a demonstration of the automatic dishwasher, the temperature gauge indicated the wash temperature to be 100 degrees Fahrenheit during the wash cycle. When the wash cycle had finished, the temperature gauge continued to read 100 degrees Fahrenheit. In an interview with staff #14, staff #14 indicated that the water should be at least 125 degrees Fahrenheit during the wash cycle and should drop quickly after the wash cycle is complete.
· A review of the document titled "Dishmachine Log" revealed that no temperature check had been performed for March 16th, 1 of the 30 days recorded.
· A document dated March 2015 appeared to be a document on which to record the temperatures of the kitchen refrigerator, chest freezer and upright freezer. The document stated no target temperature ranges for any of the three appliances listed, nor steps to take in the event that an appliance ' s temperature was outside the target range. In an interview with staff #14, staff #14 was asked to state the proper temperature range for both refrigerator and freezer. Staff #14 stated the proper temperature range for the refrigerator was "33-40 degrees" and the proper temperature range for the freezer was "0-20 degrees." A review of the temperature log for March 2015 revealed that the chest freezer temperature had registered outside the acceptable temperature range for 1 of the 30 days recorded and that the upright freezer temperature had registered outside the acceptable temperature range for 14 of the 30 days recorded.

Facility Dietary policy titled "Sanitation - Dishwashing" stated, in part:
"2.c. Make sure that wash-water temperature is at least 125 degrees F (Fahrenheit) for 52 seconds, and rinse water is at least 125 degrees F (Fahrenheit) for 25 seconds.
3. Check the following areas of the dish machine daily: ...b. Washing, rinsing and sanitizing temperatures."

Facility Dietary policy titled "Purchasing and Storage" stated, in part:
"2. A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
a. Refrigerated perishable foods: 33 degrees to 40 degrees F (Fahrenheit)
b. Frozen Foods: -10 degrees to 0 degrees F (Fahrenheit)"

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on a tour of the facility, the condition of the physical plant and the overall hospital environment was not maintained in such a manner that the safety and well-being of patients was assured.

Findings were:


During a tour of the Emergency Department on 3-31-15, the following was noted:
· In ER #1, dust was noted on high, horizontal surfaces, including the overhead exam lamp. Dust contains bacteria and other contaminants, which can transmit infection.
· In ER #1, numerous holes and a water stain were noted in the room's ceiling. Holes can allow the entry of vermin, which can carry disease. Water stains can be indicative of old or new water leaks and can be a growth medium for mold and mildew.
· In ER #1, light from outside the facility was visible around the room's air conditioner, which can allow the entry of dust, dirt and vermin into the facility.
· In ER #1, a 500 ml bottle of 0.9% sodium chloride irrigation had been opened and dated 3-30-15. Approximately 100 ml remained in the bottle and the bottle was available for patient use. The label stated "discard unused portion." Failure to discard the solution according to directions on the label can result in contamination and possible illness.
· In ER #2, dust was noted on high, horizontal surfaces, including a ceiling fan that was in use at the time of the tour. Dust contains bacteria and other contaminants, which can transmit infection.
· In ER #2, 2 areas of formica surface were missing from the cabinet edge, preventing the surface from being properly cleaned and creating an environment for bacterial growth.
· In a storage room near ER #2, dead insects were noted on the floor and walls and a live wasp was in the room. Areas of formica surface were missing on the countertop. Dead insects can transmit disease and live insects can transmit disease and injure patients. Missing formica can prevent the surface from being properly cleaned and create an environment for bacterial growth.
· Daylight was visible between the double doors leading from the ambulance entrance to the inside ER hallway, which can allow the entry of dust, dirt and vermin into the facility.
· In the area outside the ambulance/patient entrance, several areas of uneven and chipped concrete were noted, creating a safety and fall hazard.
· A patient bathroom near the emergency department and x-ray area lacked an emergency call light, preventing a patient from summoning assistance in case of a fall or other emergency.

During a tour of the x-ray reader room on 3-31-15, the following was noted:
· The walls contained holes in the sheetrock surface, preventing proper cleaning.

During a tour of the inpatient care unit on 3-31-15, the following was noted:
· In patient rooms #104, #105 and #106, light from outside the facility was visible around the room's air/heat unit, which can allow the entry of dust, dirt and vermin into the facility.

During a tour of the kitchen on 3-31-15, the following was noted:
· A pair of eyeglasses was noted hanging above measuring cups and spoons on a rack over the food preparation area. In an interview with staff #14 at the time of the tour, staff #14 confirmed that the eyeglasses belonged to staff #14. Personal items transmit bacteria onto food preparation surfaces.
· 3 of 4 corners of the food preparation table were being held in place with transparent tape, preventing proper cleaning of the area.
· The surface of the food preparation table was marred with numerous holes in the formica finish, preventing the surface from being properly cleaned and creating an environment for bacterial growth.
· During a demonstration of the automatic dishwasher, the temperature gauge indicated the wash temperature to be 100 degrees Fahrenheit during the wash cycle. When the wash cycle had finished, the temperature gauge continued to read 100 degrees Fahrenheit. In an interview with staff #14, staff #14 indicated that the water should be at least 125 degrees Fahrenheit during the wash cycle and should drop quickly after the wash cycle is complete.
· A review of the document titled "Dishmachine Log" revealed that no temperature check had been performed for March 16th, 1 of the 30 days recorded.
· A document dated March 2015 appeared to be a document on which to record the temperatures of the kitchen refrigerator, chest freezer and upright freezer. The document stated no target temperature ranges for any of the three appliances listed, nor steps to take in the event that an appliance's temperature was outside the target range. In an interview with staff #14, staff #14 was asked to state the proper temperature range for both refrigerator and freezer. Staff #14 stated the proper temperature range for the refrigerator was "33-40 degrees" and the proper temperature range for the freezer was "0-20 degrees." A review of the temperature log for March 2015 revealed that the chest freezer temperature had registered outside the acceptable temperature range for 1 of the 30 days recorded and that the upright freezer temperature had registered outside the acceptable temperature range for 14 of the 30 days recorded.

Facility Dietary policy titled "Sanitation - Dishwashing" stated, in part:
"2.c. Make sure that wash-water temperature is at least 125 degrees F (Fahrenheit) for 52 seconds, and rinse water is at least 125 degrees F (Fahrenheit) for 25 seconds.
3. Check the following areas of the dish machine daily: ...b. Washing, rinsing and sanitizing temperatures."

Facility Dietary policy titled "Purchasing and Storage" stated, in part:
"2. A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
a. Refrigerated perishable foods: 33 degrees to 40 degrees F (Fahrenheit)
b. Frozen Foods: -10 degrees to 0 degrees F (Fahrenheit)"

During a tour of the cardiac rehabilitation area on 3-31-15, the following was noted:
· In the department crash cart, 1 of 1 bottle of nitroglycerin 0.4 mg tablets had expired 2-2015 but was available for patient use.
· In the department crash cart, 2 of 2 vials of verapamil had expired 3-1-15 but were available for patient use.
· In the department crash cart, no documentation of periodic testing of the defibrillator was available.

Facility Pharmacy & Therapeutic policy titled "EXPIRED (OUTDATED) AND OTHER UNUSABLE DRUGS" states, in part:
"Drugs are considered expired according to manufacturer's labeled date or an expiration date assigned by pharmacy prior to manufacturer's expiration dating is in accord with USP labeling guidelines."

Facility documentation titled "Cardiac Rehabilitation Equipment" stated, in part:
"Standard equipment options include;
Defibrillator which is portable and charge-tested prior to program operation."

In an interview with staff #16 on 3-31-15 at 3:45 pm, staff #16 was unable to produce documentation of testing prior to program operation and stated that a monitor strip was only run once or twice a month. Based on a review of the Cardiac Rehabilitation Schedule (provided by staff #16), Cardiac Rehabilitation services were being provided and had been provided 3 times per week during the months of February 2015 and March 2015.

Based on a review of documentation, the facility failed to conduct the required number of fire drills (12) during the review period of 2014. The facility was unable to provide documentation that the drills included communication of alarms, simulation of evacuation of patients and other occupants and use of fire-fighting equipment. Failure to perform necessary drills can leave staff members unprepared in case of a true emergency.

Facility document titled " FIRE PLAN " states, in part:
"...To assist with this preparedness, the District shall conduct at least 12 fire drills per hear, one drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and the use of firefighting equipment."

During an interview with staff #16 on 3-31-15 at 4:19 pm, staff #16 stated that his/her ACLS certification had expired "in the last few months" and that s/he was not scheduled to be recertified.

Facility documentation titled "Job Description, Cardiac Rehabilitation Program Director" states, in part:
"Requirements
Current CPR and ACLS certification."

During an interview with staff #16 on 3-31-15 at 4:30 pm, staff #16 stated that none of the 3 paramedics who provided patient care in the Cardiac Rehabilitation Program held any current competencies in the provision of patient care for that program. Documentation was provided that indicated that the facility had provided cardiac rehabilitation services 3 times weekly during the months of February 2015 and March 2015.

Facility documentation titled "Staffing Policy" states, in part:
"Purpose
To establish guidelines for the staffing of the Cardiac Rehabilitation Program.
Policy
Only licensed and/or certified health care professionals who are qualified by relevant education, experience, and current competency shall provide patient care in the Cardiac Rehabilitation Program."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on observation, review of documentation, an interview with staff and a tour of the facility, there was not proper temperature control in the food preparation area. Lack of proper and controlled
temperature in food preparation areas can lead to bacterial growth and cause illness in patients and staff.

Findings were:


During a tour of the kitchen on 3-31-15, the following was noted:
· A document dated March 2015 appeared to be a document on which to record the temperatures of the kitchen refrigerator, chest freezer and upright freezer. The document stated no target temperature ranges for any of the three appliances listed, nor steps to take in the event that an appliance's temperature was outside the target range. In an interview with staff #14, staff #14 was asked to state the proper temperature range for both refrigerator and freezer. Staff #14 stated the proper temperature range for the refrigerator was "33-40 degrees" and the proper temperature range for the freezer was "0-20 degrees." A review of the temperature log for March 2015 revealed that the chest freezer temperature had registered outside the acceptable temperature range for 1 of the 30 days recorded and that the upright freezer temperature had registered outside the acceptable temperature range for 14 of the 30 days recorded.

Facility Dietary policy titled "Purchasing and Storage" stated, in part:
"2. A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
a. Refrigerated perishable foods: 33 degrees to 40 degrees F (Fahrenheit)
b. Frozen Foods: -10 degrees to 0 degrees F (Fahrenheit)"

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on observation, interviews, a review of documentation and a tour of the facility, the infection control officer failed to develop and implement adequate policies governing control of infections and communicable diseases. Failure to develop and implement adequate policies increases the likelihood of disease and illness within the facility.

Findings were:

During a tour of the Emergency Department on 3-31-15, the following was noted:
· In ER #1, dust was noted on high, horizontal surfaces, including the overhead exam lamp. Dust contains bacteria and other contaminants, which can transmit infection.
· In ER #1, numerous holes and a water stain were noted in the room's ceiling. Holes can allow the entry of vermin, which can carry disease. Water stains can be indicative of old or new water leaks and can be a growth medium for mold and mildew.
· In ER #1, light from outside the facility was visible around the room's air conditioner, which can allow the entry of dust, dirt and vermin into the facility.
· In ER #1, a 500 ml bottle of 0.9% sodium chloride irrigation had been opened and dated 3-30-15. Approximately 100 ml remained in the bottle and the bottle was available for patient use. The label stated "discard unused portion." Failure to discard the solution according to directions on the label can result in contamination and possible illness.
· In ER #2, dust was noted on high, horizontal surfaces, including a ceiling fan that was in use at the time of the tour. Dust contains bacteria and other contaminants, which can transmit infection.
· In ER #2, 2 areas of formica surface were missing from the cabinet edge, preventing the surface from being properly cleaned and creating an environment for bacterial growth.
· In a storage room near ER #2, dead insects were noted on the floor and walls and a live wasp was in the room. Areas of formica surface were missing on the countertop. Dead insects can transmit disease and live insects can transmit disease and injure patients. Missing formica can prevent the surface from being properly cleaned and create an environment for bacterial growth.
· Daylight was visible between the double doors leading from the ambulance entrance to the inside ER hallway, which can allow the entry of dust, dirt and vermin into the facility.

During a tour of the x-ray reader room on 3-31-15, the following was noted:
· The walls contained holes in the sheetrock surface, preventing proper cleaning.

During a tour of the inpatient care unit on 3-31-15, the following was noted:
· In patient rooms #104, #105 and #106, light from outside the facility was visible around the room's air/heat unit, which can allow the entry of dust, dirt and vermin into the facility.

During a tour of the kitchen on 3-31-15, the following was noted:
· A pair of eyeglasses was noted hanging above measuring cups and spoons on a rack over the food preparation area. In an interview with staff #14 at the time of the tour, staff #14 confirmed that the eyeglasses belonged to staff #14.
· 3 of 4 corners of the food preparation table were being held in place with transparent tape, preventing proper cleaning of the area.
· The surface of the food preparation table was marred with numerous holes in the formica finish, preventing the surface from being properly cleaned and creating an environment for bacterial growth.
· During a demonstration of the automatic dishwasher, the temperature gauge indicated the wash temperature to be 100 degrees Fahrenheit during the wash cycle. When the wash cycle had finished, the temperature gauge continued to read 100 degrees Fahrenheit. In an interview with staff #14, staff #14 indicated that the water should be at least 125 degrees Fahrenheit during the wash cycle and should drop quickly after the wash cycle is complete.
· A review of the document titled "Dishmachine Log" revealed that no temperature check had been performed for March 16th, 1 of the 30 days recorded.
· A document dated March 2015 appeared to be a document on which to record the temperatures of the kitchen refrigerator, chest freezer and upright freezer. The document stated no target temperature ranges for any of the three appliances listed, nor steps to take in the event that an appliance's temperature was outside the target range. In an interview with staff #14, staff #14 was asked to state the proper temperature range for both refrigerator and freezer. Staff #14 stated the proper temperature range for the refrigerator was "33-40 degrees" and the proper temperature range for the freezer was "0-20 degrees." A review of the temperature log for March 2015 revealed that the chest freezer temperature had registered outside the acceptable temperature range for 1 of the 30 days recorded and that the upright freezer temperature had registered outside the acceptable temperature range for 14 of the 30 days recorded.

Facility Dietary policy titled "Sanitation - Dishwashing" stated, in part:
" 2.c. Make sure that wash-water temperature is at least 125 degrees F (Fahrenheit) for 52 seconds, and rinse water is at least 125 degrees F (Fahrenheit) for 25 seconds.
3. Check the following areas of the dish machine daily: ...b. Washing, rinsing and sanitizing temperatures."

Facility Dietary policy titled "Purchasing and Storage" stated, in part:
"2. A reliable thermometer will be used to check the temperature of each refrigerator and freezer daily to insure that the following temperatures are maintained:
a. Refrigerated perishable foods: 33 degrees to 40 degrees F (Fahrenheit)
b. Frozen Foods: -10 degrees to 0 degrees F (Fahrenheit)"

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on interviews, observation, a review of documentation and a tour of the facility, The hospital failed to provide the appropriate equipment and types and numbers of qualified personnel necessary to furnish the rehabilitation services offered by the hospital in accordance with acceptable standards of practice. Failure to adhere to these standards compromises patient care and safety.

Findings were:


During a tour of the cardiac rehabilitation area on 3-31-15, the following was noted:
· In the department crash cart, no documentation of periodic testing of the defibrillator was available.

Facility documentation titled "Cardiac Rehabilitation Equipment" stated, in part:
"Standard equipment options include;
Defibrillator which is portable and charge-tested prior to program operation."

In an interview with staff #16 on 3-31-15 at 3:45 pm, staff #16 was unable to produce documentation of testing prior to program operation and stated that a monitor strip was only run once or twice a month. Based on a review of the Cardiac Rehabilitation Schedule (provided by staff #16), Cardiac Rehabilitation services were being provided and had been provided 3 times per week during the months of February 2015 and March 2015.

Facility documentation titled "Staffing Policy" states, in part:
"Purpose
To establish guidelines for the staffing of the Cardiac Rehabilitation Program.
Policy
Only licensed and/or certified health care professionals who are qualified by relevant education, experience, and current competency shall provide patient care in the Cardiac Rehabilitation Program."

During an interview with staff #16 on 3-31-15 at 4:30 pm, staff #16 stated that none of the 3 paramedics who provided patient care in the Cardiac Rehabilitation Program held any current competencies in the provision of patient care for that program. Documentation was provided that indicated that the facility had provided cardiac rehabilitation services 3 times weekly during the months of February 2015 and March 2015.

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.

Based on a review of documentation and an interview with staff, the director of cardiac rehabilitation services did not have the necessary knowledge, experience and capabilities to properly supervise and administer the cardiac rehabilitation services. Failure to meet these guidelines can compromise patient safety.

Findings were:


During an interview with staff #16 on 3-31-15 at 4:19 pm, staff #16 stated that his/her ACLS certification had expired "in the last few months" and that s/he was not scheduled to be recertified.

Facility documentation titled "Job Description, Cardiac Rehabilitation Program Director" states, in part:
"Requirements
Current CPR and ACLS certification."

The above was confirmed in an interview with the Chief Executive Officer and Chief Nursing Officer on the evening of 3-31-15 in the physical therapy office.