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Based on observation, staff interview and review of documents, it was determined the Director of Food and Nutrition did not provide adequate oversight for the daily sanitation management of the kitchen.

Findings include:

A tour of the kitchen was conducted on 11/5/13 at approximately 10:05 AM. The surveyor was accompanied by staff # 1 who verified the findings.
During the tour the following observations were noted in the kitchen:
1- Two freezers were observed to have temperatures that did not meet national standard (0 degree or below Fahrenheit). The freezer named " Kosher Reach-in Freezer " was observed to have a temperature of 8 degrees Fahrenheit. Freezer titled " 3 Walk-in Freezer " was observed to be 4 degree Fahrenheit.
Review of the monthly temperature logs for August to November 2013 showed that both of the freezers daily temperatures were above 0 degrees 50% of the time for each of these months. There was no documentation to show that corrective actions were taken when these temperatures were out of compliance throughout these three months.
2-The air vent above the steam table was observed to be black from dirt. The vent also had brown stains surrounding the vent.
3- The ceiling tiles throughout the kitchen was observed to be dirty and were amber colored instead of white.
4- The deck oven and combi- oven in the cook ' s station had dry accumulation of grease throughout the interior and exterior portions of the ovens.
5- Garbage cans throughout the kitchen were full of garbage. The cover of the garbage cans could not be closed due to the accumulated of garbage.
6- The plastic trash cans beneath the hand washing sinks throughout the kitchen have swivel covers. The swivel covers on the trash cans prevent the staff from placing the used paper towels directly into the trash containers.
7- Condiment rack in the kitchen had condiment containers that had been open and covered with saran wrap. These open condiment containers were not dated when they were opened. Items found in the containers were a box of Argo starch, bag of brown sugar, and a box of Old Bay Seafood Condiment.
8- A brown bag containing a piece of dry green pepper, moldy onion, and two bottles of condiments (Bacon bits and pepper) was found on the condiment shelf.
9- A meat clever and a large cook ' s knife were observed to be lying on a table that was not a work station.
10-The Pathway box was observed to be dusty and dirty.
11-Bags of fresh produce (grapes) were found to be opened and not dated in the refrigerator.
12-Two windows behind the cold prep area were dirty. There was a black filmed throughout the top and sides of the window panes. The window sill was dusty.
13-The Hobart buffalo chopper (not in use) was not covered. The chopper was exposed to dust.
14- Baking pans on rack were stacked and wet. Cooking pans were not air dry. These pans were found to be dripping wet.
15- A large hole was observed in a wall in the dry storage room. In addition, there were two large openings behind the door in the dry store room. These openings promote/allow the harboring of pests.

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code, NFPA 101, 2000 edition.
Specifically, this references Life Safety Code citations issued under survey event ID# FTD021.

Findings include:

During the survey of the facility from November 4-8, 2013, Life Safety Code deficiencies were noted in multiple areas of the Code requirements and were cited under the following Fire/Life Safety Code K-Tags:

K20
K21
K25
K62
K72
K106

The findings referenced above were verified by concurrent staff interview with staff #7 during the dates noted in corresponding K tags cited.

Based on observation and staff interview the facility failed to ensure that their facilities, supplies, and equipment was maintained to an acceptable level of safety and quality.

The findings are:

1) On the morning of 11/4/13 observation revealed that a spare wheelchair was being stored in the Ambulatory Surgery Shower Room.

2) On the morning of 11/4/13 observation in the Radiology Room revealed that a wall electrical outlet was loose and not flush with the wall.

3) On the afternoon of 11/4/13 observation in Treatment Room #8 of the Emergency Room revealed that one of the edges of the wall was damaged (i.e. the cornerguard was partially ripped out).

4) During the course of the 5 day survey the following deficiencies related to the nurse call bell system was found: a) the nurse call bells have not been installed, b) the audible/visual elements of the nurse call bells were not working.

4a) On the morning of 11/5/13 observation in both of the OR Suite bathrooms, in the vicinity of the recovery bays, revealed that neither had any nurse call bell systems installed in them.

4b) On the the morning of 11/5/13 observation of the bathroom in the vicinity of the Radiology Room revealed that the audible element of the nurse call bell system was not working when tested.

On the the morning of 11/5/13 observation of the bathroom in the vicinity of Nuclear Medicine, and both of the bathrooms in the vicinity of the X-Ray Rooms revealed that neither the audible or visual elements of the nurse call bell system was not working when tested.

5) On the morning of 11/5/13 observation in the 2nd. Floor MRI Control Room revealed that the fire extinguisher in this room had a ferrous metal pin in it.

6) On the afternoon of 11/5/13 observation in the 4th. Floor Labor and Delivery Storage Room revealed that there were miscellaneous boxes of fetal monitoring cables being stored on the floor.

The above mentioned observations were all concurrently confirmed by staff #7.

Based on observations, record review, and staff interview, it was determined the infection control officer was not effective in her role in in identifying conditions that would potentially cause contamination and the spread of infections and failed to ensure that services were provided in a clean and safe environment.

The findings are:

1. On the morning of 11/4/13 observation in the Pediatric Area revealed that:

a) inside the Housekeeping Closet one of the walls was water damaged (i.e. stained) and there were 3 unsealed holes through the wall tiles

b) inside the Janitor's Closet there were 6 packets of instant coffee being stored in the room.

2. On the afternoon of 11/4/13 observation in the Kitchen revealed that:

a) there was a dust laden ceiling return vent located directly over the Cold Patient Preparation Area.

b) a fan on the clean side of Dish wash area was dusty and blowing dust onto clean dishes.

3. While touring the facility observation revealed deficiencies regarding red bag waste containers. Specifically:

a) On the afternoon of 11/4/13 observation in the Emergency Room revealed that the privacy curtain separating Treatment Room #8 and Treatment Room #9 was under and touching a red bag waster container.

b) On the morning of 11/5/13 observation in the CT Room revealed that there were blood droplets on the outer cover of the red bag waste container.

4. While touring the facility observation revealed that certain rooms did not have the correct positive or negative airflow that is required by CDC recommendations. Specifically:

a) On the afternoon of 11/5/13 observation revealed that both of the C-Section Procedure Rooms had neutral airflow. These rooms are required to have positive airflow.

b) On the afternoon of 11/5/13 observation revealed that the 4th. Floor Soiled Utility Room, Room 494, had positive air flow. This room is required to have negative airflow.

c) On the morning of 11/7/13 observation revealed that Clean Utility Room across from Room 542 had negative airflow. This room is required to have positive airflow.

d) On the afternoon of 11/7/13 observation revealed that the Central Sterile Processing Area had negative air flow in relation to the Sterile Processing Area. Therefore the "dirty" air from the Sterile Processing Area was flowing into the "clean" Central Sterile Processing Area.

5. On the morning of 11/7/13 observation revealed that handwashing sinks were missing in specific rooms of the 4th. Floor Ambulatory Surgery Unit. Specifically:

a) Both of the Endoscopic Procedure Rooms were missing hand-washing sinks.

b) Recovery Room 443 was missing a hand-wash sink.

c) Pre-Admissions Room was missing a hand-wash sink.

6. While touring the facility observation revealed there were no negative isolation rooms in any of the Medical and Surgical Nursing Units as required in 1996-1997 Guidelines for Design and Construction of Hospital and Health Care Facilities: Section 7.2.C. Specifically:

a) On the morning of 11/5/13 during the tour of the facility the surveyor could not find any isolation rooms. During a concurrent interview staff #7 stated that when a patient comes in that requires a negative air isolation room , the staff put a HEPA Filter unit in the room.

b) On the morning of 11/8/13 record review confirmed that a HEPA unit is used when patient that requires a negative isolation comes into the facility.

7) While touring the Operating Suite on the morning of 11/5/2013, observation revealed that the hospital did not have a holding area for the patients before surgery and the hospital used the corridor as a holding area. Two patients were observed on beds on the corridor and they were observed being prepared for surgery and were receiving their medications on the corridor. This observation was concurrently confirmed by the Chief Medical Officer, staff #5.

The above mentioned observations were all concurrently confirmed by staff #7.

Based on review of the Organ, Tissue and Eye Procurement Program Manual and staff interview, it was determined that the facility failed to ensure that this program was integrated into the Hospital Wide Quality Assurance Performance Improvement Program (QAPI).
Findings include:
A review of the hospital ' s Organ, Tissue and Eye Procurement Program Manual was conducted on 11/7/13 at approximately 2:00 PM. Tracking data concerning compliance with Time Notification was reviewed.
The definition of Time Notification is when the hospital contacts the Organ Procurement Organization by telephone after an individual or patient has died. The ideal turnaround time should be one hour.
A review of this Time Notification data revealed that the compliance rate for Time Notification was at 75% on 2012. The Timeliness Rate for the year 2011 81% (2011).
Thus the timeliness rate dropped in 2012 as compared to the timeliness rate in 2011.
The surveyor interviewed staff # 4 in charge of the program. Staff #4 stated that the Organ, Tissue and Eye Procurement did not have a quality assurance program. Monitoring of data has not been done. Therefore, it has not reported any data to the Hospital Quality Performance Improvement Program (QAPI).