HospitalInspections.org

Based on clinical record review and interview, the facility failed to ensure the nursing care plans for seven (#1-#6 and #8) of eight (#1-#8) sampled patients on the current census were reviewed on a weekly basis. The failed practice did not ensure the nursing care was up-to-date with the needs of the patients and affected all eight patients on current census. The findings follow:

A. In an interview with the Director of Nursing on 12/02/10 at 1120, when asked by the Surveyor how often the nursing care plans were reviewed, she stated at least weekly and as needed as the patient's needs require it. She stated on the day when the nursing plan of care was reviewed, the date was to be placed in the "Revised" column of the care plan.
B. Review of Patient #1's clinical record on 12/02/10 revealed the patient's Nursing Plan of Care was initiated on 11/20/10. The last date in the "Revised" column of the plan of care for nursing services was 11/21/10. In an interview with the Director of Nursing on 12/02/10 at 1120, she stated the plan of care should have been reviewed on 11/28/10. There was no evidence provided the nursing plan of care was reviewed on 11/28/10.
C. Review of Patient #2's clinical record on 12/02/10 revealed the patient's Nursing Plan of Care was initiated on 11/20/10. The last date in the "Revised" column of the plan of care for nursing services was 11/21/10. In an interview with the Director of Nursing on 12/02/10 at 1250, she stated the plan of care should have been reviewed on 11/28/10. There was no evidence provided the nursing plan of care was reviewed on 11/28/10.
D. Review of Patient #3's clinical record on 12/02/10 revealed the patient ' s Nursing Plan of Care was initiated on 11/23/10. There was no date documented in the "Revised" column of the plan of care for nursing services. In an interview with the Director of Nursing on 12/02/10 at 1340, she stated the plan of care should have been reviewed on 11/28/10. There was no evidence provided the nursing plan of care was reviewed on 11/28/10.
E. Review of Patient #4's clinical record on 12/02/10 revealed the patient's Nursing Plan of Care was initiated on 11/08/10. The last date in the "Revised" column of the plan of care for nursing services was 11/21/10. In an interview with the Director of Nursing on 12/02/10 at 1430, she stated the plan of care should have been reviewed on 11/28/10. There was no evidence provided the nursing plan of care was reviewed on 11/28/10.
F. Review of Patient #5's clinical record on 12/02/10 revealed the patient's Nursing Plan of Care was initiated on 11/23/10. There was no date documented in the "Revised" column of the plan of care for nursing services. In an interview with the Director of Nursing on 12/02/10 at 1500, she stated the plan of care should have been reviewed on 11/28/10. There was no evidence provided the nursing plan of care was reviewed on 11/28/10.
G. Review of Patient #6's clinical record on 12/02/10 revealed the patient's Nursing Plan of Care was initiated on 11/18/10. The last date in the "Revised" column of the plan of care for nursing services was 11/21/10. In an interview with the Director of Nursing on 12/02/10 at 1420, she stated the plan of care should have been reviewed on 11/28/10. There was no evidence provided the nursing plan of care was reviewed on 11/28/10.
H. Review of Patient #8's clinical record on 12/02/10 revealed the patient's Nursing Plan of Care was initiated on 11/23/10. There was no date documented in the "Revised" column of the plan of care for nursing services. In an interview with the Director of Nursing on 12/02/10 at 1500, she stated the plan of care should have been reviewed on 11/28/10. There was no evidence provided the nursing plan of care was reviewed on 11/28/10.

Based on observation and interview, it was determined the requirement to integrate food service for patients related to occupational therapy (OT) into the hospital-wide infection control program was not met . The failed practice had the potential to affect food safety for patients involved in food preparation and consumption related to OT. Evidence follows:

A. During a tour of the hospital at 1235 on 12/01/10 with the Dietary Manager, the following was observed:
1. Dirty oven mitts, cup cake pans, lotion, perfume, No-Bake cheesecake mix, dirty tennis shoes, a box of peanut butter, a box of nectar thickened liquid, a box of Oreo Thin Crisps and Christmas decorations were observed stored together in the Therapist's Office.
2. Three dirty serving spoons and a pair of tongs were noted in a hand sink in the Therapy Room.
3. Patient food and disposable bowls and utensils were observed in the Employee Lounge which contained a dirty microwave.
B. The Occupational Therapist stated during interview at 1220 on 12/02/10, the dishes and utensils used for OT food preparation for patients were washed in the single sink used for hand washing with dishwashing liquid and then rinsed in the same sink. They were not sanitized. She also stated the food was prepared in the same microwave used by employees. She stated there were no policies or procedures in place for sanitary storage or sanitation of food ware used to prepare patient food.
C. The above was confirmed by the Dietary Director at 1245 on 12/02/10. She stated there were no policies or procedures in place for infection control related to food storage, preparation and sanitation of foodware related to OT patient food preparation.

Based on review of policy and procedure and interview with the Director of Nursing who was responsible for facility infection control, it was determined the facility lacked a policy and a procedure for ensuring Fit testing of respirators for employees as mandated by the Centers for Disease Control, in Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. Failure to offer Fit testing on hire and annually had the potential to allow the spread of communicable respiratory disease to staff, patients and visitors and prevented staff from being knowledgeable in proper fitting, usage, standards and practices of respiratory protection. The failed practice had the potential to affect all 7 patients on census, staff and visitors who were in the facility. Findings follow:

Interview with the Director of Nursing on 12/01/10 at 1420 revealed the facility had not ever performed Fit testing for employees on-hire and annually and there was no policy and procedure developed for Fit testing.

Based on review of Governing Body/Medical Staff Meeting Minutes from January through November 2010, Governing Body Bylaws and interview, it was determined the facility failed to report Quality Assurance/Performance Improvement activities to the Governing Body/Medical Staff quarterly per the Governing Body Bylaws for three of three quarters (1st, 2nd, 3rd). The failed practice prevented the Governing Body from evaluating outcomes to determine a plan of action to improve patient care. The failed practice had the potential to affect the current patient census of 7 and the average daily census of 8 patients. Findings follow:

A. Review of the Governing Body Bylaws Article III (B) revealed Performance Improvement reports would be submitted to the Governing Body quarterly.
B. Review of the Governing Body/Medical Staff Meeting Minutes January through November 2010 revealed there was no evidence Quality Assurance/Performance Improvement activities were reported to the Governing Body quarterly for three quarters (1st, 2nd, 3rd).
C. Interview with the Program Manager at 1005 on 12/02/10 revealed she did not attend the Governing Body Meetings and did not know if the Quality Assurance/Performance Improvement report was presented to members of the Governing Body/Medical Staff.