HospitalInspections.org

Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) failure of the RN to ensure blood glucose meter controls were being performed daily with the correct glucose meter control solution. This failed practice had the potential to impact the 2 current Diabetic patients ( #1,#2) and all Diabetic patients receiving sliding scale insulin based on capillary blood glucose results obtained via glucose meter (See findings in tag A-0395);

2) failure of the RN to obtain patient admission orders from a licensed independent practitioner for 1 (#4) of 1 patient sampled for the admission process from a total patient sample of 5 ( #1-#5) (See findings in tag A-0395); and

3) failure of the RN to perform an initial wound assessment on admission, including baseline wound measurements, on a patient (#1) who was admitted with a primary diagnosis of treatment for infected pressure wounds and failure to document descriptions of the appearance of wounds when dressing changes had been performed for 4 (#1, #2, #3, #4) of 4 (#1, #2, #3, #4) sampled patients reviewed for wounds (all of the current patients with wounds) from a total patient sample of 5 (#1-#5). This deficient practice was cited on previous recertification surveys on 5/18/15 and 4/11/18. (See findings in tag A-0395).

Based on observations, review of hospital documentation, and interviews , the hospital failed to meet the Condition of Participation relative to the physical environment as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well being of patients. This was evidenced by:

1. Failure to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors as evidenced by failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality and safety in the environment of care. This Condition of Participation relative to physical environment breaches in quality and safety was previously cited on the recertification survey on 4/11/18. (See findings in tag A-0724).

Based on observation, record review, and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failure to identify use of the incorrect glucose meter control solution and failure to identify blood glucose meter controls not being performed for 29 days in 1/2019 and 14 days in 2/2019 as areas in need of improvement to be addressed through the hospital's QAPI program. This failed practice had the potential to impact all Diabetic patients receiving sliding scale insulin based on capillary blood glucose results obtained via glucose meter.

Findings:

On 2/13/19 at 11:00 a.m. an observation was made of the glucose meter control solution. The solution was not the correct brand of solution to be used for performance of control testing for the type of meter used by the hospital.

Review of the hospital's blood glucose meter control logs, presented by S6LPN, revealed controls had only been performed on 1/11/19 and 1/12/19 for the month of January 2019. Further review revealed no documented evidence that controls had been performed for the month of February 2019 as of the dates of review on 2/13/19 and 2/14/19.

In an interview on 2/14/19 at 2:45 p.m. with S1InterDON, she reported she had not known controls for the glucose meter had not been performed for 29 days in 1/2019 and for 14 days in 2/2019 (as of the time of the interview on 2/14/19) and she had not been aware the controls had been performed using the wrong brand of control solution. S1InterDON confirmed controls were to have been performed nightly. She agreed diabetic patients receiving sliding scale insulin based upon CBG results obtained via the meter which had not had control testing could have been negatively impacted due to the inability to verify whether the CBG readings were accurate. S1InterDON confirmed failure to perform glucose meter controls and failure to use the correct control solution had not been identified as an area of improvement to be addressed in the hospital's QA plan.

Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1) failure of the RN to ensure blood glucose meter controls were being performed daily with the correct glucose meter control solution. This failed practice had the potential to impact the 2 current Diabetic patients ( #1,#2) and all Diabetic patients receiving sliding scale insulin based on capillary blood glucose results obtained via glucose meter;

2) failure of the RN to obtain patient admission orders from a licensed independent practitioner for 1 (#4) of 1 patient sampled for the admission process from a total patient sample of 5 ( #1-#5);

3) failure of the RN to perform an initial wound assessment on admission, including baseline wound measurements, on a patient (#1) who was admitted with a primary diagnosis of treatment for infected pressure wounds and failure to document descriptions of the appearance of wounds when dressing changes had been performed for 4 (#1, #2, #3, #4) of 4 (#1, #2, #3, #4) sampled patients reviewed for wounds (all of the current patients with wounds) from a total patient sample of 5 (#1-#5). This deficient practice was cited on previous recertification surveys on 5/18/15 and 4/11/18.;

4) failure of the RN to place a patient (#3) in the correct type of isolation precautions for 1 (#3) of 1 total sampled patients currently in isolation from a patient sample of 5 (#1-#5).; and

5) failure of the RN to ensure patient response to PRN pain and anti- anxiety medication administration was documented for 1 (#5) of 5 (#1-#5) sampled patients.

Findings:

1)Failure of the RN to ensure blood glucose meter controls were being performed daily with the correct glucose meter control solution.

On 2/13/19 at 11:00 a.m. an observation was made of the glucose meter control solution. The solution was not the correct brand of solution to be used for performance of control testing for the type of meter used by the hospital.

Review of the hospital's blood glucose meter control logs, presented by S6LPN, revealed controls had only been performed on 1/11/19 and 1/12/19 for the month of January 2019. Further review revealed no documented evidence that controls had been performed for the month of February 2019 as of the dates of review on 2/13/19 and 2/14/19.

Patient #1
Review of Patient #1's medical record revealed an admission date of 2/7/19 for treatment of multiple infected wounds with a co-morbid diagnosis of Insulin Dependent Diabetes Mellitus. Further review revealed the patient had orders for capillary blood glucose testing before meals and at hour of sleep (4 per day) and he was receiving sliding scale insulin based upon the results of the capillary blood glucose tests. Further review of the patient's lab results Patient #1 had not had a true glucose drawn since his admission.

Patient #2
Review of Patient #2's medical record revealed an admission date of 2/8/19. The patient had a left above the knee amputation, admitted for IV antibiotics for osteomyelitis, and had a co-morbid diagnosis of Insulin Dependent Diabetes Mellitus. Further review revealed the patient had orders for capillary blood glucose testing before meals and at hour of sleep (4 per day) and he was receiving sliding scale insulin based upon the results of the capillary blood glucose tests. Further review of the patient's lab results Patient #2 had one true glucose drawn on 2/11/19.

In an interview on 2/13/19 at 10:42 a.m. with S7RN, she reported it was the LPN's responsibility to perform controls on the glucose meter daily.

In an interview on 2/13/19 at 10:43 a.m. with S6LPN, she reported both RNs and LPNs were qualified to perform
controls on the glucose meter daily.

In an interview on 2/14/19 at 2:45 p.m. with S1InterDON, she reported she had not known controls for the glucose meter had not been performed for 29 days in 1/2019 and for 14 days in 2/2019 (as of the time of the interview on 2/14/19) and she had not been aware the controls had been performed using the wrong brand of control solution. S1InterDON confirmed controls were to have been performed nightly. S1InterDON also confirmed there were 2 current Diabetic patients (#1 and #2) receiving sliding scale insulin based upon results of the capillary blood glucose finger stick results. S1InterDON verified Patient #2 had one true glucose result lab drawn on 2/11/19 and Patient #1 had not had any true glucose labs drawn. She agreed diabetic patients receiving sliding scale insulin based upon CBG results obtained via the meter which had not had control testing could have been negatively impacted due to the inability to verify whether the CBG readings were accurate. S1InterDON confirmed glucose meter controls would not be performed until the night shift of 2/14/19 when the control solution had been delivered.

In an interview on 2/14/19 at 3:49 p.m. with S9MD, he reported he had not been notified glucose meter controls had not been performed for almost all of 1/2019 and for 2/2019. S9MD reported he only made it to the hospital once a week or at times every 2 weeks due to living about an hour away from the hospital.

2) Failure of the RN to obtain patient admission orders from a licensed independent practitioner.

Review of Patient #4's Admit Orders, dated 1/18/19, revealed the orders were pre-printed sheets with boxes next to various orders that could be "checked" to indicate an order had been selected. Further review revealed the patient had orders selected for the following labs: CBC, CMP, U/A-C&S, TSH, Vitamin D level, and Albumin level. Additional review revealed orders for a TB skin test, Regular Diet, Wound Care, Activity level, and Vital Signs every 8 hours.

In an interview on 2/13/19 at 2:45 p.m. with S7RN, she reported when a patient is admitted, the nurse would fill out the admission orders including diet, wound care, and labs based on the report from the discharging facility nurse and the paperwork from the discharging hospital. S7RN verified, after review of Patient #4's chart with the surveyor, that she had filled in the admission orders for Patient #4, making choices based on discharge paperwork from the discharging facility, and had not called the doctor for orders. She said the doctor would not see the orders until the weekend when he made rounds.

3) Failure of the RN to perform an initial wound assessment on admission, including baseline wound measurements, on a patient admitted for infected pressure wounds and failure to document descriptions of the appearance of wounds when dressing changes had been performed.

Review of the hospital's Wound Care Guideline Protocol revealed the following, in part: 1. All wounds are to be photographed, measured, and detailed documented every 7 days, preferably by wound care staff. It is okay to do wound care one day before if she is in the building but not after 7 days. We were cited for this. If the wound care staff is not available for wound care documentation and pictures, then the RN and LPN are to do the measurements and documentation.

Patient #1
Review of Patient #1's medical record revealed an admission date of 2/7/19 with the patient's reason for admission documented as referral for wound care.

Review of Patient #1's admit orders, dated 2/7/19, revealed the patient had multiple infected decubitus ulcers to his left and right hip and sacrum.

Review of Patient #1's Initial Nursing Assessment revealed no documentation of a baseline assessment describing the appearance/size/location of the wounds the patient had been admitted to the hospital for treatment.

Review of Patient #1's wound treatment records revealed the patient had dressing changes performed daily from 2/9/19 - 2/12/19.

Review of Patient #1's nurses notes revealed no documented evidence of the appearance/size/color of the patient's wounds from his admission on 2/7/19 - 2/13/19 (date of medical record review).

In an interview on 2/13/19 at 10:50 a.m. with Patient #1, he reported he had been in the hospital since 2/7/19 and was currently waiting to be seen and evaluated by the wound treatment staff person.

Patient #2
Review of Patient #2's medical record revealed an admission date of 2/8/19. The patient had a left above the knee amputation and was admitted for IV antibiotics for osteomyelitis.

Review of Patient #2's admission orders, dated 2/8/19, revealed orders to change left stump Telfa as needed and cleanse with Normal saline.

Review of Patient #2's nurses notes revealed no documented evidence of an assessment of the appearance of the patient's stump/incision from his admission on 2/8/19 - 2/13/19 (date of medical record review).

Patient #3
Review of Patient #3's medical record revealed an admission date of 2/5/19 with admission diagnosis listed as IV antibiotics and wound care. Further review revealed Patient #3 had chronic bilateral lower extremity stasis ulcers which were positive for MRSA.

Review of Patient #3's wound treatment records revealed the patient had dressing changes performed on 2/6/19, 2/10/19, 2/11/19, 2/12/19, and 2/13/19.

Review of Patient #3's nurses notes revealed no documented evidence of the appearance/size/color of the patient's wounds from her admission on 2/6/19 - 2/13/19 (date of medical record review).

Patient #4
Review of Patient #4's medical record revealed an admission date of 1/18/19 with reason for admission documented treatment of Stage IV right gluteal pressure ulcer with tunneling.

Review of Patient #4's wound treatment records revealed the patient had dressing changes performed on 1/19/19, 1/21/19, 1/22/19, 1/25/19, 1/27/19, 1/29/19, 2/1/19, 2/3/19, 2/7/19, and 2/11/19.

Review of Patient #4's nurses notes revealed no documented evidence of the appearance/size/color of the patient's wounds from 1/19/19 - 2/13/19 (date of medical record review).

In an interview on 2/14/19 at 9:40 a.m. with S1InterDON, she confirmed Patient #1 had not had any photos taken of his wounds, no wound measurements, and no descriptive assessments of the appearance, size and color of his wounds from 2/7/19 - 2/12/19. She reported photos should have been taken on admission and a baseline assessment of the appearance, size, color, and character of drainage, if present should have been documented. S1InterDON further confirmed a descriptive assessment of the wound should have been documented in the nurses' notes with each dressing change on all of the above referenced patients and verified the assessments had not been documented.

4) Failure of the RN to ensure a patient was placed on the correct type of isolation precautions.

Review of Patient #3's medical record revealed an admission date of 2/5/19 with admission diagnosis listed as IV antibiotics and wound care. Further review revealed Patient #3 had chronic bilateral lower extremity stasis ulcers which were positive for MRSA.

On 2/13/19 at 10:50 a.m. an observation was made of the isolation signage on Patient #3's door and the sign indicated the patient was on enteric isolation precautions.

Review of Patient #3's culture reports revealed a positive wound culture result for MRSA on 2/11/19. Further review revealed and no culture results indicating a need for enteric isolation.

In an interview on 2/14/19 at 9:41 a.m. with S1InterDON, she confirmed Patient #3 had been placed on the on the wrong precaution type. She reported the patient should have been on contact precautions for a positive wound culture for MRSA and not on enteric precautions.

5) Failure of the RN to ensure patient response to PRN pain and anti- anxiety medication administration was documented.

Review of Patient #5's medical record revealed the following PRN medication administrations:
On 1/31/19 at 11:00 a.m. and 5:00 p.m. PRN doses of Percocet 5 mg/325 mg had been administered. Further review revealed the nurse had failed to document the reason for administration of the PRN pain medication (pain level) and failed to document response to the pain medication.

On 2/5/19 at 2:30 p.m. a PRN dose of Percocet 5 mg /325 mg had been administered and no response to the medication had been documented.

On 2/9/19 at 8:00 p.m. a PRN dose of Percocet 5 mg /325 mg had been administered and no response to the medication had been documented.

On 2/9/19 at 8:00 p.m. a PRN dose of Valium 5 mg was administered for complaints of increased anxiety/restlessness and no response to the medication administration was documented.

In an interview on 2/14/19 at 9:43 a.m. with S1InterDON, she confirmed Patient #5's response to PRN medication administration should have been documented.

Based on record review and interview, the hosptial failed to ensure nursing staff developed, and kept current, a comprehensive plan of care with goals and interventions for 3 (#2,#3,#4) of 5 (#1-#5) sampled patients reviewed for care plans.

Findings:

Patient #2
Review of Patient #2's medical record revealed an admission date of 2/8/19. Further review revealed the patient had a left above the knee amputation, was admitted for IV antibiotics for osteomyelitis, and had a co-morbid diagnosis of Diabetes Mellitus Type I. Additional review revealed the patient was receiving sliding scale insulin based on capillary blood glucose testing that was ordered before meals and at bedtime.

Review of Patient #2's plan of care revealed problems identified for Alteration in Immune System, Alteration in Blood Glucose and Impaired Physical Mobility. Further review revealed no interventions or goals were listed for the identified problems.

Patient #3
Review of Patient #3's medical record revealed an admission date of 2/5/19 with admission diagnosis listed as IV antibiotics and wound care.

Further review of Patient #3's medical record revealed the patient had chronic bilateral lower extremity stasis ulcers with complaints of pain from wounds listed on her history and physical dated 2/8/19.

Review of Patient's #3's nurses' notes revealed the patient had complaints of pain levels of 10/10 on a pain scale of 1-10 on 2/6/19 at 10:00 p.m. and at 6:15 a.m. on 2/7/19.

Review of Patient #3's care plan revealed Pain/Pain Management had not been documented as an identified problem to be addressed on the patient's plan of care.

Patient #4
Review of Patient #4's medical record revealed an admission date of 1/18/19 with reason for admission documented as treatment of Stage IV right gluteal pressure ulcer with tunneling. Further review revealed the patient had a colostomy, was wheelchair bound, and was receiving IV antibiotics.

Review of Patient #4's care plan revealed Impaired Physical Mobility (wheelchair bound), Altered Elimination- Bowel (colostomy) and Impaired Immunity-Actual Infection had not been documented as identified problems to be addressed on the patient's plan of care.

In an interview on 2/14/19 at 9:41 a.m. with S1InterDON, she confirmed patient care plans should have included all current patient problems and should have had goals and interventions.

Based on record review and interview, the hospital failed to ensure all drugs and biologicals were prepared and administered in accordance with the orders of the practitioner or practitioners responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to ensure sliding scale insulin had been administered as ordered for 1 (#2) of 2 (#1, #2) total current Diabetic patients sampled for receiving sliding scale insulin from a total patient sample of 5 (#1- #5).

Findings:

Review of Patient #2's medical record revealed an admission date of 2/8/19 with a history of present illness listed as continued treatment after left above the knee amputation of lower extremity. Further review revealed the patient also had a co-morbid diagnosis of Type I Diabetes (diagnosed at 14 years of age).

Review of Patient #2's Physician's orders revealed an order dated 2/8/19 for blood glucose checks before meals and before bedtime with sliding scale insulin as follows:

Pre meal Bedtime
151-200 mg/dl - 0 units 0 units
201-250 mg/dl - 2 units 1 unit
251-300 mg/dl - 3 units 1 unit
301-350 mg/dl - 4 units 2 units
>350 mg/dl - 5 units 3 units

Review of Patient #2's blood glucose log revealed the following blood glucose readings and the insulin given:

2/9/19 at 9:00 p.m. the blood glucose was documented as 183 (mg/dl) with 3 units of insulin given (sliding scale required 0 units).

2/10/19 at 9:00 p.m. the blood glucose was documented as 254 (mg/dl) with 6 units of insulin given (sliding scale called for 1 unit).

In an interview on 2/14/19 at 9:41 a.m. with S1InterDON, she reported the hospital had a standard insulin sliding scale that all patients were to have been converted to on admission. She verified the standard insulin sliding scale had not been ordered for Patient #2 and indicated the staff must have admininstered the sliding scale insulin according to the hospital's standard sliding scale instead of according to the insulin sliding scale documented in the patient's chart (which was the only insulin sliding scale order on the chart). S1InterDON confirmed sliding scale insulin should be administered as ordered.

Based on observation, record review, and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by:
1) failure to maintain a clean and safe environment due to multiple breaches in quality and safety observed in the environment of care. A deficiency regarding physical plant breaches in quality and safety was previously cited on the recertification survey on 4/11/18.; and
2) failure to maintain documented evidence of Biomedical inspection/calibration of the glucose meter used for obtaining patient capillary blood glucose sampling.

Findings:

Review of the hospital's current license revealed the hospital was licensed for 14 beds. At the time of the survey
Patient Room 10 (large double occupancy room - has an A and a B side) and Patient Room 5 were unable to be used for admits due to findings noted during observations below.

On 2/13/19 from 10:45 a.m. - 11:25 a.m. an observation was conducted of the hospital's physical plant. The following breaches in quality and safety were observed:

1.Patient Room 10 ( large double occupancy room with an A and B side)
a. A water saturated bed sheet was observed on the floor outside of the 2nd entry door to Patient Room 10. Further observation revealed a large puddle of water extending beyond the saturated sheet into the hallway. A cone indicating a wet floor was observed beside the puddle.;

b.Interior of Room 10: 2 buckets filled to overflowing with water that was actively dripping through the fluorescent light fixture located in the ceiling.;

c. Standing water was noted to be covering the floor in Room 10 A;

d. A water saturated sheet was noted inside the door of the room;

e. Pooled standing water noted to partially extend into the second portion (Room 10 B) of the large double patient occupancy room;

f. The ceiling tiles were wet;

g.The curtain dividing the room was observed to have water mark staining and was noted to be dripping water; and

h. Patient beds were stored in the room.

2.Patient Room 5:
a. Light fixture above the interior bathroom door noted to have no covering with bare wires exposed; and

b. Toilet noted to have an out of order sign secured to it.

3.Patient Room 4:
a. Broken floor tile on the threshold between the bedroom and bathroom;

b. Lighting dim due to fluorescent light flickering and giving off a faint amount of light;

c. Toilet seat broken due to hinge of seat not being secure; and

d. Bed mattress standing on its side contacting the floor.

4.Patient Room 2:
a.Mattress covering ripped; and

b.Bathroom window noted to be raised with shards of broken glass observed in the inside frame of the window and outer panel of of double pane of glass noted to have jagged edges from having been broken.

5. Hallway leading to kitchen:
a.Water stained ceiling tiles; and

b.Pale yellow stained drip marks in the light fixture indicating water had collected in the fixture.

6. Equipment Storage Room:
a.Drip marks on the wall; and

b.Drip mark stains noted in fluorescent light fixture.

7. DON's Office:
a.Fluorescent light fixture with exposed bulbs; and

b.Fluorescent light fixture cover hanging open with visible drip marks on the cover.

8. Hallway in Front of Nurses' Station:
Light brown stained ceiling tiles located near the fluorescent light fixture.

9. Kitchen:
Vent grate near rear exit door partially pulled away from the wall.

10. Employee Bathroom (next to nurses' station):
ceiling tiles at entry to bathroom buckling

A second observation was conducted of Patient Room 10 A/B on 2/13/19 at 4:20 p.m. The water was still dripping from the light fixture, onto the floor, and a water soaked sheet was observed on the floor outside of the room ( used to catch water leak seepage from inside Room 10).

Review of requested documentation regarding roof leaks, provided by S2Staff, revealed the following communications sent to S4Adm:

12/10/18: Water on floor by Room 10A. Water squishes out from under the tiles in the hallway. Three trashcans in the room, one overflowing. Water all over in room. Sheets and towels on floor by room doorway. Maintenance stated he came by on Saturday when it was raining to check things out. He placed trash cans under leaks. Some tiles have fallen by the nurses' station. I asked him to make a list of all leaks he noticed so I can inform the owner of leaks in the building. He will get them for me. As usual no one from facility notified me of leaks.

12/28/18: Census 4 patients. More places leaking today after hard rain yesterday/last night. Clean equipment room light fixture is full of water and water leaking everywhere in room. Larger area outside PT gym/S1InterDON's office. Bathroom by PT gym has leaks and tile has fallen down. Storage closet in hallway by Coke machine leaking. Boxes of paperwork are wet. It is getting to be a hazard to go into the clean equipment/wheelchair room with all the leaks and water in the light fixture. There were 2 IV pumps on the floor in that room with water on the floor beside them. It was embarrassing yesterday to have to put the patients in the hallway due to bad weather and have 3 buckets catching water by the nurses' station and 2 buckets catching water in the hallway near where patients had been put. We are expecting rain again tonight and some this weekend and part of next week. It is a definite hazard to have patients, much less employees in the building if the roof is not fixed. If someone turned on the light switch in the clean equipment room and stepped in the water on the floor they could have really been hurt.

1/7/19: Census 6. I did not know about the leak in S1InterDON's office last week. It leaks in the light fixture and from ceiling tiles behind her desk.

1/17/19 (dated 1/17/18 but fax date is 1/17/19): Census 7. Room 4 leaked last weekend when it rained. I asked staff to move the patient to another room (probably 3) due to rain today, tomorrow, and Saturday. Nursing should have moved her last weekend instead of leaving her in a room that was leaking. We should never leave a patient in a room with a leaking ceiling. I was told about room leaks but could not find out which room it was until today. I have repeatedly asked nursing to fill out work orders so I know what needs to be fixed. I checked Room 10 and it still has water in buckets. There is a dirty blanket by the door in the room to keep water from coming into the hallway. Water is still leaking into one of the buckets. Also the curtain in Room 10A has water stains on it as well as the blind behind it. Roof leaks are getting worse. Something is going to have to be done soon for patient/employee health/safety. Mold on tiles and water in light fixtures is not good.

Further review of requested documentation regarding roof leaks revealed the following communication with the owner of the building:
1/22/19: Leaks in building:
1. End of hallway- Room 1
2. Patient Room 4- had to move patient
3.Outside Patient room 2- water leak and tiles missing
4.Room 10A- several places. Tiles Squish water when you walk on them after raining.
5. Tiles outside of Room 10 cracking and squish water when walking on them after raining.
6. Nursing supply room
7.Discharge PLanner's office light and ceiling
8.Hallway by nurses' station
9. Hallway by linen room and bathroom. This wall has our electrical boxes and water was coming out of this wall.
10. Numerous light fixtures with water.
11. Storage room outside Social Service Office
12. Clean equipment room: sheetrock replaced previously has to be replaced again. Light fixture has water in it. Walls all leak.
13. Hallway by Discharge Planner's office/PT gym
14. Bathrom by PT gym is leaking
15. Linen closet is leaking
16. Patient dining room is leaking.

In an interview on 2/13/19 at 1:35 p.m. with S4Adm, he said the roof had been leaking in room 10 for a while. He said the landlord would not fix it and he did not have the money to fix it. He also said he had trouble keeping employees. He said when one leaves it was like a domino effect.

In an interview on 2/13/19 at 1:40 p.m. with S2Staff, she said the water had been leaking through the light fixtures for at least several months. She said the landlord would repair it and then it would leak somewhere else.

In an interview on 2/13/19 at 1:50 p.m. with S6LPN, she indicated the roof leaked whenever it rained heavily. S6LPN reported the roof leaks had started in 2018 when she was asked how long the roof had been leaking.

In an interview on 2/14/19 at 2:00 p.m. with S1InterDON, she was informed of the above referenced findings in the hospital's physical plant. She acknowledged she had known about some of them such as the roof leaks and the broken toilet. S1InterDON agreed the referenced quality/safety issues needed to be addressed.


2) Failure to maintain documented evidence of Biomedical inspection/calibration of the glucose meter used for obtaining patient capillary blood glucose sampling.

On 2/13/19 at 11:00 a.m. an observation was made of the hospital's glucose meter (Reli-On brand). Further observation revealed no biomedical tag indicating the meter had been inspected/calibrated.

On 2/14/19 at 3:00 p.m. documentation of inspection/calibration of the glucose meter (Reli-on brand meter currently in use) was requested from S1InterDON and S2Staff.

In an interview on 2/14/19 at 3:05 p.m. with S1InterDON, she reported the hospital had a Biomedical contract for equipment inspection. S1InterDON reported she was not sure if the Reli-On blood glucose meter had been inspected/calibrated, but she would check.

No documented evidence of calibration of the Reli-On glucose meter was produced as of the time of survey team exit on 2/14/19 at 4:55 p.m.

Based on observation, interview, and record review, the hospital failed to ensure the infection control officer developed and implemented a system for controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by the following infection control breeches in the hospital's kitchen:
1)Failure to ensure food temperatures were measured (after preparation and prior to serving patients) and logged;
2)Failure to ensure frozen foods were maintained at freezer temperatures of 0 degrees F (Fahrenheit) or below; and
3)Failure to ensure chemicals and the temperature of the water used in the 3 compartment sink for sanitizing patient dishes, after use, were monitored and logged.

Findings:

1) Failure to ensure food temperatures were measured (after preparation and prior to serving patients) and logged.

On 2/13/19 from 11:30 a.m. - 11:40 a.m. an observation was made of the hospital's kitchen. S3Cook, present during the observation, was asked if food temperatures had been taken prior to meal service and she replied she had not taken food temperatures. The hospital's food temperature logs were then requested for review and S3Cook replied S5DietMgr was not at the hospital at present and the food temperature logs were locked in her office.

Review of the food temperature logs, presented by S5DietMgr as current, revealed an entry penciled in for breakfast and lunch meal service on 2/13/19 (S3Cook had indicated to the surveyor that she had not taken meal temperatures for breakfast and lunch meal service on 2/13/19).

In an interview on 2/13/19 at 1:40 p.m. S5DietMgr was informed S3Cook had indicated, to the surveyor, that she had not taken food temperatures on 2/13/19. When S5DietMgr was questioned regarding the food temperatures documented for breakfast and lunch for 2/13/19 she replied she had asked S3Cook to tell her what she thought the food temperatures might have been and she had entered them on the log.

2) Failure to ensure frozen foods were maintained at freezer temperatures of 0 degrees or below.

During the observation of the hospital's kitchen on 2/13/19 from 11:30 a.m. - 11:40 a.m. an observation was made of the freezer. The temperature gauge of the freezer was reading 26 degrees F. Further observation revealed the freezer contained frozen foods, including a portion of frozen beef wrapped with saran wrap and a box of hamburger patties, to be used for patient consumption.

Review of the hospital's freezer temperature logs revealed the following freezer temperatures: 20 degrees F on 2/11/19, 23 degrees F on 2/12/19, and 26 F degrees on 2/13/19.

According to LAC, Title 51, Public Health - Sanitary Code, Part XXIII, Section 1313.Frozen Food: A. Stored frozen food should be stored at a temperature of 0 degrees F or below and shall be maintained frozen.

In an interview on 2/13/19 at 1:45 p.m. with S5DietMgr, she reported she had been aware the freezer temperatures were above 0 degrees F. S5DietMgr further reported the freezer had begun reading high on 2/11/19 and had continued to have increased temperatures. S5DietMgr indicated the freezer was to be serviced on 2/13/19.

Another observation of the freezer was made on 2/14/19 at 12:30 p.m. and the freezer thermometer was reading 12 degrees F. Further observation revealed the freezer still contained frozen foods to be used for patient consumption.

In an interview on 2/14/19 at 1:50 p.m. with S5DietMgr, she was informed the freezer had just been observed to have a temperature of 12 degrees F. S5DietMgr reported she was aware the freezer was still reading above 0 degrees F and acknowledged that was not the proper temperature for safely maintaining frozen foods.

3) Failure to ensure chlorine testing and temperature of the water used in the 3 compartment sink, utilized for sanitizing patient dishes after use, were monitored and logged.

On 2/13/19 from 11:30 a.m. - 11:40 a.m. an observation was made of the hospital's automated dish wash machine and 3 compartment sink. S3Cook, present during the observation, was asked to present temperature and chemical logs for the automated dish wash machine and the 3 compartment sink. S3Cook indicated there were logs posted on the wall for the dish wash machine and could not present any documentation of temperature/chemical logs for the 3 compartment sink.

Review of the temperature/chemical logs for the automated dishwashing machine revealed there were no entries for 2/6/19, 2/7/19, 2/11/19, 2/12/19, and 2/13/19. Further review of the kitchen log books revealed no documented evidence of chlorine testing/temperature logs for the 3 compartment sink.

According to LAC, Title 51, Public Health - Sanitary Code, Part XXIII, Section 2513. Sanitization: A. After food contact surfaces of all equipment and utensils are washed and rinsed, they shall be sanitized before use. Clean food contact surfaces of all equipment and utensils shall be sanitized in: 2. chemicals.iii. a quaternary ammonium compound solution shall: (a) have a minimum temperature of 75 degrees F, (b) have a concentration of 200mg/L (ppm) or as indicated by the manufacturers use directions included in labeling.

In an interview on 2/14/19 at 3:00 p.m. with S5DietMgr, she confirmed the hospital used autochlor- a quaternary ammonium sanitizer for sanitizing. She reported the days where there were no entries for chlorine testing and water temperatures on the above referenced chemical/temperature logs were the days when the automated dish wash machine had been broken. S5DietMgr indicated the 3 compartment sink had been used for sanitizing patient dishes after use and reported she had never kept chlorine testing/temperature logs for the 3 compartment sink.