HospitalInspections.org

Based on document review and interview the facility failed to:
A. meet the statutory definition of a hospital.
A review of the Medicare regulations revealed:
"The Medicare regulations at 42 C.F.R. ? 488.3(a)(1) state that, in order to be approved for participation in or coverage under the Medicare program, a prospective provider or supplier must meet the applicable statutory definitions in (among others) section 1861 of the Act. The Act defines hospital as an institution that ". . . is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons; . . ." Act ?1861(e)."
A review of a document titled Inpatient Discharge Register revealed the last inpatient was 02/15/2014.
An interview on 04/29/2014 at approximately 10:30 AM in the Marketing Conference Room with staff# 1 revealed the facility did not have inpatients.
An interview on 04/29/2014 at approximately 1:30 PM in the Marketing Conference Room with staff# 34 confirmed the last inpatient was 2/15/2014.
B. Provide evidence of an organized governing body responsible for approving Governing Body Bylaws, Medical Staff Bylaws, Medical Staff Rules and Regulations or Policies and Procedures.
An interview on 04/30/2014 at approximately 12:45 PM in the Marketing Conference Room with the governing board members and owners, staff #1, staff #2, staff #3and staff #36 confirmed the last meeting of the old Governing Board was 11/22/2014. The governing board members and owners, staff #1, staff #2, staff #3and staff #36 confirmed a meeting was held on 2/21/2014 by the owners staff #2, staff #3and staff #36 and at that time they appointed staff #1 as the Interim Chief Executive Officer (CEO and as Chief Nursing Officer (CNO) of the hospital. The interviews confirmed another meeting was held on 3/18/2014 and the old governing body was dismantled and a new governing board was appointed consisting of staff #1, staff #2, staff #3and staff #36. The interviews confirmed there had been no reviewed and/or approved Governing Body Bylaws, Medical Staff Bylaws, Medical Staff Rules and Regulations or Policies and Procedures.
In an attempt to gain a clear understanding of the expectations of the governing body and their governing of the facility, an example of an interview with surgical staff was given.
Example: An interview with a contracted surgical staff #21 on 4/30/14 at approximately 11:00 in the Surgical Department. Staff #21 was asked what policies and procedure guided the surgical department. Staff #21 responded, we follow the policies from the hospital we are contracted from. Staff #21 was asked has the governing body approved the policies. Staff #21 responded, I don ' t know if they have or not.
The governing board members and owners, staff #1, staff #2, staff #3and staff #36 were asked if the surgical staff were expected to follow the facility ' s policies or the policies from contracted hospital. Staff #1, staff #2, staff #3 and staff #37 all gave conflicting answers. Some responding the facility's policies and other responding the contracted hospital's policies.
C. Provide approve Policies and Procedures for the Emergency Department.
Refer to tag A0093
D. Protect patient rights.
Refer to tag A0118 and 0144
E. Provide an effective Quality Assessment Performance Improvement Program. The facility was not monitoring the quality of care provided by the hospital.
Refer to tag A0273and A0286
F. Ensure policy and procedures were followed for the safe administration of blood products.
Refer to tag A0409
G. Provide a safe dietary department to prepare food. The dietary department did not have an experienced dietary director, a dietitian, trained staff.
Refer to tag A0620, A0621, A0622, A0628 and A0631.
H. provide a Surgical Department Supervisor and aprove policies and procedures for the Surgical Departments.
Refer to tag A0942 and A0951

Based on records review and interviews the facility and/or Governing Board failed to:

A. to establish a current process for prompt resolution of patient grievances.

a. refer to Tag A 0118

B. to provide a sanitary environment in the dietary department (food storage, preparation, and cooking surfaces). The likelihood of cross-contamination can occur due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, and serving carts) storage and use, unsanitary food storage, and poor general sanitation practices was found throughout the dietary department. The facility failed to provide menus that met the therapeutic dietary needs of all patients. The facility failed to have trained and competent dietary staff and director. The dietary director failed to have therapeutic menus, provide food substitutions, staff training, and an updated diet manual.
b. refer to Tag A 0144

Based on records review and interviews the facility and/or Governing Board failed to:

A. collect quality improvement data, from the following departments, Materials Management, Plant Operations, Housekeeping, Surgery, Linen/Laundry, Radiology, Dietary, Respiratory, and Nursing services.

a. Refer to Tag A 0273

B. track medical errors and adverse patient events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the hospital.

b. Refer to Tag A 0286

Based on interview the Governing Body failed to provide approved Medical Staff Bylaws.

An interview on 04/30/2014 at approximately 12:45 PM in the Marketing Conference Room with the governing board members and owners, staff #1, staff #2, staff #3and staff #37 confirmed the last meeting of the old Governing Board was 11/22/2014. The governing board members and owners, staff #1, staff #2, staff #3and staff #37 confirmed a meeting was held on 2/21/2014 by the owners staff #2, staff #3and staff #37 and at that time they appointed staff #1 as the Interim Chief Executive Officer (CEO and as Chief Nursing Officer (CNO) of the hospital. The interviews confirmed another meeting was held on 3/18/2014 and the old governing body was dismantled and a new governing board was appointed consisting of staff #1, staff #2, staff #3and staff #37. The interviews confirmed there had been no review and/or approval of Governing Body Bylaws, Medical Staff Bylaws, Medical Staff Rules and Regulations or Policies and Procedures.

Based on records review and interviews the facility and/or Governing Board failed to follow their own policy/ procedures in administering blood transfusions in a safe manner on 3 (#27, 30, and 31) out of 5 (#27-31) charts reviewed. Failure to safely administer blood and blood products poses Immediate Jeopardy to patient's health and safety and placed patients at risk of potential harm, serious injury, and possibly subsequent death.

a. Refer to tag A 0409

Based on observation, record review, and interview the facility failed to
A. provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to poor hand hygiene, unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department.

It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in a likelihood of harm, serious injury, and subsequent death to all patients, staff, and visitors consuming food prepared in the dietary department.
a. Refer to Tag A0619
B. have a qualified or experienced dietary director.
b. Refer to Tag A0620
C. have a qualified dietician to supervise the nutritional aspects of patient care.
c. Refer to Tag A0621
D. have a qualified dietician to supervise and perform adequate training and competencies to the dietary staff.
d. Refer to Tag A0622
E. failed to follow "CRH Food and Nutrition Services" policy and procedures. The facility failed to ensure the Dietician would approve menus and implement patient care when needed.
e. Refer to Tag A0628
F. provide a current Therapeutic Diet Manual to the dietary staff.
f. Refer to Tag A0631

Based on observations during the facility walk-through Life Safety Code Survey/inspection, with the director of plant operations, infection control officer, COO, and CIO, on 04/02/2014, it was noted that the facility was out of compliance with the Standard for Physical Environment. based on the following documented observations on the Life Safety Code Survey items:

Based on observations during the facility walk-through inspection with the facility director of plant ops., COO, and CIO, the following deficiencies were noted:

a). It was observed that the main electrical switchgear room which also contained the automatic transfer switches and the main fire alarm panel, had approximately 1/2" of standing water on the floor through-out the room. All electrical switchgear were on 4" to 6" curbs, and out of the water. However anyone working in this room would be standing in water, creating a dangerous shock hazard. The water was determined to be coming from a leaking and defective boiler unit located in the adjacent boiler plant.

b). It was noted that the building's boilers were non-functioning (water leaking from the non-functional boilers was the cause of the standing water in the main electrical room) . The facility had a temporary boiler located on a trailer outside the mechanical room and hooked to the building systems with surface cabling laid on the floor slab of the mechanical room.

c). It was observed that the nurse call system for the entire second floor was not working. This is the patient sleeping floor. No patients were housed on the second floor at the time of this inspection and the staff stated that the second floor had been closed since the February 2014 survey first documented the lack of a working nurse call system.

d.) It was noted that the fire alarm system was not functioning as follows;
1) the visual strobe signals on the second floor did not function during testing;
2) smoke barrier doors did not close when the fire alarm system was activated on the second floor;
3) tests of the corridor smoke detectors on the second floor did not activate the fire alarm system
either in "trouble" or "alarm" modes.

Note that the second floor is the nursing floor for this hospital, and has been closed since the fire alarm system has been malfunctioning. Only the audio signals were functioning on the second floor during this inspection. Documentation from a licensed fire alarm contractor (dated March 2014) stated that most of the smoke detectors located in the facility were not functioning.

Based upon record review, observation, and interviews, the facility failed to provide a sanitary environment in the dietary department (food storage, preparation, and cooking surfaces). The likelihood of cross-contamination can occur due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, and serving carts) storage and use, unsanitary food storage, and poor general sanitation practices was found throughout the dietary department.

It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in a likelihood of harm, serious injury, and subsequent death to all patients, staff, and visitors consuming food prepared in the dietary department.

A tour of the kitchen was performed on 4/30/2014 at 2:00 PM with staff #5 and staff #14. Findings were as follows:
1. A stack of disposable food containers were found uncovered, on a bottom shelf, under the food preparation area. Dust and food crumbs were found in the open containers. The food containers were unclean. The likelihood for food borne illnesses can occur.
2. Staff #14 confirmed the containers were used to serve food and was not aware they needed to be covered.
3. Disposable cups and containers found in shipping boxes in the kitchen. A dirty trash can was found next to the containers. Shipping boxes and dirty trash found in the clean supply area can bring in outside contaminates. The likelihood for food borne illnesses can occur.
4. A wire cart was found to have aprons and linens on the bottom shelf. The shelf, the black aprons, and white linens were found to have food crumbs, dust, and a greasy substance on them. Linens exposed to a contaminate environment and used during meal preparation causes a likelihood for food borne illnesses.
5. A black wire cart was found to have linen on the bottom shelf uncovered and no protective barrier from the floor. The protective barrier was needed to protect the linen from contaminated materials on the floor.
6. The grill was coated in a greasy sticky substance. A caked up greasy substance was found in between each grate, around the sides of the grate and on the foil covered back splash. Dried food particles and dust were found around the edges of the grill. Cooking foods on an unclean surface increases the likelihood of food borne illnesses.
7. The pots and pans were found with a large amount of carbon build up preventing even cooking and cleanliness. The pans are not able to be cleaned properly creating the likelihood for a food borne illness.
Pans used for cooking had Teflon coating missing from the bottom and sides of the pan. There were scratches and a greasy substance on them. Scratched pans allow for Teflon to flake off into the consumer's food. The pans are not able to be cleaned properly creating the likelihood for a food borne illness.
8. The top of the gas stove was dirty with food particles, dust, hair and grease. The front of the stove was sticky with a greasy like substance. The front of the oven was rusted and greasy. The rust and missing coating on the stove did not allow for proper cleaning. Inability to clean the stove properly creates a likelihood for a possible food borne illness.
9. The threshold and floor to the walk in cooler was rusted with large pieces of rusted metal flaking off. Two large rubber mats were found covering the coolers rusted floor. The mats were found with rust colored stains on the back and condensation. The mats were found to have food particles and dirt on them. The ceiling of the refrigerator had a rusted sprinkler system. Rust particles were easily flaked off of the sprinkler head. The floor was not able to be properly cleaned and excessive condensation allows bacteria to grow allowing for food borne illnesses.
10. Inside the walk in cooler wire carts were found to be rusted and the wheels were caked in a dirty, greasy substance. Hair and food particles were found on the shelves and floor around it. Food in containers on the wire racks were exposed to the rust, hair, dirt, and dust on the back walls and floors. Exposed food to unclean containers and storage creates the likelihood for a possible food borne illnesses.
A ? emptied container of pickle relish and an opened jar of mayonnaise were found with no open or expiration date. No open or expiration date allows the condiments to be served after expiration creating the likelihood for a possible food borne illnesses.
11. The counter food preparation area had a greasy substance on it, food particles, and a pan of cooked chicken covered with plastic wrap. Above the food preparation area was a shelf with several drawers. The fronts of the drawers were covered in dried food particles, grease, and dust. On the top of the shelf were 12 opened spice containers with no open or expiration dates. An unclean food preparation area and cooked chicken left unrefrigerated can harbor bacteria creating the likelihood for a possible food borne illnesses.
12. Two doors of the bottom and top oven had a greasy substance on the metal and glass. A white, dried, spilled substance was found on the outside doors. The surveyor wiped a finger along the control knob. Hair, dust, food particles, and grease were removed. An unclean work surface and oven creates the likelihood for food borne illnesses to occur.
13. The top part of the oven was found to have a soiled baking sheet with a dried liquid substance on it. The pan was covered in carbon. The lower part of the oven was found to have a soiled baking sheet with a white dried liquid substance on it. The wire racks were soiled with carbon and dried food particles. An unclean oven and pans create the likelihood for food borne illnesses to occur.
14. There were two vats of grease in the fryer nest to the stove. The first vat had dark, foul smelling grease with food particle build up on the sides and lip of the vat. The second vat had lighter grease. The well of the second vat was covered in food particles, and a greasy build-up on the sides and lip of the vat. The frying baskets had a greasy build-up.
The front outside exterior of the fryer had missing paint, rust along the front with a greasy, dirty build-up on the doors and legs. Inability to properly clean cooking equipment creates the likelihood for a food borne illnesses to occur.
15. The shelf under the grill had an open bag of skewers, a soiled spatula, and knife. The shelf was covered in a greasy substance, dust, dried food particles and hair. An unclean work surface, utensils, and cooking area created the likelihood for food borne illnesses.
16. An upright wall oven had an upper oven and lower oven. The upper oven had 2 empty backing pans inside with a dried brown liquid substance on them. The bottom oven had dried food particles, carbon covered baking pans, and rusted wire racks. A towel was found in the door of the upper oven.
An interview with staff #14 on 4/30/2014 at 2:00 PM revealed the hand towel was left in the oven door to keep it from closing. Staff #14 reported, "When the oven door is closed it continues to keep heating. The thermostat is broken on the oven. The oven is unable to be turned off unless the door is open." Staff #14 confirmed that a work request was put in 2 months prior. Staff #5 and Staff #1 were made aware of the broken oven thermostat by the surveyor. Staff #5 and #1 confirmed the oven was still heating when the switch was put in off position. The electrical inspection sticker on the front of oven had no date or signature.
A towel used to keep the oven door open to prevent the oven from heating would be a potential high risk for fire and potential death in the hospital.
17. A second upright refrigerator along the wall had one shelf covered in white butcher paper. The paper was covered in a dried liquid and food particles. The second shelf had metal food containers with no opening or expiration dates. The metal containers had carbon build up and a greasy substance on the outside. Unclean surfaces allow for potential food borne illnesses.
18. The body of the mixer was missing paint. The paint primer and metal was exposed. The legs on the mixer had missing paint exposing metal. Inside of the mixer bowl a dried liquid and food particles were found in it. On the inside top of the mixer there was a dried liquid substances, and a greasy residue. Inability to properly clean a cooking device and preparing in a soiled device can lead to a food borne illness.
19. The legs of the food preparation table had missing paint exposing rust and metal. The shelf of the preparation table had missing paint exposing rust and metal. The shelf was dirty with dust and hair. Unpainted and unclean surfaces can lead to potential food borne illnesses.
20. Multiple floor tiles in the kitchen were broken and cracked. The floor is not able to be properly cleaned allowing food to be potentially exposed to outside contaminates. The likelihood of food borne illnesses can occur.
21. A large trash can with wheels was beside the food prep area. Staff #14 confirmed the trash can was wheeled out of the kitchen and through the hospital to be dumped. The trash can was brought back into the clean preparation area without being cleaned. Allowing the trash barrel to be exposed to outside contaminates and introducing it back into the clean kitchen area can lead to a food borne illness.
22. The back of the ice machine was rusted. The top of the ice machine was coated in a sticky residue with food particles on top. The outside of the ice machine was soiled with hard water stains and rust. The water filter had no date on it to be changed. Staff #5 confirmed there was no log or guideline to clean out the ice machine. Exposure to contaminated water can lead to water borne illness.
23. A drain in the floor was found between the wall and the fryer. The drain cover was broken and a broken floor tile was found lying across it. The drain was dirty with black particles and dried food particles in it. A second floor drain was found in front of the walk in cooler. The drain was filled with mildew and food particles.
24. Two clean muffin pans were found on a bottom shelf with greasy, carbon build up. Twenty clean baking sheets were found to have a sticky, greasy, carbon build up. The clean pan rack had food particles and dust on the shelves. The clean baking rack had a pan with a white dried residue. The bottom of a clean pot on the rack had dried food particles and dust on it. Three metal pans were found on the clean rack wet. The pans were not allowed to dry properly. Wet stacked pans can lead to a growth of bacteria causing a potential food borne illnesses.
25. The dry storage area had packing boxes on the shelves. The wire shelves in the clean food storage had rusted legs and shelves. The wheels of the shelves were soiled with food particles and a greasy substance. Unclean surfaces can lead to food borne illnesses.
26. The wire shelf of the walk in freezer had no barrier; food was stored on the bottom shelf unprotected.
Shipping boxes were found on the shelves in the freezer. Freezer burned meat was found on the lower rack of the freezer. The floor was soiled with a greasy substance, paper, trash, and food particles. Preparing meats not properly stored with freezer burn can lead to food borne illnesses.
27. The kitchen staff was hand washing pots and pans in the industrial sink. The kitchen staff was questioned how the pots and pans were properly being cleaned at the appropriate temperature. Staff #14 stated, "We have thermometers to check the water. I'm not sure if that was done this time or not."
A return visit to the kitchen with staff #1 and #5 on 4/30/2014 at 4:00 PM revealed the kitchen staff had gone home. The sink was left plugged up with dirty dish water in it. The wash towels were found floating in the water and around the sink. A steamer pan was found under the garbage disposal. The steamer pan was full of water from a leaking disposal and half full sink. The soap bottle was empty. There were no full soap bottles in the kitchen or storage areas. Improper cleaning temperatures and exposure to unclean surfaces may lead to food borne illnesses.
28. The cooler behind the cafeteria line had upper and lower compartments. The upper shelf had a soiled tray with a dried red liquid. Lettuce and tomatoes were found uncovered with no dates. A package of bread was found unopened with no dates. Food left exposed with no opening or expiration dates can harbor bacteria causing a potential for food borne illnesses.
29. Clean dishes behind the pots and pans sink was found on a rusted and soiled wire rack, with a greasy substance on the dishes.
A meat slicer was found next to the sink with a plastic cover. The cover had a greasy substance with dried food particles on it.
A plastic covering on a food cart was found to have a ripped top. The top was not able to be cleaned properly.
An interview with staff #1, 5, and 14 confirmed the above findings. Staff #1, 5 and 14 confirmed they could not guarantee that a food borne illness would not occur in this kitchen.

Based on observation, document review and interview the facility failed to
A. provide an organized, safe environment to provide surgeries to patients. The facility was unable to provide evidence the Surgical Department's temperature and humidity was constantly maintained and/or monitored. The Surgical Department was not secured after hours. The Surgery Department was open for the public to enter and pillage.
A tour of the Surgical Department was conducted on 04/30/2014 at approximately 10:30 AM with staff #20 and staff #21. While touring the sterile processing area a large rack filled with surgical instruments were observed (too numerous to count), staff #20 revealed the instrument had been in the department for an indefinite period of time and the temperature and humidity logs along with sterile processing log books had not been maintained. The staff was uncomfortable using those instruments because the sterility could not be guaranteed without documentation. The instruments were available for patient use.
The tour continued to the area of the surgical suites. In the hallway next to a surgical suite was a fan. This surgical suite was described as the only surgical suite in operation. The fan was on and blowing down the hallway.
During the tour, two men entered the Surgical Department pulling a large green trash can. The two men were from a contracted, document shredding company. The two men were wearing their working clothes. The area of the Surgical Department the two men were in required surgical attire.
Review of the AORN Perioperative Standards and Recommended Practices, "Temperature should be maintained between 68 degrees F to 73 degrees F." These recommendations apply to both operating rooms and sterile processing areas. A relative humidity level of 30 to 70 percent is acceptable.
"Room temperature, humidity and ventilation of each work area should be monitored and recorded daily."
A review of a document titled OR Temperature and Humidity Records revealed for the moths of:
February- the temp and humidity was recorded on 3rd, 4th, 5th, 6th, 7th, 10th, 11th, 12th, 13th and 14th. There were no other dates with documented temperatures and humidities.
March- there was no dates with documented temperatures and humidities.
April- the temp and humidity was recorded on the 16th and 17th. There were no other dates with documented temperatures and humidities.
An interview on 05/01/14 at approximately 10:00AM in the Surgical Department, staff # 34 confirmed the door to the postoperative area was broken and could not be locked. Staff #34 confirmed from the postoperative area the public had direct access to the Surgical Department. The Surgical Department was not secure. A review of the document titled OR Temperature and Humidity Records with staff# 34 confirmed the temperatures and humidities of the Surgical Department were not being monitored and recorded as per AORN standards. Staff #34 confirmed fans were not allowed in the Surgical Department. Fans pose a risk of infections.
B. provide evidence of a supervisor of Surgical Services.
Refer to tag A0942
C. provide policies and procedures for surgical services.
Refer to tag A0951

Based on record review and interview the Governing Body failed to approve the Medical Staff Bylaws and the Medical Staff Rules and Regulation.
Based on record review and interview the Governing Body failed to assure the Medical Staff Bylaws, Rules and Regulations were reviewed and approved.

Review of the Governing Board meeting minutes on 3/18/2014 revealed; 4. New Business; Dissolve old board members (send letter); assign new board members .... 5. Round Table/ Assignments; .... New board members; staff #36, staff #2, staff #3and staff #1. This was the first meeting of the new ownership and the establishment of a new Governing Body.

There was no evidence the new Governing Body reviewed and/or approved Governing Body Bylaws, Medical Staff Bylaws, Medical Staff Rules and Regulations. There was no evidence the new Governing Body reviewed and/or approved any Policies and Procedures.

A interview was held on 4/29/2014 at approximately 9:30AM in the Marketing Conference Room with staff #35. Staff #35 was asked, what were the names of the people on the Governing Board. The names given by staff #35 were later found not to be the name of pople on the Governing Board. The name of the Governing Board had been changed and staff #35 was not made aware of the changes.

Interview with staff #1 on 4/29/2014 confirmed the Governing Body had not reviewed and/or approved Governing Body Bylaws, Medical Staff Bylaws, Medical Staff Rules and Regulations.

Based on record review and interview the facility failed to ensure the Emergency Department's policies and procedures were adopted by the facilities current Governing Body.

Findings include:
Review of the Governing Board meeting minutes on 4/29/2014, dated 2/21/2014 and 3/18/2014 revealed no documentation that the current policies and procedures of the hospital departments were approved and/or adopted.

Interview with staff #1 on 4/29/2014 confirmed the findings..

Based on record review and interview the facility and/or Governing Body failed to ensure a current process for prompt resolution of patient grievances.

Findings include:
Review of the facility complaint and grievance data on 4/30/2014 at 11:00 am revealed the following:
1. No documentation of any patient complaints and/or grievances for 3/2014 and 4/14.

Review of the Cleveland Regional Medical Center Complaint/Grievance Process revealed the following:
"1. Providing quality care with a personal touch is the ultimate goal of the staff of the facility. Patients have the right to express concerns and expect resolution in a timely manner.
The Governing Body has delegated the Grievance process tot he Hospital Quality Improvement Committee. A sub-committee of the Quality Improvement Committee may be formed to monitor effectiveness of the grievance process and to review and resolve grievances in a appropriate manner and time frame. The Quality Improvement Committee has designated specific responsibilities tot he following roles:
A. CEO: writing and sending response letters to patient/family
B. PI Director: Auditing, aggregating and analyzing data to present to Quality Improvement Committee for review and recommendation.
2. Complaints or grievances may be in written or verbal form.
3. The patient/patient representative shall be informed of whom to contact to file a complaint/grievance. This may be done via a variety of mechanisms:
A. Patient Family Handbook (if available)
B. Business Office admission packet.
C. Results of the grievance process.
D. Date of completion.
4. The Hospital Quality Improvement Committee ensures the patient is provided written notice of its decision regarding a complaint/grievance within 7 days of the Hospital receipt of the grievance, even though the hospital's resolution need not be complete within the seven-day limit. The written notice shall contain the following:
a. Name of the Hospital contact person.
b. Steps taken on behalf of the patient to investigate the grievance.
c. Result of the grievance process.
d. Date of completion.
5. Grievances shall be tracked for the purpose of trending, improving the processes, and ensuring customer satisfaction with follow-through. (See Complaint/Grievance Log)
6. The Medicare Beneficiary patient/patient representative or appeal if premature discharge, coverage decision, or qualities of care issues arise upon request.
Procedure:
In the event a patient or the patient's family or representative have a comment, complaint, or grievance he/she is encouraged to do one or more of the following:\
*Inform or ask any staff member,
*Speak to the Department Director or Manager of the area involved,
*Request to speak with someone in Administration,
*Other complaints may be received from patient /family satisfaction surveys.

Interview with staff #1 on 4/30/2014 at 1:00 pm confirmed at the present time there was no process in place to review patient complaints and/or grievances.

Based upon record review, observation, and interviews, the facility failed to provide a sanitary environment in the dietary department (food storage, preparation, and cooking surfaces). The likelihood of cross-contamination can occur due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service items (pots, pans, and serving carts) storage and use, unsanitary food storage, and poor general sanitation practices was found throughout the dietary department. The facility failed to provide menus that met the therapeutic dietary needs of all patients. The facility failed to have trained and competent dietary staff and director. The dietary director failed to have therapeutic menus, provide food substitutions, staff training, and an updated diet manual.
A tour of the kitchen was performed on 4/30/2014 at 2:00PM with staff #5 and staff #14. Findings were as follows:
1. A stack of disposable food containers were found uncovered, on a bottom shelf, under the food preparation area. Dust and food crumbs were found in the open containers. The food containers were unclean. The likelihood for food borne illnesses can occur.
2. Staff #14 confirmed the containers were used to serve food and was not aware they needed to be covered.
3. Disposable cups and containers found in shipping boxes in the kitchen. A dirty trash can was found next to the containers. Shipping boxes and dirty trash found in the clean supplies can bring in outside contaminates. The likelihood for food borne illnesses can occur.
4. A wire cart was found to have aprons and linens on the bottom shelf. The shelf, the black aprons, and white linens were found to have food crumbs, dust, and a greasy substance on them. Linens exposed to a contaminate environment and used during meal preparation causes a likelihood for food borne illnesses.
5. A black wire cart was found to have linen on the bottom shelf uncovered and no protective barrier from the floor. The protective barrier was needed to protect the linen from contaminated materials on the floor.
6. The grill was coated in a greasy sticky substance. A caked up greasy substance was found in between each grate, around the sides of the grate and on the foil covered back splash. Dried food particles and dust were found around the edges of the grill. Cooking foods on an unclean surface increases the likelihood of food borne illnesses.
7. The pots and pans were found with a large amount of carbon build up preventing even cooking and cleanliness. The pans are not able to be cleaned properly allowing for food borne illnesses.
Pans used for cooking had Teflon coating missing from the bottom and sides of the pan. There were scratches and a greasy substance on them. Scratched pans allow for Teflon to flake off into the consumer's food. The pans are not able to be cleaned properly exposing the consumer to a possible food borne illness.
8. The top of the gas stove was dirty with food particles, dust, hair and grease. The front of the stove was sticky with a greasy like substance. The front of the oven was rusted and greasy. The rust and missing coating on the stove did not allow for proper cleaning. Inability to clean the stove properly allows for a possible food borne illness.
9. The threshold and floor to the walk in cooler was rusted with large pieces of rusted metal flaking off. Two large rubber mats were found covering the coolers rusted floor. The mats were found with rusted colored stains on the back and condensation. The mats were found to have food particles and dirt on them. The celling of the refrigerator had a rusted sprinkler system. Rust particles were easily flaked off of the sprinkler head. The floor was not able to be properly cleaned and excessive condensation allows bacteria to grow allowing for food borne illnesses.
10. Inside the walk in cooler wire carts were found to be rusted and the wheels were caked in a dirty, greasy substance. Hair and food particles were found on the shelves and floor around it. Food in containers on the wire racks were exposed to the rust, hair, dirt, and dust on the back walls and floors. Exposed food to unclean containers and storage allows for a possible food borne illnesses.
A ? emptied container of pickle relish and an opened jar of mayonnaise were found with no open or expiration date. No open or expiration date allows the condiments to be served after expiration; allowing for a possible food borne illnesses to occur.
11. The counter food preparation area had a greasy substance on it, food particles, and a pan of cooked chicken covered with plastic wrap. Above the food preparation area was a shelf with several drawers. The fronts of the drawers were covered in dried food particles, grease, and dust. On the top of the shelf were 12 opened spice containers with no open or expiration dates. An unclean food preparation area and cooked chicken left unrefrigerated can harbor bacteria causing a possible food borne illnesses.
12. Two doors of the bottom and top oven had a greasy substance on the metal and glass. A white, dried, spilled substance was found on the outside doors. The surveyor wiped a finger along the control knob. Hair, dust, food particles, and grease were removed. An unclean work surface and oven allows for food borne illnesses to occur.
13. The top part of the oven was found to have a soiled baking sheet with a dried liquid substance on it. The pan was covered in carbon. The lower part of the oven was found to have a soiled baking sheet with a white dried liquid substance on it. The wire racks were soiled with carbon and dried food particles. An unclean work oven and pans allow likelihood for food borne illnesses to occur.
14. Next to the stove there were two vats of grease in the fryer. The first vat had dark, foul smelling grease with food particle build up on the sides and lip of the vat. The second vat had lighter grease. The well of the second vat was covered in food particles, a greasy build up on the sides and lip. The frying baskets had a greasy build up.
The front outside exterior of the fryer had missing paint, rust along the front with a greasy, dirty build up on the doors and legs. Inability to properly clean cooking equipment allows for a potential food borne illnesses to occur.
15. The shelf under the grill had an open bag of skewers, a soiled spatula, and knife. The shelf was covered in a greasy substance, dust, dried food particles and hair. An unclean work surface, utensils, and cooking area allow for potential food borne illnesses.
16. An upright wall oven had an upper oven and lower oven. The upper oven had 2 empty backing pans inside with a dried brown liquid substance on them. The bottom oven had dried food particles, carbon covered baking pans, and rusted wire racks. A towel was found in the door of the upper oven.
An interview with staff #14 on 4/30/2014 at 2:00PM revealed the hand towel was left in the oven door to keep it from closing. Staff #14 reported, "When the oven door is closed it continues to keep heating. The thermostat is broken on the oven. The oven is unable to be turned off unless the door is open. Staff #14 confirmed that a work request was put in 2 months prior. Staff #5 and Staff #1 were made aware of the broken oven thermostat by the surveyor. Staff #5 and #1 confirmed the oven was still heating when the switch was put in off position. The electrical inspection sticker on the front of oven had no date or signature.
A towel used to keep the oven door open to prevent the oven from heating would be a potential high risk for fire and potential death in the hospital.
17. A second upright refrigerator along the wall had one shelf covered in white butcher paper. The paper was covered in a dried liquid and food particles. The second shelf had metal food containers with no opening or expiration dates. The metal containers had carbon build up and a greasy substance on the outside. Unclean surfaces allow for potential food borne illnesses.
18. The body of the mixer was missing paint. The paint primer and metal was exposed. The legs on the mixer had missing paint exposing metal. Inside of the mixer bowl a dried liquid and food particles were found in it. On the inside top of the mixer there was a dried liquid substances, and a greasy residue. Inability to properly clean a cooking device and preparing in a soiled device can lead to a food borne illness.
19. The legs of the food preparation table had missing paint exposing rust and metal. The shelf of the preparation table had missing paint exposing rust and metal. The shelf was dirty with dust and hair. Unpainted and unclean surfaces can lead to potential food borne illnesses.
20. Multiple floor tiles in the kitchen were broken and cracked. The floor is not able to be properly cleaned allowing food to be potentially exposed to outside contaminates. The likelihood of food borne illnesses can occur.
21. A large trash can with wheels was beside the food prep area. Staff #14 confirmed the trash can was wheeled out of the kitchen and through the hospital to be dumped. The trash can was brought back into the clean preparation area without being cleaned. Allowing the trash barrel to be exposed to outside contaminates and introducing it back into the clean kitchen area can lead to a food borne illness.
22. The back of the ice machine was rusted. The top of the ice machine was coated in a sticky residue with food particles on top. The outside of the ice machine was soiled with hard water stains and rust. The water filter had no date on it to be changed. Staff #5 confirmed there was no log or guideline to clean out the ice machine. Exposure to contaminated water can lead to water borne illness.
23. A drain in the floor was found between the wall and the fryer. The drain cover was broken and a broken floor tile was found lying across it. The drain was dirty with black particles and dried food particles in it. A second floor drain was found in front of the walk in cooler. The drain was filled with mildew and food particles.
24. Two clean muffin pans were found on a bottom shelf with greasy, carbon build up. Twenty clean baking sheets were found to have a sticky, greasy, carbon build up. The clean pan rack had food particles and dust on the shelves. The clean baking rack had a pan with a white dried residue. The bottom of a clean pot on the rack had dried food particles and dust on it. Three metal pans were found on the clean rack wet. The pans were not allowed to dry properly. Wet stacked pans can lead to a growth of bacteria causing a potential food borne illnesses.
25. The dry storage area had packing boxes on the shelves. The wire shelves in the clean food storage had rusted legs and shelves. The wheels of the shelves were soiled with food particles and a greasy substance. Unclean surfaces can lead to food borne illnesses.
26. The wire shelf of the walk in freezer had no barrier; food was stored on the bottom shelf unprotected.
Shipping boxes were found on the shelves in the freezer. Freezer burned meat was found on the lower rack of the freezer. The floor was soiled with a greasy substance, paper, trash, and food particles. Preparing meats not properly stored with freezer burn can lead to food borne illnesses.
27. The kitchen staff was hand washing pots and pans in the industrial sink. The kitchen staff was questioned how the pots and pans were properly being cleaned at the appropriate temperature. Staff #1 stated, "We have thermometers to check the water. I'm not sure if that was done this time or not."
A return visit to the kitchen with staff #1 and #5 on 4/30/2014 at 4:00PM revealed the kitchen staff had gone home. The sink was left plugged up with dirty dish water in it. The wash towels were found floating in the water and around the sink. A steamer pan was found under the garbage disposal. The steamer pan was full of water from a leaking disposal and half full sink. The soap bottle was empty. There were no full soap bottles in the kitchen or storage areas. Improper cleaning temperatures and exposure to unclean surfaces may lead to food borne illnesses.
28. The cooler behind the cafeteria line had upper and lower compartments. The upper shelf had a soiled tray with a dried red liquid. Lettuce and tomatoes were found uncovered with no dates. A package of bread was found unopened with no dates. Food left exposed with no opening or expiration dates can harbor bacteria causing a potential for food borne illnesses.
29. Clean dishes behind the pots and pans sink was found on a rusted and soiled wire rack, with a greasy substance on the dishes.
A meat slicer was found next to the sink with a plastic cover. The cover had a greasy substance with dried food particles on it.
A plastic covering on a food cart was found to have a ripped top. The top was not able to be cleaned properly.
An interview with staff #1, 5, and#14 confirmed the above findings. Staff #1, 5 and #14 confirmed they could not guarantee that a food borne illness would not occur in this kitchen.


Review of the dietary personnel files #5, #14, and #23 revealed the dietary staff did not receive adequate training and competencies in food preparation, infection control, food safety, therapeutic diets, and food substitutions.
An interview was conducted with staff #5 and #14 on 4/30/2014. Staff #5 and #14 confirmed that the dietician had not been at the facility to in-service the staff, sign the menus, create substitute menus, or collaborate with other hospital services since 9/2013. Staff #5 and 14 confirmed the dietician has not given any in-services.



Review of the patient menus had no signature or approval from the dietician.
Review of the facilities policy and procedures "CRH Food and Nutrition Services" states, "All menus will be reviewed once a month by the dietician."
An interview was conducted with staff #5 and #14 on 4/30/2014. Staff #5 and #14 confirmed that the dietician had not been at the facility to sign the menus, create substitute menus, or collaborate with other hospital services (e.g., medical staff, nursing services, pharmacy service, social work service, etc) to plan and implement patient care as necessary.
Staff #14 reported that the menus are rotated every two weeks with no approval of changes or substitutions from the Dietician.
Review of the Therapeutic Diet Manual available to the dietary staff revealed the manual was out dated since January 2014.
Interview with staff #5 and 14 confirmed the manual was outdated.

Based on records review and interviews, the facility failed to collect quality improvement data from the following departments: Materials Management, Plant Operations, Housekeeping, Surgery, Linen/Laundry, Radiology, Dietary, Respiratory, and Nursing services.

Findings include:
Review of the Cleveland Regional Medical Center Plan for Quality Improvement 2014 revealed the following:

"I. Mission: We are caring people, operating an extraordinary community hospital, dedicated to providing quality healthcare in a professional, cost effective and compassionate manner. We are committed to the health, well-being and satisfaction of our community.
II. Purpose: The Quality Improvement Program is designed to provide a systematic and organized mechanism to promote safe and quality patient safety. Ultimate authority and accountability for the quality and safety of patient care and services lies with he Governing Board and is delegated through the Quality Improvement Program to the Medical Staff, Administration and staff of the hospital.
IV. Goals:
*To improve safety and quality of care and services by measuring, assessing, and improving leadership, clinical and support processes.
*To shift the primary focus from the performance of individuals to the performance of the organizations's systems and processes, while continuing to recognize the importance of individual competence.
*To utilize internal and external customer feedback to improve the services necessary to excel in a competitive health care environment.
*To organize and analyze data into useful information, including comparison to internal and external data.
*To utilize external information sources representing "Best Practices" in the design of systems to improve patient outcomes and processes.
*To utilize results from Infection Control, Utilization Review, Risk Management, EOC and Patient Safety to improve processes and outcomes.
*To promote the provision of a comparable level of care throughout the hospital.
*To utilize results of the Quality Improvement Program in a continuing education program.
*To integrate and document all performance improvement activities.
To enhance communication of quality monitoring results between the Medical Staff, Hospital Department/Services, and the Governing Body."

Interview with staff throughout the survey in departments including: Materials Management, Plant Operations, Housekeeping, Surgery, Linen/Laundry, Radiology, Dietary, Respiratory, and Nursing services throughout the survey confirmed that since the last QAPI meeting on 2/6/2014 no data is being collected at this time.

Interview with staff #1 on 4/30/2014 at 3:00 pm in the conference room confirmed the findings.

Based on record review and interview the facility and Governing Body/Medical Staff failed to ensure the Quality Assessment Performance Improvement (QAPI) program measured, analyzed, and track adverse patient events and/or medical errors.

Findings include:
Review of QAPI program meeting minutes dated 2/6/2014 in the facility conference room on 4/30/2014 revealed the following:
1. No documentation of review of adverse events and/or medical errors from the 3rd Quarter data collection.

Review of the Cleveland Regional Medical Center Bylaws dated 11/23/2013 in the conference room on 5/1/2014 revealed the following:
"Section 12.3 The Quality Improvement Council
12.3 (a) Composition
Members of the committee shall include the following:
1. The Chairman (Chief of Staff Elect)
2. The Vice-Chairman of each Clinical Department
3. The CEO, ex-officio or his/her designee;
4. the Chief Nursing Officer, ex-officio;
5. The Quality Management/Regulatory Compliance Director, ex-officio; and
6. The Chief Financial Officer, ex-officio.
12.3 (b) Functions
The Quality Improvement Council is the multidisciplinary body charged by the Governing Board with oversight of all aspects of the Quality Improvement Program throughout the facility. The Council accomplishes the oversight function through:
1. Implementing a systematic, continuous improvement process;
2. Receiving recommendations from various sources regarding quality improvement efforts;
3. Integrating findings and outcomes of reviews conducted by Medical Staff Committees;
4. Evaluating and prioritizing problems and identified opportunities to improve;
5. Chartering and facilitating Quality Improvement Teams and projects;
6. Acting on reports from Quality Improvement Team activities;
7. Facilitating communication of the team progress and improvements throughout the organization; and
8. Maintaining a permanent record of its proceedings.
9. Serve as the Peer Review Committee, in executive session, to review quality trends issues and make recommendations to the Department Chief and/or the MEC.
12.3 (c) Meetings
The QIC shall meet quarterly or as needed and maintain a permanent record of its proceeding and actions.
12.3 (d) Special Meeting of the Quality Improvement Council
A special meeting of the QIC may be called by the Chief of the Medical Staff or quorum of the MEC members, when a quorum of the MEC can be convened."

Interview with staff #1 on 4/30/2014 at 3:00 pm confirmed there was no current collection of data concerning adverse events and/or medical error and no current director of the QAPI Program and/or designated members of the Quality Improvement Council..

Based on review of policy /procedures, interviews, and patient chart reviews the facility failed to follow their own policy/ procedures in administering blood transfusions in a safe manner on 3 (#27, 30, and 31) out of 5 (#27-31) charts reviewed. Failure to safely administer blood and blood products poses Immediate Jeopardy to patient's health and safety and placed patients at risk of potential harm, serious injury, and possibly subsequent death.
Review of patient #31's chart revealed a 36 year old female who had presented to the emergency room with heavy menses (vaginal bleeding) on 2/7/14 at 9:45 AM. Review of the nursing notes dated 2/7/14 revealed patient #31 was sent from her primary care physician to the ER for a blood transfusion.
Review of the policy and procedure "Blood and Blood Products Administration " stated, "Procedure: 1. Verify the physicians order. The physician's order should include the name of the specific blood component to be infused and the amount and duration of the infusion."
Review of the ER physician orders for patient #31 revealed there was no date on any orders. Review of the ER physician orders had an order written at 10:00 AM. The order stated, "Type and cross with transfuse 2 units" The physician order did not include specific blood component, amount, and duration of infusion.
Review of patient #31's blood transfusion sheet dated 2/7/2014 revealed the patient was given red blood cells. The unit of blood was checked out by staff #26 and the lab technologist on 2/7/2014 at 1:24 PM. Staff #26 and the lab technologist both failed to verify and confirm the physician order for the specific blood component, amount, and duration.
Review of the policy and procedure "Blood and Blood Products Administration" stated, "#17 after the blood has infused for 15 minutes at 10-15gtts (drops) per minute adjust the rate to infuse at the rate prescribed."
Review of patient 31's nursing notes dated 2/7/2014 1:45 PM revealed the blood transfusion had been started with no documentation of the rate. At 2:05 PM staff #26 documented "Infusion rate increased to 90 ml/hr." At 3:15 PM staff #26 documented, "tolerating infusion well. Infusion rate increased to 120 ml/hr. will continue to monitor." Staff #26 failed to obtain a physician order for the blood amount, rate, and duration to be administered. Staff #26 failed to follow the policy and procedure of blood administration.
Review of patient #31's blood transfusion sheet dated 2/7/2014 revealed the first unit of blood was completed on 2/7/14 at 4:30 PM.
Review of patient #31's blood transfusion sheet dated 2/7/2014 at 5:00 PM revealed the patient was given a second unit of red blood cells. The second unit of blood was checked out by staff #26 and the lab technologist on 2/7/2014 at 4:48 PM. Staff #26 and the lab technologist both failed to verify and confirm the physician order for the specific blood component, rate, and duration. Staff #26 failed to follow the policy and procedure of blood administration.
Review of the policy and procedure "Blood and Blood Products Administration" stated, " #18 after transfusion of whole blood or packed red blood cells, the primary tubing should be flushed with 0.9% normal saline. Documentation must include date/time completed or stopped, volume transfused, 1-hour post transfusion vital signs and post nursing assessment regarding patient's tolerance of the procedure."
Review of patient #31's second blood transfusion sheet dated 2/7/2014 at 5:00 PM revealed staff #26 did not document the one hour post transfusion vital signs, volume of blood transfused, date/time transfusion completed. Staff #26 failed to complete the transfusion form and follow the blood products administration policy and procedure.
Review of the policy and procedure "Medication Administration" stated, "Persons who administer drugs shall record the administration on a medication administration record (MAR). The MAR is a legal record of all drugs administered to the patient. The original MAR shall remain in the patient's medical record after discharge."
Review of the policy and procedure "Blood and Blood Products Administration" stated, "MAR is to be completed by placing the unit number in the appropriate space with the following information: Whole blood, packed cells, or name of blood product, route IV, time started, and nurses signature. "
Review of the ER physician orders for patient #31's revealed an order timed at 6:00 PM. The order stated, " Lasix 40 mg IV. " The order was initialed by staff #26. Review of patient #31's nurse's notes and transfusion record had no documentation that the drug Lasix (diuretic) was administered. The MAR provided on the nurses notes had no blood information. Staff# 26 failed to document administration of a prescribed medication or documentation of blood administration on the MAR per policy and procedures.
Review of patient #30's chart revealed she was a 79 year old female admitted to the facility with anemia on 2/13/14 at 3:06 PM. Review of physician orders dated 2/13/14 revealed a verbal order was taken by staff #31. The order was dated but not timed. The order read, "Please type and cross match and transfuse 2 units PRBC irradiated. Please draw extra tubes for antibody screen. Pre-medicate with Tylenol (analgesic) 650 mg po (oral) and Benadryl (antihistamine) 12.5 mg IV. CBC I hour post- transfusion. Fax results to xxx-xxx-xxxx. Ok to access port-a-cath per hospital protocol if available." Staff #31 failed to time the order, and obtain a rate and duration for the blood transfusion.
Review of the policy and procedure "Blood and Blood Products Administration stated, "Pre- Transfusion vital signs must be taken and documented on the blood or blood components transfusion record in the space provided. #16 monitor the patient' s vital signs prior to administration, 15 minutes after initiation, and every 30 minutes until the unit is completely transfused or transfusion is stopped, and 1- hour post transfusion.
Review of patient #30' blood transfusion sheet dated 2/14/2014 revealed the Pre-transfusion vital signs taken on 2/14/14 at 11:20 AM had no temperature documented. The vital signs for 4:00 PM were not documented. The blood transfusion was completed at 4:30 PM. Staff #29 failed to document vital signs at pre-transfusion and during transfusion.
Review of patient #27's chart revealed she was a 38 year old female admitted for vaginal bleeding due to a postoperative hemorrhage, status post cervical conization.
Review of the nurse's notes dated 2/17/14 at 1:20 AM stated, "Notified MD of CBC results new orders received will continue to monitor."
Review of patient #27's physician orders on 1/27/14 at 1:23 AM revealed a sticker on the order stating, "critical value". There was no documentation of what type of critical value.
Review of patient #27's physician orders for 1/27/14 at 1:25 AM stated, "Type and cross blood for 2 units of PRBC each unit infused for 2 hours."
Review of patient #27's "Transfusion of Blood & Blood Components Consent/Refusal" revealed patient #27 refused the blood. Review of the nurse's notes dated 1/27/14 at 1:55 AM revealed patient #27 wanted to wait until the next morning and recheck the lab. The Licensed Vocational Nurse (LVN) documented, "House supervisor spoke with the patient, MD new orders to wait until am to redraw labs and continue monitoring patient." There was no documentation from the house supervisor. There was no physician order to hold the transfusion.
Review of patient #27's chart revealed a second "Transfusion of Blood & Blood Components Consent/Refusal" form dated 1/27/14 at 5:25 AM. Patient #27 had consented to the blood transfusion.
Review of the policy and procedure "Blood and Blood Products Administration stated, "#11 Documentation in the patients' medical record should include and will be documented on the blood or blood components transfusion record to include: A. The pre- transfusion assessment. F. Patient's response to transfusion (including laboratory data before/after transfusion).
Review of patient #27's blood transfusion record dated 1/27/14 at 6:00 AM revealed no 1 hour post transfusion vital signs were recorded at 9:00 AM.
Review of patient #27's nurse's notes on 1/27/2014 at 6:00 AM was documented by the LVN. The LVN documented, "Patient alert and oriented x3. Blood transfusion initiated by house supervisor, vital signs taken and recorded on transfusion record, no distress noted." There was no documentation on nurse's notes or blood transfusion form of patient assessment before the transfusion, addressing the transfusion, or completion of the transfusion. Staff #32 failed to assess the patient before, during, or after the administration of the blood.
Review of patient #27's physician orders revealed staff #33 wrote a telephone order on 1/27/14 at 9:10 AM. The order stated, "Type and cross match for two more units." The physician order failed to include specific blood component, amount, and duration of infusion.
Review of patient #27's nurse's notes for 1/27/14 at 8:30 AM revealed the patient was taken to surgery. Review of the Operating Room Progress Notes for the nurses at 10:25 AM revealed 3 units of packed red blood cells were administered by the Anesthesiologist in surgery.
Review of patient #27's blood transfusion records, for 1/27/14, are as follows:
PRBC Transfusion #1- 1/27/14 started at 9:10 AM by staff #34. The transfusion was stopped by staff #35 at 10:15. There was no documentation why the blood was stopped or amount transfused. There was no order or documentation that this was an emergent transfusion. There were no physician orders to transfuse the blood, specific blood component, amount, and duration of infusion. No documentation on the MAR.
PRBC Transfusion #2- 1/27/14 started at 10:27 AM by staff #35 and completed at 10:57 AM. There was no order or documentation that this was an emergent transfusion. There were no physician orders to transfuse the blood, specific blood component, amount, and duration of infusion. No documentation on the MAR.
PRBC Transfusion #3- 1/27/14 started at 11:08 AM by staff #35. The last vital signs were taken at 11:38 AM. There was no date or time the transfusion was completed. There was no documentation on how the patient tolerated the transfusion before, during or after the transfusion. No documentation on the patient's MAR.
Review of patient #27's physician orders revealed staff #34 wrote a telephone order on 1/27/14 at 11:30 AM. The order stated, "Type and cross match for two more units of blood." The physician order failed to include specific blood component, amount, and duration of infusion.
Review of a physician order written on 1/27/14 at 5:00 PM states, "Please transfuse 2 units of PRBC."
Review of a physician order written on 1/27/14 at 5:45 PM states, "Transfuse only one unit of PRBC's. "There were no physician orders to transfuse the amount and duration of infusion.
Review of the blood transfusion sheet for 1/27/14 showed the transfusion was started at 5:00 PM. The units of PRBC's were completed at 8:30 PM. There was no nursing documentation of a before, during, or after assessment of the patient. There was no documentation on the MAR.
An interview on 5/1/14 at 11:30 PM with staff #35 and staff #1 confirmed the above findings.

Based on record review and interview the facility failed to ensure all medical records were legible, complete, dated, timed and authenticated by the person responsible for providing or evaluating the service provided. Citing 19 of 31 patient medical records reviewed. (Patient's #1, 2 , 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 17, 18, 19, 20, 21, 23, and 24).


Findings include:
Review of medical records on 4/29/2014 and 4/30/2014 in the conference room revealed the following: (Patient's #1, 2 , 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 17, 18, 19, 20, 21, 23, and 24).

1. Emergency room record for patient #1 dated 2/27/2014- no documentation per the emergency room staff of the time the consent for treatment was witnessed. No documentation of patient's immunization status. No documentation of patient's discharge vital signs found. On the physician examination sheet- no documentation of the x-rays ordered and/or EKG ordered.
2. Emergency room record for patient #2 dated 2/1/2014- no documentation of patient's immunization status. No documentation of the pain level. On physician physical examination sheet, no documentation of x-rays and/or lab work ordered.
3. Emergency room record for patient #3 dated 2/1/2014- no documentation of the patient's chief complaint. On physician physical examination sheet, no documentation of x-rays and/or lab work ordered.
4. Emergency room record for patient #4 dated 2/1/2014- no documentation of patient immunization status and no documentation of patient's admit vital signs found. On physician physical examination sheet, no documentation of EKG ordered.
5. Emergency room record for patient #5 dated 2/11/2014- no documentation per emergency room staff on the time the consent for treatment was witnessed. No documentation by the nurse of the patient's discharge vital signs found.
6. Emergency room record for patient #6 dated 2/28/2014- no documentation of the triage level of the patient on admission to the emergency department. No documentation of the patient immunization status. No documentation of the patient's discharge vital signs. No documentation by the physician of the time the physical examination sheet was signed.
7. Emergency room record for patient #7 dated 2/28/2014- no documentation of the physician date/time of signature on physical examination sheet.
8. Emergency room record for patient #8 dated 2/4/2014- no documentation per the emergency room staff of the time the consent for treatment was witnessed. No documentation of the discharge vital sign found.
9. Emergency room record for patient #9 dated 3/1/2014- no documentation per emergency room staff of the time the consent for treatment was witnessed.
10. Emergency room record for patient #10 dated 3/1/2014- no documentation of the patient complaint on admission, no documentation of the patient's immunization status, no documentation of the patient's pain level, no documentation of the patient's past medical history, no documentation of the patient's social history, and no documentation of the patient's discharge vital signs. On the physician examination sheet, no documentation of the time of the physician signature.
11. Emergency room record for patient #12- no documentation per emergency room staff of the time the consent for treatment was witnessed.
12. Emergency room record for patient #13 dated 3/3/2014- no documentation per emergency room staff of the time the consent for treatment was witnessed. No documentation of the triage level on admission found. No documentation on the physical examination sheet per the physician of the x-rays, labs, and EKG ordered.
13. Emergency room record for patient #14 dated 3/4/2014- no documentation per emergency room staff of the time the consent for treatment was witnessed.
Emergency room record for patient #15 dated 3/5/2014- no documentation per emergency room staff of the time the consent for treatment was witnessed.
14. Emergency room record for patient #17 dated 3/27/2014- no documentation per emergency room staff of the time the consent for treatment was witnessed. No documentation of the patient's immunization status. No documentation on the physical examination sheet per the physician of the x-rays ordered and no documentation of the physician signature found.
15. Emergency room record for patient #18 dated 2/27/2014- no documentation per emergency room staff of the time the consent for treatment was witnessed. No documentation of the patient's triage level on admission. No documentation on the physical examination sheet per the physician of the labs ordered.
16. Emergency room record for patient #19 dated 2/26/2014- no documentation per emergency room staff of the time the consent for treatment was witnessed.
Review of out-patient surgery record for patient #20 dated 2/26/2014- no signature of the Registered Nurse on the Day-Surgery Pre-Assessment form.
17. Review of the out-patient record for patient #21 dated 4/15/2014- no patient and/or staff signature documented on the pre-op instruction sheet. No signature of the Registered Nurse on the Day-Surgery Pre-Assessment form. No documentation by the Registered Nurse of the pain level of the patient on discharge.
18. Review of the out-patient record for patient #23 dated 4/29/2014- no signature of the Registered Nurse on the Day-Surgery Pre-Assessment form, no documentation on the operative note found, and no patient signature on the Pre-op instruction sheet.
19. Review of the out-patient record for patient #24 dated 4/15/2014- no signature of the Registered Nurse on the Day-Surgery Pre-Assessment form, documentation on the Physical Assessment, Medication administration during surgery, and Pre-Op procedure checklist incomplete.

Interview with staff #1 on 4/30/2014 at 3:00 pm confirmed the findings.

Based upon observation and interview, the facility failed to provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to poor hand hygiene, unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department.

A tour of the kitchen was performed on 4/30/2014 at 2:00 PM with staff #5 and staff #14. Findings were as follows:
1. A stack of disposable food containers were found uncovered, on a bottom shelf, under the food preparation area. Dust and food crumbs were found in the open containers. The food containers were unclean. The likelihood for food borne illnesses can occur.
2. Staff #14 confirmed the containers were used to serve food and was not aware they needed to be covered.
3. Disposable cups and containers found in shipping boxes in the kitchen. A dirty trash can was found next to the containers. Shipping boxes and dirty trash found in the clean supply area can bring in outside contaminates. The likelihood for food borne illnesses can occur.
4. A wire cart was found to have aprons and linens on the bottom shelf. The shelf, the black aprons, and white linens were found to have food crumbs, dust, and a greasy substance on them. Linens exposed to a contaminate environment and used during meal preparation causes a likelihood for food borne illnesses.
5. A black wire cart was found to have linen on the bottom shelf uncovered and no protective barrier from the floor. The protective barrier was needed to protect the linen from contaminated materials on the floor.
6. The grill was coated in a greasy sticky substance. A caked up greasy substance was found in between each grate, around the sides of the grate and on the foil covered back splash. Dried food particles and dust were found around the edges of the grill. Cooking foods on an unclean surface increases the likelihood of food borne illnesses.
7. The pots and pans were found with a large amount of carbon build up preventing even cooking and cleanliness. The pans are not able to be cleaned properly creating the likelihood for a food borne illness.
Pans used for cooking had Teflon coating missing from the bottom and sides of the pan. There were scratches and a greasy substance on them. Scratched pans allow for Teflon to flake off into the consumer's food. The pans are not able to be cleaned properly creating the likelihood for a food borne illness.
8. The top of the gas stove was dirty with food particles, dust, hair and grease. The front of the stove was sticky with a greasy like substance. The front of the oven was rusted and greasy. The rust and missing coating on the stove did not allow for proper cleaning. Inability to clean the stove properly creates a likelihood for a possible food borne illness.
9. The threshold and floor to the walk in cooler was rusted with large pieces of rusted metal flaking off. Two large rubber mats were found covering the coolers rusted floor. The mats were found with rust colored stains on the back and condensation. The mats were found to have food particles and dirt on them. The ceiling of the refrigerator had a rusted sprinkler system. Rust particles were easily flaked off of the sprinkler head. The floor was not able to be properly cleaned and excessive condensation allows bacteria to grow allowing for food borne illnesses.
10. Inside the walk in cooler wire carts were found to be rusted and the wheels were caked in a dirty, greasy substance. Hair and food particles were found on the shelves and floor around it. Food in containers on the wire racks were exposed to the rust, hair, dirt, and dust on the back walls and floors. Exposed food to unclean containers and storage creates the likelihood for a possible food borne illnesses.
A ? emptied container of pickle relish and an opened jar of mayonnaise were found with no open or expiration date. No open or expiration date allows the condiments to be served after expiration creating the likelihood for a possible food borne illnesses.
11. The counter food preparation area had a greasy substance on it, food particles, and a pan of cooked chicken covered with plastic wrap. Above the food preparation area was a shelf with several drawers. The fronts of the drawers were covered in dried food particles, grease, and dust. On the top of the shelf were 12 opened spice containers with no open or expiration dates. An unclean food preparation area and cooked chicken left unrefrigerated can harbor bacteria creating the likelihood for a possible food borne illnesses.
12. Two doors of the bottom and top oven had a greasy substance on the metal and glass. A white, dried, spilled substance was found on the outside doors. The surveyor wiped a finger along the control knob. Hair, dust, food particles, and grease were removed. An unclean work surface and oven creates the likelihood for food borne illnesses to occur.
13. The top part of the oven was found to have a soiled baking sheet with a dried liquid substance on it. The pan was covered in carbon. The lower part of the oven was found to have a soiled baking sheet with a white dried liquid substance on it. The wire racks were soiled with carbon and dried food particles. An unclean oven and pans create the likelihood for food borne illnesses to occur.
14. There were two vats of grease in the fryer nest to the stove. The first vat had dark, foul smelling grease with food particle build up on the sides and lip of the vat. The second vat had lighter grease. The well of the second vat was covered in food particles, and a greasy build-up on the sides and lip of the vat. The frying baskets had a greasy build-up.
The front outside exterior of the fryer had missing paint, rust along the front with a greasy, dirty build-up on the doors and legs. Inability to properly clean cooking equipment creates the likelihood for a food borne illnesses to occur.
15. The shelf under the grill had an open bag of skewers, a soiled spatula, and knife. The shelf was covered in a greasy substance, dust, dried food particles and hair. An unclean work surface, utensils, and cooking area created the likelihood for food borne illnesses.
16. An upright wall oven had an upper oven and lower oven. The upper oven had 2 empty backing pans inside with a dried brown liquid substance on them. The bottom oven had dried food particles, carbon covered baking pans, and rusted wire racks. A towel was found in the door of the upper oven.
An interview with staff #14 on 4/30/2014 at 2:00 PM revealed the hand towel was left in the oven door to keep it from closing. Staff #14 reported, "When the oven door is closed it continues to keep heating. The thermostat is broken on the oven. The oven is unable to be turned off unless the door is open. "Staff #14 confirmed that a work request was put in 2 months prior. Staff #5 and Staff #1 were made aware of the broken oven thermostat by the surveyor. Staff #5 and #1 confirmed the oven was still heating when the switch was put in off position. The electrical inspection sticker on the front of oven had no date or signature.
A towel used to keep the oven door open to prevent the oven from heating would be a potential high risk for fire and potential death in the hospital.
17. A second upright refrigerator along the wall had one shelf covered in white butcher paper. The paper was covered in a dried liquid and food particles. The second shelf had metal food containers with no opening or expiration dates. The metal containers had carbon build up and a greasy substance on the outside. Unclean surfaces allow for potential food borne illnesses.
18. The body of the mixer was missing paint. The paint primer and metal was exposed. The legs on the mixer had missing paint exposing metal. Inside of the mixer bowl a dried liquid and food particles were found in it. On the inside top of the mixer there was a dried liquid substances, and a greasy residue. Inability to properly clean a cooking device and preparing in a soiled device can lead to a food borne illness.
19. The legs of the food preparation table had missing paint exposing rust and metal. The shelf of the preparation table had missing paint exposing rust and metal. The shelf was dirty with dust and hair. Unpainted and unclean surfaces can lead to potential food borne illnesses.
20. Multiple floor tiles in the kitchen were broken and cracked. The floor is not able to be properly cleaned allowing food to be potentially exposed to outside contaminates. The likelihood of food borne illnesses can occur.
21. A large trash can with wheels was beside the food prep area. Staff #14 confirmed the trash can was wheeled out of the kitchen and through the hospital to be dumped. The trash can was brought back into the clean preparation area without being cleaned. Allowing the trash barrel to be exposed to outside contaminates and introducing it back into the clean kitchen area can lead to a food borne illness.
22. The back of the ice machine was rusted. The top of the ice machine was coated in a sticky residue with food particles on top. The outside of the ice machine was soiled with hard water stains and rust. The water filter had no date on it to be changed. Staff #5 confirmed there was no log or guideline to clean out the ice machine. Exposure to contaminated water can lead to water borne illness.
23. A drain in the floor was found between the wall and the fryer. The drain cover was broken and a broken floor tile was found lying across it. The drain was dirty with black particles and dried food particles in it. A second floor drain was found in front of the walk in cooler. The drain was filled with mildew and food particles.
24. Two clean muffin pans were found on a bottom shelf with greasy, carbon build up. Twenty clean baking sheets were found to have a sticky, greasy, carbon build up. The clean pan rack had food particles and dust on the shelves. The clean baking rack had a pan with a white dried residue. The bottom of a clean pot on the rack had dried food particles and dust on it. Three metal pans were found on the clean rack wet. The pans were not allowed to dry properly. Wet stacked pans can lead to a growth of bacteria causing a potential food borne illnesses.
25. The dry storage area had packing boxes on the shelves. The wire shelves in the clean food storage had rusted legs and shelves. The wheels of the shelves were soiled with food particles and a greasy substance. Unclean surfaces can lead to food borne illnesses.
26. The wire shelf of the walk in freezer had no barrier; food was stored on the bottom shelf unprotected.
Shipping boxes were found on the shelves in the freezer. Freezer burned meat was found on the lower rack of the freezer. The floor was soiled with a greasy substance, paper, trash, and food particles. Preparing meats not properly stored with freezer burn can lead to food borne illnesses.
27. The kitchen staff was hand washing pots and pans in the industrial sink. The kitchen staff was questioned how the pots and pans were properly being cleaned at the appropriate temperature. Staff #14 stated, "We have thermometers to check the water. I'm not sure if that was done this time or not."
A return visit to the kitchen with staff #1 and #5 on 4/30/2014 at 4:00 PM revealed the kitchen staff had gone home. The sink was left plugged up with dirty dish water in it. The wash towels were found floating in the water and around the sink. A steamer pan was found under the garbage disposal. The steamer pan was full of water from a leaking disposal and half full sink. The soap bottle was empty. There were no full soap bottles in the kitchen or storage areas. Improper cleaning temperatures and exposure to unclean surfaces may lead to food borne illnesses.
28. The cooler behind the cafeteria line had upper and lower compartments. The upper shelf had a soiled tray with a dried red liquid. Lettuce and tomatoes were found uncovered with no dates. A package of bread was found unopened with no dates. Food left exposed with no opening or expiration dates can harbor bacteria causing a likelihood for food borne illnesses.
29. Clean dishes behind the pots and pans sink was found on a rusted and soiled wire rack, with a greasy substance on the dishes.
A meat slicer was found next to the sink with a plastic cover. The cover had a greasy substance with dried food particles on it.
A plastic covering on a food cart was found to have a ripped top. The top was not able to be cleaned properly.
An interview with staff #1, 5, and #14 confirmed the above findings. Staff #1, #5 and #14 confirmed they could not guarantee that a food borne illness would not occur in this kitchen.

Based on review of employee files and interviews the facility failed to have a qualified or experienced dietary director.
Review of staff #5's employee file revealed that staff #5 had no dietary training or experience.
An interview was conducted with staff #5 on 4/30/2014. Staff #5 reported that she had been in a supervisory position for less than a year. Staff #5 confirmed that she had no dietary experience or training.

Based on review of employee files and interviews the facility failed to have a qualified dietician to supervise the nutritional aspects of patient care.
Review of staff #22's employee record revealed staff #22 became the contract dietician on 9/30/2013. Review of the dietary records revealed no visit from staff #22 to the dietary department since 9/30/2013. Review of the dietary records revealed the hospital did not make adequate provisions for qualified consultant coverage when the dietitian was not available.
An interview was conducted with staff #5 and #14 on 4/30/2014. Staff #5 and #14 confirmed that the dietician had not been at the facility to in-service the staff, sign the menus, create substitute menus, or collaborate with other hospital services (e.g., medical staff, nursing services, pharmacy service, social work service, etc) to plan and implement patient care as necessary.

Based on review of employee files and interviews the facility failed to have a qualified dietician to supervise and perform adequate training and competencies to the dietary staff in 3(#5, 14, and 23) out 3(#5, 14, and 23) files reviewed.
Review of the dietary personnel files #5, #14, and #23 revealed the dietary staff did not receive adequate training and competencies in food preparation, infection control, food safety, therapeutic diets, and food substitutions.
An interview was conducted with staff #5 and #14 on 4/30/2014. Staff #5 and #14 confirmed that the dietician had not been at the facility to in-service the staff, sign the menus, create substitute menus, or collaborate with other hospital services since 9/2013. Staff #5 and 14 confirmed the dietician has not given any in-services.

Based on observation and interviews the facility failed to provide a current Therapeutic Diet Manual to the dietary staff.
Review of the Therapeutic Diet Manual available to the dietary staff revealed the manual was out dated since January 2014.
Interview with staff #5 and 14 confirmed the manual was outdated.

Based on observation, document review and interview the facility failed to individually secure 20 of 20 H cylinders (Oxygen cylinder size H is a large container that hold just over 7000 liters of oxygen. The tank is not portable, however, and weighs over a hundred pounds) filled with oxygen.
While touring the Oxygen storage area on 4/30/14 at approximately 9:30 AM with staff #35 and staff #36, twenty oxygen filled H cylinders were observed standing in racks. The twenty H cylinders were not secured to prevent them from falling.
A review of the NFPA (National Fire Protection Association) 99 Chapter 5

5.1.3.3.2 Design and Construction. Location for central supply systems and the storage of positive-pressure gasses shall meet the following requirements.

(7) They shall be provided with racks, chains, or other fastening to secure all cylinders from falling, whether connected, unconnected, full, or empty.
Interview at approximately 9:30 AM with staff #35 and staff #36 confirmed the twenty H cylinders were not secured to prevent them from falling.

Based on interview the facility failed to provide evidence of a supervisor of Surgical Services.
An interview was conducted on 04/29/14 at approximately 2:00 PM with staff #1 in the Marketing Conference Room. The interview confirmed the facility did not have a Surgical Department Supervisor.
An interview was conducted on 04/30/14 at approximately 10:30 AM with staff #21 in the Surgical Department. Staff #21 was asked, who is the Surgical Department Supervisor. "I haven't been told I'm the Supervisor but if my staff has questions they know to come to me. We are contracted from facility A and we come to this facility when they have surgeries. I'm an employee of facility A."

Based on interview, the facility failed to provide approved surgical policies and procedures to provide guidance for the contracted Surgical Staff.
An interview was conducted with a contracted surgical staff #21 on 4/30/14 at approximately 11:00 in the Surgical Department. Staff #21 was asked what policies and procedure guided the surgical department. Staff #21 responded, "we follow the policies from the hospital we are contracted from". Staff #21 was asked had the governing body approved the policies. Staff #21 responded, "I don't know if they have or not".
An interview was held on 04/30/2014 at approximately 12:45 PM in the Marketing Conference Room with the governing board members and owners, staff #1, staff #2, staff #3and staff #36. The governing board members and owners, staff #1, staff #2, staff #3and staff #36 were asked if the surgical staff were expected to follow the facility's policies or the policies from contracted hospital. Staff #1, staff #2, staff #3 and staff #36 all gave conflicting answers. Some responding the facility's policies and other responding the contracted hospital's policies.

Based on record review the interview the facility failed to provide a physician with knowledge, experience, and capabilities to supervise and administer respiratory services. This has the potential to put all patients receiving care in the facility at risk.

Findings include:
Review of the facility organizational chart on 5/1/2014 at 1:30 pm in the conference revealed no appointment of a medical director over respiratory services

Interview with staff #1 on 5/1/2014 at 2:00 PM confirmed the findings.

Based on review of patient menus, policy and procedure, and interviews the facility failed to follow "CRH Food and Nutrition Services" policy and procedures. The facility failed to ensure the Dietician would approve menus and implement patient care when needed.
Review of the patient menus had no signature or approval from the dietician.
Review of the facilities policy and procedures "CRH Food and Nutrition Services" states, "All menus will be reviewed once a month by the dietician."
An interview was conducted with staff #5 and #14 on 4/30/2014. Staff #5 and #14 confirmed that the dietician had not been at the facility to sign the menus, create substitute menus, or collaborate with other hospital services (e.g., medical staff, nursing services, pharmacy service, social work service, etc) to plan and implement patient care as necessary.
Staff #14 reported that the menus are rotated every two weeks with no approval of changes or substitutions from the Dietician.