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Based on observation, interview, and documentation review the facility failed to maintain an environment safe from fire related to failure to maintain the fire rating of the vertical openings, ensure fire rated smoke barriers were maintained, to ensure hazardous area protection, sprinklers maintained, and battery back up light testing with NFPA 101; sprinkler testing complied with NFPA 25, fire alarm component and smoke sensitivity testing complied with NFPA 72 and failed to ensure documentation of the humidity levels after adjustments/repairs are made of HVAC system. (A710) This has the potential to affect all 50 patients receiving services from the facility The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of the patients. The facility's census was 50.

Based on policy review, observations, and staff interviews the facility failed to ensure there was an active infection control program to monitor, document, and maintain a sanitary dietary environment to prevent potential contamination sources, the hospital failed to ensure food products were properly cooked to regulated temperatures, failed to ensure food products were stored at regulated refrigeration and freezer temperatures, failed to ensure dish ware was sanitized at regulated sanitation temperatures, and failed to ensure food products that were opened and not completely used or prepared at the facility and stored either in dry storage or refrigerated storage were labeled with a "use by" date as required by hospital policy. (A749) The cumulative effect of these systemic practices resulted in a risk to the health and safety of the 50 patients serviced by the dietary department.

Based on medical record review, policy review, and staff interview the facility failed to ensure a daily assessment for restraint release was documented by a registered nurse. This affected one, Patient #23, of seven medical records reviewed for restraint use. The hospital census was 50.


Findings include:


On 05/17/16 hospital policy # H-PC 05-010 PRO, Physical Restraints and Seclusion, revised 08/2015, was reviewed. The policy documented non-violent behavior restraints should have at least daily assessments by a registered nurse of a patient's behavior, whether the unsafe situation is resolved and whether the criteria for discontinuing the restraints are met.

On 05/17/16 the medical record for Patient #23 was reviewed including restraint documentation from 05/06/16 through 05/14/16. The daily restraint monitoring form dated 05/09/16 lacked nursing documentation including notes of whether the unsafe situation was resolved or not, whether the restrains could be discontinued or not, a date and time of the assessment, and the assessing registered nurse's signature.

On 05/17/16 at 3:00 PM Staff C confirmed the daily restraint monitoring form was not documented as assessed by a registered nurse per hospital restraint policy.

Based on observation, staff interview and policy review it was determined the facility failed to ensure all medical records were protected against loss and/or destruction. This affected approximately one thousand medical records that were being stored in the medical records department. The active census was 50.


Findings include:

Review of the Confidentiality and Security of Patient Records Policy H-IM 05-001 with a release date of 08/2014 states the facility shall protect the contents of of every patient medical record against loss, destruction, tamper, and unauthorized use.


1. During a tour of the medical records department on 05/17/15 at 1:00 PM an observation was made of manilla folders filed by an indexing system on multiple sliding shelves within the department. These files were located directly below a sprinkler system and were found to be not protected from loss and/or destruction in the event the sprinkler system activated.

Staff B stated medical records are scanned into the electronic system and retained onsite for a minimum of two years, and then sent to an offsite warehouse where they are retained for an additional seven years. Staff B stated the medical records being retained on the shelves were from May 2014 and he/she could not verify that all were scanned into the electronic health records.

Staff A confirmed on 05/18/16 at 4:24 PM that approximately one thousand medical records from May 2014 through November 2015 were not scanned into the electronic health record to date. The medical records on the shelves were unprotected from loss and/or destruction in the event the sprinkler system activated.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

1. Please see K20 for findings related to the facility failing to maintain the fire rating of the vertical openings.
2. Please see K25 for findings related to the facility failing to ensure fire rated smoke barriers were maintained.
3. Please see K29 for findings related to the facility failing to ensure hazardous area protection is maintained.
4. Please see K46 for findings related to the facility failing to ensure battery opperated lighting is tested annually.
5. Please see K54 for the findings related to the facility failing to ensure fire system components are inspected per NFPA 72.
6. Please see K62 for the findings related to the facility failing to ensure the 5 year sprinkler system testing complied with NFPA 25.
7. Please K78 for the findings related to the facility failing to ensure documentation of the humidity levels after adjustments/repairs are made of HVAC system.

Based on observation, policy review, and staff interview the facility failed to ensure infection control surveillance for a safe and sanitary dietary department was implemented including food temperature monitoring, refrigerator and freezer temperature monitoring, dishwasher sanitation temperature monitoring, and labeling and dating stored food products. This had the potential to affect all patients who consumed foods prepared in the hospital's dietary department. The hospital census was 50.


Findings include:


On 05/18/16 hospital policy #HD: H-FNS 04-003, Food and Supply Storage, revised on 05/2015 was reviewed. The policy documented all food and non-food items and supplies used in food preparation shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption. The rationale was for proper storage of food and food service supplies to minimize the risk of food borne illness. The policy documented food products that are opened and not completely used or prepared at the facility and stored must be labeled as to the contents and the "use by" date.

On 05/18/16 the hospital protocol entitled; Food Storage Guidelines, dated 09/04/12 was reviewed. The guidelines identified food items with day and month storage times including dry storage, refrigerated storage,and freezer storage.

On 05/18/16 the hospitals ServSafe Manager Book 6.10; Cooking Requirements for Specific Types of Food, was reviewed. The requirements identified types of food and the minimum internal temperatures to ensure thorough cooking to prevent food borne illnesses.

On 05/18/16 at 10:30 AM a tour of the dietary department was conducted with the Dietary Department Head, Staff D. A review of the May 2016 food temperature logs revealed a lack of food temperature documentation on six of 18 days including 05/07/16, 05/08/16, 05/10/16, 05/09/16, 05/15/16, and 05/18/16. Staff D then provided food temperature logs for all of 2016 which revealed patterns of meals prepared without documented food temperatures. Staff D acknowledged and confirmed the pattern of undocumented food temperatures.

During the tour of the dietary department the Refrigeration and Freezer Temperature Log and the Dish Machine Temperature Log were reviewed. The Refrigeration and Freezer Temperature Log for May 2016 revealed a lack of daily documentation for the kitchen's seven refrigerators and three freezers. The Dish Machine Temperature- High Temperature Sanitation Log for May 2016 revealed a lack of daily documentation for the wash temperatures and the final rinse temperatures. Staff D confirmed the pattern of undocumented temperature logs for the kitchen's refrigerators, freezers, and dishwasher sanitation.

A review of food products that were opened and not completely used or prepared at the facility and stored either in dry storage or refrigerated storage revealed a lack of labeling with a "use by" date as required by hospital policy. Various kitchen staff were questioned as to expiration dates of the food products but confirmed the food products were not labeled with a "use by" date and therefore could not identify expiration dates. Staff D confirmed the pattern of not labeling food products with a "use by" date.