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Based on observation, policy review, and staff interview, the hospital failed to maintain a sanitary kitchen. Findings include:

During the initial tour on 10/20/14 at 1:30 p.m. with staff member C, dietary manager (DM), the kitchen appliances were coated with food debris, dust, and grease. The following were noted areas of concern:

Sanitary concerns
-The deep fryer cooking surface, back splash, and heat lamp were coated with grease, food debris, and dust. The doors under the fryer were opened and the mechanical components were coated with grease and food debris.
-The sprinkler head over the cooking surface of the broiler was coated with grease, dust, and food debris.
- The inside of the broiler was coated with food debris, dust and grease. There were long vertical strands of food debris, dust and grease hanging from the cooking element. The side of the broiler unit was covered with dried batter and grease.
-The grease trap on the broiler was full.
-The convection oven's outside surface and handles were coated with grease, dust and food debris. The internal area of the convection oven was black and coated with grease and food debris. The inside of the glass doors were coated with grease.
-The thermometer for the oven was attached to the outside of the oven, was broken, and was covered with grease and food debris.
-The outer surface and the handles of the toaster were coated with grease, dust and food debris. The inner rack of the toaster was black and had a large accumulation of food debris.
-There was a pressure gage next to the deep fryer with an accumulation of dust and grease.
-There was a cart next to the prep table which contained two bottles of cleaner, a toilet brush, funnel, and oven mitt coated in grease and dust. The shelf of the cart was coated with dust and grease.
-The rack above the food prep area had pots, pans, and pitchers hanging from hooks. The pitchers, pots, and pans were hung so dust could accumulate in the cookware.
-The Teflon coating on multiple fry pans was missing.
-The ice scoop was left in the ice maker with the lid open on 10/21/14.

The dietary manager stated the appliances were used daily to prepare food for the patients. When the dietary manager was asked when the appliances were to be cleaned, he stated every three months. He further stated the appliances were dirty but it was not time to clean them.

On 10/21/14 from 10:30 a.m. to 11:30 a.m., the food preparation area was observed and the following were noted concerns:

Hair net usage
-The kitchen staff members H, I and K did not restrain their hair. Facial hair was not restrained with a facial hair net.

Dating food items
-Kitchen staff members were not dating prepared food items correctly. There was a container of tuna salad dated 10/16/14. Staff member I, kitchen worker, stated all food items were to be thrown out after three days from the prep date. The tuna salad should have been thrown away on 10/19/14. The surveyor observed the date of 10/16/14 on the tuna salad was changed to 10/21/14. The old tuna salad and new tuna salad were blended together. Staff member I stated new prepared tuna salad was added to the container.
-There were two containers of sliced cheese. The containers were marked with a date of 9/21/14. Staff member I stated she just looked for mold on the cheese to tell her when to throw away the cheese.
-Egg salad had a date of 10/12/14 and was not discarded on 10/15/14. Staff member H, kitchen staff member, stated new egg salad was added and the date changed to 10/21/14.
-Ham slices were dated 10/8/14 and should have been discarded on 10/11/14 but a new date of 10/21/14 was placed on the container. Staff member H and I both stated there was no reason to waste the food and new stickers dated 10/21/14 were placed on the containers.

Cooler
On 10/21/14 at 11:00 a.m., two large beef roasts were observed in the cooler. The beef roasts were cooked on 10/20/14 and placed in the cooler to cool down. Staff member H stated the beef roasts were put in the cooler overnight and the cooling temperature was not monitored.

Hand hygiene
On 10/21/14 at 10:30 a.m., kitchen staff members H, I, and K were observed not to wash or sanitize their hands prior to placing gloves on their hands. These kitchen staff members were observed with gloves on their hands touching many surfaces including dirty dishes during the food preparation. Staff member I had gloves on preparing food for patients. Staff member I would leave the prep area, go into the cooler, retrieve a food item, and continue to prepare the food. Staff member I was observed to handle dirty dishes with the same gloves on. Staff member K was observed with gloves on entering the dirty dish area, cleaning dishes, and then retrieving clean dishes for the patients. Staff member K was not observed to change her gloves prior to returning to the food prep area. Kitchen staff members H, I, and K kept the same gloves on to prepare food for patients. Staff member H was observed with gloves on using the ice scoop to fill containers with ice. Staff member H, with the same gloves, left the kitchen and prepped the salad bar.

In an interview on 10/21/14 at 11:30 a.m., staff member A, CEO, stated the kitchen manager was new to his job. She further stated that kitchen staff members all had worked in the kitchen for a long period of time and had been trained on what was acceptable. The kitchen staff were provided training yearly.

A review of the hospital's Food Safety Sanitation policy showed food safety and sanitation practices are followed to ensure infection control. The policy further showed dietary staff were to:
-wear hair nets;
-use good hand washing techniques;
-food which was prepared for service was to be discarded after two days;
-equipment and work areas were to be clean; and
-toxic cleaning products should be locked up.

Review of the hospital's Performance Improvement Plan policy showed the kitchen department was not captured.

During an interview on 10/21/14 at 4:30 a.m., staff member J, regional food director, stated he was aware of the condition of the kitchen and would be training the entire kitchen staff members on the identified areas of concern.

On 10/22/14 at 7:30 a.m., a written statement of training held for all kitchen staff members on 10/21/14 was provided by the regional food director.

During an interview on 10/23/14 at 8:40 a.m., staff member B, Area Director of Compliance, stated that the kitchen was not part of the infection control program.

Based on record review and staff interview, the hospital failed to ensure restraints were not used on an as needed basis (PRN) for 1 (#8) of 16 sampled patients. Findings include:

Patient #8 was admitted to the hospital on 8/11/14 with diagnoses including acute respiratory failure requiring mechanical ventilation, coronary artery disease with bypass grafting, atrial fibrillation, deep venous thrombosis, type II diabetes, hypertension, and stage IV sacral ulcer.

Review of patient #8's medical record showed bilateral wrist restraints were implemented on 8/28/14 to prevent dislodgement of a tracheal tube for airway management. The medical record showed the patient remained in bilateral wrist restraints. On 9/10/14 at 4:00 p.m., the restraint flow sheet showed the patient was released from wrist restraints. At 8:30 p.m. on 9/10/14, the wrist restraints were, again, placed on patient #8 by a nurse. An order was not obtained for the reapplication of the restraint, which indicated the restraints were used PRN.

On 9/26/14 at 2:00 p.m., bilateral wrist restraints were implemented. A new order was not obtained for the reapplication of the restraints, which had been discontinued on 9/24/14 at 6:00 p.m. The application of the restraint was PRN by the nurse.

During an interview on 10/23/14 at 8:09 a.m., staff member B, area director of compliance, stated there should have been a new order for the restraints, and stated this would be a PRN use of a restraint.

A review of the hospital policy on restraints read,"...after the patient is released from restraint, a new order must be obtained for each additional encounter...", and "...if the restraint was applied by a registered nurse without a physician order, an order will be obtained as soon as possible, but within 30 minutes of restraint application. Following a trial release, if a patient has been released and then begins to exhibit the same behavior that initiated the order, a new order is required to initiate the restraint..." and "...a restraint order may NEVER be written as a PRN order..."

Based on record review and staff interview, the hospital failed to notify the attending physician of the release of the restraint and reapplication of the restraint for 1 (#8) of 16 sampled patients. Findings include:

Patient #8 was admitted to the hospital on 8/11/14 with diagnoses including acute respiratory failure requiring mechanical ventilation, coronary artery disease with bypass grafting, atrial fibrillation, deep venous thrombosis, type II diabetes, hypertension, and stage IV sacral ulcer.

Review of the medical record reflected on 9/10/14, at 6:50 a.m., the patient was released from wrist restraints at 4:00 p.m. At 8:30 p.m., on 9/10/14, the wrist restraints were, again, placed on patient #8. The medical record lacked a new order for the implementation of wrist restraints on 9/10/14, at 8:30 p.m.

During an interview on 10/23/14 at 8:09 a.m., staff member B, area director of compliance, stated the physician should have been contacted to obtain a new order for the use of the restraints.

Review of the hospital policy on restraints indicated that, "...The physician must be notified of the use of restraint as soon as possible after application, but within 30 minutes of its application..."

Based on record review the hospital failed to ensure staff members followed hospital policy regarding contacting the physician when a restraint was renewed for 1 (#8) of 16 sampled patients. Findings include:

Patient #8 was admitted to the hospital on 8/11/14 with diagnoses including acute respiratory failure requiring mechanical ventilation, coronary artery disease with bypass grafting, atrial fibrillation, deep venous thrombosis, type II diabetes, hypertension, and stage IV sacral ulcer.

Review of patient #8's medical record showed bilateral wrist restraints were implemented on 8/28/14 to prevent dislodgement of a tracheal tube for airway management.

Review of the renewal orders for 9/1/14 through 9/5/14 showed five days of renewal orders for bilateral wrist restraints for patient #8. The orders were not signed daily by the physician. Review of the daily progress notes for 9/1/14 through 9/5/14 showed a lack of documentation that the physician had addressed the restraint use for the patient.

Review of the renewal orders for 9/13/14 through 9/15/14 indicated three days of renewal orders for bilateral wrist restraints for patient #8. The orders were not signed daily by the physician. Review of the daily progress notes for 9/13/14 through 9/15/14 showed a lack of documentation that the physician had addressed the restraint use for the patient.

Review of the hospital policy on restraints indicated that, "...the physician/L.I.P. must do a face-to-face reassessment of the patient to determine the need for restraints at least every calendar day..." and components of orders are "...clinical justification, restraint type, time limited (maximum duration one calendar day), date of order, physician signature, located in the physician restraint orders (each day of restraint use)..."

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Based on record review, the facility failed to ensure that medical records were complete/accurate with a time, date, and signature for 1 (#8) of 16 sampled patients. Findings include:

Review of the medical record for patient #8 showed the following restraint orders were incomplete:
-8/28/14: location of restraint;
-9/7/14: order indicated restraints to both lower extremities. Documentation indicated the patient had bilateral wrist restraints;
-9/7/14: not timed under the restraint criteria section;
-9/8/14: order indicated restraints to both lower extremities. Documentation indicated the patient had bilateral wrist restraints;
-9/9/14: order indicated restraints to both lower extremities. Documentation indicated the patient had bilateral wrist restraints;
-9/18/14: order indicated restraints to both upper and lower extremities. Documentation indicated the patient had bilateral wrist restraints;
-9/23/14: order indicated restraint to both upper and lower extremities. Documentation indicated the patient had bilateral wrist restraints. The order was not timed under the restraint criteria section;
-9/24/14: order indicated restraints to both upper and lower extremities. Documentation indicated the patient had bilateral wrist restraints. The order was not timed under the restraint criteria section;
9/27/14: order indicated restraints to both upper and lower extremities. Documentation indicated the patient had bilateral wrist restraints. The order was not timed under the restraint criteria section.

Review of the facility policy on restraint orders indicated the components of restraint orders are "...clinical justification, restraint type, time limited (maximum duration one calendar day), date of order, and physician signature..."

Based on record review the hospital failed to ensure all orders were authenticated with a date, time and signature for 9 (#s 2, 3, 4, 5, 6, 8, 12, 13, and 16) of 16 records reviewed. Findings include:

1. Review of patient #2's medical record reflected a physician's order written on 10/12/14 that was not dated or timed. The practitioner failed to complete the DVT Prophylaxis Physician Order and Guidelines form. The activity level, contraindication to anticoagulant therapy, DVT risk assessment, and recommended prophylactic based on the level of risks and benefits were blank. The wound care orders, dated 10/9/14 and 10/21/14, showed the practitioner did not date or time the orders.

2. Review of patient #3's medical record reflected the practitioner failed to complete the DVT Prophylaxis Physician Order and Guidelines form. The section DVT risk assessment and recommended prophylactic based on the level of risks and benefits was blank. Verbal orders, dated 10/6/14 and 10/12/14, were not authenticated with a signature, date, or time.

3. Review of patient #4's medical record reflected the practitioner failed to complete the DVT Prophylaxis Physician Order and Guidelines form. The activity level, contraindication to anticoagulant therapy, DVT risk assessment, and recommended prophylactic based on the level of risks and benefits sections were blank. A telephone order dated 10/15/14 was not authenticated with a signature, date, or time. Verbal orders, dated 10/11/14 and 10/14/14, were not authenticated with a signature, date, or time. The admission orders and the admission medication reconciliation orders, dated 10/11/14, were not timed.

4. Review of patient #5's medical record reflected a verbal order on 10/2/14 was not authenticated with a date, time, or signature.

5. Review of patient #6's medical record reflected the practitioner failed to complete the DVT Prophylaxis Physician Order and Guidelines form. The activity level, contraindication to anticoagulant therapy, DVT risk assessment, and recommended prophylactic based on the level of risks and benefits sections were blank. A telephone order, dated 9/26/14, was authenticated 18 days after the order was written. An order, dated 10/11/14 to discontinue two medications, was not authenticated with a date, time, or signature.

6. Review of patient #12's medical record reflected a telephone order dated 10/20/14 was not authenticated with a date, time, and signature. The practitioner failed to complete the DVT Prophylaxis Physician Order and Guidelines form. The activity level, contraindication to anticoagulant therapy, DVT risk assessment, and recommended prophylactic based on the level of risks and benefits sections were blank.

7. Review of patient #13's medical record reflected the practitioner failed to complete the DVT Prophylaxis Physician Order and Guidelines form. The activity level, contraindication to anticoagulant therapy, DVT risk assessment, and recommended prophylactic based on the level of risks and benefits sections were blank. The practitioner did not time the order.

8. Review of patient #16's medical record reflected the practitioner failed to complete the DVT Prophylaxis Physician Order and Guidelines form. The activity level, contraindication to anticoagulant therapy, DVT risk assessment, and recommended prophylactic based on the level of risks and benefits sections were blank.

Contained in each medical record was a form which showed all providers must sign, time, date verbal orders or telephone orders within 48 hours.

Review of the hospital's Medication Orders policy showed orders not completed were not to be accepted and blanket order to resume previous medication was prohibited.

9. Review of patient #8s medical record showed following dates did not contain an order for restraint renewal/application:

-9/10/14 there were not orders for the implementation of restraints;
-9/13/14 the orders were not signed by the physician;
-9/14/14 the orders were not signed by the physician;
-9/15/14 the orders were not signed by the physician; and
-9/26/14 there was no order for implementation of restraints.

Review of the facility policy for restraint orders indicated that the components were to include "...clinical justification, restraint type, time limited (maximum duration one calendar day), date of order, and physician signature (each day of restraint use)..."

Based on record review the hospital failed to ensure informed consents for procedures and treatments were properly executed for 2 (#'s 3 and 8) of 16 medical records reviewed. Findings include:

1. Review of patient #3's medical record showed a consent for an invasive procedure or specialized treatment dated 10/6/14 which did not contain a patient signature or the patient's representative's signature.


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2. Review of patient #8's medical record showed a consent for blood transfusion dated 9/7/14 which did not contain a patient signature or a date or time of verbal consent by the patient's representative.

Based on observation and staff interview, the hospital failed to ensure equipment was maintained in the kitchen. Findings include:


During the initial tour of the kitchen on 10/20/14 at 1:30 p.m., with staff member C, DM, the freezer had noticeable ice and condensation buildup on the ceiling and on boxes of food. Staff member C stated the ice accumulated when the freezer was defrosting. Staff member C stated he did not inform the maintenance director of the ice buildup.

In interview on 10/22/14 at 10:30 a.m., staff member G, maintenance director, stated he did not know there was a problem with the freezer until now. Staff member G stated he had arranged for a repair worker to come to the hospital and fix the problem.