HospitalInspections.org

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based on record review and interview, the facility failed to ensure that nursing staff are performing required assessments of patients needs for 1 of 3 (#25) records reviewed. Findings include:

During review of patient #25's medical record on 06/09/2010 at 0800, document titled Restraint Order/Assessment Sheet for May 17,2010, 18th and 19th the area for the RN's signature who completed the form "Daily Comphrehensive Assessment by RN " was blank. The assessment document indicated "within baseline" with no evidence of a baseline being completed on the patient.

These findings were confirmed during an interview with the director of nurses on 06/09/2010 at 1430.

During record review on 06-09-10 at 1300 on closed charts (#14,#18 #20), it was identified there were incomplete physician orders that were awaiting signatures within the 48 hour time frame.


28267

Based on record review, interview, and policy review the facility failed to ensure that all verbal and telephone orders are dated , timed, and authenticated within 48 hours per the medical staff rules and regulations in 6 of 11 open patient's medical records (#1, #2, #3, #4, #5, and #6). Findings include:

On 6/7/10 at approximately 1130 during a review of the medical staff rules and regulations, section D "General Conduct of Care" reveals that all verbal and telephone orders shall be authenticated by the responsible practitioner within 48 hours.

On 6/7/10 between the hours of 1000 and 1130 during a tour of the facility, the following open medical records were reviewed and the following was found:
Medical record #2 had a telephone order taken on 6/3/10 at 11:45 am and no physician signature was noted.
Medical record #3 had a telephone order taken on 5/5/10 at 0820 and no physician signature was noted, a verbal order taken on 6/1/10 at 1103 and no physician signature present, and on 6/3/10 a telephone order was taken at 1600 and no physician order was noted.
Medical record #4 had three pages of telephone admission orders dated 5/30/10 that have not been authenticated to date.
Medical record #5 had a telephone order taken on 5/26/10 at 1005 and no physician signature was noted.
Medical record #6 had a physician order with no date and time.
On 6/8/10 at 0800 while reviewing patient #1's medical record the following was noted:
A telephone order was taken on 6/5/10 at 1900 and does not have a physician signature to authenticate the order.

All the above delinquencies were confirmed with the Director of Clinical Services at the time of the observations.

Based on interview, record review and policy review, the facility failed to ensure that the responsible person for daily management of dietary services provides oversite. Findings include:

During observation of the lunch meal preparation on 06/08/2010 from 1045-1300, the chicken on the lunch trays did not meet the temperature for safe food preparation as defined by the hospital "Serving= temperature" log that reads, serving temperatures should be above 150 degrees for hot food and colder than 60 degrees for cold food.

CNA #2 who was responsible for meals, stated that since 2 trays with chicken were tested and they both were below "160 "degrees then she would have to remove all the entrees with chicken and replace them with another entree that was in the refrigerator from the day before.

During the above time a review of the Serving=Temperature logs for May and June that were hanging on the refrigerator was completed and the documentation revealed : May 1 to May 12 for breakfast, lunch and dinner no temperatures (temps) on the hot or cold foods were completed. May 13th breakfast and dinner-no temps completed. May 15th and May 16th- no temps completed all 3 meals. May 22nd and may 23rd-no temps all 3 meals. June's documentation revealed no temps on breakfast for the 7th or 8th, no temps for the lunch cart on 7th and temps on the dinner cart June 4th-7th.
These observations were confirmed during an interview with the director of quality and the director of nurses on 06/08/2010 at 1400.

Further review of the policies and procedures for Select Specialty Hospital Food and Nutrition
1. Policy number 6.19 Subject : Food Handling reads "Keep food hot (140 F or above) or cold (45 F or below)"
2. Policy number 6.15 Subject: Food Preparation reads Policy : I General Guidelines 7. "Proper serving temperatures of food will be: Hot food: All hot food must be held at a temperature of 160 F or higher. Cold food: All cold food must be held at a temperature of 45 F or below."

The findings regarding the discrepancies of the 2 policies and the Serving=Temperature logs were discussed during an interview with the director of nurses on 06/08/2010 at 0900.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on June 8, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated June 8, 2010, for Life Safety Code.