HospitalInspections.org

Based on review of Governing Body Bylaws and interview the facility failed to recognize and adopt bylaws stating only the Governing Body has the authority to grant privileges to the Medical Staff. This deficient practice affects all patients in the facility. The facility census was 45.

Findings included:

1. Review of the Medical Staff Bylaws, on 11/02/11, showed the following:
C. TEMPORARY PRIVILEGES
Temporary Privileges are only granted by the Chief Executive Officer (CEO), or his designee.

2. Review of the Governing Body Bylaws, on 11/02/11, showed the following:
3.2 COMPOSITION
c. The Administrator, who shall serve as an ex officio, non-voting member of the Board of Managers.

The governing body bylaws failed to recognize that they must be responsible for granting medical staff privileges.

3. Review of physician credentialing files, on 11/03/11, showed the following:
- Staff Z, Physician, was granted temporary privileges from 12/10/09 to 01/10/10 and again from 01/11/10 to 02/11/11 by Staff CC, CEO, while awaiting Board approval.
- Staff AA, Physician, was granted temporary privileges from 01/02/11 to 02/04/11 by Staff CC, CEO, while awaiting Board approval.

4. During an interview on 11/03/11 at 2:15 PM, Staff CC, CEO, stated he/she did grant temporary privileges to physicians while awaiting the Board of Managers approval.

Based on observation, record review, interviews and policy review the facility failed to:
- Ensure appropriate supervision of patient care by not documenting accurate skin/wound assessments and not obtaining physician's orders for treatment for one patient (#8) of four patients reviewed;
- Ensure staff followed the facility policy for daily patient assessments and documentation of the assessment for one patient (#5) of four patients reviewed. The facility census was 45.

Finding included:

1. Record review of the facility's policy titled, "Assessment and Reassessment - Nursing" dated 01/09/08, showed the following direction:
- A Registered Nurse completes an assessment of each patient admitted and reassesses the patient as needed in order to determine the appropriate care, treatment and services to meet the need of the patient.
-A complete initial nursing assessment shall include physical, psychological, pain management, functional, visual and hearing, nutritional, spiritual needs, social status, including social barriers such as language or culture, communication, educational and discharge planning.
-Each patient is re-assessed by a Registered Nurse daily, or more often as needed.
-All assessment and reassessment information collected shall be recorded on the discipline specific assessment and reassessment forms and shall be available to all those disciplines involved in the care of the patient.

2. Record review of the facility's undated policy titled, "Physician Orders", showed that the patient can expect care to be delivered accurately, appropriately and in accordance with physician orders.

3. Record review of the facility's clinical exceptions policy showed that Lippincott Williams & Wilkins was the official facility reference guide for clinical procedures regarding wound care, effective 09/14/11. The wound implementation procedure directed nursing to verify the doctor's order for specific wound care and instructions. It also directed nursing to document the date, time, type of wound management procedure; amount of soiled dressing and packing removed; wound appearance (size, condition of margins, presence of necrotic tissue) and odor (if present); type, color, consistency and amount of drainage (for each wound); presence and location of drains; additional procedures, such as irrigation, packing, or application of a topical medication; type and amount of new dressing or pouch applied; the patient's tolerance of the procedure and any patient teaching provided.

4. Review of Patient #8's history and physical showed she/he was admitted to the facility on 10/27/11 for inpatient rehabilitation following an automobile accident that resulted in a right ankle fracture which was surgically repaired on 10/24/11. The physician's physical examination dated 10/28/11 showed the patient had a significant amount of swelling on the left, bruising and abrasions that were evident on the upper thighs. The physician's intervention plan included skin integrity, "we will do skin assessments every shift and monitor wounds for drainage". (Note: there was no documented description of the wounds noted by the physician.) Record review showed there was no physician's order found for Patient #8's wound care as of 11/02/11.

Review of the patient's nursing admission assessment flow sheet dated 10/27/11 showed the following wound documentation:
Location - left inner thigh
Type of wound - abrasion
Size (length, width and depth) - blank
Wound base (pink, red, slough, eschar [eschar is dead tissue that falls off from healthy skin]) - blank
Drainage (amount, color) - blank
Odor - blank
Pain - blank
Treatment - Mepilex (a self-adherent soft silicone foam dressing that absorbs exudates (fluid), maintains a moist wound environment, supporting debridement) X1

Review of the patient's nursing assessment flow sheet dated 10/31/11 showed the following wound documentation:
Location - left inner thigh
Type of wound - blank
Size (length, width and depth) - blank
Wound base (pink, red, slough, eschar) - scabbed areas
Drainage (amount, color) - N
Odor - N
Pain - N
Treatment - Mepilex

Observation on 11/02/11 at approximately 11:20 AM showed Staff FF, Registered Nurse (RN) performed a head to toe skin assessment and showed the following wounds to the patient's lower left leg:
- a small pea size (approximately 0.5 centimeter) puncture type wound to the left inner ankle that was open to air (no drainage and no redness noted);
- a Mepilex dressing covered the patient's inner left thigh area above the knee. Staff FF removed the dressing and the skin assessment showed three skin abrasions (each approximately 1 inch long and ¾ inch wide, with slight redness surrounding the abrasions) and two small puncture type wounds (one was approximately one centimeter round and the other two centimeters round both scabbed over) with slight redness surrounding the wounds. During the assessment, the patient stated that the area was very tender to touch. After the dressing was removed, Staff FF cleansed the area with saline wound cleanser and reapplied a Mepilex dressing.

During an interview on 11/02/11 at 1:20 PM, Staff FF stated that morning was the first time they had seen the patient's wounds and stated, "I didn't know what they looked like". Staff FF stated that she/he was given report from the previous nurse that stated they were using Mepilex dressing to the left upper thigh and changing the dressing every five days or as needed. Staff FF stated that she/he was told the wounds were getting better but stated that there was no documentation in the patient's record of actual measurements or descriptions of the wounds. Staff FF stated, "Report of the wounds and treatment was just by word of mouth". Staff FF also confirmed there were no physician's orders for treatment.

During an interview on 11/02/11 at 1:35 PM, Staff Y, RN Clinical Supervisor confirmed there was no physician's order for skin treatment or wound care for Patient #8 and stated that nursing staff were expected to obtain orders and/or clarifications as needed prior to wound care and were also expected to document accurate wound assessments on the nursing flow sheets to include measurements and descriptions.

During an interview on 11/02/11 at approximately 2:00 PM, Staff O RN Staff/Wound Nurse stated that he/she tried to conduct weekly rounds and document assessments/measurements on patients with more severe wounds and therefore, had not seen Patient #8. Staff O stated that he/she tried to communicate with the staff nurses at least weekly and relied on them to let him/her know if he/she was needed. Staff O stated that there was no written procedure for him/her to follow.

5. During an interview on 11/03/11 at approximately 2:25 PM, Staff H, Executive Director and Quality Assurance stated that the facility's official procedure reference guide for wound care management (other than for pressure ulcers) was Lippincott Williams & Wilkins clinical policies. Staff H provided a printed copy as reference for wound dressing application, revised July 09, 2011 which showed implementation included, "Verify the doctor's order for specific wound care and instructions". She stated that they are formalizing a wound care team that will make rounds weekly and were scheduled to start in October but was canceled. She stated that this would be primarily for problem wounds and they would still rely on the staff nurses to obtain physician's orders, assess and document appropriately.


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6. Record review of Patient #5's history & physical (H&P) showed the patient was admitted to the facility on 10/31/11 for rehabilitation after being struck by a car with resulting brain injury. The patient developed a sacral decubitus (sore at the base of the spine)and a scalp wound in the occipital region (back of the head).

The initial Nursing Assessment dated 10/31/11 showed the patient had sutures of the head. The RN failed to document the characteristics of the wound such as location of the sutures, length, width, color or drainage. Further review of the medical record showed no documentation of the sacral or occipital ulceration.

The daily Nursing Assessment dated 11/01/11 showed the patient had "scabs"; not sutures of the head. The RN failed to document the characteristics of the "scabs" such as location, size (length, width and depth), color or drainage. No documentation was found which stated the "sutures" had been removed.

Review of the Admission orders dated 10/31/11 showed the patient was to have Eucern cream (a moisturizing cream) applied to the sacrum twice a day and as needed.

Observation of Patient #5 on 11/02/11 at 2:35 PM showed a healed incision on the left side of his/her head with no sutures of the head. Observation revealed two scabbed areas on the back of the head.

During an interview on 11/03/11 at 2:00 PM Staff F, Director of Nursing, after review of Patient #5's medical record, stated that he/she saw no description of the wound besides "sutures" on the initial nursing assessment and no location, drainage, color size (length, width and depth). Staff F stated that the nursing assessment of 11/01/11 documented "scabs" without a description of location, drainage, color, size (length, width and depth). Staff F stated that the wound assessments did not address the sacral or occipital wounds. He/she stated that all wounds should be assessed daily with complete descriptions.



29047

Based on observation, interview, record review, and policy review, the facility failed to ensure safe medication administration by not following physician's orders and/or obtaining clarification orders for three (#1, #10, and #14) of four patient medication passes observed. This had the potential to affect any patient in the facility receiving medications. The facility census was 45.

Findings included:

1. Record review of the facility policy titled, "Medication Administration" dated 09/14/11 showed that failure to administer the correct dose of medication at the correct time was considered a medication variance (error).

2. Record review of Patient #14's current medical record showed an order for Synthroid (thyroid hormone) 25 micrograms (mcg) to be administered daily. The order was written on 11/01/11 at 11:30 AM. Review of the Medication Administration Record (MAR) showed that the patient was administered the medication on 11/01/11 at 9:00 PM, but was not scheduled to be given another dose until 11/03/11 at 6:00 AM, 35 hours later.

During an interview on 11/02/11 at 9:25 AM, Staff G, RN, stated that Patient #14 should have received the first dose of Synthroid immediately after the order was written on 11/01/11 at 11:30 AM. The next dose should have been given on 11/02/11 at 6:00 AM, and again on 11/03/11 at 6:00 AM so that the dose was given daily as written.

3. Record review of the facility policy titled, "Definition of Stat, Now, and ASAP" dated 10/21/10, showed "Now" was to be treated as a synonym (with the same meaning) for STAT and that STAT meant "at once".

Record review on 11/02/11 at 1:00 PM of Patient #1's current medical record, showed an order for one bottle of Magnesium Citrate (laxative) to be administered now. The order was written on 11/02/11 at 11:29 AM, but review of the patient's MAR showed the laxative had not yet been administered.

During an interview on 11/02/11 at 1:05 PM, Staff HH stated that he/she just saw the physician's order for Patient #1's laxative and could give it now.

Observation on 11/02/11 at 1:25 PM showed that Staff HH entered Patient #1's room to administer the laxative, almost two hours after the "now" order was written.


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4. Record review of the facility's Bylaws showed physician orders which were improperly written will not be carried out until rewritten or understood by the authorized person functioning with their sphere of competence.

Record review of the facility's policy titled, "Unclear or Incomplete Medication Orders" revised 06/01/07 showed that medication orders that were unclear would be clarified with the prescriber before the medication was dispensed or administered and that the medication clarification would be documented in the patient's permanent medical record. A nurse or pharmacist should contact the prescriber to clarify questionable medication orders prior to dispensing or administering the drug.

5. Record review of the facility's policy titled, "Medication Administration" dated 09/14/11, showed that Registered Nurses and Licensed Practical Nurses administer and document medications by utilizing the six rights of medication administration; right patient, right medication, right dose, right time, right route and right documentation. Prior to medication administration, the nurse compares the medication to be administered to the order/MAR (medication administration record) and compares medication to the MAR at bedside before administration.

6. Observation on 11/02/11 at 8:45 AM showed Staff EE, Licensed Practical Nurse (LPN) gave the following medications to Patient #10:
Colchicine (medication to prevent gout) 0.6 milligrams (mg) one tablet by mouth (PO); and
Cymbalta (an antidepressant medication also used for fibromyalgia treatment) 20 mg one tablet PO.

Review of the patient's physician order showed 0.4 mg of Colchicine was ordered instead of the 0.6 mg that was given. Review of the patient's MAR showed that 0.4 mg was documented as substituted by pharmacy. However, there was no physician clarification order or notification to the physician found in the record for the substitution. Also, the review showed the physician ordered Cymbalta 20 mg at bedtime but it was observed as given at 8:45 AM and Staff EE did not document (initial) on the MAR that it was given at all (the pre-printed time to administer at bedtime was left on the MAR to give that night).

7. Observation on 11/02/11 at 8:50 AM showed that Staff EE took Patient #10's blood pressure which measured 139/56 and heart rate of 74 beats per minute. Staff EE gave Metoprolol (medication to treat heart failure and high blood pressure) 100 mg one tablet PO to the patient and held (did not give) Diltiazem CD (medication to treat heart failure and high blood pressure) 120 mg capsule PO.

Review of the patient's physician's order and MAR showed to hold the Metoprolol and Diltiazem CD for systolic blood pressure less than 100 or heart rate less than 60 (the patient's systolic blood pressure was 139 and their heart rate was 74). Staff EE documented that the Metoprolol was given and the Diltiazem was held but did not document the rationale for holding the medication.

During an interview on 11/02/11 at 1:25 PM, Staff EE, LPN stated that pharmacy substituted the 0.6 mg Colchicine for the 0.4 mg that was ordered and stated that she/he would call the physician for a clarification order. Staff EE also stated that she/he would get a clarification order to change the Cymbalta to morning because the patient wanted to take it in the morning instead of bedtime. However, when questioned, she/he did not provide an answer for not documenting (initialing) that she/he gave the medication and also that she/he left the preprinted time on the MAR to give that night. Staff EE stated that she/he held the one blood pressure medication because, "I didn't want the patient's pressure to bottom out".

During an interview on 11/03/11 at 1:35 PM, Staff Y, RN Clinical Supervisor confirmed that the above physician orders for medications were incorrect as shown and stated that the nurse was expected to obtain clarification orders prior to medication administration. Staff Y also confirmed that the patient's blood pressure and heart rate was not below the parameters listed and therefore, the medication should not have been held.

8. During an interview on 11/02/11 at 2:05 PM, Staff GG, Director of Pharmacy and Registered Pharmacist (RPh) stated the following:
-Patient #10 's ordered Colchicine dose of 0.4 milligrams (mg) was substituted by a pharmacist with a 0.6 mg dose on 11/01/11, without entering a clarified physician order in the patient's chart;
-"I know these doctors well enough to know what they mean" and stated that he/she would not contact the physician for clarification of the dose because Colchicine only came in 0.6 mg doses;
-The physician had written in the patient's chart between the time the physician ordered the Colchicine 0.4 mg and the time the order was substituted by the pharmacist, but the physician was not asked to clarify the order;
-We should try to clarify a physician's order with the physician before substituting it for another dose.

During an interview on 11/03/11 at 12:25 PM, Staff AA, Physician and Facility Medical Director stated that a pharmacist should not change a medication dosage in question without clarification from the physician.

Based on record review and interview, the facility failed to obtain accurate physician's orders to ensure the safe administration of blood transfusions in one (#8) of two patients receiving blood during the survey. The facility census was 45.

Findings included:

1. Record review of the facility's policy titled, "Blood and Blood Product Transfusion" revised 10/26/10, showed that blood products would be administered safely and effectively to the intended recipient. All preparations for transfusion are made before any blood product is obtained from the Blood Bank which included "a physician's order for transfusion must be on the patient's chart". The procedure showed that completing the Blood Bank Order - Transfusion Request Form included completing the blood product section of the requisition form: "Indicate the number of the appropriate blood product desired (PRBC [packed red blood cells], platelets, FFP [fresh frozen plasma], . . .).

2. Review of Patient #8's history and physical showed she/he was admitted to the facility on 10/27/11 for inpatient rehabilitation following an automobile accident that resulted in a right ankle fracture which was surgically repaired on 10/24/11. The patient's physician wrote an order on 10/31/11 at 11:00 AM for "blood transfusion 2 units". Review of the nurse's notes and blood transfusion flow sheet showed that the patient received two units of "packed red blood cells without difficulty".

During an interview on 11/02/11 at 1:35 PM, Staff Y, Registered Nurse (RN) Clinical Supervisor confirmed that the physician's order for "blood transfusion two units" was not a specific order. Staff Y stated that the procedure was that once a physician's order was received, the nurse should fill out the blood bank transfusion request form and fax the form to the blood bank to be delivered. Staff Y stated that the nurse would mark the specific blood product on the request form, per physician's order, to include the following blood product choices: packed red blood cells, leukoreduced red blood cells, autologous blood, platelets, Rh immune globulin, fresh frozen plasma and/or cryoprecipitate. Staff Y stated, "The nurse should have called the physician and got a clarification order but the nurse was probably just used to packed red blood cells being ordered."

Based on record review and Medical Staff Rules and Regulations review, the facility failed to ensure all entries in the medical record were complete for three patients (#3, #4 and #6) of six records reviewed. The facility census was 45.

Findings included:

1. Record review of the facility Medical Staff Rules, Regulations and Policies, Article XIII, revised 03/11 showed the following direction:
-Section F Medical Records, paragraph #12 All clinical entries in the patient's medical record including dictation and transcription shall be accurately dated, timed and authenticated.

2. Record review of Patient #3's current medical record on 11/01/11 showed a History & Physical and Post Admission Physician Evaluation dictated 10/28/11 was not signed, dated or timed by the physician.

3. Record review of Patient #4's current medical record on 11/01/11 showed the following:
-An order written by the physician for Adult Diabetic Order Sheet did not have a complete date (no year) or complete time indicating AM or PM.
-An Admission order written by the physician did not have a complete date (no year) or complete time indicating AM or PM.
-A telephone order for a chest x-ray taken by a Registered Nurse (RN) did not include the complete date (no year).
-An order written by the physician for cervical range of motion (ROM) for occupational therapy (OT) did not have a complete date (no year) and did not have a complete time indicating AM or PM.
-An order for Ester (a vitamin) left hand/arm for bio feedback did not have a complete date (no year) or complete time indicating AM or PM.
-A History and Physical dictated 10/20/11 did not have a date or time with the physician's signature.

4. Record review of Patient #6's current medical record on 11/01/11 showed the following:
-An order written by the physician for x-ray of the left shoulder did not have a complete date (no year) or a complete time indicating AM or PM.
-An order written by the physician for a consult to psychology did not have a complete date (no year) or a complete time indicating AM or PM.

Based on interview and record review the facility failed to ensure orders, including verbal orders were dated, timed and signed for six (Patient #10, #14, #18, #20, #21 and #31) of six current patients and two (Patient #25 and #26) of six discharged patients medical records reviewed for dated, timed, and signed physician's orders. The facility census was 45.

Findings included:

1. Record review of the facility Medical Staff Rules, Regulations and Policies, Article XIII, revised 03/11 showed the following direction:
-Section F Medical Records, paragraph #12 All clinical entries in the patient's medical record including dictation and transcription shall be accurately dated, timed and authenticated.
-Section F Medical Records, paragraph #21 A practitioner's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, dated and signed by the practitioner.
-Section H Verbal and Telephone Orders, paragraph #1 Verbal orders must be authenticated by the ordering practitioner within twenty-four (24) hours.

2. During an interview on 11/03/11 at 8:32 AM Staff DD, Manager of Health Information Management (HIM) stated all orders should be dated, timed and signed by the physician and all verbal/telephone orders should be dated, timed and signed by the physician within twenty-four hours as stated in the Medical Staff Rules and Regulations.

3. Record review on 11/03/11 of current Patient #14's physician's orders showed the following:
- An undated, untimed verbal order for admission to the Comprehensive (COMP) unit.
- A physician's telephone order received on 10/31/11 at 9:00 AM and a physician's telephone order received on 10/29/11 at 10:30 PM, were signed by the physician, but were not dated or timed.

4. Record review on 11/02/11of current Patient #18's physician's orders showed an undated, untimed order for admission.

5. Record review on 11/02/11of current Patient #20's physician's orders showed an undated, untimed verbal order for admission signed without a date and time.

6. Record review on 11/02/11of current Patient #21's physician's orders showed an untimed verbal order dated 11/24/11 for Eucerin cream to dry skin.

7. Record review on 11/03/11of discharged Patient #25's physician's orders showed the following:
-An untimed order for admission to the COMP unit dated 07/19/11.
-An untimed order for PMR (physical medicine and rehab) admission dated 07/19/11.
-An untimed order dated 07/24/11.
-An undated, untimed telephone order for Zofran {anti nausea medication}.

8. Record review on 11/03/11of discharged Patient #26's physician's orders showed an order dated 08/05/11 signed without a date and time of the signature.


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9. Review of Patient #10's medical record showed the following orders:
A physician's order (no date or time of entry, but was written sometime between an order entry dated 10/30/11 at 11:00 AM and an order entry dated 10/30/11 at 2:50 PM) for CBC (complete blood count) and Mag Phos (magnesium phosphate) in AM (morning.) The order was not signed, dated and/or timed by the physician as of 11/02/11 at 2:35 PM.

A telephone order dated 10/30/11 at 2:50 PM by the Registered Nurse to discontinue Cipro (an antibiotic) and ordered Amoxicillin (an antibiotic) 500 milligrams (mg) by mouth (PO) every 12 hours. The order had not been signed, dated and/or timed by the physician as of 11/02/11 at 2:35 PM.

During an interview on 11/02/11 at approximately 3:00 PM, Staff Y Registered Nurse (RN) Clinical Supervisor confirmed the above orders were not signed, dated and/or timed by the physician.


29047

12. Record review on 11/02/11 at 9:52 AM of Patient #31 current medical record, showed physician's telephone orders received on 10/28/11 and 10/31/11 were not signed, dated, or timed.
















27727

10. Record review of Patient #3's current medical record on 11/01/11 showed the following:
-A 10/27/11 telephone order for Medication Administration Record (MAR) Reconciliation From Referring Facility did not have a date and time of the physicians signature.
-A 10/27/11 telephone Admission Order did not have a date and time of the physicians signature.
-A 10/28/11 telephone order to repeat chest x-ray tomorrow was not signed, dated or timed by the physician.

11. Record review of Patient #4's current medical record on 11/01/11 showed a telephone order for Euceren cream to dry skin on face BID did not have a time of the physician's signature.

Based on record review and interview, the facility failed to document nutritional supplements in the patients medical record for one (#30) of two patient medical records reviewed for nutritional supplements. This had the potential to affect any patient ordered to receive nutritional supplements. The facility census was 45.

Findings included:

1. Record review of Patient #30's current medical record showed a physician order dated 10/28/11 at 12:37 PM for Glucerna (nutritional supplement to maintain weight or promote wound healing), one can by mouth, three times a day with meals. Review of the patient's nutritional record showed no documentation that the supplemental nutrition was offered or consumed on:
-10/28/11 for the evening meal;
-10/29/11 for the morning or evening meal;
-10/30/11 for the morning, afternoon, or evening meal;
-10/31/11 for the morning meal;
-11/01/11 for the morning, afternoon, or evening meal.

Further review of the patient's record showed the patient lost more than eight pounds between 10/15/11 and 10/29/11.

2. During an interview on 11/03/11 at 3:40 PM, Staff F, Chief Nursing Officer (CNO), stated that nutritional supplement intake could be documented in one of two places, but was unable to locate any documentation in the medical record for the meal times listed above.

During an interview on 11/03/11 at 3:25 PM, Patient #30 stated that he/she only received a nutritional supplement when he/she requested it, which was usually at dinner.


27727

Based on observation, interview and record review facility staff failed to ensure a current therapeutic diet manual was approved by the clinical dietitian and was available to all medical, nursing and dietary personnel. The facility census was 45.

Findings included:

1. Record review of the facility's policy titled, "Manual of Clinical Dietetics" revised 09/14/11 showed the following direction:
-The manual served as a guide for ordering diets.
-The manual used dietary standards of care established by the Food and Nutrition Board, National Research Council, National Academy of Sciences and set forth in the Recommended Dietary Allowances dated 1989.
-Each patient care unit was provided with a copy of the Manual of Clinical Dietetics.
-A copy of the manual was also maintained in the dietary department.
-The clinical dietitian was directed to review the manual every three years, revise it as needed and date the review and revisions that were made.

2. During an interview on 11/02/11 at 8:15 AM, Staff P, Manager of Support Services {Support Services included the dietary department}, stated the facility used the Manual of Clinical Dietetics as the therapeutic diet manual and a copy of the manual could be found on four of the inpatient units.

3. Record review of the Manual of Clinical Dietetics, provided by Staff P during the interview showed the following:
-The manual was the sixth edition, dated 2000 (an eleven year old reference).
-The review page did not have the signature of the clinical dietitian.

4. During an interview on 11/02/11 at 2:38 PM on the Traumatic Brain Injury (TBI) Unit Staff W, Patient Care Technician, (PCT) stated the following:
-He/she had worked in the facility for four years.
-PCTs occasionally worked as unit clerks.
-He/she did not know if the unit had a diet manual.

Record review of the TBI unit diet manual, (found by the clinical dietitian) showed the copy was the sixth edition, dated 2000 and there was no revision and review page signed by the clinical dietitian.

5. During an interview (and after a search for the diet manual) on 11/02/11 at 2:40 PM on the Stroke Unit, Staff Q, Clinical Dietitian stated he/she could not find the diet manual on the Stroke unit.

6. During an interview on 11/02/11 at 2:50 PM on the Comp Unit, Staff X, Licensed Practical Nurse (LPN) stated the following:
-He/she had worked in the facility for four years.
-He/she did not know there was a facility diet manual.

Record review of the Comp Unit diet manual, (found on a shelf in the nurses unit by the clinical dietitian) showed the copy was the sixth edition, dated 2000 and there was no revision and review page signed by the clinical dietitian.

Based on observation, interview, and record review, the facility Dietary staff and nursing staff failed to store food supplies and remove outdated food supplies to maintain safety and quality of the foods. The facility census was 45.

Findings included:

1. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed the following direction:
-Chapter 3-302.12 Food storage containers shall be identified with the common name of the food.
-Chapter 3-302.13 Food shall be protected from contamination by storing in a clean, dry location.

Review of the facility's policy titled, "Food Storage and Expiration Codes" dated 09/14/11 showed the following direction:
-The policy was to prevent contamination that may be caused by prolonged storage and storage of foods.
-Foods should be labeled with an expiration date.
-Foods which exceed the expiration codes (dates) must be discarded.

2. Observations on 11/02/11 from 9:40 AM through 10:29 AM in the Dietary department dry food storeroom showed the following:
-An unlabeled, undated partial package of dry powder (identified later as cheesecake mix) stored on a shelf.
-An opened partial package of biscuit mix, labeled use by 10/31, stored on a shelf.
-An opened partial package of chocolate cake mix, labeled use by 10/31, stored on a shelf.
-A soiled card board box on a shelf with partial packages of undated chicken gravy mix, turkey gravy mix dated use by 10/25/11, an opened to air undated package of gluten free spaghetti, an opened to air undated box of rice cereal and an undated container of waffle mix.
-An unlabeled, undated partial packet (identified later as Spanish rice seasoning mix) stored on a shelf.
-An opened undated packet of Italian dressing seasoning mix stored on a shelf.
-Two, opened, undated ten pound bags of pasta stored on a shelf.
-An opened, partial two quart bottle of low sodium soy sauce with a manufacturer's label to refrigerate after opening stored unrefrigerated on a shelf.
-An opened, partial gallon container of Worcestershire sauce (labeled with ingredients including anchovy puree or pureed fish) stored unrefrigerated on a shelf.
-An opened five quart container of Balsamic vinegar labeled use by 10/22 stored on a shelf.
-Undated partial packets of blanched almonds and peanuts stored on a shelf.
-An opened gallon container of marinade sauce with a manufacturer's label to refrigerate after opening stored unrefrigerated on a shelf.

During an interview on 11/02/11 from 9:40 AM through 10:29 AM Staff P, Manager of Support Services (Support Services included the dietary department), stated the following:
-All of the partial packages of dry foods should be labeled and dated.
-The foods labeled use by a specific date should have been discarded.
-He/she was the staff member who was assigned responsibility for discarding expired foods.
-Staff routinely stored the low sodium soy sauce, the Worcestershire sauce and the marinade unrefrigerated on shelving in the dry food storeroom.

Observation on 11/02/11 at 10:29 AM in the cook's area showed staff stored
an opened, partial two quart bottle of low sodium soy sauce with a manufacturer's label to refrigerate after opening on a shelf under the cooks prep table.

Observation on 11/02/11 at 10:30 AM showed staff stored six fruit flavored desserts labeled use by 10/30 on a shelf in a reach in freezer.

3. During an interview on 11/02/11 Staff P stated he/she was unsure if there was a policy and procedure directing staff on proper food storage. (No policy was provided by the end of survey).


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4. Observation on 11/02/11 at 1:30 PM showed the Stroke Unit Nourishment Center contained:
-Three milk cartons that expired 11/01/11;
-One Nepro (nutritional supplement) that expired 05/01/11;
-Two cans of powdered thickener (used to thicken liquids to prevent patients with swallowing difficulties from choking) were opened and not labeled with an open date.

5. Observation on 11/02/11 at 1:33 PM showed the Stroke Unit Medication Room contained Rice Baby Cereal, which expired 07/16/11, was open and not labeled with an open date.

6. Observation on 11/02/11 at 1:35 PM showed Staff F, Chief Nursing Officer (CNO), on the telephone requesting all refrigerators to be checked for expired contents and for the expired contents to be removed.

During an interview on 11/02/11 at 1:50 PM, Staff F stated she did not know if there were additional expired items found in the facility because he/she had asked that they be removed.

During an interview on 11/02/11 at 2:00 PM, Staff F stated that dietary department staff were to check for and remove outdated food and drinks from the Nourishment Centers every morning. Staff F added that the outdated baby cereal found in the medication room should have been monitored and removed by the nursing staff. Staff F added that the open food products, such as the powdered thickener and baby cereal, did not require an open date to be labeled on the product.

During an interview on 11/03/11 at 3:20 PM, Staff F stated that the facility did not have a policy related to the removal of outdated food or supplies or a policy related to the labeling of open food products.

Based on observation, interview and record review the facility failed to ensure Dietary department staff wore effective hair restraints and failed to ensure Dietary department staff covered kitchen trash containers to prevent cross contamination of foods prepared for patient meal service. The facility census was 45.

Findings included:

1. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed the following direction:
-Chapter 2-402.11 Effective hair restraints. Food employees shall wear hair restraints such as hair coverings or nets, beard restraints and clothing that cover body hair that were designed and worn to effectively keep hair from contacting exposed food, clean equipment, utensils and linen.

Review of the facility's policy titled, "Uniform, Personal Hygiene and Appearance" dated 07/19/07 showed the following direction:
-Good grooming and personal hygiene included hair restraints (hair nets, beard protectors or ball caps) will be worn in all food production, receiving and sanitation areas.
-All hair must be effectively restrained.

2. Observation on 11/02/11 at 10:29 AM in the facility kitchen showed the following:
-Staff R, Cook, with short facial hair prepared foods for patient meal service and failed to wear a beard cover.
-Staff S, Diet Aide, with short facial hair moved trash receptacles, handled food carts and assembled foods for patient meal trays and failed to wear a beard cover.
-Staff T, Diet Aide, with strands of hair approximately five inches long hanging outside a hair net, prepared trays for patient noon meal and failed to wear an effective hair restraint.
-Staff, U, Diet Aide, with short facial hair scooped ice from the kitchen ice bin and failed to wear a beard cover.

During an interview on 11/02/11 at 10:41 AM Staff P, confirmed all hair needed to be covered and Dietary staff should be wearing effective hair restraints.

3. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed the following direction:
-Chapter 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse shall be kept covered with tight fitting lids if the receptacles contain food residue.

Review of the facility's policy titled, "Infection Control - Garbage Disposal", dated 07/19/07 showed the following direction:
-The policy was to hold, transfer and dispose of garbage in a manner that does not create a nuisance or a breeding place for insects, rodents and vermin (rats or insects like cockroaches that harm people and are difficult to control).
-The policy failed to provide direction to cover all trash receptacles.

Observations on 11/02/11 from 9:45 AM through 10:41 AM in the facility kitchen showed staff failed to cover four (approximately fifty gallon each) plastic trash receptacles, partially filled with trash and food residue. Further observation showed staff maintained two of the open trash receptacles next to (touching) equipment containing stacks of dishes used for patient meal service.

During an interview on 11/02/11 at approximately 10:15 AM Staff P, Manager of Support Services (Support Services included the dietary department), stated the following:
-He/she had never purchased trash receptacle covers.
-The two open trash receptacles next to (touching) equipment containing stacks of dishes were routinely maintained in that position.