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Based on observation, interview and document review, the hospital failed to ensure that dietary services met the needs of all patients as evidenced by failure to:

1. Provide organized dietetic services as evidenced by findings of unsafe food handling practices and supervision of the dietary department ( Refer to A 619, A 620).

2. Provide a comprehensive therapeutic diet manual that reflected the diets offered in the hospital (Refer to A 631).

3. Ensure the nutritional needs of patients were met as evidenced by the lack of a comprehensive nutritional analysis of regular and therapeutic menus ( Refer to A 630).

4. Lack of menus for all physician ordered diets ( Refer to A 628).

5. Develop performance improvement activities that reflected the scope and nature of the services ( Refer A 265).

6. Ensure safe and effective food storage/production practices (Refer to A 749).

7. Ensure the maintenance of dietetic services equipment per manufacturers' guidance (Refer to A 701).

The cumulative effect of these systemic problems resulted in the inability of the hospitals' food and nutrition services to direct in such a manner to ensure that the nutritional needs of the patients' were met in accordance with practitioners' orders and acceptable standards of practice.

Based on observation, interview, and review of record, the facility failed to maintain surgical facilities that prevented infections and communicable diseases. The facility failed to follow professional surgical standards to prevent infection. The facility did not meet the Condition for Coverage for surgical services, as follows:

1. The facility failed to ensure the surgical staffs followed the policies & procedures for "Infection Control Practices" and "Aseptic Techniques" in surgical area. Several observations were made in the operating room where the doors to the OR were kept open during surgical procedures. (Refer to A 951).

2. The facility failed to ensure the operative reports were electronically signed for completion by the surgeon immediately following surgery for Patient 29 (Refer to A 959).

The cumulative effect of these systematic problems resulted in the facility's inability to ensure the provision of surgical services.

Based on observation, interview, and record review, the facility failed to ensure that the privacy curtains were maintained to provide privacy during personal care.

Findings:

On February 12, 2013 at 11:40 a.m., a tour of the facility's emergency room revealed that the triage area had a privacy curtain that did not completely provide privacy during the triage process.

During a concurrent interview, the intensive care unit (ICU) director stated the curtain did not completely cover the triage area and would be replaced.

Based on record review and interview, the facility failed to ensure the patients were provided care in a safe environment.

Findings:

1. During a review of one (1) of five (5) employee files on February 15, 2013, at 7:30 a.m., with Employee 1, one (1) employee who had a history of a positive purified protein derivative skin test (PPD is skin test is a method used to diagnose silent (latent) tuberculosis (TB) infection) and did not have a current tuberculosis test. Employee 1 stated when the system was changed, the employee was somehow "accidentally dropped." She further stated the employee would not work until a chest x-ray was done. Employee 2 was scheduled for a chest x-ray today (February 15, 2013).

A review of a facility's policy and procedure titled, Employee Health Program dated October 2012 indicated an annual skin test shall be performed on those individuals with a previously documented negative tuberculin skin test. All employees would be screened annually or every 4 years (depending upon exposure assessment, and exposure categories) for the presence of tuberculosis.

2. During an environment tour of the Behavioral Health Unit, 1 (one) West, on February 12, 2013, at 9 a.m., the following was observed:
a. An environmental services staff (EVS) was mopping the medication room and the EVS cart in the hallway was unlocked. The cart had cleaning chemicals.
b. In the seclusion room, a mattress was torn.

3. In the Behavioral Health Unit 1 (one) South, Shower Room 1275 did not have a call light.
During an interview on February 12, 2013, at 2:30 p.m., Employee 2 stated the shower area was recently repaired and they forgot to replace the call light.

A review of a facility's policy and procedure titled, General Safety Rules dated January 2010 indicated the EVS carts must be locked at all times and never unattended. Cleaning chemicals must be kept locked.

Another facility's policy and procedure titled Patient Safety dated October 2012 indicated this policy contains the principles on ensuring safe patient care is provided to the patients. In regard to the shower and tub safety, the nursing staff would be in contact with the patient during the bathing procedure via the emergency call system.

Based on record reviews and interviews, the facility failed to implement an abuse protection training program to ensure the patients are free of all forms of abuse, neglect or harassment.

Findings:

During a review of five (5) of five (5) employee files, on February 15, 2013, at 7:30 a.m., Employee 1 reviewed the employees files and stated there was no formal abuse training. She stated all employees are mandated reporters and would sign an acknowledgement of mandated reporting upon hired. Later, at 11:30 a.m., Employee 1 stated that all nurses did not receive abuse training and there was no online training for abuse protection. She further stated the red book (training records) did not include abuse protection training.

A review of a facility's policy titled Staff Responsibility Patient Abuse Reporting dated March 2012 indicated that at the date of hire, all employees would be given copies of the employee statements, Child Abuse and Adult Abuse Reporting to read and sign. One sign employee's statement would be given to the employee and one would be placed in the employee's file.

Based on record review and interview, the facility nursing staff failed to ensure the facility registered nurses (RN) assessed the patient's risk for falls and conducted an admission assessment for 3 of 30 sample patients (Patient 20, 21, and 29). Patient 20 was was not assessed for the risk of fall upon admission. Patient 29, who was at risk for falls, was not assessed for potential fall risk daily from January 26, 2013 to January 28, 2013. Patient 21 did not have an admission assessment. This deficient practice had the potential for not providing appropriate care to meet the needs of the patients.


Findings:


1. On February 12, 2013, a review of the clinical record revealed Patient 20 was admitted to the facility on February 8, 2013, with diagnosis of foot diabetic cellulitis with deep tissue.

The electronic medical record was reviewed and disclosed the patient had been assessed at high risk for falls (score 15) on February 11, 2013, which was 3 days after the admission. There was no documentation the RN had assessed the patient upon admission for potential fall risk.

During a concurrent interview with Administrator 5 on February 12, 2013 at 3:23 p.m., she stated the RN had not assessed the patient upon admission for potential fall risk.

2. On February 13, 2013, in the Labor and Delivery Unit, a review of the clinical record revealed Patient 21 was admitted to the facility on February 9, 2013, with diagnosis of repeat C (caesarian) section.

The electronic medical record was reviewed and disclosed there was no documentation the RN (Registered Nurse) had conducted the admission assessment for the patient.

During a concurrent interview with Administrator 3 on February 13, 2013 at 10 a.m., she stated there was no documentation the RN had conducted the admission assessment for the patient.

3. On February 15, 2013, a review of the closed clinical record revealed Patient 29 was admitted to the facility on January 26, 2013, with diagnoses of possible occult hip fracture, hypertension, and arthritis. The patient was discharged on January 31, 2013.

The electronic medical record was reviewed and disclosed the patient had been assessed at high risk for fall on January 29, 2013 (Morse Fall Risk Score 75) and January 30, 2013 (Morse Fall Risk Score 75), which was 3 days after the admission. There was no documentation the RN had assessed the patient upon admission for potential fall risk.

During a concurrent interview with Administrator 3 on February 15, 2013 at 10:32 a.m., she stated the RN had not assessed the patient who was at risk for falls daily from January 26, 2013 to January 28, 2013.

The policy for "Fall Assessment & Prevention Program" (Policy#:PCM-06-101) indicated the RN would assess all patients upon admission for potential fall risk and daily for those who are at risk for falls. A patient who is found to have "at risk" score 6-10 and "at high risk" score 11 and above, are identified as "at risk for fall."

According to the policy for "Nursing Assessment/Reassessment" (Policy#: LDM-01-103), an admission assessment shall be performed by the RN within 30 minutes of admission to Labor and Delivery.

Based on record review and interview, the facility nursing staff failed to develop a care plan within 24 hours of admission to include appropriate nursing interventions in response to the patients' needs for 2 of 30 sample patients (Patient 19 and 29).


Findings:

1. On February 12, 2013, a review of the clinical record disclosed Patient 19 was admitted to the facility on February 3, 2013, with diagnoses of chronic obstructed pulmonary disease, vascular dementia, hypertension, and diabetes. The Physician Progress Notes dated February 11, 2013 indicated the patient was confused.

A review of the "Braden Score" disclosed the patient had been assessed as high risk for skin breakdown (Braden Score: 14) from February 3, 2013 to February 7, 2013. However, the listed Interdisciplinary plans of care disclosed the Interdisciplinary Plan of Care for self care deficit had been developed on February 11, 2013, which was 8 days after the admission. The Interdisciplinary Plan of Care for impaired skin integrity was developed on February 6, 2013, which was 3 days after the admission.

During a concurrent interview with Administrator 5 on February 12, 2013 at 3:04 p.m., she stated the Interdisciplinary Plan of Care should be initiated and developed within 24 hours of the patient's admission.

2. On February 15, 2013, a review of the clinical record disclosed Patient 29 was admitted to the facility on January 26, 2013, with diagnoses of possible occult hip fracture and hypertension. The patient was discharged on January 31, 2013.

A review of the "Braden Score" disclosed the patient had been assessed as high risk for skin breakdown on January 26, 2013 (Braden Score: 21), January 27, 2013(Braden Score: 22), January 28, 2013(Braden Score: 16), January 29, 2013(Braden Score: 17), January 30, 2013 (Braden Score: 21), and January 31, 2013(Braden Score: 20).

A review of the listed Interdisciplinary plans of care disclosed the Interdisciplinary Plan of Care for impaired skin integrity had not been developed.

During a concurrent interview with Administrator 3 on February 15, 2013 at 11:35 a.m., she stated the Interdisciplinary Plan of Care for impaired skin integrity had not been developed.

According to the policy for "Nursing Assessment/Reassessment" (Policy#:PCM-01-112), skin breakdown risk screening (Braden Score), a total score of 8 or greater indicated the patient is at risk for injury or had impaired skin integrity. Interdisciplinary Plan of Care for impaired skin integrity would be automatically triggered.

According to the facility's policy for "Interdisciplinary Plan of Care" (Policy#:PCM-09-104), a registered nurse (RN) is responsible for initiating and developing an Interdisciplinary Plan of Care within 24 hours of admission or as specified in unit specific standards.

Based on observation, review of hospital documents and patient and staff interviews, the hospital failed to ensure that nursing staff accurately documented the amount of food consumed by 1 of 30 sample patients (Patient 23) and 2 randomly selected patients (Patients A and B). Behavioral Health Worker (BHW) C had recorded the amount of food consumed by all the patients on the unit ahead of time prior to them finishing their meals. There were a total of sixteen patients on the unit. Inaccurate documentation could result in incorrect assessment of the patient, improper application of medical nutrition therapy and incorrect evaluation of care provided. The facility failed to ensure that records were protected from unauthorized access and damage from fire and water.

Finding:

1. At approximately 12:35 p.m., on February 1, 2013, the patients in the Behavioral Health Unit were observed eating in the multi-purpose room of the unit. Patient 23 was observed sitting at the head of a table with two other patients (Patient A and B) and a "sitter" who was providing 1:1 supervision.

Patient 23 was observed to have all of the food offered untouched. In response to a question by the surveyor, she indicated that she did not like the food. She had consumed 0% of her meal. The sitter stated that she was not eating much.

Patient A was observed sitting at the table with all of the containers empty. He had asked if he could eat Patient 23's food since she did not want it. Closer observation revealed that he had more containers of food on his tray than he would have been served. He had consumed than 100% of his meals.

Patient B was also observed still sitting at the table. She stated that she feel like eating. The sitter stated that she had only soup. This would be less than 10% of her meal.

The meal percentage log was requested to review Patient 23's intake. The log titled, "Meal Percentage/Shower Log" was on the clip board of BHW C, who was in the hallway, outside the room when the meals were being consumed. Review of the log showed that the meal percentages of all sixteen patients listed had been completed including the three still sitting at the table.

BHW C had recorded that Patient 23 had consumed 50% of her meal when she consumed 0%. Patient B was recorded as having consumed 100% when she consumed about 10%. Patient A was documented as eating 100% when he ate more than 100% and had eaten food items from other patients.

BHW C was interviewed at approximately 1:00 p.m. on how he had been able to document meals when the patients were still at the table eating. He stated "I do this but I have another thing going." It is unclear what else he was referring to.

Review of clinical record for Patient 23 showed that she was admitted on February 8, 2013 with diagnoses including schizophrenia. Review of the meal percentage documented from February 8, 2013 through February 11, 2013 showed averaged 75 to 100%, with two meals at 50% or below. The accuracy of the documented meal percentage is questionable.

Nurse present on the unit stated that it was not customary or good practice to record information when the meals had not been completed. The nurse manager was away from the unit and was unable to be interviewed regarding what training had been provided to BHW C.

Meal percentages is one of the tools a registered dietitian would use to evaluate extent of nutritional diagnosis, meal acceptance, the efficacy of therapy, validate causes of weight changes among other things. An incorrect assessment of this parameter could result in the provision of the wrong nutrition therapy.


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2. During an observation of the stored medical records in the basement, with Employee 3, on February 14, 2013, at 10:50 a.m., she stated the medical records stored in this basement were from 2012 to 2013. She stated the older medical records were stored across the street at another location. The surveyor asked Employee 3, how were the open medical record file cabinets protected from fire and water damaged. She stated there was no coverage or protection for the medical records stored in the open file cabinets. Employee 3 and the surveyor did not observe any protection or coverage above the cabinets for open medical record. There were sprinklers above the file cabinets for open medical records.




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3. On February 14, 2013, during a tour of the partial hospitalization (PHU) unit at 9 a.m., a cabinet located in the common room contained patient records. The cabinet drawers were not secured and unlocked making the protected health information (PHI) easily accessible.

During a concurrent interview with the PHU supervisor, he stated the drawers should be locked. The practice had the potential to allow unauthorized access of PHI.

Based on record review and interview, the facility failed to ensure 1 of 30 patients (Patient 18) post-operative note was timed by the physician.

Findings:

On February 12, 2013, a review of the clinical record revealed Patient 18 was admitted to the facility on February 3, 2013, with diagnoses of cervical myelopathy and cord compression.

The physician's pre-operative special procedure checklist and post-operative special procedure note was reviewed and disclosed the physician signed and dated on February 12, 2013. However, the physician did not write the time.

During an interview with Administrator 4 on February 12, 3013 at 11:25 a.m., she stated the physician did not document the time on the note.

Based on observation, interview, and record review, the facility failed to ensure the medication storage room located in the behavioral health unit was secured. An unsecured medication room had the potential for allowing patients to unauthorized access to drugs.

Findings:

On February 12, 2013, during a tour of the behavioral health unit (BHU) at 2:30 p.m., a metal curtain was drawn over the window that allows dispensing of medication by a licensed staff member. Further inspection revealed that the window metal curtain was not secured and could be easily opened. The medication room stored medications in unlocked cabinets. The practice potentially allowed access to patients in the BHU to various medications.

During a concurrent interview, the BHU charge nurse indicated the metal curtain should be locked to prevent access.

Based on observation, interview, and document review, the facility failed to control medication by failing to:

1. ensure the medication dispensed to the patients were appropriately labeled;
2. ensure the integrity and stability of the medication by monitoring the temperatures of medication storage area;.
3. maintain the temperature in the facility 's medication refrigerators in accordance with hospital policy to ensure stability, potency and safety of refrigerated medications, for two of five refrigerators reviewed (Nursing Unit C and Nursing Unit 2 North).

Findings:

1. On February 14, 2013, at 10:31 a.m., during an inspection of the medication room located in the nursing unit, "1 South" of the Mental Health Unit (MHU), the evaluator found two tubes of Blistex medicated lip ointments inside an unmarked medication tray located on the medication shelf. Both ointment tubes were labeled with hand-writings: " for all PTs (patients) with dry lips. " There was no first use date or expiration date noted.

During a concurrent interview, Staff 4 stated Blistex should be individually labeled.

During another interview at 11 a.m., Staff 1 stated Blistex should be dispensed to the nursing unit with individually labeled with patient's name on each tube.

Review of the facility's policy and procedure titled, "Dispensing Labels," dated "1/13," indicated that "all drugs stocked in the pharmacy, supplied to floor stock, or dispensed to patients shall be clearly, accurately, appropriately and safely labeled... Drugs that are mislabeled... shall not be available for use... All labels shall include at least: patient name ... expiration date ... "

2. On February 14, 2013, at 10:10 a.m., during the inspection of the night locker closet located on the second floor between nursing unit B and C, the evaluator noticed there was an operating medication refrigerator inside the windowless closet.

During a concurrent interview, Staff 1 stated there was no thermometer or temperature maintenance measure for the night locker.

According to the facility's night locker formulary, the night locker housed 520 types of medications.

Review of the facility's policy and procedure, titled, "Storage: After dispensing until administration," dated "01/2013," indicated " ...Drugs and devices shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation ... Temperatures and ventilation in the storage area shall ensure integrity and security of the drugs ... "

3. On February 14, 2013, at 10:05 a.m., during an observation of the refrigerator located on the second floor in the medication storage room for Nursing Unit C, the temperature gauge inside the refrigerator displayed a temperature of 32 degrees Fahrenheit (F)and there was a thick layer of frost inside the refrigerator.

During a concurrent interview, Staff 3 stated the temperature gauge read 32 degrees Fahrenheit and maintenance would be notified to check the refrigerator. Nursing Unit C refrigerator contained the following medications:
a. 10 doses - Morphine 30 milligrams (mg)/30 milliliters (ml) PCA, Patient Controlled Analgesia, is a device that can be programmed to give the patient the control to safely manage the pain often after surgery.
b. 10 doses - Hydromorphone (narcotic controlled substances used for pain management) 3mg/30ml
c. One liter of 5 % Dextrose in 0.45 % Normal Saline (source of water and calories)
d. One liter of 5 % Dextrose in 0.45 % Normal Saline and 20 milliequivalent (mEq) of Potassium (source of water, electrolytes and calories)

On February 14, 2013, at 10:20 a.m., during an observation of the refrigerators located on the second floor for Nursing Unit 2 North, inside the medication storage room there were two refrigerators, one located near the entrance door and one further inside the storage room near the back wall. The refrigerator located near the entrance door temperature gauge inside the refrigerator displayed a temperature of 48 degrees Fahrenheit. According to the temperature log sheet attached to the refrigerator, the acceptable temperature range should be between 36-46 degrees Fahrenheit.

During a concurrent interview, Staff 3 stated the maintenance should be notified and requested Staff 8 to notify maintenance. Staff 3 stated all the medications on Nursing Unit 2 North refrigerator will be replaced because the refrigerator temperature was out of range.

On February 14, 2013, at 10:30 a.m., Staff 3 acknowledged the refrigerator on Nursing Unit 2 North located near the entrance door contained five different medications with multiple doses and an Emergency Kit (E-Kit) which contained an additional five medications:
a. Oral Vancomycin (treat infections caused by bacteria) 500mg 1 milliliter (ml) each - 6 single doses
b. Diltiazem HCL (treatment of hypertension) Injection 25 milligrams/5 ml - 3 doses
c. Procrit (treat anemia in certain patients with kidney failure) 4000 units/ml - 1 dose
d. Flu Vaccine 0.5 ml - 2 doses
e. Pneumovax (pneumococcal vaccine) 0.5 ml - 1 dose
f. E-Kit - Rapid Sequence Intubation (RSI) (RSI incorporates a rapidly acting sedative (i.e., induction) agent and a neuromuscular blocking (i.e., paralytic) agent to create optimal intubating conditions and enable rapid control of the airway
1. Succinylcholine (muscle relaxant) 20mg/ml - 10 ml
2. Rocuronium (muscle relaxant) 10mg/ml - 5 ml
3. Vecuronium (muscle relaxant) 10mg (dilute to 1mg/ml)
4. Sterile water (10ml)
5. Etomidate (a sedative and hypnotic administered intravenously for induction and maintenance of general anesthesia) 2mg/ml - 10 ml

Review of the facility's policy and procedure titled, "Refrigeration and Freezing," dated "1/13," and indicated the following: " ...Drugs that require refrigeration or freezing shall be stored in a refrigerator ... that is capable of maintaining the necessary temperature ...Refrigerator temperatures shall be maintained between ...36-46 degrees Fahrenheit ...Any variances will be reported to the Director of Pharmacy and the Engineering Department and the corrective action will be recorded."

Based on observation, interview, and document review, the facility failed to ensure unusable medication was not available for patient use.

1. A Rapid Sequence Intubation (RSI) Kit (a procedure performed when a patient cannot breathe on their own, whether it is due to surgery, disease, or an emergency), was found in the medication storage area refrigerator for Nursing Unit 2 North and contained one dose of Vecuronium 10 milligram injectable, a muscle relaxants with an expired date of
" 1/13. " The availability of an expired medication, Vecuronium in the RSI Intubation Kit created the potential of a patient being administered a medication with decreased effectiveness and stability during an emergency situation.

2. One undated, used, unlabeled, vial of Humalog insulin (used in treatment of high blood sugar) was found in the medication refrigerator of the Post-anesthesia care unit (PACU).

Findings:

1. On February 14, 2013, at 10:30 a.m., during an observation of the medication storage room refrigerator located on the second floor on Nursing Unit 2 North, a RSI Intubation Kit was found inside the refrigerator that was located near the entrance door of the medication storage room. The content list taped to the outside of the kit indicated there was item in the kit that would have expired on " 1/13 ."

During a concurrent interview, Staff 3 stated, "We should have changed the RSI Intubation Kit before 1/31/13."

Review of the Facility's January 2013, Medication Storage Area Inspection Report, signed on " 1/31/13 " , indicated, " Outdated or unusable ...medications are removed from stock and returned to Pharmacy for disposal ... "

Review of the facility ' s policy and procedure titled, " Unusable Drugs and Devices " , dated " 1/13 " , indicated the following: " Unusable drugs and devices include those that are: ... Expired (outdated) ...Otherwise unsuitable for administration or use (e.g., questionable integrity, effectiveness, and stability) ...The pharmacy shall store unusable drugs and devices in specially designated areas to prevent their distribution or administration and ensure they are disposed of safely.

2. During an inspection of the PACU medication refrigerator on 2/14/2013 at 10:05 AM, there was one used 10-ml vial of the Humalog insulin inside the refrigerator. There was not a visible open date on the vial.

During a concurrent interview, Staff 2 acknowledged that the date of opened (first date being used) was unknown and indicated that the vial should be dated on first use.

Review of the facility's policy and procedure titled, "Infection Control: Multiple-use Sterile Drugs", dated " 1/13 " , indicated the following: " ...Multidose injectables may be used for 28 days after initial opening ..."

Based on observation and interview, the facility failed to maintain safety precautions in relation to appropriate storage of its lead aprons in order to prevent damage to the protective their integrity.

Findings:

On February 12, 2013 at 10:30 a.m., during a tour of the surgical suite, in the company of Administrator 3, there were 12 aprons observed as being hung over various structures such has handles and bars which were part of other pieces of equipment. This subjected their contents and integrity to stress as opposed to their being hung in a manner from a rack or hanger so as to avoid their being folded.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the food service department was organized in a manner that met the needs of the patients.

Findings:

The hospital failed to ensure that there was adequate oversight of food service operations in both campuses. The person responsible for day to day management of food service operations in the South Campus was not provided adequate oversight and support.

1. The campus had been provided an outdated menu that the main hospital had discontinued three years earlier. There was no menu or product specification for one of the menu item. There was no awareness of this error or oversight till it was identified during the survey.

2. The South campus had not been provided with menus for the vegetarian diet.

3. There was equipment that was not functioning correctly that had been in operation that resulted in food items being stored under unsatisfactory conditions.

4. There were plumbing concerns that could result in contamination of the hospital water.

5. The main hospital had several refrigeration units and freezer that were not functioning properly. There were work orders placed that did not appear to have been followed up on including leaking pipes and water faucets.

6. There was inappropriate storage of flowers in the kitchen refrigerator.

7. Food service equipment was not effectively cleaned and sanitized to prevent cross-contamination.

8. Plates for patient service had lost its glaze, needed to be replaced.

9. There was lack of oversight with food ordering resulting in food being stored in the refrigerator longer (as in the case of the beef) or too little (frozen juice) that recommended.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the director of food services was able to effectively manage the food service operation.

Finding:

Review of the job description for the position of Director of Food indicated that the position was responsible for the plans, directs and controls all unit operations. The director had been away from the hospital on a temporary assignment by the contract food management company that had hired him, but would return a day or so a week to the hospital. The following deficient practices were shared with him during the interview.

1. The South campus had been provided an outdated menu and spreadsheet that the main hospital had discontinued three years earlier. There was no menu or product specification for one of the menu item. There was no awareness of this error or oversight till it was identified during the survey.
2. The South campus had not been provided with menus for the vegetarian diet.
3. There was equipment that was not functioning correctly that had been in operation that resulted in food items being stored under unsatisfactory conditions.
4. There were plumbing concerns that could result in contamination of the hospital water.
5. The main hospital had several refrigeration units and freezer that were not functioning properly. There were work orders placed that did not appear to have been followed up on including leaking pipes and water faucets.
6. There was inappropriate storage of flowers in the kitchen refrigerator.
7. Food service equipment was not effectively cleaned and sanitized to prevent cross-contamination.
8. Plates for patient service had lost its glaze and needed to be replaced.
9. There was lack of oversight with food ordering resulting in food being stored in the refrigerator longer (as in the case of the beef) or too little (frozen juice) that recommended.

In an interview with the director on February 14, 2013 at approximately 10:00 a.m., he indicated that there were systems in place to prevent some of the deficient practices.

There was no explanation provided on the lack of oversight of the South Campus.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that it had an approved therapeutic diet manual. The nutrition care manual that was approved by the medical staff had not been modified to be used as a therapeutic diet manual. In addition, the nutrition care manual was not available to all food service personnel.

Findings:

During interviews with the registered dietitian (RD1) and Clinical Nutrition Manager (CNM) on February 12, 2013 and February 13, 2013 respectively, indicated that the hospital utilized the Academy of Nutrition and Dietetics' (formerly American Dietetic Association) Nutrition Care Manual (NCM). The NCM is an "Internet based diet and professional practice manual. " It provides overview and nutrition care for over 100 diets and conditions. The NCM had not been modified/customized to identify what diets are routinely ordered at the hospital to ensure consistency and ease of use by hospital staff.

It was unclear whether the NCM had been approved by the medical staff. Review of minutes from the Pharmacy and Therapeutics Committee meeting dated May 12, 2012, indicated that a review of a manual was done. It was unclear if it was the NCM or department policy and procedure manual. The hospital did not provide further evidence that the NCM manual went through the proper approval channels.

RD1 on February 12, 2013 at approximately 2:35 p.m., stated the NCM was an icon on the hospital's computer system and therefore available to all medical and nursing staff. The Nutrition Assistants (NA) do not have access to the computers that the NCM was loaded. RD1 stated there was a different binder (hard copy) used by the Nutrition Assistants (NA) as reference to modify hospital menus and diets. Nutrition Assistants are the first line employees that interact with patients to obtain food choices and distribute meals. Their responsibilities include ensuring appropriateness of food being delivered to the patients based on the physician ordered diets for each patient. Knowledge of food allowed or to be avoided is paramount to the job duties, therefore a good resource / reference on the various hospital diets is important

In an interview with CNM on February 13, 2013 at approximately 3:00 p.m., she acknowledged the use of the NCM and "diet manual" used by the NAs. She stated that she developed the manual over ten years ago to aid the NAs in their job responsibilities. In response to whether the NCM manual was approved, she stated that she had prepared the document (face sheet) for approval by medical staff but was does "not know" where the document was.

Review of the manual showed that it had the characteristics of a diet manual. The manual had the diets commonly ordered by physicians and diets for which menus had been developed. It included what foods were allowed or not allowed on the diets. This manual had not been approved by the medical staff and was not readily available to medical or nursing staff because there was only one copy.

Based on observation and interview the facility failed to ensure the condition of the physical plant and overall environment was maintained in a manner that the safety and well-being of patients was assured.


Findings:

1. On February 12 - February 15, 2013, the evaluator conducted inspections of the facility and observed the following:
a. In the Decontamination Room, there was bubbled and peeling wall over the 3-compartment sink, a plastic tube held in the sink and below the counter top creating a possible cross-contamination of the potable water source.
b. In the Sterilizer Room, an aluminum 2-shelf push cart with wood colored top shelf cover used to transport non-sterile operating instruments and a sterile pack. The storage cabinets had adhesive tape remnants left on the contact surfaces.
c. In the Basement Woman's Restroom, the toilet supply water pipe was missing the wall flange.
d. In Patient room 171, the handwash sink had white tape wrapped around the neck of the faucet.
d. In the Shower Room located near patient room 162, there was damaged and unclean non-slip shower tape.
e. In the Seclusion room, the handwash sink faucet had an aerator.
f. In the OB/Building III, the 3-shelf push cart had a terry cloth lining the top shelf.
g. In Patient Room 242, there was peeling wall paint behind the head of the bed.
g. In Patient Room 244, there was blackened wall streaks on the ceiling from the airvent.
h. In the ICU/B, the nurse station counter had missing facing along the edge and top, and a section of the drop ceiling tile was missing along one of the support columns.
i. In the ICU/C, the nurse counter top had missing facing.

j. The evaluator observed a set of cross corridor doors, located near the cafeteria exit door, closed with a sign posted, "Do not enter." There was a black carpet mat in the doorway covered with white dust and the mat was very dirty and oily.

An interview was held with the building supervisor and he stated that the double doors led to the suspended Skilled Nursing Unit (SNF). The evaluator entered the suspended area and observed that the walls were only framing with exposed ceiling and electrical wiring. The floors and equipment were very dusty. The suspended area was being used to store construction and cut metal materials for the hospital's seismic building project. The evaluator observed that the area held a lot of construction and hospital furnishing such as wall boards, couches, desks and chairs, bags of plaster and cement, architect drawing plans, a large metal container on wheels for electrical equipment, a welding compressed gas cylinder, buckets, a portable electric circular saw used to cut metal lying on the floor, and orange extension cords plugged into electrical outlets.

An interview was held with the building supervisor and he stated that he was staging the hospital's seismic project material. An interview was held with the epidemiologist and he stated that he monitors areas of potential contamination in regards to construction and remodeling. The epidemiologist could not produce any documentation that the suspended area was on the monitor listed area. The epidemiologist stated that he classified the construction as a Class II - Construction and remodeling activities that increase risk for nosocomial infection. (Policy # IC-11-004, Manual Infection Control)

A review of the Manual Infection Control indicated, "Debris, when transported, must be completely covered to contain dust during transport. An interview was held with the building supervisor and he stated that the housekeeping staff has to vacuum the corridor leading to the suspended area fourteen times on a daily basis because of the dust and material track into the hospital's corridor.

An interview was held with the Authority having Jurisdiction, the Office of Statewide Health Planning and Development (OSHPD) and he stated that the suspended area cannot be used for anything and all the material shall be removed as soon as possible.




16281


Main Hospital Campus

On February 12, 13, 15, 20, 21, 2013, accompanied by the Director of Facilities Operation, the evaluator observed the following:


Main Hospital Building 1; 2nd floor.

2. On February 12, 2013 between 11:40 a.m. and 4:40 p.m. accompanied by the Director of Facilities Operation the evaluator observed the following.

a. At same day surgery, there was a burned out ceiling light.

b. At same day surgery, there was peeling at the ceiling of the patient discharge area.

c. Room 204 had peeling paint at the wall.

d. Room 208 had a loose privacy curtain rail.

e. The EVS supplies room had emergency transfer equipment locked in it. Closer observation revealed the R.N. Administrative Supervisor/House Supervisor did not have keys with her to unlock the EVS supplies room. Further observation revealed the House Supervisor obtained a second set of keys from the nurses station that also did not have the key to unlock the EVS room.

During an interview the House Supervisor stated she was trained to use the transfer equipment and that the expectation was that everyone including nursing staff would use the equipment if needed in an evacuation emergency. She also stated she was aware the transfer equipment was locked in the EVS room and that she and nursing didn't have a key to unlock the EVS supplies room to access the emergency patient transfer equipment.

Main Hospital Building 3; 1st floor BHU.

3. On February 15, 2013 between 1:30 p.m. and 3:00 p.m., accompanied by director of facilities operation, the evaluator observed the following:

a. At BHU 1 West and BHU 1 South, there were fixtures in patient areas that were not designed so there were no hanging points where something could be tied to including patient room and seclusion/quiet room bathroom sink faucet fixtures and safety grab bars; patient room door handles; patient room door closer bars; common shower fixtures and safety grab bars.

During an interview at the same time as the observation, the BHU 1 West Charge Nurse stated, "we have had some patients on this unit with suicide precautions and we do have one now."

b. There were twenty five loose fist sized landscaping river stones at the perimeter of a drain at the 'tranquility' patio that was visited by BHU 1 West and BHU 1 South patients.

During an interview at the same time as the observation, the BHU 1 South Charge Nurse stated the patients of BHU 1 South had the highest acuity of the three BHU units, were much younger and more highly assaultive.

c. Room 170 at BHU 1 West had chipped paint at the doorway.

d. BHU 1 West had a loose handrail at the corridor next to room 170.

e. The BHU 1 West seclusion room had a ceiling mounted smoke detector with electrical components outside of the smoke head.

f. The BHU 1 West kitchen had a corroded electrical conduit at the wall.

g. The BHU 1 West kitchen had a sign of water damage at the ceiling.

h. A BHU 1 South cross corridor door release mechanism was missing its cover exposing the metal mechanical parts including springs.

i. The BHU 1 South EVS supplies room had emergency patient transfer equipment locked in it. During an interview the director of Facilities Operation stated that only EVS and Engineering had the keys.


Main Hospital Building 3; 2nd floor OB and OB overflow/med unit:

4. On February 13, 2013 between 11:35 p.m. and 12:13 p.m., accompanied by engineering the evaluator observed the following:

a. The OB unit ice machine had an accumulation of white and brown substances at the dispenser.

b. The OB unit sink had an accumulation of calcification on the spout.

c. At the OB scrub sink room serving the Delivery and C-Section rooms, the wall mounted clock was obstructed from view from the scrub sink by a warming cabinet. There was no other timing device visible from the scrub sink.

d. The OB EVS supplies room had emergency patient transfer equipment locked in it. During an interview at the same time as the observation, the director of Facilities Operation stated the nursing staff did not have a key to the room.

5. On February 15, 2013 between 10:45 p.m. and 11:35 p.m. accompanied by engineering staff, the evaluator observed the following:

a. The OB Delivery room had cracks at the ceiling.

b. The OB C-Section room had a damaged ceiling.

c. At the OB overflow/med unit dirty utility room, there was peeling paint at the wall.

d. At the OB overflow/med unit dirty utility room, there were sections of veneer missing from the sink counter exposing the particle board.

e. At the OB overflow/med unit dirty utility room, the dispensing end of a paper towel dispenser was 3 inches from the sink counter so the dispensed length of the towel would lay on the sink counter with the potential to contaminate the towel and washed hands.

f. The OB overflow/med unit kitchen ice machine had an accumulation of calcification at the dispenser. There was also an accumulation of dust under the machine.

g. The OB overflow/med unit EVS supply room had emergency patient transfer equipment locked in it. During an interview at the same time as the observation, the director of Facilities Operation stated only EVS and engineering had a key to the room.


Main Hospital Building 4; 2nd floor ICU B and C.

h. ICU B had four suites each missing sleeves, diffusers or shields to contain shattered glass at three fluorescent ceiling light fixtures next to the exterior window in suites B-3, B-4, B-5 and B-6.

i. Suites B-5 and B-6 had sections of the bed head panels missing exposing the cavity inside.

j. The ICU B Staff Lounge had an ice machine with an accumulation of calcification at the spout of the dispenser.

k. The nurses breakroom between ICU B and C had an ice machine with an accumulation of brown slime and calcification at the spout of the dispenser.

l. ICU C had four suites each missing sleeves, diffusers or shields to contain shattered glass at the fluorescent ceiling light fixtures next to the exterior window in suites C-3, C-4, C-5 and C-6.


South Campus D/P Acute Psychiatric Hospital:

6. On February 14, 2013, between between 8:20 a.m. and 10:00 a.m., accompanied by engineering, the evaluator observed the following:

a. Fixtures in patient areas were not designed so there were no hanging points where something could be tied to including patient room, seclusion/quiet room and dining/recreation room bathroom sink faucet fixtures and safety grab bars; patient room door handles; patient room door closer bars; common shower fixtures, safety grab bars and shower curtain. ANTI room 1259 also had a privacy curtain rail with 2 1/2 ft. supports that was not designed so there were no hanging points.

During an interview, at the same time as the observation, the security stated ANTI room 1259 was used for the examination of patients.

During an interview, at the same time as the observation, the engineering stated "the (shower) curtain is suppose to be a Velcro supported curtain".

b. There was a shorted blackened and melted electrical receptacle in the activity/dining room. On the same day during an interview, the engineer stated that upon replacing the shorted receptacle, they had found aluminum foil in the receptacle.

c. Common shower room #1215 had the metal mixing valve plate bent and pulled away from the base creating a thin metal exposed edge. There was also a rusted sprinkler head scutcheon and a rusted exhaust register vent at the shower room.

d. Patient Rooms 1, 10 and 11 had loose toilet seats.

e. Patient Room 10's corridor door had a split down the spine of the door.

f. There was no call bell at common shower room 1215. During an interview, at the same time as the observation, the engineering stated "looks like its (call bell) been kicked in."

g. There was an accumulation of calcification at the ice and water dispensers of the counter top ice machine in the dining room.

h. A paper towel dispenser dispensed the length of the towel so it laid on the sink counter in the exam room with the potential to contaminate the towel and washed hands.

i. There were five water stained ceiling tiles at a basement office. Three of the tiles were bulging and one of the tiles missing from the ceiling was broken on the floor. The water damaged ceiling tiles were directly below a sewer drain line.


Outpatient Services - OB and Family Health:

7. On February 15, 2013, between 8:30 a.m. and 10:35 a.m., accompanied by the director of Facilities Operation, the evaluator observed the following:

a. There were six loose hand rails at the corridors by rooms 410, 411, 412, baby room and nurses station.

b. There was a loose faucet and and damaged counter/backsplash at the nurses station. The loose faucet was pulled away from the counters plumbing access creating a penetration between the faucet and the counter top. Closer observation revealed the counter/backsplash was cracked, sagging, water damaged, and had an accumulation of black material.

c. There were signs of water damage at the wall of procedure room 414 and at the ceiling tile and support rails by room 403.

d. There was a damaged wall next to the roll down fire door in the basement.

Based on observation, interview, and record review, the facility failed to ensure that potentially infectious wastes was disposed in the proper receptacle. An indwelling urinary catheter was disposed in a non-biohazardous waste bin.


Findings:

On February 12, 2013 during a tour of the intensive care unit (ICU) at 9:15 a.m., a urinary catheter and the urine collection bag were seen in a trash can located in the dirty utility room. The trash can was a non-biohazardous waste trash can.

During a concurrent interview, the director of the ICU stated the catheter should be disposed in a biohazardous waste bin.

Based on observation and staff interviews, the hospital failed to ensure that it had installed backflow preventer on the faucet in the janitorial closet in the South Campus. In addition, it failed to adequately maintain the sewage trap and prevent malodorous gas from building up in the kitchen. It has failed to maintain the kitchen to reflect the scope and complexity of the services it offers in accordance with accepted standards of practice.

Findings:

1. During the tour of the South Campus on February 13, 2013, at approximately 10:10 a.m., there was a large sink with a hose attached to the end of the faucet. The end of the faucet was lying at the bottom of the sink. No backflow preventer was observed as part of the plumbing. The food service manager (FSM), food service supervisor (FSS) and clinical nutrition manager (CNM), who were all present during the tour, stated that there had been no modifications made to the sink and seemed to be the way the sink had always been plumbed. A janitorial sink faucet requires a backflow regulator or any faucet that has a hose attached to prevent backflow into hospital system and contamination of the hospital water system.
In an interview on February 14, 2013, at approximately 9:26 a.m., the director of plant operations (DPO) was interviewed regarding the lack of a backflow preventer in the sink in the janitorial closet. He stated that there was a back flow preventer for the whole building. The backflow preventer the DPO had referred to was a large one that prevents the hospital contaminated water from transferring into the municipal water system.
According to the 2009 Food Code Chapter 5-203.14, "a plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose bibb if a hose is attached or on a hose bibb if a hose is not attached and backflow prevention is required by law." A hose bibb is a threaded faucet with a nozzle that is bent down.
2. There was a smell of sewage that permeated the kitchen in the South Campus. This observation was shared with the FSM, CNM and FSS. The FSS, who is responsible for the day to day management of the kitchen, at the South campus, acknowledged the sewage smell. She explained that the plant operations clean out the sewage trap frequently approximately every two months but that the kitchen always smells.

In the same interview with the DPO on February 14, 2013, he stated that the sewage smell was due to the fact that the facility was not being fully utilized and therefore need water to be poured down the drain to create a barrier.

3. The freezers in both the main hospital and South Campus had a significant build-up of ice along the door frame and air curtains.

Main Campus:
1. The freezer door in the main campus had a worn out rubber gasket that resulted in an incomplete closure of the freezer door. The incomplete closure causes warm air from the kitchen to get into the freezer causing condensation and build- up of ice along the doors, floor and air curtains. The ice build-up would crystallize and so as staff walked through the air curtain to obtain items from the freezer, the ice crystals would break off onto the floor and threshold/ ramp causing it refreeze and build-up.

FSW who maintained food storage indicated that several times a week he would chip ice off the door. Each of the slats on the air curtain had about1/8th to ? inch thick the whole length of the curtain. The build-up of ice on the floor threshold was about a foot long and an inch to two inches thick and slippery, and an accident hazard. In addition there was a black substance along the perimeter of the door and door frame.

The director of food service in an interview on February 14, 2013 at approximately 10:00 a.m., indicated that he was aware of the problem and that the door gaskets had been repaired in the past.

The floor strips that could minimize falls had also worn out and FSM stated that work orders had been placed for replacement. Review of the work order dated August 18, 2011 indicated that a request was made to "add three strips of Grip tape to the ramp on the floor to walk in freezer #3 in the kitchen." Under the status history, it stated it was completed. No other documentation was provided to indicate that if the problem had not been resolved, it had been reported.

2. At approximately 9:26 a.m. on February 13, 2013, there was a leak observed in the dish room. The sprayer for the dish machine had a leak at the base of the stem. The FSM stated that was a work order for the leak had been submitted.

Review of the work order dated January 14, 2013, indicated that a work order was placed and a hose was installed on January 16, 2013. Based on the observation on February 13, 2013 at 3:42 p.m., the problem had not been fixed.

The faucet on the 3 -compartment sink also had a leak. The work order for the leak dated September 26, 2012, was reviewed. It indicated that it was completed (repaired). This sink had a leak on February 14, 2013.

3. At approximately 12:00 p.m. on February 12, 2013, the refrigerator next to the tray line was observed to read 28 degrees Fahrenheit. Orange juice and milk were stored in the refrigerator. A check of the temperature of a carton of orange juice showed it to be ice slushy and reading 30 degrees Fahrenheit, while the carton of milk was 33.9 degrees. Both temperatures were too low (cold) for the recommended temperature for service of cold items. Consuming the items at the sub-freezing temperatures observed could be uncomfortable for some patients with teeth sensitivity to cold (cross refer 749).

4. There were carts along the corridor outside of the dry food storage area. On the carts were loaves of bread. In addition, there food bins with dry foods like beans, sugar, etc. There is inadequate space in the present food storage area to hold all the items observed in the corridor. The storage of food in the area could be fire hazard as the corridor is not fire rated for the items that was stored in it.

5. During lunch tray line observation on February 12, 2013, several white plates were observed with dark brown discoloration. Closer interview revealed that the plates had lost its glaze. The use of plates that has lost its glaze could result in the leaching of unwanted substances from the plate into food.

South Campus:
1. There was a build-up of ice in the freezer in the South Campus. The condenser had approximately six to eight inches of frozen ice hanging from the rear portion. There was about a small area of ice on the floor directly above the frozen ice above approximately three inches in diameter and about three inches thick, indicating that the water had dripped and had frozen. There was also condensation and ice build-up on the ice curtain at the entrance to the freezer. The condenser fan was also clogged with ice, and as the fan blew, particles of ice, resembling snow blow out of the fan.

At 10:51 a.m. on February 13, 2013, the walk-in refrigerator was 41 degrees Fahrenheit. The temperature of a carton of a health shake was 45 degrees Fahrenheit. The recommended temperature of refrigerated foods is 41 degrees Fahrenheit or below. There was a box of hot dogs with ice crystals, a sign of previous thawing and refreezing. The FSS who was present during the tour was unable to explain why the hot dogs showed signs of previous thawing.

Review of the refrigerator logs dated Feb 2013 revealed morning temperatures taken at 6 a.m. were in the 39- 40 degrees range. The afternoon temperatures were in the 40 to 48 degrees Fahrenheit range. These temperatures were higher (warmer) than the hospital contractor recommended range of 34 to 38 degrees Fahrenheit. The FSS indicated that work order had been placed to repair the door.

Review of the work order dated December 28, 2012, indicated that the problem identified was a broken part (piston) that prevented a complete closure of the door. The part had been ordered but as of six weeks later the problem had not been resolved resulting in food safety concerns.

2. There were carts of food along the corridor leading into the kitchen. There was another cart of canned food items along the wall in the kitchen. The size of the food storage area would prevent the storage of the food items observed on the carts. These are potential source of danger during evacuation from the kitchen.

An interview was conducted on February 14, 2013, with the Director of Plant Operations at approximately 9:26 a.m. He stated that he was aware of some of the identified problems but because of the age of the building some of the problems could not be prevented. He further stated that his department attempts to fix problems with the amount of staff he had.

Review of the hospital's website revealed that the hospital had a 96-bed construction completed in 1978. "in 1997 ...since the change of ownership the hospital has tripled the inpatient census." The hospital is currently "licensed with 157 acute care beds" not counting the South Campus). The kitchen facilities had not been updated and upgraded to meet the increased needs of the patients.

Based on observation, interview, and record review, the facility failed to ensure that the facility was maintained in a manner that was safe for patients. Light fixtures did not have a method of containing broken glass if a light bulb should break. Patients from the behavioral health unit (BHU) had access to stones in the patio area.

Findings:

a. On February 12, 2013, during a tour of the intensive care unit (ICU) at 9:15 a.m., a light fixture located on the ceiling in the ICU walkway did not have a method to contain glass shards if the bulbs were to break.

During a concurrent interview, the ICU director stated she understood the potential for injury of the light bulb should break.

b. On February 12, 2013, during a tour of the Behavioral Health Unit's patio area revealed several stones on the ground.

During a concurrent interview with the BHU's charge nurse, she stated that the BHU at times would care for patients with violent behaviors and homicidal ideation's.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the kitchen refrigerator was maintained in a manner to keep food safe and inhibit the growth of microorganisms and ensure patient comfort.

Finding:

During kitchen observation on February 12, 2013 at approximately 10:20 a.m., the external thermometer on refrigerator # 4 read 31 degrees Fahrenheit. The internal thermometer of the unit read 27 degrees Fahrenheit. At both temperatures, the items should be partially frozen, none of the items stored in the unit showed signs of freezing. It appeared that both thermometers were inaccurate.

A review of the temperature log titled "HACCP refrigerator temperature log - Critical Control Point " dated February 2013 posted on the unit was done. It showed that earlier that morning at 5 a.m., the temperature was 35 degrees. The recommended temperature range for the unit per the contractor, a food management company is 34 - 38 degrees Fahrenheit. The corrective action steps were geared towards temperature s above 41 degrees Fahrenheit.

Further review of the log showed of 23 recorded temperatures 13 were out of the parameters set. A facility calibrated thermometer was placed in the refrigerator to validate the thermometer readings. The thermometer read 37 degrees Fahrenheit.

There was no documentation that any corrective action was taken when the temperatures were outside of the range set. The food service manager, who was present during the observation, provided no comment on why there was no further investigation done when the temperatures were out of range.

South Campus:
1. There was a build-up of ice in the freezer in the South Campus. The condenser had approximately six to eight inches of frozen ice hanging from the rear portion. There was about a small area of ice on the floor directly above the frozen ice above approximately three inches in diameter and about three inches thick, indicating that the water had dripped and frozen. There was also condensation and ice build-up on the ice curtain at the entrance to the freezer. The condenser fan was also clogged with ice, and as the fan blew, particles of ice, resembling snow blow out of the fan.

At 10:51 am on February 13, 2013, the walk-in refrigerator was 41 degrees Fahrenheit. The temperature of a carton of a health shake was 45 degrees Fahrenheit. The recommended temperature of refrigerated foods is 41 degrees Fahrenheit or below. There was a box of hot dogs with ice crystals, a sign of previous thawing and refreezing. The FSS who was present during the tour was unable to explain why the hot dogs showed signs of previous thawing.

Review of the refrigerator logs dated Feb 2013 revealed morning temperatures taken at 6 a.m. were in the 39- 40 degrees range. The afternoon temperatures were in the 40 to 48 degrees Fahrenheit range. These temperatures were higher (warmer) than the hospital contractor recommended range of 34 to 38 degrees Fahrenheit. The FSS indicated that work order had been placed to repair the door.

Review of the work order dated December 28, 2012, indicated that the problem identified was a broken part (piston) that prevented a complete closure of the door. The part had been ordered but as of six weeks later the problem had not been resolved resulting in food safety concerns (refer to A 726).

Failure to check to ensure the accuracy of the documentation gave the hospital a false sense of security. It was not aware that there was about a six degree difference between the external thermometer and a ten degree difference with the internal thermometer. The addition of six to ten degrees to some of the recorded temperature would put the temperature out of range, causing food to be stored at temperatures that would support the growth of microorganisms.

2. In the walk- in refrigerator #2 on February 12, 2013, at approximately 11:00 a.m., the internal thermometer read 38 degrees Fahrenheit. A large cardboard box stored on the shelf was dated "2/6/13." The box held 7-5 lb eye of round beef pieces. The stock keeper who was present during the observation responded that that that box of meat was kept refrigerated for two weeks based on manufacturer's guidelines.

Closer examination of the box revealed manufacturer's instructions to store at 28 to 34 degrees Fahrenheit. Review of the refrigerator log labeled "dairy #2 for the month of February showed that of the 13 recorded temperatures (AM and PM) from February 6, 2013, only three was within the manufacturer's recommended temperature range.

Review of the hospital untitled policy posted on the refrigerator showed that raw meats should be discarded "5 days after pulled from freezer." There was no policy on length of time of storage of raw meat (not previously frozen). According to the Food and Drug Administration, fresh meat should be stored in the refrigerator for 3 to 5 days.

Improper storage of food could result in the growth of microorganisms that could cause food spoilage and /or food borne illness.

3. At approximately 12:00 p.m. on February 12, 2013, the refrigerator next to the tray line was observed to read 28 degrees Fahrenheit. Orange juice and milk were stored in the refrigerator. A check of the temperature of a carton of orange juice showed it to be ice slushy and reading 30 degrees Fahrenheit, while the carton of milk was 33.9 degrees. Both temperatures were too low for the recommended temperature for service of cold items. Consuming the items at the sub-freezing temperatures observed could be uncomfortable for some patients with teeth sensitivity to cold. According to the National Dairy Association, milk tastes best when it's served between 35? and 40?F.

The food service manager who was present during the observation acknowledged the temperatures and explained that items had been received frozen and there had not been adequate time to thaw. Due to inadequate refrigerator space items are ordered without adequate time to ensure proper thawing. In an interview with the CNM, on February 14, 2013 at approximately 2:27 p.m., she indicated that reviewing of temperature logs was part of the department Quality Assurance Performance Improvement plan and was discussed monthly at the meetings. No explanation was given for the non- action when the temperatures were out of range.

Based on record review and interview, the facility failed to ensure a single-use medication was used in one dose on one patient.

Findings:

On February 14, 2013 at 3:15 p.m., in the pharmacy, during a review of controlled substances reconciliation reports with Staff 3 and 5, Staff 5 confirmed he reconciled Anesthesiologist 1's tray usage report dated February 12, 2013. Staff 5 agreed that the record indicated Anesthesiologist 1 used one vial of the fentanyl 250 microgram (mcg) /5 milliliter (ml) for six patients on February 12, 2013.

A review of the fentanyl packaging, obtained from Staff 5, indicated the vial is "Preservative-free" and "single dose- destroy unused contents."

On February 15, 2013, at 10 a.m., during an interview, the director of infection control stated the single-use vial should only be used on one patient and could not be used for multiple patients.

A review of the facility's policy and procedure, titled "Infection Control: Single-use sterile drugs and devices," dated "1/13," indicated "... Single-use sterile drugs ... shall not be reused ... "

Based on observation, interview, and record review, the hospital failed to ensure that infection prevention and control strategies were implemented to prevent the spread of infection. Inappropriate cleaning of potentially contaminated equipment and practices may facilitate the spread of infections. The hospital failed to ensure that an effective system was for identifying and developing practices, procedures and maintaining equipment to ensure that proper food sanitation procedures were followed to prevent the growth of microorganisms.

Findings:

1. On February 12, 2013, during a tour of the ICU at 9 a.m. a glucometer had tape residue on the casing and was in direct contact with clean gauze.

During a concurrent interview RN 1, she indicated that the glucometer should be cleaned and free of residue. In addition, RN 2 indicated that soap and water was used to clean the glucometer.

Tape residue on the glucometer has the potential to hinder the appropriate cleaning whereby pathogens may adhere to the sticky residue. Moreover, the use of soap and water will not deactivate blood borne pathogens that may have contaminated the glucometer.

2. On February 12, 2013 at 10:05 a.m., during a tour of the ICU a staff member was wearing gloves was seen caring for a patient. The staff member then exited the patient's room and removed her gloves. The staff member did not perform hand hygiene prior to touching inanimate objects in the nurses' station.

During a concurrent interview, the director of ICU stated the staff member should have performed hand hygiene prior to exiting the patient 's room.

According to the Centers for Disease Control and Prevention (CDC), health care workers should perform hand hygiene after patient contact.

3. On February 12, 2013, during an inspection of the ICU s pantry, an ice machine was inspected. The ice machine, which provided ice for patient consumption, had a heavy accumulation of white debris at the dispensing spout. Further inspection revealed a spider located in the chute where ice was dispensed from.

During a concurrent interview, the ICU director stated the ice machine would be cleaned.

4. On February 12, 2013 at 11:40 a.m., a tour of the facility's emergency room Room 3 was inspected. Room 3 had dust located in the patient care areas. Drawers that stored patient care items and an electrocardiogram (EKG) machine had adhesive film on its surface.

5. In the emergency room refrigerator, there were "iStat" laboratory supplies. The thermometer located in the refrigerator measured the temperature at 5 degrees Celsius. However, a review of the monitoring log, the acceptable temperature parameters was 18-30 degrees Celsius. Moreover, the thermometer found in the refrigerator had a range that measured up to 15 degrees Celsius.

During a concurrent interview with the director of ICU, she stated the wrong thermometer was used to measure the refrigerators temperature.

6. On February 12, 2013, during a tour of the Behavioral Health Unit (BHU) at 2 p.m., an ice dispenser had debris and grime on its spout.

During a concurrent interview, the BHU director stated the ice machine would be cleaned.




10933


7. At approximately 11:38 a.m. on February 12, 2013, a food blender that had been stored away as clean was observed to have a light brown residue in the plastic container portion of the blender. When the plastic container was separated from the base and blade, it revealed a yellow thick substance on the base of the container, blade and rubber gasket.

It appeared that the blender parts had not been separated prior to washing. The cook who had used the blender stated that she had sent it through the dish machine without removing the parts. Review of the hospital policy titled " Sanitation Procedures- Food Processor," reviewed 11/12 showed that the procedure was to " .....remove the lid, blade and bowl from the base by lifting out of base. Soak all removable parts in the pot sink in hot solution of cleaner ...wash and sanitize in the three compartment sink ... "

8. On February 13, 2013, at approximately 10:30 a.m., at the South Campus, a blender that had been stored away as clean was found to have a black and brown colored residue on the lid, blade and rubber gasket. There was a white substance on the base of the blade underneath where the rubber gasket had been removed. There was also a crack at the base of the plastic container. The crack could cause food residue to be caught in the crevice making it difficult to clean and providing a medium for bacterial growth.

The food service supervisor was informed by one of the cooks present that it had been used the night before by another cook who was not present during the interview. Review of training logs for all staff did not reveal education on the appropriate procedure to clean blenders and food processors.

9. There was a build-up of ice in the freezer in the South Campus. The condenser had approximately six to eight inches of frozen ice hanging from the rear portion. There was about a small area of ice on the floor directly above the frozen ice above approximately three inches in diameter and about three inches thick, indicating that the water had dripped and had frozen. There was also condensation and ice build-up on the ice curtain at the entrance to the freezer. The condenser fan was also clogged with ice, and as the fan blew, particles of ice, resembling snow blow out of the fan.

At 10:51 a.m. on February 13, 2013, the walk-in refrigerator was 41 degrees Fahrenheit. The temperature of a carton of a health shake was 45 degrees Fahrenheit. The recommended temperature of refrigerated foods is 41 degrees Fahrenheit or below. There was a box of hot dogs with ice crystals, a sign of previous thawing and refreezing. The FSS who was present during the tour was unable to explain why the hot dogs showed signs of previous thawing.

Review of the refrigerator logs dated Feb 2013 revealed morning temperatures taken at 6 a.m. were in the 39- 40 degrees range. The afternoon temperatures were in the 40 to 48 degrees Fahrenheit range. These temperatures were higher (warmer) than the hospital contractor recommended range of 34 to 38 degrees Fahrenheit. The FSS indicated that work order had been placed to repair the door.

Review of the work order dated December 28, 2012, indicated that the problem identified was a broken part (piston) that prevented a complete closure of the door. The part had been ordered but as of six weeks later the problem had not been resolved resulting in food safety concerns.

10. At approximately 11:50 a.m. on February 12, 2013, several vases of fresh red flowers were observed in a refrigerator in the kitchen labeled " ED (Emergency Department) Sandwich and Employee Meals. There were plated sandwiches for patients and plastic bags for employee meals stored in the refrigerator.

Food service manager who was present during the tour stated that the facility did not have any policy on the storage of fresh cut flowers in the kitchen refrigerator.

11. At approximately 11:00 a.m., on February 13, 2013, two red buckets underneath the counters were tested to check the chemical sanitizer concentration. The test strip revealed no color change, implying that there was little or no chemical in the solution to react.

12. The can opener in the main kitchen was observed on February 12, 2013 at approximately 10:15 a.m. to have a black, sticky residue that did not appear to be new dirt. The dirt could harbor and support the growth of microorganisms that could cause food borne illness. The presence of dirt and other residue on the blade of the opener could result in the cross-contamination of food that come in contact with the blade.

The food service supervisor stated in a concurrent interview that the bucket was filled at approximately 6 a.m. earlier that morning. Approximately five had lapsed since the bucket had been filled. According to FSS the bucket should have been discarded after about three hours. The lack of sanitizer in the solution would not allow the sanitizing of non- contact food surfaces and work areas.

The infection control preventionist (ICP) was interviewed on February 14, 2013 at approximately 8:52 a.m. He discussed his role is between the food service director and RD. he stated that he participated in rounds to the kitchen and checks that temperature logs are completed and ensures all areas are clean. He stated he had not observed the flowers in the kitchen refrigerators. He acknowledged that the rounds did not include the South Campus.

Review of the check list dated July 18, 2012, utilized by the ICP on his infection control rounds revealed the 12-question checklist did not evaluate the areas of concerns and deficient practices identified during the survey. Of the 12 questions, three was (N/A) not applicable for the kitchen.

Based on observation, interview with staff, and review of the policy, the facility failed to ensure that accepted professional surgical standards were maintained in the operating rooms. During several observations the doors to the operating rooms were observed to be kept open during surgical procedures. The facility failed to ensure the surgical staff followed the policies & proceures for "Infection Control Practices" and "Aseptic Techniques" in surgical area.

Findings:

During the tour to the surgical area with Administrator 4 on February 12, 3013 between 9 a.m. and 10:30 a.m., the following were observed:

1. The pocket doors to the OR (Operating Room) 1 and OR 2 were kept partially opened to the semi-restricted area while the surgical procedures were being performed with the sterile field created.

During an interview with Administrator 4 on February 12, 2013 at 10:05 a.m., she stated the pocket door should be maintained closed during the surgical procedure.

2. The door from OR 2 to the Sub-Sterile Room (between OR 1 and OR 2) was kept opened during the surgical procedure was being performed with the sterile field created while the door from OR 1 to the Sub-Sterile Room had been kept opened for cleaning after the procedure. There was no other access to the Sub-sterile Room, except from OR 1 and OR 2.

According to Administrator 4 on February 12, 2013 at 10:15 a.m., the door from OR 2 to the Sub-Sterile Room should be maintained closed during the surgical procedure.

3. There were multiple broken ceiling in the semi-restricted area for OR 1.
During an interview with Employee A on February 12, 2013 at 10:05 a.m., she stated those broken ceiling tiles should be fixed.

A review of the Surgery Schedule for February 12, 2013, disclosed the "Decompression laminectomy and disectomy at L3-S1" was performed in OR 1 and "C3-5 decompression of spinal cord followed by fusion" was performed in OR 2.

According to the policies & proceures for "Infection Control Practices in OR" (Policy#: SUR-09-001), all operating room doors would be closed at all times during surgery or procedure.

Based on the policy & procedure for Aseptic Technique" (Policy#: SUR-01-007), aseptic technique guidelines, included doors into the OR Suite are to be kept closed.



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4. On February 13, 2013, during a tour of the operating room (OR), in OR 1, a surgery was in progress. The pocket doors to OR 1 were open and created a conduit to the semi-restricted area.

In OR 1, the sub-sterile room door was also open during the surgical procedure.

5. In OR 2, the door that leads to the semi-restricted area was open while a surgical procedure was in progress.

During a concurrent interview, the OR charge nurse stated the doors should be closed during surgery. The charge nurse stated the doors were difficult to open and close.

6. Foot rests used to position the patients for surgery had adhesive residue on its surface which does not allow for through cleaning of the surface.

7. The supply room that housed sterile instrument packs had a vent grill that had a heavy accumulation of dust.

The sterile packs were stored in such a manner that exposed them to dust.

8. Carts with sterile packs were stored in the semi-restricted area where OR 4 and OR 5 were located. The covers placed over the cart were open which exposed the sterile packs and put them a risk for dust and splashing.

During a concurrent interview, the OR charge nurse stated the sterile packs should be covered with the cart cover.

9. In the instrument reprocessing room a sink was used to mix water and an enzymatic solution for instrument precleaning. The sink did not have a demarcation line which indicated the number of gallons for appropriate mixing of the precleaning solution.

During a concurrent interview with the surgical technician he stated there should be a demarcation line to measure the amount of water and assure consistency.

10. In the instrument reprocessing room, the piping was wrapped with insulating material. The insulating material was torn and had the insulating fibers exposed.

On February 12, 2013, at approximately 10:50 a.m., a third observation of the OR was conducted, the doors to OR 1 and OR 2 were observed to be left open while surgeries were being performed. The doors were also left open to the semi-restricted area.

The OR charge nurse was notified of the observation. The doors were closed; however, once closed, there was a gap between the door and the door frame that measured approximately one and a half inch.

According to the Association of Perioperative Registered Nurses (AORN), open OR door create conduits for potentially contaminated air and increase the risk of operative site infections.

Based on record review and interview with staff, the facility failed to ensure the operative reports were electronically signed for completion by the surgeon immediately following surgery for Patient 29.

Findings:

On February 15, 2013, a review of the clinical record disclosed Patient 29 was admitted to the facility on January 26, 2013. The patient was discharged on January 31, 2013.

The Operative Record was reviewed and disclosed the patient had undergone a surgical procedure, right total knee replacement on January 29, 2013. However, the operative report was performed by the surgeon on January 31, 2013, which was 2 days after the procedure.

During an interview with Administrator 3 on February 15, 2013 at 10:35 a.m., she stated the operative report was performed by the surgeon 2 days after the procedure.

According to the "General Medical Staff Rules & Regulations,"
"5.5 Operative Reports," the operative reports shall be dictated, or completed in the hospital electronic medical record immediately after surgery.

Based on observation, interview and document review, the facility failed to ensure patient records were secured at all times and in all locations to ensure that unauthorized individuals could not gain access to the records.

Finding:

On February 14, 2013 at 10:00 a.m., accompanied by security and engineering, the evaluator observed 13 stacks of patient records on a counter top and 15 stacks of patient records on a utility cart in an area of the transportation office used for storage at the south campus. The area was open to 3 outside contract transportation staff, security and engineering. Without opening the record, the evaluator was able to see patient names and list of body parts on the cover sheets of the records at the top of the stacks.

During an interview, at the same time as the observation, the litigation liaison stated the records were patient hearing files that were being prepared for court, that the transportation staff do not work with the records and cannot look at them, and that they are usually locked in his office.

On February 20, 2013, accompanied by the litigation liaison manager and the director of business office, review of a sample record of the stack revealed the following patient information was part of the record:

Name, social security number, birthday, gender, address, telephone number, diagnosis, physical exam, medical procedures, medical record review, relevant medical history, disability status, allergies, emergency notification, social and family history, work restrictions, limitations to activities of daily living, accidents/injuries, occupation and employer information.

During an interview at the same time as the record review, the litigation liaison manager and the director of business office stated they did not have a policy for securing of records at the billing business office.

Based on observation, electronic patient record review, review of hospital menus and other documents and staff interviews, the hospital failed to ensure that a vegetarian menu was developed for one sampled patient (Patient 2.) of 30 sample patients. The hospital also failed to ensure that the menu met the nutritional needs of all patients.

Findings:

1. At approximately 11:20 a.m. on February 13, 2013, veggie burger was observed on the lunch tray line. The cook stated it was for patients on the vegetarian diet. Review of the Active Diet Orders dated February 13, 2013, for the South Campus indicated that Patient 2 was on a vegetarian diet.

Review of the hospital menu/spreadsheet was completed. It did not include a menu for vegetarian diets. There were eleven diets on the spreadsheets as follows: regular/3-4 Gm (gram) sodium, Heart healthy 3-4 Gm sodium Lo Chol (cholesterol), 2 Gm sodium, Carbohydrate controlled Diabetic, renal, Soft, Mechanically Altered, Pureed, Full liquid, Thickened Pureed and Clear Liquid.

The Food Services Supervisor (FSS) and Clinical Nutrition Manager (CNM) were present during the tour of the kitchen acknowledged that there was no vegetarian diet on the spreadsheet. The FSS stated that the food service staff and cook have a list of food items posted in the kitchen that could be served to the patients on vegetarian or vegan diets.

The use of a food list instead of a written diet could result in the possibility that the nutritional needs of the patient would not be met because the food choices made by the cook was not analyzed by the registered dietitian as part of the complete diet to ensure it met nutritional needs based on age, weight, sex and medical condition. In addition, it could result in decreased variety and food choices, therefore reduced food intake which could impact caloric and other nutrient needs.

2. Review of the menu showed that for lunch the non-select regular diet was offered following food items: Seasonal Mixed Green Salad/dressing, Ball Park frankfurter on a bun, mustard/ketchup, baked Beans, Fresh Baked Dinner roll, brownie, tea, butter, half and half.

The salad served was an iceberg lettuce, carrots and red cabbage mix. The FSS and RD were asked for the recipe for the seasonal Mixed Greens. The FSS stated that there was no recipe and could not state the difference between what she served and what was planned for dinner which was tossed green salad. Serving the iceberg lettuce salad in place of mixed greens would result in decreased vitamins and minerals.

The nutritional content of both salads are significantly different. According to Fresh Express, a national producer of produce, the "Spring Mix Greens" contains a variety of green leafy vegetables including romaine lettuce, Swiss chard, baby spinach, arugula, radicchio. The serving size of this mix also contains 80% of Vitamin A 20% Vitamin C and 6% iron of the daily values based on a 2000 calorie diet. This is in comparison to the "Iceberg Garden,", which contained iceberg lettuce, carrots and red cabbage (similar to what was served in the hospital.) the
"Iceberg Garden" same serving size which has 50% vitamin A, 10% Vitamin C, and 2% iron (Freshexpress.com).

The CMN was asked the nutrient analysis of the menu to validate that it met the nutritional needs of the patients in the south campus. It was at this time she realized that the menu served to the patients was different from those on the main campus. The menu had been changed three years earlier. The FSS stated that she never received any updated menu from the main hospital. There was no nutrient analysis available to validate that the nutritional needs of the patients were being met.

Review of the nutrient analysis of the menu served to the patients at the main hospital revealed that the nutrients had not been compared to the demographics and population served. According to the CNM, the main population of patients served by the hospital is the 51 to 70 year old. The lack of identification of the nutritional needs of these patients according to recognized dietary practices to current national standards for recommended dietary allowances, therefore has resulted in the hospital's inability to evaluate the adequacy of the nutrients needed against the meals provided.