Observations:
Based on observation, review of facility policy and interview with staff (EMP), it was determined that the facility failed to ensure patient food supplies were maintained by the facility in a safe manner for patient use and consumption.
Findings include:
A review of facility policy "Safe Environment for Endoscopy Center" last reviewed March 23, 2020, revealed "PURPOSE: The purpose of this policy is to ensure adequate safeguards to protect patients from healthcare acquired infections and injury while under the care of the Center. PROCEDURE: ...5.i. Only patients are permitted to consume food or drink in patient care areas."
An observation tour conducted on September 6, 2023, at 10:25 AM through 11:30 AM with EMP1 revealed:
Two Gallon Size plastic bags with single serve packages of Saltine Crackers and Graham Crackers with expiration dates of March 12, 2023, and August 15, 2023 in a facility storage cabinet directly outside of the Procedure Rooms adjacent to the Endoscope Cabinet.
Two Cases of containing 12 ounce cans of ginger-ale with no date on the cases and or on the 12 ounce cans.
Two gallon size Plastic Canisters containing single service packages of Graham Crackers and single serve packages of Saltines Crackers sitting on the counter at the nurse's desk with no date on the packages.
An interview conducted on September 6, 2023, at 11:35 AM with EMP1 confirmed the observational findings observed during the tour conducted on September 6, 2023, from 10:25 through 11:30 AM. EMP1 stated "All of these items are for patient consumption. __________
Based on observation and interview with staff (EMP), it was determined that the facility failed to ensure the handling of the high level disinfection endoscopes were transported in a safe manner to the storage cabinet.
Findings include:
An observation tour conducted on September 6, 2023, at 11:22 AM with EMP5 of the Decontamination Room revealed there was a gastrointestinal endoscope storage cabinet located outside of the Decontamination Room in the hallway corridor. Further observation revealed EMP5 transported the gastrointestinal endoscope storage cabinet without protective covering to prevent contamination.
An interview conducted on September 6, 2023, at 11: 30 AM with EMP5 confirmed the high level disinfected endoscopes were transport to the scope cabinet without the use of protective covering.
| | Plan of Correction - To be completed: 10/26/2023
The manufacturer of the ginger-ale was contacted for instructions to determine the expiration or best by date of the product; the manufacturer uses the Julian Calendar to determine such dates. A Julian Calendar was placed in the storage cabinet housing the beverages, in addition to instructions for deciphering the code on the outside of the box. All dates will be marked on the outside of the box and each individual can. Graham Crackers and Saltines will be stored in plastic bags with the expiration date changed upon any new product procurement. In addition, the expiration date of all crackers will be listed on the plastic containers at the Nurses Station. A rolling cart was purchased in September to transport the high-level disinfected endoscopes to the scope cabinets. The endoscopes will be transported in covered containers. All staff were educated on the Environment of Care plan of correction with instructions for labeling beverages and nourishments with expiration dates and transporting the endoscopes, via cart, in covered containers. Education was completed on 10/13/2023 and included demonstration, discussion and Q & A. The Nurse Administrator will be responsible for monitoring the transport of endoscopes in covered containers and labeling of expiration dates on all nourishments, and will audit this process during the monthly Environment of Care rounds. The results of the Environment of Care audits will be reported to the Quality Improvement Committee at the quarterly meetings.
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