HospitalInspections.org

I. Based on review of documents, policies, observation and staff interview, the Critical Access Hospital (CAH) dietary staff failed to follow safety practices for monitoring and recording food storage temperatures. The administrative staff identified a current census of 1 patient and an average daily census of 2 inpatients.

Failure to ensure dietary staff measure and record food storage temperatures could affect the foods appearance and palatability potentially result in a food borne illness.

Findings include:

1. Review of CAH position/job descriptions for dietary cooks and food service workers revealed in part..."Follows all safety, infection control and general hospital policies."

2. Review of CAH dietary policy titled "Food and supply storage" dated April, 2010 revealed in part: "...Refrigerated storage...foods are stored at 33 degrees Farenheit (F)- 40 degrees F immediately."...Frozen foods ... are stored at 0 degrees F or below immediately."

3. During an interview at the time of the tour and observation of the dietary department on 12/13/10, at 9:50 AM, Staff A, dietary aide, stated, "It's [monitoring refrigerator/freezer temperatures] for food safety, we don't want bacteria growing in things that are not cold enough."

4. During an interview on 12/13/10, at 10:05 AM the dietary manager presented the surveyor with refrigerator and freezer temperature log sheets. The dietary manager reported there were "a large amount of incomplete spaces" on the log sheets. He/she stated, "I've posted and talked with [the dietary staff] about this and how it could potentially be a deficiency because if it's not documented then it's not done." He/she reported the hospital purchased new milk coolers "a couple of months ago and the milk temps for October and November are not good, there's a lot of blank spaces. There's no excuse for this."

5. Review of refrigerator and freezer temperature log sheets revealed dietary staff failed to monitor and document refrigerator and freezer temperatures in accordance with CAH policy, as noted below:
a. 3 of 31 days in March 2010.
b. 2 of 30 days in April 2010.
c. 3 of 31 days in May 2010.
d. 2 of 30 days in June 2010.
e. 2 of 31 days in July 2010.
f. 5 of 31 days in August 2010.
g. 13 of 30 consecutive days in September 2010.
h. 4 of 31 days in October 2010.
i. 3 of 31 days in November 2010.
j. 7 of 13 consecutive days in December 2010.

6. Review of milk cooler temperature log sheets revealed dietary staff failed to monitor and document milk cooler temperatures temperatures in accordance with CAH policy, as noted below:
a. 26 of 31 days in October 2010.
b. 27 of 31 days in November 2010.
c. 7 of 13 days in December 2010.

7. During an interview on 12/14/10 at 11:45 AM, the dietary manager reported that they had implemented a new form for monitoring temperatures for all refrigerators, freezers and milk coolers on 12/13/10.

II. Based on review of documents, policies, observation and staff interview, the Critical Access Hospital (CAH) dietary staff failed to follow safety practices for monitoring and recording dishwasher temperatures. The administrative staff identified a current census of 1 patient and an average daily census of 2 inpatients.

Failure to monitor dishwasher temperature could potentially lead to unsanitary dishes and utensils, increasing patient risk for food born illnesses.

Findings included:

1. Review of CAH policy titled "Dish Machine" dated April, 2010 revealed in part:..."Proper dishwasher techniques are essential in maintaining infection control and these techniques shall be utilized to insure infection control...Temperatures will be monitored to meet protocol."

2. During an observation on 12/13/10 at 10:18 AM, Staff B, dietary aide demonstrated how staff use temperature test strips [Temp Rite test strip] in the hot water temperature dish machine to verify the water reaches the recommended hot water temperature. According to Staff B, staff test the water 3 times per day to make sure the water is hot enough to sterilize and clean the dishes. After staff tests the water using the Temp Rite test strip, they tape the strip on the daily temperature logs. Staff B reported that all dietary staff had food and sanitization safety training when they were hired.

The dietary manager, present at the time of the observation, acknowledged that staff was not documenting and/or mounting the test strip on the temperature log in accordance with their policy/protocol. The Dietary Manager said, " I know they're [dietary staff] doing them because I go back and ask them. " The Dietary Manager reported that they were reviewing these issues in their department meetings because, " if it's not documented it's not being done " and failure to consistently run a strip through the dishwasher and document the results has been a problem on and off since last summer.

3. During an interview on 12/13/10 at 10:35 AM the Dietician stated he/she did not know dietary staff had failed to monitor and document dish washing machine temperatures.

4. Review of dishwasher daily temperature log sheets revealed dietary staff failed to follow infection control practices for monitoring and recording dishwasher temperatures as noted below:
a. 15 of 30 days in April 2010.
b. 12 of 31 days in May 2010.
C. 11 of 30 days in June 2010.
d. 13 of 31 days in July 2010.
e. 20 of 31 days in August 2010.
f. 14 of 30 days in September 2010.
g. 18 of 31 days in October 2010.
h. 6 of 30 days in November 2010.

5. During an interview on 12/14/10 at 11:58 AM the dietary manager reported using the test strip to assure the gauge in the dish washing machine was working and that he/she instructs all dietary staff to use the test strips daily as well. According to the dietary manager the facility protocol requires dietary staff to verify the dish machine temperatures with test strips and document the results on temperature log sheets. The dietary manager stated he/she had instructed staff to monitor and document dish washing machine temperatures "at least daily" and "staff will be disciplined [if they] do not follow these protocols."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all physicians (1 of 1 pathologist, and 3 of 3 radiologists from Hospital A) received external peer review. The laboratory manager identified an average of 25 tissue samples per month reviewed by the pathologist. The radiology manager identified an average of approximately 250 radiology procedures interpreted per month by the radiologists from Hospital A.

Failure to perform external peer review could potentially result in patients receiving inappropriate or inadequate care from the physicians at the CAH.

Findings include:

1. Review of the policy "MEDICAL STAFF PEER REVIEW", reviewed 8/10, revealed in part, "Upon reappointment one chart will be selected from the 3 top [diagnosis of patients treated by the physician] per provider for Peer review at [Name of Hospital A]."

2. Review Pathologist A's credential file revealed CAH administrative staff did not send any clinical records from patients who received Pathologist A's services for external peer review.

3. Further review of Pathologist A's credential file revealed a letter dated 5/24/10 from the Medical Staff Coordinator to the Medical Staff. The letter revealed "[Pathologist A's Name] has had no activity at Humboldt County Memorial Hospital for the previous 2 year period. Therefore, no charts are available for Physician PEER Review."

4. During an interview on 12/15/10 at 7:50 AM, the Laboratory Manager stated the laboratory sent all tissue from surgical procedures for review by Pathologist A. The Laboratory Manager stated they did not have physician peer review performed on tissues reviewed by Pathologist A.

5. During an interview on 12/15/10 at 8:10 AM, the Medical Staff Coordinator stated that since Pathologist A only looked at tissue specimens, they did not think Pathologist A saw patients. In the future, the Medical Staff Coordinator would send specimens reviewed by Pathologist A for external peer review.

6. Review of Radiologist B's credential file revealed CAH administrative staff did not send any clinical records from patients who had radiological tests interpreted by Radiologist B for external peer review.

7. Review of Radiologist C's credential file revealed CAH administrative staff did not send any clinical records from patients who had radiological tests interpreted by Radiologist C for external peer review.

8. During an interview on 12/14/10 at 11:25 AM, the Medical Staff Coordinator stated Radiologists B and C worked at Hospital A. The CAH had 3 Radiologists from Hospital A who interpreted radiologic tests from procedures performed at the CAH. The Medical Staff Coordinator stated they did not send medical records from the radiologists from Hospital A for external peer review. Instead, the Medical Staff Coordinator had the radiologists from Hospital A provide peer review for the other radiologists at Hospital A.