HospitalInspections.org

Based on document review, observation, and interview, the facility failed to maintain a sanitary hospital environment, failed to have an appropriate technique for food sanitation, and failed to implement adequate techniques for cleaning and disinfecting environmental surfaces, in 9 instances.

Findings include:

1. Review of Hospital Policy Number: 3, last revised 4-6-2017, titled General Safety - Housekeeping, indicated spills and broken objects are promptly and safely removed, and, debris of all varieties (paper clips, rubberbands, paper, etc.) are removed immediately when reported and observed..

2. Review of a hospital document titled CLEANING SCHEDULE CAFETERIA, indicated the following was to be done daily:

a. Coffee Urn - clean thoroughly
b. Soda Machine - Clean all surfaces
c. Microwave - Clean & dry inside
d. Condiment Table - Clean & dry as needed making sure to remove any used
condiments
e. Tables/Chairs - clean as needed paying attention to legs, backs & under table
top surfaces

3. Review of a hospital document titled CLEANING SCHEDULE GENERAL, indicated daily, All Freezers - Clean & Polish. Defrosting and inner cleaning should be done on a weekly basis as required.

4. Review of 2 hospital documents titled SANITATION CHECKLIST (MONTHLY), dated 10/18/2017 and 11/22/2017, each indicated the following was to be checked:

18. Walk-In Freezer - Clean, minimal ice build-up, food elevated 6" off the floor
25. Kitchen Walls, Ceiling, Lighting
44. [Dining Room] Clean tables and chairs
47. [Dining Room] Neat & clean condiment stands

5. In interview on 01-09-2018 at 12:40 pm, employee #A1, Contracted Food Service Manager, confirmed all the above-stated documents were to be followed, as indicated.

6. On 01-09-2018 at approximately 9:20 am, in the presence of employee #A1, Chief Operating Officer, the following was observed in the dining cafeteria:

a. There was a soda dispenser, coffee maker/dispenser, juice dispenser, and
condiment dispenser on top of a stainless steel table. It was also observed
around and behind each item there were soda straw wrappers, open/used
condiment packets, and miscellaneous other used paper items. It was also
observed there was some type of liquid condensate underneath the coffee
maker/dispenser and juice dispenser.

b. Underneath the above-mentioned counter, there were 2 microwave heating
machines. Inside each machine there was food residue.

c. Beneath each microwave, there was a wooden drawer. On the outside of each
drawer, there was a sticky residue to the touch.

7. On the 01-09-2018 at approximately 9:30 am, in the presence of employee #A1, the following was observed in the dining cafeteria:

a. There were 16 ceiling light fixtures, 15 of which contained a multiple number
what appeared to be dead insects.

b. There were 2 dining tables with pedestals. Each table had a dried residue on
top of the pedestals and each had dirt and refuse underneath the pedestals.

8. In interview on 01-09-2018 at approximately 9:40 am, Employee #A7, a hospital environmental services employee indicated the pedestals were cleaned once per week.

9. On 01-09-2018 at approximately 9:40 am, in the presence of employee #A1, it was observed in the dining cafeteria, there were clumps of dust on the top of a soda vending machine.

10. On 01-09-2018 at approximately 9:50 am, in the presence of employee #A1, it was observed in the kitchen, there was an uncovered hole in the ceiling approximately 1 foot by 2 feet, through which dirt, dust and insects could fall down onto food preparation area.

11. On 01-09-2018 at approximately 9:50 am, in the presence of employee #A1, it was observed in the kitchen there were 2 large vents on the wall, over a stainless steel sink counter. Each of the vents were observed to have a dark residue.

12. On 01-09-2018 at approximately 9:55 am, in the presence of employee #A1, it was observed in the kitchen there was a freezer. It was observed there was a package of bread product and miscellaneous trash on the floor, beneath wire storage racks.

Based on document review, observation and interview, the Chief Executive Officer, Medical Staff and Director of Nursing Services failed to be responsible for the implementation of successful corrective actions in areas of infection control.

1. Facility Policy (no number) Dietary Procedures for Infection Control, last revised 4/3/2017, indicated: X. A. Floors are scrubbed with germicide detergent once daily. B. Floors are cared for by kitchen personnel.

2. Kitchen and dining area observations:
A. On 01/9/2018 at 0920 hours, accompanied by staff member #A1, COO and #N3, kitchen staff, 5 of 25 dining room tables were moved to observe the floor under them. All 5 had food, dust and other debris under them. A commercial soda dispensing machine had a buildup of dust and debris under and behind it. This was confirmed by staff member #N3 on 01/9/2018 at 0930 hours.
B. On 01/9/2018 at 0945 hours, accompanied by staff member #A1, COO and #A3, food services manager, the kitchen was toured. On 01/9/2018 at 0945 hours, it was observed that the counters, sink and dishwasher all had a buildup of dark colored food and other substances accumulated under them on the floor. In the area of the sink drain, 2 dark colored roach type insects were observed on the floor. The serving areas counters and the stove, oven and fry areas all had a buildup of dark colored food and other substances accumulated under them on the floor.

3. Facility Policy (no number) Routine Cleaning Procedures, Patient Rooms- Discharge Cleaning, last updated 4/3/2017, pages 24-25, indicated: 1.) Flip mattress completely, and thoroughly clean the newly exposed surfaces. 2.) Damp mop all non carpeted areas. 3.) Patient Rest Rooms, Page 30, Clean toilets, Use a disposable cloth, abrasive pad, lotion cleanser, and a spray bottle if germicidal detergent solution to remove soil from the exterior of toilets and adjacent wall and partition surfaces. Floors in 2 cleaned patient rooms had dust and debris on floors, trash under a mattress and the exterior bases of toilets had dried yellow substance on them.

4. On 01/9/2018 at 1020 hours, the inpatient units were toured.
Adult Unit: Observations:
A. On 01/9/2018 at 1030 hours, patient room 507 was examined. It was an empty room, cleaned for the next admission. It was observed that there was dust and debris on the floor, including popcorn kernels, along wall and bed bases. There was a snuff can, dust and a small amount of paper trash under the mattress of the bed nearest to the window. The bases of the toilet in the restroom appeared to have a dried yellow substance on both sides of the toilet.
1.)This was confirmed by staff #A1 interview on 01/9/2018 at 1045 hours.
B. Patient room 509 was examined at 1040 hours. It was an empty room, cleaned for the next admission. There was dust and debris on the floor, along walls and bed bases. The bases of the toilet in the restroom appeared to have a dried yellow substance on both sides of the toilet. In addition, the shower had hair in it and there was a dried spot of dark liquid on the sink.
1.)This was confirmed by staff #A1 interview on 01/9/2018 at 1045 hours.
Adolescent Unit:
C. The hold room was examined. The bases of the toilet in the restroom appeared to have a dried yellow substance on both sides of the toilet.
1.) This was confirmed by staff #A1 in interview on 01/9/2018 at 1045 hours.

5. On 1/9/2018 at 1300 hours, staff member #A4 indicated in interview, that we are working on these long-standing housekeeping problems.