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Observations, review of the cleaning schedule, and interviews with the Dietary Manager (DM), revealed the Critical Access Hospital (CAH) failed to ensure the kitchen was clean and in good repair. The CAH failed to comply with the Nebraska Food Code at 4-202.11 and 6-501.11. The CAH is licensed for 25 beds and had a census of 0. Findings are:

A. Observations and interviews while on tour of the kitchen on 2/24/10 at 2:00 PM with the DM revealed the following areas to be of sanitation or equipment maintenance issues and acknowledged the kitchen also provides food for the long term care patients:

1. Six exhaust filters located directly above a 6-burner gas stove has builtup grease and a black furry substance along the edges and inner grids. Observation noted a 3-gallon boiling pan identified by the DM as"having stew meat boiling for beef and noodles" to be uncovered and having a potential for cross contamination from the greasy filters located directly above the uncovered pan with the boiling meat in it. DM revealed the exhaust filters are cleaned "once a month, and it has been awhile."

2. Eleven 24" x 27" baking sheets were blackened along the edges on the inner and outer portion of the sheets and lacked the manufacturer's sealed finish, exposing the underlying metal. When surveyor scraped the baking sheets with a fingernail, the blackened substance came off.

3. A 2 1/2' x 2' rusted area located on the floor upon entrance into the walk-in refrigerator lacked the manufacturer's sealant. There was scattered food debris on the refrigerator floor and in the corners. The outside of the walk-in refrigerator door and sides had a darkened unidentified substance and lacked a large portion of the manufacturer's sealant. This does not allow for the refrigerator floor or outside door to be properly cleaned and sanitized.

4. The walk-in freezer had scattered food debris on the floor and buildup in the corners. The outside of the freezer door and along the sides had a darkened unidentified substance and lacked a large portion of the manufacturer's sealant. This does not allow for the outside freezer door to be properly cleaned and sanitized.

5. Located in the dry food area along the west wall in the corner there were 4 open-ended commercial water pipes. The open ends of the water pipes were stuffed with a fiberglass insulation. The insulation was also stuffed into the openings on the floor where the pipes entered the dry food area. Interview with the DM revealed "little knowledge of what the pipes are going to be used for."

Interview with the maintenance personnel and contractors revealed "the pipes are being constructed for the purpose of running water from a boiler in the basement to the Operating Room." The fiberglass stuffing located in the water pipes has a high potential for airborne food contamination and the fiberglass stuffing on the floor allows openings for rodent infestation in the dry food storage area.

6. Along the upper west wall of the kitchen there was a sealant. The sealant was cracked, pulled away from the wall, and missing large portions of the sealant. Interview with the maintenance personnel revealed "the sealant was applied to the ceiling when an additional room was added on."

7. The dry food utility room ceiling that measures approximately 12' x 15' had portions of the ceiling with blistered, peeling paint exposing the underlay and had a dull yellow appearance.

8. The ceiling located in the kitchen had several cracked areas, exposing the underlay, and had a dull yellow appearance. DM was unsure how long it had been since the ceilings were painted and the cracks occurred when they hung the metal appliance that holds the pots and pans.

9. The Hobart electric commercial mixer located in the kitchen and identified by the DM as "being used on a regular basis" to mix food that is served to the patients, had chipped green paint exposing the underlying metal and the rotator bar identified by the DM and dietary cook to "leak grease." The grease leakage has potential to contaminate patient food when in use and was removed from the kitchen at the time of the survey.

10. The Robo-Coupe 3-quart food processor located in the kitchen and used to process patients' food had a hard plastic bowl that is chipped and the on-off button falls off.

11. The commercial dishwasher located in the kitchen had a lime buildup along the inner and outer sides and a greasy debris on the top.

12. A 12-door wooden cabinet located in the kitchen and used to stored dry food goods was extensively chipped, missing several portions of the wood finish, and missing a door handle. This does not allow for proper cleaning or sanitization of the wooden cabinet.

13. The floor boards located throughout the kitchen, dishwashing area, and dry food area had a buildup of a darkened unidentified substance.

14. The wooden door that allows entrance from the kitchen into the dry goods area was chipped, exposing the underlying wood, and lacked the manufacturer's finish. This does not allow for proper cleaning and sanitation.

15. The metal threshold allowing entrance into the kitchen had chipped paint exposing the metal underlay. This does not allow for proper cleaning and sanitization.

16. Along the north wall in the kitchen were 8 windows that had a filmy, greasy appearance. Interview with the DM revealed the washing of the windows was the responsibility of housekeeping and did not think the windows had been washed for at least the last 2 years.

B. Review of the kitchen cleaning schedule proved to be inconclusive and identified by the DM stating: "the kitchen staff is signing off cleaning duties prior to completing the cleaning assignments, so is unsure if the cleaning assignments are actually getting done; they know what they are supposed to do."

Based on record reviews, staff interviews, and review of the Critical Access Hospital (CAH) Medical Staff Bylaws revealed the CAH failed to maintain a record system in accordance with the Medical Staff Rules and Regulations to ensure the completion of patients' medical records within 15 days of patients' discharge for 11 closed skilled care patients (Patients 2, 3, 4, 5, 05, 6, 06, 7, 8, 011 and 012), 1 closed medical surgical patient (02), 1 closed Emergency Department patient (010), 40 closed out patient cardiac consultation reports (20-60), and 1 closed treatment room patient (61). The CAH failed to initiate disciplinary action against physicians as directed in the Medical Staff Bylaws. The CAH is licensed for 25 beds and had a census of 0. Findings are:

A. Review of the Medical Staff Rules and Regulations, Page 7, I. Delinquent Charts: "The entire medical record shall be completed within fifteen (15) days following the patient's discharge, or if any part of the record is otherwise delinquent, the Administrator or the President of the Medical Staff, or their designee, shall notify the practitioner in writing of the delinquency. In addition, the practitioner's clinical privileges, including admitting privileges, may be automatically suspended if the medical records are not completed five (5) days from the date of notice, unless such suspension is waived by the Administrator, the Administrator shall notify the Executive Committee of the delinquency, fines and suspension (unless waived) and shall notify the Hospital admissions office of any suspensions."

B. Review on 2/24/10 at 11:00 AM of the Medical Staff Bylaws, Section 4, Page 22, Automatic Sanctions, Delinquent Medical Records reads: "A temporary suspension of all of a practitioners privileges, including the privilege of admitting patients to the Hospital, will be imposed automatically five (5) days after notification from the Administrator or the President of the Medical Staff of failure to complete records within the time periods required by the Medical Staff Rules and Regulations, unless the suspension is waived for good cause by the Administrator. This subsection does not limit the ability of the Medical staff or the Board to take other corrective action when a practitioner fails to properly or timely complete medical records."

C. Interview with the Medical Records Supervisor (MRS) on 2/24/10 at 2:00 PM first acknowledged there were no delinquent medical records. Further interview with the MRS revealed a total of 55 delinquent medical records due to the lack of outpatient records with physician signatures on consultation reports, the lack of physical and occupational therapist (PT, OT) signatures, the medical records just not getting them signed, and that there are currently no physicians on disciplinary action, nor have letters been sent out to notify physicians of their delinquent medical records.

Examples of delinquent medical records are:

1. Record review on 2/24/10 for closed skilled care Patient 01 revealed an admit date of 11/6/09 with discharge on 11/25/09. Further review revealed the medical record lacked PT signatures on 11/06/09 and 11/17/09, OT signatures on 11/06/09 and 11/24/09.

2. Record review on 2/24/10 for closed Outpatient 20 revealed the medical record lacked a physician signature for a cardiac consultation report dated 9/28/09.

3. Record review on 2/24/09 for closed Outpatient 61 who presented to the Treatment Room (TR) for treatment and care of a maceration on 9/28/09 lacks a physician signature on the TR report.