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Based on observation, interviews, review of records and other documents, the Food Service Director failed to maintain a safe and sanitary condition in the kitchen; monitor dietary staff for compliance with infection control practice and provide diets to patients in accordance with physician orders and approved policies and procedures.

Findings Include:

The failure to maintain a sanitary condition in the kitchen (refer to 0747 Infection Control Condition) and ensure the implementation of Food and Dietetic policies and procedures (refer to 0620, 0628,0629 and 0631).

1 - Based on medical record review and staff interview, it was determined that the facility failed to implement a policy that ensures timely nutritional referral of patients with pressure ulcers and establish a protocol for the provision of vitamins and minerals to these patients.
Findings include:
The review of medical records # 1, #2 and #3 on 12/6/12 revealed that these patients with pressure ulcers lacked nutritional referrals following their initial assessment by the nursing staff in accordance with nursing protocol.
Upon request of the nutrition policy regarding the care of patients with pressure ulcers, the Staff Dietitian stated that there is no nutritional policy that addresses the management of these patients. The Staff Dietician added that vitamins and minerals such as ascorbic acid and zinc are provided to patients with pressure ulcers at the discretion of the dietician. There was no protocol to ensure the provision of vitamins and minerals to these patients was consistently implemented.

2- Based on review of the Food Service Department Emergency Preparedness Manual, it was determined that the facility did not ensure that emergency food supplies are centralized and easy to retrieve.
Findings include:
A review of the Food Service Department Emergency Preparedness Manual done in the presence of the Operation Manager of the Food Service Department found that it has generic menus and was not user friendly. The department has two (2) emergency preparedness manuals. The operation manager informed the surveyor that one manual is more detailed than the other. In reviewing the simpler version manual it was observed that the menu was generic and specific food items was not listed, for example, juice, cold cereal etc.
Therapeutic diets or texture modified diets were not documented. The manual did not include the amount of food to be distributed to the units per meal, nor the location of equipment such as can openers, apron and paper supplies as well the availability of enteral feeds. It was observed during the tour of the kitchen on 12/5/12 at 2:30 PM that emergency food supplies were stored throughout the kitchen. There was no instruction/diagram to direct staff to the location of these food item and other supplies.

Based on menu review, nutrient analysis of menu and staff interview, it was determined that the Food and Nutrition Department did not ensure that diets prescribed by physicians met the therapeutic nutritional needs of the patients.
Findings include:
A review of hospital menus and nutrient analysis was conducted on 12/6/12 in the presence of the Clinical Nutrition Manager, Sodexho Regional Vice President and Food Service Director. It was found that the food and nutrition department did not have nutrient analysis for any of the diets. The surveyor was provided a list of diets (6 pages) approved by the hospital. The list contained over 40 therapeutic diets available to physicians for diet selection. The Clinical Nutrition Manager provided the surveyor three (3) incomplete nutrient analyses for 1800 calorie diet, 2300mg sodium diet and low fiber diet. The review found that none of the three nutrient analyses had food items that corresponded to the count of calories, sodium and fiber that were indicated. Since the food and nutrition department did not have nutrient analysis for their therapeutic diets, there is no evidence the diets provided to patients matched the diet ordered by the physician.

Based on dietary menu review, physician's diet prescription and staff interview, it was determined that the physician prescribed diet was not documented as it was prescribed on the patient's menu.
Findings include:
A review of 16 of 16 patient's menus on 12/5/12 noted that diet orders were not transcribed on the patients' menus as prescribed. The patient in MR #4 was prescribed "Small Bowel Diet #3"; however, the patient ' s menu read SMBOW3. Similarly, the patient in MR #5 had an order " Cardiac- do not give food items with seeds"; the menu read "CARD, NO SEED."
The physician prescribed diet is transcribed on to the patients menu in an abbreviate format to fit on the menu. The diet on the menu is not clearly understood by patients and staff except dietary employees.

Based on observation, review of diet formulary and patients menu, it was determined that the facility failed to ensure the approved current therapeutic diet manual is utilized for ordering and preparing patients diets.
Findings include:
Review of the hospital's formulary diets and patient menus on 12/6/12 noted diets that are not included or approved by the Academy of Nutrition and Dietetics (ADA) that authored the diet manual currently in use in the hospital. Examples of these diets are " Graft vs. Host Disease diet No 1-4, Low Bacteria Diet, Metabolic Protein Restriction Diet 4gm-20gm, Metabolic Diet Type 1 &2, and Small Bowel diet No 1-3. "
At interview with the Clinical Nutrition Manager on 12/6/12 at 2:00 PM, she stated that these diets are created at physician request. The diets were not in the approved diet manual. The diets have no nutrient analysis and are not approved by the hospital's nutrition committee.

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Based on observations, staff interviews, the review of policies and procedures, and infection control and quality assurance documentation, it was determined that the facility failed to provide a sanitary environment to minimize the possibility of contamination and transfer of infection.
Specific reference is made to the failure of the Infection Control Officer to monitor all areas of the hospital including food storage, handling and preparation, housekeeping and maintenance, provision of appropriate storage for clean and sterile supplies, and having adequate hand washing sinks.

Findings include:


On 12/5/2012, from 10:45 am - 4:00 pm, during a joint survey of the kitchen with the Principal Sanitarian / Field Coordinator of Environmental Health - Monticello, NY, the following findings were identified in the presence of the Hospital's Director of Food Services and the VP of Operation who acknowledged the findings.

1-Temperatures:
Most of the walk-in coolers were found to be operating with internal food temperatures measuring between 42 and 44 degrees F. The US FDA 2009 Food Code sets this temperature at 41 F (3-501.16(A) (2)).
The operator stated that he planned to have all refrigeration equipment evaluated and if needed adjusted to ensure compliance with the US FDA Code requirements for cold holding temperatures.

The above referenced cooler temperatures were as follows:
(i)- The temperature of I-R Roll in Refrigerator was 47 F.
(ii)- The temperatures of some food items within E-R Cooler in the cold preparation area were as follows:
Turkey breast had a temperature of 42.2.
(iii)-The temperature of the F-R Cooler as well as the temperature of some food items (Example is: Chicken) that stored in that refrigerator for more than two hours was 44.9F.
(iv)-The temperature of the Q-R Cooler was 44F, and temperature of some food items within that refrigerator were as follow:
Peeled egg temperature was 42.3
The main produce and meat storage walk-in cooler was operating with ready to eat foods (sliced tomatoes, turkey, chicken) holding at 46-47 degrees F. These food items were determined to have been in the cooler for over two hours. The hospital staff agreed that these food items were a potential hazard for the health and safety of patients and elected to discard them.

Discarded items included sliced tomatoes, cut cantaloupe and honeydew melon, cut lettuce and cabbage, hot dogs, chicken breast, chicken pieces, turkey, roast beef, and ham. These food items were observed discarded into the trash compactor onsite on 12/5/2012 at approximately 2:45 pm.

Discarded items included:
1- 5 cases of Honeydew melon chunk, 5 cases of Cantaloupe chunks, (6) Turkeys, (2) Pastrami, (7) ham, (4) Prosciutto, (2) Buffalo chicken, (3) Bologna, 11 cases of sliced tomato, 2 cases of chicken breast, 5 cases of ham, 3 cases of ground beef, 12 cases of turkey, 3 cases of iceberg lettuce, 2 cases of spring mix lettuce.
2- Cleaning and Sanitizing:
It was observed that thorough cleaning and sanitizing of the kitchen was not being done.

(i) Parts of the floors and ceilings were dirty, especially near edges and corners throughout the kitchen.

(ii) The catering prep room slicer had old food debris caught in the carriage. The slicer was not in use at the time.

(iii) Mixers in the main kitchen and the kosher kitchen both had debris and a black substance on the part of the mixer that attaches to the blade (such that food could splash on the mixer and fall back into the bowl). The bottom of the Floor model Hobart mixer had a large hole that is inaccessible and cannot easily be cleaned after each use.

(iv) Food storage bins for cornstarch, sugar, flour were dirty and encrusted with food debris, inside and out.

(v) The can opener that was removed from sanitizing solution still had material on the inside of it.

(vi) Wiping cloths were not consistently stored in sanitizing solution. Some that were in sanitizing solution had visible food particles and debris on them.

(viii) Floor tiles were cracked or had missing parts making them a non-cleanable surface.

(ix) One food service employee was observed to be mopping the floor next to the robot coupe. The mop was swished from side to side regardless of the kitchen equipment beside it. The robot coupe bowl was uncovered and located in the area where the mopping took place. Mopping procedure to clean the floor and prevent splashes was not implemented.

(x) The Kosher kitchen dairy and meat walk-in freezers had debris on the floor under the shelves (container tops, wrappings, food debris were found on the freezer floors).

3 Cooling:
A prior inspection conducted on 11/29 by NYS- Environmental Health Department found improper cooling of chicken stock in the kosher kitchen. On 12/5/12 the surveyor found improper cooling of 8-9 lb beef roasts in the same kitchen.

Five (5) beef roasts approximately 8 to 9 pounds each were found cooled in the kosher meat walk-in refrigerator. The roasts were cooked the prior day and cooled whole, stacked on a tray. The chef, who did not cook or cool these roasts, stated that the procedure was to cool them spread out on trays. The roasts were congealed together indicating that the appropriate procedure was not followed. Roasts and other large cuts of meat must be cooled in a manner that reduces the internal temperature from 120 to 70 degrees F in two hours and to 45 F or below in four additional hours. FDA 2009 Food Code requires cooling from 135 F to 70 F in two hours or less and from 135 F to 41 F or below in six total hours. Although the roasts were 40 degrees F at the time, they could not have cooled in the required time frame.

4- Rodent and insect control:

(i) Flies and roaches observed in kitchen. Flies were noted in the main kitchen and dishwashing area and roaches in the catering prep room. A live roach was observed on the floor beneath the ice machine.

(ii) Ceiling, floors, doors, and walls had openings to provide rodent access. The ceiling in the dishwashing area had openings greater than two inchesd. The wall on the right hand side of the ice machine had a large opening.

(iii) The wall to floor molding was missing in parts (especially in the catering prep room)

(iv) The sink drain area is also an access point for vermin activity. The grate cover for the sink drain in the main kitchen was not attached.

5- Cross contamination:

It was observed that staff failed to separate clean and dirty items in the kitchen.
(i) The main kitchen Robot Coupe is located right next to a hand washing sink with potential for splash and contamination. This mixer is used to prepare ready to eat tuna salad.

(ii) Some hand washing sinks were still lacking hand washing signs (hand sink in dishwashing area)

(iii) Several refrigerators had foam insulation duct taped on condenser lines - not a cleanable surface.

(iv) Clean bowls and pots stored right side up with utensils stored inside on lower shelves of dish racks in walkway by the main kitchen cook chill area - risk for cross contamination and debris to collect in the bowls and pots and on utensils that will not be cleaned again prior to use.

(v) Large round shallow pots in the dishwashing area were not stored upside down to prevent them from collecting dust.

(vi) On 12/5/12 at approximately 10:15 AM and in the presence of the Food Service Administrator, two standardized recipes binders were found in a metal container. The plastic sheets in the binders were discolored and had .food crusts stuck on them. The pages of the binders were sticky. A cook was observed turning the pages in the binder with his plastic gloves and then placed the binder into a bin that was on the metal cart.
(vii) A metal cart located beside the steam kettle was found to have two large stainless steel bins. One of the bins had a metal container with water, water hose and slotted cooking spoons. The other metal container had a dusty dirty tool box with kitchen utensils, two recipe binders with no covers, open boxes of rubber gloves and a large prescription medicine bottle titled "Welchol Tablets". At interview with kitchen staff, it was stated that the medication belonged to an employee. On top of this metal cart was the floor model robot coupe blade. The blade was exposed to the steam coming from the steam kettle.
(viii) Employees were not compliant with the departmental dress code. Three employees were observed to be in street clothes and not in uniform. One employee was wearing a plaid shirt, another employee was wearing a gray hoody and the last employee was wearing a blue shirt.
(ix) The door covering the two fire extinguishers in the kitchen were stuck with dry paint due to recent painting of the walls. The door was opened by the Director of Engineering after unsuccessful attempts by the surveyor and another staff member.



6-Cardiac Surgery Intensive Care Unit (CSICU):

During a tour of the Cardiac Surgery Intensive Care Unit (CSICU) on the morning of 12/6/2012, the following findings were identified in the presence of VP of Operation and the Director of Engineering who acknowledged the findings:

(i) Dirty surgical instruments that was used for chest tube removal was found on the counter right next to the hand washing sink of cubicle 9 of the CSICU.

(ii) The hand washing sink of cubicle 9 of the CSICU was found to be cracked.

(iii) The floor of the corridor in front of cubicle 3 was broken and covered with duct tape.

(iv) The soiled utility room of the CSICU was found to have positive air pressure instead of the required negative air pressure for this type of room.

(v) 12 oxygen cylinders, isolation cart, Work station on Wheel (WOW) and a patient lift were stored on the corridor in front of the soiled utility room.

(vi) The floors of the rooms of the CSICU especially at the perimeters of the rooms were observed to be dirty and in part lacked the base moldings.

(vii) The medication room was found to have negative air pressure instead of the required positive air pressure for this type of room.

(viii) The ceiling tiles of all the rooms of the ICU were of the regular type, instead of the washable ceiling tile that is required for this type of room.

7- 7 West:
During a tour of the Cardiac Surgery Step down unit on the afternoon of 12/6/2012, the following findings were identified in the presence of VP of Operation and the Director of Engineering who acknowledged the findings:

(i) The soiled utility room was found to have a positive air pressure instead of the required negative air pressure for this type of room.

(ii) The clean utility room was found to have negative air pressure instead of the required positive air pressure for this type of room.

8 - Central Sterile Supply:
During a tour of the Central Sterile Supply on 12/6/2012 at approximately 3:15pm, the following findings were identified in the presence of VP of Operation and the Director of Engineering.

(i) A hand washing sink was not provided for the staff to wash their hands in the clean preparation area. At interview with the Manager of Central Sterile Supply on 12/6/12 at 3:20 PM, he was asked how staff assigned to the clean preparation area performs hand hygiene. He stated there was no requirement for a hand washing sink in the clean preparation area but if staff needs to wash their hands, they can use the bathroom sink.


(ii) The decontamination room was found to have positive air pressure in relation to the corridor, instead of the required negative air pressure for this type of room/area.

(iii) The ceiling tiles of the decontamination area were not positioned correctly and some were bent, leaving gaps between the tiles which is a potential for collection of dirt that might fall on top of the instruments being disinfected or sterilized.

(iv) One ceiling tile was observed to be missing in the decontamination area.
Some other ceiling tiles were broken and observed being taped with adhesive duct tape in the decontamination room.

9-Operating Room

Tours of the Operating Suit, specifically utilized for cardiothoracic surgery located on GP3, conducted on 12/5 and 12/6/12 revealed lack of appropriate storage for clean and sterile supplies and lack of appropriate infection control practice to prevent cross contamination.

(i) Nine metal cabinets containing orthopedic supplies located in the hallway adjacent to the entrance of the Operating Suit had dust in the interior and exterior of the cabinets. Two Wire racks next to the metal cabinets that held sterile and clean supplies were not covered and protected from dust. There was a sealed off construction area across the hallway from the nine (9) metal cabinets and (4) wire racks.

At interview with the Director of Perioperative Services on 12/5/12 at 12:30 PM, he stated that the construction site was not accessible from the Operating Suit and had been walled off to prevent dust from entering the OR. There was no explanation given for the dust accumulation in the interior and exterior surfaces of these metal cabinets.

The doors to Rooms N3-348 and N3-349 located in GP3 (Operating Suit) were observed propped open on 12/5/12 at 12:35 PM. These rooms contained sterile and clean supplies. Two (2) additional wire racks located in close proximity to the two storage rooms were not covered. The wire racks held supplies such as surgical needles and other sterile and clean supplies.

At interview with the Manager of Central Sterile Supply on 12/6/12 at 3:15PM, he stated that racks containing supplies are delivered covered with plastic shield and should remain covered while in the Operating Suit.

(ii) The floor of the Tissue Room located across the hallway from the Post Anesthesia Care Unit (PACU) was dirty with grime. The Tissue Room contained several gas cylinders and a freezer for the storage of Allographs and other tissues.

At interview with a Nurse Manager from Perioperative Services on 12/5/12 at 2:00 PM, she stated tissues are picked up from the Tissue Room by a nurse and delivered to a member of the surgical team in the operating room. She added that the delivery nurse does not go into the operating Room. However, there is evidence that the staff would have to walk across the dirty floor of the Tissue Room to a clean and semi restricted area in the Operating Suit.

(iii) On 12/6/12 at 11:00 AM an anesthesiologist was observed on GP3, OR #2 adjusting equipment in preparation for a surgical case. The anesthesiologist picked up a plastic tube from the floor and disposed it in a cabbage bin and then proceeded to work on the anesthesia equipment. The anesthesiologist was not wearing gloves and mask and did not conduct proper hand hygiene to prevent the spread of infection after he picked up the tube from the floor. The anesthesiologist did not comply with the facility's policy titled " Operating Room - Surgical Attire " revised on 8/12 that notes unsterile gloves may be worn in the OR for tasks other than sterile procedures.

The review of the Operating Room Hand Washing surveillance for 6/28/12 through 11/23/12 revealed a compliance rate of 89% which is below the overall hospital compliance rate of 97% in 2011 and the expected goal of 95% or greater in 2012.








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