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Based on interview and record review the facility failed to assess and evaluate the ongoing care needs for 1 of 30 sampled patients (31). A night nurse verbal report of Patient 31's refusal for a renal hemodialysis treatment (a procedure used to remove toxins in the blood for the treatment of kidney failure), was not reassessed by the oncoming day shift nurse. In addition, the information was not communicated to the patient's physician in a timely manner. The lack of ongoing patient assessment and communication had the potential to affect the patient's health outcome and well being.

Findings:

Patient 31 was admitted to Hospital A on 12/30/15 with diagnoses which included end stage renal disease (chronic progressive kidney failure) per the admission History and Physical Examination report. The same report indicated that the patient had received renal hemodialysis as an outpatient prior to this hospital admission and a Nephrology (physician specialist for the treatment of kidney disease) consultation was planned.

During a joint interview and record review on 1/5/16 at 11:15 A.M., Patient 31's medical record was reviewed with the Director of Telemetry (DT). The DT stated that nursing staff had informed her that the patient had refused a scheduled "dialysis" treatment. The record indicated that renal hemodialysis was planned for 1/4/16. There was no documentation in the nurse progress notes of the patient's refusal of the planned treatment or communication of the patient's refusal of that treatment to the physician. The DT stated the expectation for nurse reassessments and communication of patient refusal of treatments to the physician.

During an interview on 1/5/16 at 2:40 P.M., Registered Nurse (RN) 33 stated that she had been assigned to the care of Patient 31 on the day shift of 1/4/16. RN 33 stated the prior night shift had reported to her, that the patient had refused the planned renal hemodialysis treatment, which was scheduled for that day, 1/4/16. RN 33 stated that she had not reassessed or confirmed the treatment refusal with the patient. In addition, RN 33 stated that she had not called the patient's physician to discuss the patient's refusal and "waited for the doctor to come in". RN 33 acknowledged she had not documented the occurrence in the patient's record.

A review of the a hospital policy and procedure entitled Assessment and Reassessment, Patient Condition, dated "May 2014" included "to provide a clear, relevant, concise and complete legal record, the Nursing Process will utilized by the Registered Nurse (RN) to provide goal directed nursing care for each hospitalized patient...The RN is accountable for documentation of this record."

Based on interview and record review the facility failed to develop a nursing care plan that reflected the care needs for 1 of 30 sampled patients (31). A nursing care plan had not been developed for Patient 31's ongoing renal hemodialysis treatment (a procedure used to remove toxins in the blood for the treatment of kidney failure). This deficient practice had the potential to interfere with the communication, coordination and implementation of interventions related to the patient's renal hemodialysis procedures.

Findings:

Patient 31 was admitted to Hospital A on 12/30/15 with diagnoses which included end stage renal disease (chronic progressive kidney failure) per the admission History and Physical Examination report. The same report indicated that the patient had received renal hemodialysis as an outpatient prior to this hospital admission and that a Nephrology (physician specialist for the treatment of kidney disease) consultation was planned.

During a joint interview and record review on 1/5/16 at 11:15 A.M., Patient 31's medical record was reviewed with the Director of Telemetry (DT). The record indicated that the patient had received renal hemodialysis since admission to the hospital. The medical record included that the patient had a vascular access site (vein/artery catheter used for hemodialysis) located in the right subclavein (neck area) which required scheduled observations and dressing changes. The DT stated that the patient's renal dialysis treatments were performed at the hospital by a contracted agency. The DT stated the expectation that hospital staff and the contract agency were expected to coordinate that patient's renal hemodialysis treatment and procedures.

During a joint interview and record review on 1/5/16 at 2:00 P.M., the Chief Operating Officer of Renal Dialysis [name of contracted dialysis provider] (COORD) stated the expectation that a plan of care, for renal hemodialysis, was to be developed and coordinated between the hospital nursing staff and the dialysis staff. The COORD acknowledged that a plan of care for Patient 31's hemodialysis had not been developed, which created a potential for inconsistent coordination of the patient's renal hemodialysis treatments.

A review of the hospital policy and procedure entitled Plan of Care, Interdisciplinary, dated "May 2014" included "Inpatients will have a POC [plan of correction] developed that includes assessment based on comprehensive patient needs, treatments and goals. The RN [registered nurse] is ultimately responsible and accountable for the POC, however, all members of the health care team are responsible for contributing to the plan of care and documenting whenever a need is identified."

Based on interview and record review, the hospital failed to ensure the rate of infusion for an intravenous (IV, directly into a vein) insulin infusion was ordered by the physician. The hospital administered an insulin infusion at a rate that was not ordered by the physician. This failure resulted in the potential for patients to be exposed to avoidable medication errors.

Findings:

During a concurrent interview and medical record review, on 1/7/16 at 11:20 am, Nurse Director of Intensive Care (NDIC 21) identified Patient 21's electronic medical record (EMR, computer medical chart). Inspection of the EMR showed Patient 21 was admitted to the hospital on 12/3/15. A physician's order dated "12/3/15 at 22:25 (10:25 P.M.) for Rx (prescription) number U000690475 (100 units insulin (drug for the control of blood sugar) regular in 99 ml (milliliter) sodium chloride (salt water) 0.9%) IV sliding scale (insulin rate dependent on blood glucose) protocol (orders)". NDIC 21 reviewed the EMR and identified the IV insulin was started on 12/3/15 at 11:41 P.M. at an infusion rate of 7.7 units per hour. The IV insulin infusion rate was changed on 12/4/15 at 1:30 A.M. to 9 units per hour. Continued review of the EMR did not show a physician order to change the rate from 7.7 to 9 units per hour on 12/4/15 at 1:30 A.M.. NDIC 21 acknowledged the EMR did not contain a physician order to change the insulin infusion rate from 7.7 to 9 units per hour on 12/4/15 at 1:30 A.M.

Based on interview and record review the hospital failed to maintain complete and consistent information for 1 of 30 sampled patients (31). Patient's 31's refusal of a planned renal hemodialysis treatment (a procedure used to remove toxins in the blood for the treatment of kidney failure), had not been documented in the patient's medical record. Patient 31's medical record had not reflected the description of an occurrence which had the potential to affect the patient's health and well being. In addition, a handwritten date, on a paper Hemodialysis Order form had been transposed with another date, which made the dates illegible. The handwritten error had not been corrected in a manner that clarified the intended date and posed the potential for confusion and/or error.

Findings:

Patient 31 was admitted to Hospital A on 12/30 15 with diagnoses which included end stage renal disease (chronic progressive kidney failure) per the admission History and Physical Examination report. The same report indicated that the patient had received renal hemodialysis as an outpatient prior to this hospital admission and that a Nephrology (physician specialist for the treatment of kidney disease) consultation was planned.

During a joint interview and record review on 1/5/16 at 11:15 A.M., Patient 31's medical record was reviewed with the Director of Telemetry (DT). The DT stated that nursing staff had informed her that the patient had refused a scheduled "dialysis" treatment. The record indicated that the patient had received renal hemodialysis since admission to the hospital, however there was no documentation in the record of the patient's refusal of a planned procedure. The DT acknowledged that Patient 31's refusal of the renal hemodialysis treatment was an occurrence that should have been documented in the patient's medical record.

In addition, Patient 31's medical record included a paper version of the contracted agency's Hemodialysis Orders form, which also reviewed with the DT. The same form included an area which indicated "Schedule the next treatment for [date]" The handwritten date was illegible, as it had been transposed or overwritten by another date. The error had not been corrected, clarified or authenticated by the writer.

The DT acknowledged that the reviewed handwritten date, on the Hemodialysis Orders form, was not legible and that the record had not been maintained in a concise manner.

Based on observation, interview, and administrative record review, the hospital failed to ensure drug waste was disposed in a pharmaceutical (drug)/medication waste container (not regular trash). In the computerized tomography (CT/X-ray diagnostic procedure) room a medication vial was not discarded in a pharmaceutical/medication waste container.

Findings:

During a concurrent observation, interview, and record review, on 1/5/16 at 11:05 A.M., in the CT room, CT Technologist (CT Tech 21) identified a power injector (syringe pump). Inspection of the power injector showed it contained two syringes. Each syringe was filled with clear intravenous (IV, directly into a vein) fluid. CT Tech 21 was requested to identify the fluid in the two syringes. CT Tech 21 stated the left side syringe was filled with contrast material. CT Tech 21 was requested to identify the contrast's medication vial. CT Tech 21 removed the medication vial from a regular trash container. The trash container was located next to the sink. Inspection of the medication vial showed that it contained a small volume of clear liquid. Inspection of the vial's label showed it contained Optiray 350 (loversol injection 74% (medication used to improve visualization in a CT study). Director of Pharmacy (DPH 21) acknowledged the Optiray medication vial was disposed of in the regular trash. DPH 21 stated the medication vial should have been disposed in the CT room's pharmaceutical waste container (ensures drugs are handled and disposed of in accordance with state and federal laws).

An administrative record review, of the hospital's policy and procedure for Pharmaceutical Waste Disposal (Reviewed: 7/2015) showed, Procedure:, 3. Pharmaceutical/Medication Waste Disposal, 3.1 "All unused or expired medications shall be disposed of in the proper container located in each medication room/area."

Based on observation, interview, and administrative record review, the hospital failed to ensure syringes containing intravenous (IV, directly into a vein) medications were labeled. Two IV medication syringes, in a computerized tomography (CT-an special diagnostic x-ray) room's power injector (syringe pump) were unlabeled. These failures resulted in the potential for patients to be exposed to avoidable medication errors.

Findings:

During a concurrent observation, interview, and record review, on 1/5/16 at 11:05 A.M., in the CT room, CT Technologist (CT Tech 21) identified a power injector. Inspection of the power injector showed it contained two syringes. Each syringe was filled with clear IV fluid. CT Tech 21 was requested to identify the fluid in the two syringes. CT Tech 21 stated the left side syringe was filled with contrast and the right side syringe was filled with normal saline (salt water). CT Tech 21 was requested to identify the contrast's medication vial. CT Tech 21 removed the medication vial from a trash container. The trash container was located next to the sink. Inspection of the medication vial showed that it contained a small volume of clear liquid. Inspection of the vial's label showed it contained Optiray 350 (loversol injection 74%. A medication used to improve visualization in a CT study). An inspection of the two syringes did not show they were labeled. Director of Pharmacy (DPH 21) acknowledged the two syringes were not labeled. DPH 21 stated the two syringes should have been labeled.

During an administrative record review, of the hospital's policy and procedure for Labeling of Medications, on and off the Sterile Field (Last Reviewed: April 2012) showed, Key Elements:, B. Medication labeling, B.1. Medication shall be labeled according to the following guidelines:, B.1. 2. "Labeling will occur when any medication or solution is transferred from the original container to another container."

Based on dietetic services observations, dietary staff interview, and dietary and administrative document review, the hospital failed to ensure the provision of dietetic and nutrition services in a safe and effective manner as evidenced by:

1. Lack of effective food storage practices in accordance with hospital procedures, manufacturers recommendations and standards of practice (Cross Reference A-620 #1,4; A-749 #1)

2. Lack of effective time/temperature monitoring of Potentially Hazardous Foods (PHF's) which are defined as those which have the potential to grow bacteria associated with foodborne illness (Cross Reference A-620 #2; 749 #3, 4)

3. Lack of a position description that fully delineated supervisory and day to day responsibilities of dietary management staff at Hospital B (Cross Reference A-620 #3)

4. Therapeutic menus that did not meet physician specified nutritional parameters (Cross Reference A-629 #1 a, b and 4)

5. Lack of development of a vegetarian menu for Hospital B (Cross Reference A-629 #3)

6. Lack of a Clinical Diet manual that comprehensively reflected the hospitals' therapeutic menus (Cross Reference A-631)

7. Lack of adequate guidance for implementation of dietetic services in the event of a widespread disaster and lack of equipment maintenance in accordance with standards of practice (Cross Reference A-701, A-749 #1).


The cumulative effects of these systemic problems resulted in the hospitals' inability to provide clinical nutrition care and dietetic services in a safe and effective manner in accordance with the statutorily-mandated Conditions of Participation for Dietetic Services

Based on food storage observations, dietary staff interview and dietary document review the hospital failed to ensure an effective oversight of food services systems as evidenced by: 1) Storage of staple foods at temperatures greater than hospital developed parameters. 2) Lack of development of an effective system to monitor time/temperature parameters for foods capable of bacterial growth associated with foodborne illness. 3) Lack of approval of a position description that accurately reflected the responsibilities of the Food Service Manager at Hospital B. 4) Lack of a system to ensure that products that were either expired or compromised were not retained. Failure to ensure effective oversight of departmental operations may compromise the medical and nutritional status of patients.
Findings:
1. During initial tour at Hospital A on 1/6/16 beginning at 4:25 P.M., the ambient air temperature of Dry Storage room B was 80ºF (degrees Fahrenheit). Concurrent review of the log titled "Storeroom Temperature Chart-Food" from 1/1/16-1/6/16 noted that the room temperature was recorded as 74ºF and 76ºF on 1/5/16 and 1/6/16. It was also noted that the instructions printed on the form guided staff of acceptable room temperatures between 50ºF-70ºF. The form also noted, "If the temperature is out of range, corrective measures must be documented." There was no documentation of corrective measures.
In an interview on 1/7/16 at 11:35 A.M., with Dietary Staff (DS) 34, he acknowledged that he probably should have called plant operations.
2. On 1/7/16 beginning at 3:00 P.M., food holding practices in Hospital A's café were reviewed. It was noted that food was held at temperatures that could support bacterial growth associated with foodborne illness (Cross Reference A 749). Review of hospital document titled "Statement of Deficiencies", dated 11/3/15, noted that temperature issues were identified for foods held in the "grab and go" refrigerator as well as the melons held on the salad bar. The document also noted there was a development of a system that would "carefully and accurately" check food temperatures of hazardous foods.
In an interview with Dietary Management Staff (DMS) 32, he stated he reviewed the logs and on occasion checked temperatures himself however, he did not document the oversight of the established system. Review of hospital A's undated document titled "CMS Survey - October 2015 POC Dashboard", noted that the hospital evaluated it's compliance for storing potentially hazardous foods at 41 degrees Fahrenheit as 100% compliant for December 2015 despite the lack of monitoring all at risk foods.
Hospital document, dated 1/14/14, titled "Food Service Manger" revealed that it was the responsibility of DMS 32 to direct and control the day-to-day operation of food service. It was also noted this position supervised all food and nutrition staff.
3. On 1/8/16 beginning at 12:00 P.M., in an interview with DMS 33, she was asked to describe her responsibilities with respect to Hospital B's food services. She stated she routinely ordered food supplies, supervised staff, evaluated meal distribution, processed work orders, provided training for dietary staff as well as menu development and other food service related functions. The surveyor also asked if she completed food service employee evaluations. She stated she did not, and was told by DMS 32 that she would not be completing evaluations.
On 1/8/16 beginning at 12:30 P.M., the position description for DMS 33 was reviewed. It was noted that she was working under the position description for a Clinical Dietitian. It was also noted that this position description failed to include any of the foodservice related responsibilities for Hospital B. In an interview on 1/8/16 beginning at 1:00 P.M., with DMS 31, she stated that while a position description for food service management was developed for Hospital B, it has not been approved.
4. During initial tour at Hospital A on 1/6/16 beginning at 4:25 P.M., it was noted that in the main dry storage area there was a case (96 pieces) of individual servings of dry cereal that expired in December 2015. In a concurrent interview with DMS 31, she stated that departmental management and supervisory staff conducted regular food safety rounds.
There were also 10 undated individual servings of rice cereal on top of the expired box. It was also noted that while there was no clear expiration date printed on the cereal, there was a code printed on the side of the container. In a concurrent interview with DMS 32 he stated he did not know what the code depicted and since the box was discarded he would not know the expiration date of the product.
Review of hospital documents titled "Weekly Inspection Sheet for Dry Storerooms", dated December 2015 and "Weekly Inspection Sheet for All Storage Areas for FIFO [First in First Out] and Proper Storage" for December 2015, failed to note the expired items. Follow up of a document provided by the hospital on 1/8/16 at 9 A.M., noted that the product was stamped utilizing production runs. While it was determined that the individual rice cereals were not expired, it would be within the responsibility of dietary management staff to have a working knowledge of purchased products and how they were labeled.
Review of position description dated 1/14/14, titled "Food Service Manger", it was noted this position was responsible for the "day to day operation of food services which includes...purchasing, inventory..."

Based on food distribution observations, dietary staff interview and departmental document review the facility failed to ensure meals were delivered in accordance with hospital developed procedures as evidenced by 1) Preparation of substitutes that were not of equal nutritive value. 2) Plating of meals that were not in accordance with physician ordered therapeutic diets. 3) Lack of development of a vegetarian menu that met the nutritional needs of patients at Hospital B. 4) menus that did not fully meet the physician specified parameters for calorie restricted diets.
Findings:
1. During general food production observations at Hospital A on 1/6/16 beginning at 4:45 P.M., it was noted that Dietary Staff (DS) 38 was preparing a grilled cheese sandwich utilizing 3 slices of American cheese. In a concurrent interview he stated the item would be utilized as a meal substitute for a patient. He further stated it was one of the typical substitutes offered. In a follow up observation on 1/7/16 at 7:15 A.M., the cheese that was utilized provided 9 grams of protein for 3 slices, an amount that was equal to slightly more than 1 ounce of protein. Review of the facility nutritional analysis on 1/8/16 beginning at 8:30 A.M., revealed that depending on the day of the week, the protein value of entrée items ranged between 3-4 ounces. Review of standardized recipe titled "Grilled Cheese Sandwich" guided staff to utilize 2 ounces of cheese for each sandwich.
2. During meal plating observations at Hospital A on 1/6/16 beginning at 4:50 P.M., the following was noted:
a. Random Patient 35 had a physician ordered pureed diet. It was noted that the tray card depicted 1-1/2 serving of pureed pizza. DS 38 was observed taking a pureed mold, cutting it in half and placing it on the plate along will a full serving of a pureed corn mold and ¾ cup mashed potatoes.
In an interview on 1/8/16 beginning at 8:00 A.M., with DS 36, she was asked to interpret the tray card for Patient 35. She stated that the card was intended to provide 1 and ½ half servings of the pureed pizza. Review of the hospital document titled "Cheese Pizza Soufflé" dated 1/7/16, noted that each pre-shaped mold contained 151 calories. The patient received an approximate 75 calorie entrée serving rather than the intended 225 calories.
b. Random Patients 36 and 37 each had physician ordered 1800-calorie diets. It was noted that for an 1800-calorie diet, patients were scheduled to receive one-half portion of peas. Rather it was noted that both residents received full portions, which equated to 4-ounce servings. In an interview on 1/8/16 beginning at 8:00 A.M., with DS 36, she stated that the 1800-calorie diets were intended to limit calories as well as equally distributing the carbohydrates equally throughout the day.
3. During review of physician ordered diets at Hospital B on 1/7/16 beginning at 9:45 A.M., it was noted there was a patient with a vegetarian diet. In an interview on 1/7/16 at 10:00 A.M., with DS 39, he was asked what the vegetarian entrée would be for the noon meal. He stated he was not sure what he was going to serve, perhaps vegetarian egg rolls or cheese ravioli. He also stated that while there were defined menus for most diets, there was no menu for vegetarian diets. The cooks usually determine what they will cook from available items. In a concurrent interview with Dietary Management Staff 31, she stated that while she had developed a vegetarian menu and nutritional analysis for Hospital A, the system was not implemented at Hospital B as this hospital had a 4 week cycle menu, rather than a 1 week menu cycle.
4. On 1/8/16 beginning at 8:30 A.M., the hospitals' nutritional analysis was reviewed with DMS 31. Review of the calorie-restricted diets revealed that the 1800-calorie, non-select diet was limited to 1566 calories on Wednesday and exceeded physician specified parameters by 188 calories on Thursday of each week. Similarly the 2000 calorie diet was limited to 1673 calories on Wednesday of each week. In a concurrent interview with DMS 31, she stated she missed these discrepancies when she evaluated the menu.

Based on Dietary Management Staff interview and departmental document review, the hospital failed to ensure the development of a comprehensive diet manual that fully presented descriptive elements of the hospitals' routinely ordered diets. Failure to provide comprehensive ordering information for the hospitals' diets may hinder the hospitals ability to provide nutrition care that met patient needs.
Findings:
The purpose of a diet manual is to establish a common language and practice for physicians and other healthcare professionals to use when providing nutritional care to individuals. A comprehensive diet manual would include the diets purpose; diet principles, adequacy, foods to allow and foods to avoid as well as a sample menu that is consistent with the hospitals' menu for the most commonly ordered diets.

On 1/8/16 beginning at 8:30 A.M., the departments' diet manual was reviewed with Dietary Management Staff (DMS) 31. It was noted that while the facility revised portions of the diet manual, it did not include all the descriptive elements required of a diet manual. As an example the hospitals' renal, non-dialysis diet was deficient in copper, iron and magnesium; however, the diet manual did not mention these deficiencies. Lack of a comprehensive description was also discovered in the gluten free diet. In a concurrent interview with DMS 31, she stated she had not completed all the descriptions or inserted a sample meal plan that was consistent with the hospitals' menus for all diets.

Based on general and disaster meal planning food storage, dietary management staff interview and dietary document review, the hospital failed to ensure: 1) A comprehensive plan that addressed the hospitals' need for food supplies in accordance with the County and Accreditation body requirement of 4 days. 2) That food storage equipment was maintained in accordance to standards of practice as evidenced by equipment that was not easily cleanable. Surfaces that are not easily cleanable may provide an environment for cross contamination of patient food.
Findings:
1. On 1/7/16 beginning at 7:45 A.M., Hospital B's plan for disaster preparedness was reviewed with Dietary Management Staff (DMS) 31 and 33. It was noted that the hospital had a 3 day plan and concurrent supply of foods to be implemented in the event of a widespread disaster. In an interview and concurrent observation with DMS 31 and 32 on 1/7/16 beginning at 12:15 P.M., Hospital A's plan for disaster preparedness was reviewed. They stated that the supply was intended for 3 days. In an interview on 1/7/16 beginning at 3 P.M., with Administrative Staff 40, he stated that the person who was responsible for disaster preparedness recently resigned. He further stated that to his knowledge the county as well as the hospitals' accrediting organization guided hospital staff to be self sufficient for a period of 96 hours (4 days). In a follow up interview on 1/8/16 beginning at 8:00 A.M., with DMS 31, she stated that the disaster plan would also include perishable foods.
Hospital document titled "Disaster Plan" dated "July 2013", noted that the basic meal plan would be limited to canned and packaged food. An additional undated hospital document titled "Emergency (No-Cooking) Menu", guided staff that if utilities were not available, to use perishables and food on hand first; however, there was no guidance on which foods to use, nor was the hospital able to demonstrate a plan for the use of perishable foods that incorporated the foods that would be served, quantities of food that would be available nor procedures to ensure food safety of the perishable foods.
2. The standard of practice would be to ensure that all non-food contact equipment was constructed in a manner to ensure surfaces are corrosion resistant, smooth and cleanable (Food Code, 2015).
During food storage observations at Hospital A on 1/6/16 beginning at 4:25 P.M., it was noted the storage racks in the cold production refrigerator, adjacent to the dry storage area, were compromised. The protective plastic coating was worn off resulting in areas on the racks covered with a brown material resembling rust. Similarly during initial tour on 1/7/16 beginning at 7:30 A.M., at Hospital B, it was noted that the serving area refrigerator was also compromised. The plastic edge was broken, exposing an unfinished edge. It was also noted that in this refrigerator, there was a wire rack resting on the bottom, which resulted in the build up of a brown rust-like material. In a concurrent interview with Dietary Management Staff (DMS) 31, the surveyor asked if department managers regularly evaluated the physical environment of dietetic services. She stated that rounds were completed a minimum of monthly; however the compromised refrigerator was not identified.
In an interview on 1/7/16 beginning at 11:00 A.M., with DMS 32, he stated that he verbally requested an order to be placed for replacement shelves at Hospital A with a plant operations staff member. In an interview on 1/7/16 beginning at 3:00 P.M., with Administrative Staff 40, the position responsible for plant operations, he stated that all work orders should be processed through an electronic system. Review of dietary services work orders beginning in December 2015 failed to document a request for replacement shelves for refrigerator shelves at Hospital A. Review of hospital documents titled "Food Safety Inspection", dated 11/13/15 and 12/30/15 respectively for Hospitals A and B, revealed that while the facility physical environment was a component of the rounds, the staff completing the rounds did not identify the compromised surfaces.

Based on dietetic services observations, the hospital failed to ensure effective food production and food storage procedures as evidenced by: 1) Retention of foods for patient use after they were delivered to patients. 2) Lack of an effective air break in the food production sink at Hospital B. 3) Lack of temperature monitoring of mayonnaise based salads in accordance with departmental procedures. 4) Lack of an effective system for time/temperature control monitoring for café foods held for service. 5) unclean food production equipment. Failure to deliver food services in a safe and effective manner may promote bacterial growth associated with foodborne illness and promote contamination of patient food.
Findings:
1. During food storage observations at Hospital B on the 2nd floor nursing unit it was noted that dietary staff was retaining foods that were previously offered to patients. These items included unlabeled, uncovered, orange slices as well as milk and juice containers. Concurrent interview with Registered Nurse (RN) 41, revealed that the items would be utilized as snacks for patients between meals. In a concurrent interview with Dietary Management Staff (DMS) 31, she stated that served foods should be returned to the kitchen if not consumed. She also stated that with the exception of physician ordered snacks, the dietary department did not store food on the nursing unit. While the facility had a policy titled "Storage and Distribution of Outside Patient Food" this guidance was limited to food that was brought from outside the facility, such as from home. The policy did not include food that was delivered to patients and not consumed.
2. It would be the standard of practice to ensure that all food production equipment maintained an adequate air gap to mitigate the risk of cross contamination from wastewater. During initial tour on 1/7/16 beginning at 7:30 A.M., it was noted that the food production sink at Hospital B did not have an adequate air gap. Review of hospital document titled "Statement of Deficiencies" dated 11/3/15, revealed that the hospital had properly installed an air gap. In a concurrent interview with DMS 31, she was unable to provide information as to why the previously identified deficiency was not repaired.
3. In an interview on 1/7/16 beginning at 11:45 A.M., with Dietary Staff (DS) 37, the surveyor asked him to describe how he prepared and monitored the preparation of mayonnaise based salads such as tuna and chicken salad. He described a process whereby he would mix the protein item with mayonnaise, as well as other ingredients. He further stated that after the item was prepared it was labeled, dated and placed in the refrigerator. He further stated that after preparation he would periodically monitor the temperature to ensure that it met specified temperatures. He also stated that while egg salad was prepared every Sunday, this item was not monitored. Concurrent review of the hospital document titled "HACCP Daily Temperature Log" for position 731 from 11/24/15-1/7/16, revealed that while chicken and tuna salads were regularly monitored, the egg salad was not. In a follow up interview on 1/8/16 beginning at 9:00 A.M., with DMS 32, he stated that egg salad was produced by both position 731 and 134. Standardized recipe titled "Egg Salad, LF" guided staff to combine all ingredients ...Refrigerate and check temperature after 2 hours and record in log ..."
4. Potentially hazardous foods (PHF) are those defined as capable of supporting bacterial growth associated with foodborne illness. These foods require time/and or temperature control for food safety. The standard of practice would be to ensure that cold PHF's are held at 41ºF (degrees Fahrenheit) or below. Protein based items as well as cut melons are capable of supporting bacterial growth associated with foodborne illness (Food Code 2013).
On 1/7/16 beginning at 4:00 P.M., the food holding practices of Hospital A's café were evaluated. It was noted that cut melons on the salad bar were held at 53ºF. Similarly a chicken Cesar salad that was stored in the café's "grab and go" refrigerator, had a temperature of 48ºF.
In a concurrent interview with DMS 32, he stated that the facility developed a monitoring system for PHF's that were held in the café for service. He further stated that melons were offered approximately 2-3 times/week. Review of hospital document titled "Café Temperature Log" dated 12/15/15 through 1/7/16, failed to reveal monitoring of cut melons. Similarly the log failed to monitor PHF's in the "grab and go" refrigerator.
5. It would be the standard of practice to ensure that food production equipment be clean to sight and touch (Food Code 2013). On 1/7/16 beginning at 8:30 A.M., the departments' sanitation practices for fixed equipment was reviewed with Dietary Staff 39. He described a sanitation practice accordance with standards of practice however, upon visual inspection of the meat slicer, it was noted there were multiple unidentified food particles on the equipment.