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Based on observation and interview the facility staff failed to assure that personal medical information was not posted on a wall of one of 64 patients' rooms (Patient 51) which made the information visible to all visitors to the unit. This violated the residents right to privacy and had the potential to embarrass the patient.

The findings.

On 12/10/12 at 2:30 p.m. a tour of the burn unit revealed a hand made sign affixed to the exterior wall of Patient 51's room. The sign read "C DIFF" in letters 2 inches high on the top line. "C DIFF " is Clostridium difficile a highly contagious bacterium that can cause symptoms ranging from malodorous diarrhea to life-threatening inflammation of the colon.
The Nurse Manager of the unit stated he was aware of the sign and the resident was on infection control precautions related to the infection. He stated that all visitors to the unit could pass the room and the sign was visible to them.
The Manager of Infection Control was present and spoke to the Nurse Manager about standard signs available and used in other area of the hospital. She stated that facility approved signs should not identify the organism of infection.

Based on observation, interview, and document review, the hospital failed to administer pharmaceutical services to meet the needs of patients in accordance with standards of practice as evidenced by failing to ensure the development and implementation of policy and procedures to assign beyond-use dating (BUD, the date or time beyond which a medication cannot be stored) for sterile (germ-free) compounded (mixed) intravenous (IV, directly into a vein) medications. The pharmacy assigned BUD dating of 12 hours, or greater, from the time of compounding. The use of 12 hours, or greater, in the absence of direct sterility testing results (testing of compounded IVs for bacteria), was not supported by the United States Pharmacopeial Convention (USP, scientific organization that sets standards for drug quality) <797> (USP chapter describing conditions and practices for compounding sterile drugs). This failure resulted in the potential for any admitted patient to have received a compounded IV medication with an incorrectly-established BUD.

Findings:

During an interview on 12/10/12 at 9:15 a.m., the Director of Pharmacy stated the hospital had pharmacy locations on the eighth, sixth, third, and basement floors.

During a concurrent tour and interview, on 12/10/12 at 12:05 p.m., in the sixth floor pharmacy, the sterile IV compounding area was identified. Inspection of the compounding area showed that it was not separated by walls and doors from the general pharmacy. The compounding area was not segregated (separated) from the general pharmacy by a boundary line on the floor. In the compounding area was an IV mixing hood (equipment to maintain a germ-free mixing area). Pharmacist 1 stated that IVs made in the hood were labeled with a "Start administration before" (BUD) of 12 hours from the time of mixing.

During an observation on 12/11/12 at 10:20 a.m. in the eighth floor pharmacy, the sterile IV compounding area was identified. Inspection of the compounding area showed that it was not separated by walls and doors from the general pharmacy. The compounding area was not segregated from the general pharmacy by a boundary line on the floor.

During a concurrent observation and interview on 12/11/12 at 10:30 a.m. in the eighth floor pharmacy, a medication refrigerator was identified. Inspection of the refrigerator showed it contained compounded IVs for Patient 9, Patient 19, and Patient 20. Patient 9's 5% dextrose in lactated ringer's (IV solution) with potassium chloride (electrolyte) was mixed on 12/10/12 and expired (BUD) four days later. Patient 19's daptomycin (antibiotic) was mixed on 12/4/12 and expired seven days later. Patient 20's vancomycin (antibiotic) was mixed on 12/9/12 and expired four days later. Pharmacist 2 inspected the three labels and stated the IVs were made in the basement pharmacy.

During a concurrent tour and interview on 12/12/12 at 1:50 p.m. in the basement pharmacy, the sterile IV compounding room was identified. The IV compounding room was separated from the general pharmacy by walls and doors. The IV compounding room consisted of an ante-area (a place to prepare for sterile IV compounding) and a buffer area (where sterile IV compounding took place). The ante-area was not physically separated from the buffer area by walls and doors. The ante-area was separated from the buffer area by a red line on the floor. In the buffer area were the hoods used to compound sterile IV medications. Pharmacy Manager 1 stated the hospital performed low-risk (low risk of contamination) IV compounding in the area. Pharmacy Manager 1 further stated that BUD dates of 48 hours (if stored at room temperature) or 14 days (if stored in the refrigerator), were assigned to IVs compounded in the basement pharmacy. In addition, Pharmacy Manager 1 stated that the hospital follows USP <797> standards for BUD dating of compounded medications. The hospital was requested to provide documentation of the air flow rate from the buffer area, across the red line on the floor (line of demarcation), into the ante-area. No documentation was provided prior to the end of the survey.

Review, of the USP <797>, Guidebook to Pharmaceutical Compounding-Sterile Preparations (2008, pg. 33) revealed the following requirement for Low-Risk Level CSPs (compounded sterile preparations) with 12-Hour or Less BUD "If the PEC (hood)...is a laminar airflow workbench (LAFW, type of hood)...that cannot be located within an ISO Class 7 (measure of air particles) buffer area...administration of such CSPs shall commence within 12 hours of preparation or as recommended in the manufacturers' package insert, whichever is less. Low-risk level CSPs with a 12-hour or less BUD shall meet all of the following four criteria: 1. PECs (LAFWs...) shall be certified and maintain ISO Class 5 as described...and shall be in a segregated compounding area restricted to sterile compounding activities that minimize the risk of CSP contamination." USP<797> defined a segregated compounding area as "a designated space, either a demarcated area or room, that is restricted to preparing low-risk level CSPs with 12-hour or less BUD...and shall be void of activities and materials that are extraneous to sterile compounding." Review of USP<797 showed the hospital failed to meet all the requirements for assigning 12-hour BUD to IVs compounded in the sixth and eighth floor pharmacies.

Review of the USP<797>, Guidebook to Pharmaceutical Compounding-Sterile Preparations (2008, pg.43) revealed Facility Design and Environmental Controls, "For buffer areas not physically separated from the ante-areas, the principle of displacement (moving) airflow shall be employed. This concept utilizes a low pressure differential (difference), high airflow principle. Using displacement airflow typically requires an air velocity (speed) of 40 ft (foot) per minute or more from the buffer area across the line of demarcation (red line on the floor) into the ante-area."

Review of USP<797> revealed the hospital failed to meet all the requirements for assigning BUD of 48 hours at room temperature, or 14 days if refrigerated, to IVs compounded in the basement pharmacy.

Based on observations, interviews and record reviews, the hospital failed to ensure that the Food and Nutrition Services Manager was effective in the daily management of the dietary services when:
· Unsafe food handling practices were observed in the department. (Refer to A 749).
· The disaster food supplies were not adequate to ensure the disaster plan could be implemented (Refer to A 701).
· The dietary service department did not measure, track and analyze quality indicators for deficient and unsafe food handling practices identified during a previous validation survey to ensure remediation of those practices (Refer to A 267).

These failures had the potential to result in food borne illness and/or inadequate nutrition during a disaster in a susceptible patient population in a hospital with a licensed bed capacity of 620.

Findings:

1. A. During a tour of the kitchen on 12/10/12 between 10:30 and 11:30 a.m., several previously cooked, potentially hazardous foods (foods that support bacterial growth when not properly stored) were observed in the refrigerators:
· A pan of diced chicken breasts, dated 12/8/12
· A pan of soy taco meat, dated 12/8/12
· Three beef sirloin roasts, approximately 5 pounds each, dated 12/8/12
· Six pans of sausage gravy, dated 12/9/12
· One pan of pork gravy, dated 12/8/12
· One pan of macaroni noodles, dated 12/10/12.

During an interview with Food Service Manager 2 at 10:30 a.m., he stated that the dates on the products indicated the date the items were cooked. He further stated that all the items should have been properly cooled and monitored for safe cool down by logging the cooling temperatures on the cooling logs.

According to the 2009 US Food and Drug Administration's Food Code, safe cooling of potentially hazardous food requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of potentially hazardous foods (PHF) has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, PHF are subject to the growth of a variety of pathogenic microorganisms (disease causing bacteria and toxins). If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135°F to 41°F in 6 hours, with cooling from 135°F to 70°F in 2 hours.

A review of the hospital's Cooling Temperature Logs for 12/8 through 12/10/12 showed that these items were not documented. The logs further instructed staff to record temperatures of these foods every hour during the cooling cycle.

During an interview with the Senior Cook on 12/10/12 at 1:30 p.m., he was unable to state why the above PHF were not documented on the Cooling Temperature Logs to ensure they were cooled safely.

B. During an observation of the dish machine on 12/10/12 at 2:30 p.m. during dish washing, the water temperature gauge on the machine was noted to register a final rinse temperature of 210 degrees Fahrenheit (F). Also noted around the gauge was direction to the staff by the dish machine manufacturer that the final rinse temperature should not exceed 195 degrees F. The temperature was concurrently verified by Food Service Worker 1 as he was washing dishes. He continued to wash dishes.

During a concurrent interview with Food Services Manager 1, he stated that as long as the final rinse temperature reached 180 degrees or higher, the dishes were being properly sanitized. He stated that 210 degrees F water in the final rinse would still sanitize the dishes. He was unable to state why the directions on the dish machine stated that the maximum temperature should be 195 degrees F.

A review of the hospital's policy titled, "Dish Machine/Pot Machine/Dishwasher Operation" dated 9/2010, revealed that the kitchen dish machine final rinse temperature should be 180 degrees to 195 degrees. It further stated that "any variance below or above these temperatures required that the machine be stopped, the supervisor called and the problem reported. The supervisor will correct the problem before continuing the washing of washables."

According to the 2009 US Food and Drug Administration's Food Code, the temperature of hot water delivered from a dish machine's sanitizing rinse manifold (where the temperature gauge measures) must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens (disease cause bacteria) that may remain on such surfaces after cleaning. When the sanitizing rinse temperature exceeds 90°C (194°F) at the manifold, the water becomes volatile and begins to vaporize, reducing its ability to convey sufficient heat to utensil surfaces.
C. During a tour of the kitchen on 12/10/12 at 2:05 p.m., two electric can openers were noted to have a build-up of black residue on the cutting blades. Also noted was an accumulation of paper can label pieces around the blades.
During a concurrent interview with Food Service Manager 2, he verified the findings. He stated that the can openers appeared as though they had not been cleaned in a while. He further stated that the can openers should be cleaned after each use to prevent cross contamination.

A review of the hospital's food and nutrition policy titled "Infection Control," dated 4/2012, revealed that, "Equipment such as food grinders, choppers, mixers, etc. are to be cleaned with water, sanitized and allowed to air dry."

A review of the hospital's policy titled, 'Cleaning and Sanitation of Food Contact Surfaces" dated 11/2011, revealed that, "Employees will clean and sanitize food contact surfaces after they are used, when switching to work with another type of food, as often as possible during the shift....and at the end of the shift."

D. During an observation in the kitchen on 12/11/12 at 11:00 a.m., Food Service Worker 3 was observed removing whole tomatoes from a sink filled with water.

During a concurrent interview with Food Service Worker 3, she stated that she soaked the tomatoes in water to wash them, then emptied the water from the sink and soaks the tomatoes a second time. She verified that the tomatoes were soaked and not rinsed with running water.

During a concurrent interview with Food Service Manager 2, he stated that the produce should be rinsed under running water in a sink where the produce is in a colander, not standing or soaking in the water. He was unable to explain why Food Service Worker 3 did not know the proper procedure.

A review of the hospital's policy titled' "Food Preparation, Storage, Distribution and Service" dated 4/2012 revealed that "Raw, unprocessed fruits and vegetables are to be washed twice under a heavy stream of cold running water and drained."

According to the 2009 US Food and Drug Administration's Food Code, pathogenic microorganisms such as Salmonella and chemicals such as pesticides may be present on the exterior surfaces of raw fruits and vegetables. Therefore, all fresh produce, except commercially washed, pre-cut, and bagged produce, must be thoroughly washed under running, potable water before eating, cutting or cooking.

E. During an observation in the hospital cafeteria, a refrigerated open display case was observed. A thermometer at the front of the display case registered 48 degrees F. A second thermometer registered 46 degrees F. The display case contained single portion sized containers of yogurts and cottage cheese. The temperature of a yogurt registered 42.8 degrees F. The finding was concurrently confirmed by Food Service Manager 2. He stated that the yogurt and cottage cheese were stocked in the display case before 6:00 a.m. and were replenished throughout the day as needed. There was no way of knowing how long the yogurt was at temperatures greater than 41 degrees F.

A review of the hospital's policy titled' "Food Preparation. Storage, Distribution, and Service" dated 4/2012, revealed that "potentially hazardous food shall be held at or below 41 degrees F or lower or at or above 135 degrees F.
According to the 2009 US Food and Drug Administration's Food Code, except during preparation, cooking, or cooling, refrigerated potentially hazardous food shall be maintained at 41 degrees F or less. It further explains that bacterial growth and/or toxin production can occur if potentially hazardous food remains in the temperature "Danger Zone" of 41°F to 135°F too long.

F. During a concurrent observation in the kitchen and interview with Food Service Worker 2 on 12/10/12 at 2:40 p.m., Food Service Worker 2 demonstrated how she tested the concentration of the sanitizer used for sanitizing food contact surfaces. She filled a spray bottle with the sanitizer solution, then immersed a test strip into the solution for approximately 30 seconds.
A review of the manufacturer's instructions on the test strip container revealed the procedure was to immerse the strip in the solution for 10 seconds, then compare the wet strip to the color chart to determine the concentration.

During an interview with Dietitian Supervisor 1, she verified that Food Service Worker 2 did not use the proper procedure for testing the sanitizer concentration which may result in a false reading. She was unable to state why Food Service Worker 2 did not know the proper procedure.

2. During a concurrent observation and record review, the hospital's Disaster Plan, dated 1/2012, and supplies were reviewed on 12/10/12 between 3:00 and 4:00 p.m. The plan stated assumptions which included, "420 inpatients will be fed 3 meals a day for 4 days including bottled water; sufficient non-perishable food to provide meals will be maintained on-site; 3200 staff will be fed one meal a day for 4 days including bottled water; sufficient non-perishable food to provide meals will be maintained on-site." The facility had multiple pallets of cases of MRE's (meals ready-to-eat) stored on the third floor. Each pallet was labeled with the number and type of MRE's it contained.

During an interview with Dietitian Supervisor 1 the same day at 3:00 p.m., she stated that the hospital was in the process of converting from their previous disaster menu to the MRE's. She stated that the MRE's would be served to staff and patients who had a physician's order for a diet that was not pureed consistency, full or clear liquids only. She stated that the plan required that they have 16,880 MRE's on-site. She stated that they had 11,472 meals on-site and they were gradually transitioning to the MRE's due to the cost of replacing the previous food supplies with these MRE's. They needed maintain enough of the previous food supplies to serve the remaining 5408 staff meals.

During the observation of disaster food supplies the following was noted:
The plan required 5,408 cereal bars; the hospital had 5,340 on hand.
The plan required 10,816 cracker packets; the hospital had 3,500 on hand.
The plan required 10,816 servings of peanut butter; the hospital had 1,128 on hand.
The plan required 5,408 fruit cups; the hospital had 1,728 on hand.
The plan required 5,408 cookies; the hospital had 3,435 on hand.

During a concurrent interview, Food Services Manager 1 confirmed these findings. He was unable to explain why the hospital did not maintain adequate supplies to feed the staff during the transition from the previous menu to the MRE's.

3. Throughout the survey, the following deficient practices were observed which had also been observed during a recertification survey in January of 2012:
· Cooked potentially hazardous foods were not monitored for safe cooling in accordance with the 2009 Food Code standards and the hospital's policy
· Fresh produce was not properly washed to prevent cross contamination in accordance with the 2009 Food Code standards and the hospital's policy
· The disaster food supply was not adequate to implement the hospital's disaster food plan.

During an interview with the Food and Nutrition Services Manager and concurrent review of the departments quality plan on 12/13/12 at 10:30 a.m., he stated that the department was not tracking or analyzing any quality indicators related to these unsafe food handling practices and inadequate disaster food supplies. He verified that the above findings were repeat findings that had been observed during the previous survey in January 2012. He was unable to explain why these deficient practices were not being tracked and analyzed to ensure remediation.

Based on observation and interview, the hospital staff failed to
1. Assure that air conditioner condensation collection pans were designed to drain safely in 3 of 3 pharmacies (the basement pharmacy, the 6th floor pharmacy and the 8th floor pharmacy. This had the potential to create an airborne hazard in the pharmacies.
2. Implement their disaster food plan in order to ensure the safety and well-being of the patients and staff in the event of a disaster. This resulted when the hospital failed to maintain adequate supplies to carry out their disaster food plan. This had the potential to result in inadequate nutrition for the hospital staff that was responsible for caring for patients during a disaster.


The findings.

1. On 12/12/12 at 8:20 a.m. the Plant Operations and Maintenance Manager stated that three pharmacy areas had air conditioning units in the ceilings and each unit had 2 collection pans to collect condensation(water). The primary collection pans had copper pipes which either connected to the regular plumbing waste water system or emptied into a sink. The secondary condensation collection pans were designed to drain any water away from the unit via copper pipes which extended 6 inches below the ceilings and then opened so that any water could fall freely to the sinks 5 feet below. He stated that antibacterial/antifungal chemicals were not used in the collection pans in the pharmacy units but, were used in some collection pans in other areas in the facility. The use of antibacterial/antifungal chemicals in collection pans would treat the water and decrease the risk of airborne contamination of waterborne bacteria and fungi. Observation of the area above the ceilings in the three pharmacy areas found the area dry and free from obvious water damage, mold, or fungi.

The secondary condensation collection pan drain pipe in the 8th floor pharmacy extended 6 inches from the ceiling and opened directly above three shelves used to store pharmacy supplies. Any water from this drain could hit all three shelves before falling into the sink 5 feet below. The shelves held the following items: a box marked "Chemotherapy Prep Drapes", a plastic basket marked "Compounding meds", and a case of bottles marked "fluconazole." If water drained onto the supplies it could create a damp environment which could lead to the growth of mold or fungi.

The secondary condensation collection pan drain pipes in the basement and 6th floor pharmacies extended 6 inches from the ceilings and opened to allow any water to fall freely to the sinks 5 feet below. This would provide an opportunity to dispense any waterborne infectious agents into the pharmacy environment.

Articles regarding the association of water and dampness with bacterial and fungal growth are frequently published. The Centers for Disease Control (CDC) on 6/1/2011 published on line at
titled a Legionellosis Resource Site which stated, "The Legionella bacteria are found naturally in the environment, usually in water. The bacteria grow best in warm water, like the kind found in hot tubs, cooling towers, hot water tanks, large plumbing systems, or parts of the air-conditioning systems of large buildings. They do not seem to grow in car or window air-conditioners. "

The CDC published an alert on line on 11/2012 related to the association of dampness and mold and fungi at
which stated, "Office buildings, schools, and other nonindustrial buildings may develop moisture and dampness problems from roof and window leaks, high indoor humidity, and flooding events, among other things. For this Alert, we define "dampness" as the presence of unwanted and excessive moisture in buildings [AIHA 2008]. This can lead to the growth of mold, fungi, and bacteria; the release of volatile organic compounds; and the breakdown of building materials."



2. During a concurrent observation and record review, the hospital's Disaster Plan, dated 1/2012, and supplies were reviewed on 12/10/12 between 3:00 and 4:00 p.m. The plan stated assumptions which included, "420 inpatients will be fed 3 meals a day for 4 days including bottled water; sufficient non-perishable food to provide meals will be maintained on-site; 3200 staff will be fed one meal a day for 4 days including bottled water; sufficient non-perishable food to provide meals will be maintained on-site." The facility had multiple pallets of cases of MRE's (meals ready to eat) stored on the third floor. Each pallet was labeled with the number and type of MRE's it contained.

During an interview with Dietitian Supervisor 1 the same day at 3:00 p.m., she stated that the hospital was in the process of converting from their previous disaster menu to the MRE's. She stated that the MRE's would be served to staff and patients who had a physician's order for a diet that was not pureed consistency, full or clear liquids only. She stated that the plan required that they have 16,880 MRE's on-site. She stated that they had 11,472 meals on-site and they were gradually transitioning to the MRE's due to the cost of replacing the previous food supplies with these MRE's. They needed maintain enough of the previous disaster menu's food supplies to serve 5408 staff meals (16,880 meals needed - 11,472 MRE's on hand).

During the observation of disaster food supplies the following was noted:
The plan required 5,408 cereal bars; the hospital had 5,340 on hand.
The plan required 10,816 cracker packets; the hospital had 3,500 on hand.
The plan required 10,816 servings of peanut butter; the hospital had 1,128 on hand.
The plan required 5,408 fruit cups; the hospital had 1,728 on hand.
The plan required 5,408 cookies; the hospital had 3,435 on hand.


During a concurrent interview, Food Services Manager 1 confirmed these findings. He was unable to explain why the hospital did not maintain adequate supplies to feed the staff during the transition from the previous menu to the MRE's.

Based on observation, interviews and record reviews, the hospital failed to develop an effective infection control surveillance system for identifying unsafe food handling practices in the dietary department when:
· Refrigerated, previously-cooked, potentially hazardous foods (PHF - foods that support bacterial growth when not properly stored) were not monitored for safe cool down
· The dish machine final rinse water temperatures exceeded safe temperatures for effective sanitizing of patient dishes and utensils
· Two electric can openers were not maintained in a sanitary manner
· Produce was soaked instead of rinsed under running water, creating the potential for cross contamination
· A refrigerated display case in the cafeteria did not maintain potentially hazardous foods at 41 degrees F or less
· Dietary staff was unable to demonstrate proper testing of the concentration of the sanitizing solution used to sanitize food contact surfaces.

The lack of surveillance of these unsafe food handling practices had the potential to result in a foodborne illness outbreak in a highly susceptible patient population in a hospital with a census of 490 patients.

Findings:

1. During a tour of the kitchen on 12/10/12 between 10:30 and 11:30 a.m., several previously-cooked, potentially hazardous foods were observed in the refrigerators:
· A pan of diced chicken breasts, dated 12/8/12
· A pan of soy taco meat, dated 12/8/12
· Three beef sirloin roasts, approximately 5 pounds each, dated 12/8/12
· Six pans of sausage gravy, dated 12/9/12
· One pan of pork gravy, dated 12/8/12
· One pan of macaroni noodles, dated 12/10/12.

During an interview with Food Service Manager 2 on 12/10/12 at 10:30 a.m., he stated the dates on the products indicated the date the items were cooked and refrigerated. He further stated that all the items should have been properly cooled and monitored for safe cooldown by logging the cooling temperatures on the cooling logs.

According to the 2009 US Food and Drug Administration's Food Code, safe cooling of potentially hazardous food requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of PHF has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, PHF are subject to the growth of a variety of pathogenic microorganisms. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135°F to 41°F in 6 hours, with cooling from 135°F to 70°F in 2 hours.

A review of the hospital's Cooling Temperature Logs for 12/8 - 12/10/12 showed that these items were not documented. The logs further instructed staff to record temperatures of these foods every hour during the cooling cycle.

During an interview with the Senior Cook on 12/10/12 at 1:30 p.m., he was unable to state why the above PHF were not documented on the Cooling Temperature Logs to ensure they were cooled safely.

2. During an observation of the dish machine on 12/10/12 at 2:30 p.m. during dish washing, the water temperature gauge on the machine was noted to register a final rinse temperature of 210 degrees Fahrenheit (F). Also noted around the gauge was direction to the staff by the dish machine manufacturer that the final rinse temperature should not exceed 195 degrees F. The temperature was concurrently verified by Food Service Worker 1 as he was washing dishes. He continued to wash dishes.

During a concurrent interview with Food Services Manager 1, he stated that as long as the final rinse temperature reached 180 degrees or higher, the dishes were being properly sanitized. He stated that 210 degrees F water in the final rinse would still sanitize the dishes. He was unable to state why the directions on the dish machine stated that the maximum temperature should be 195 degrees F.

A review of the hospital's policy "Dish Machine/Pot Machine/Dishwasher Operation" dated 9/2010 revealed that the kitchen dish machine final rinse temperature should be 180 to 195 degrees. It further stated that "any variance below or above these temperatures required that the machine be stopped, the supervisor called and the problem reported. The supervisor will correct the problem before continuing the washing of washables."

According to the 2009 US Food and Drug Administration's Food Code, the temperature of hot water delivered from a dish machine's sanitizing rinse manifold (where the temperature gauge measures) must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens (disease-causing bacteria) that may remain on such surfaces after cleaning. When the sanitizing rinse temperature exceeds 90°C (194°F) at the manifold, the water becomes volatile and begins to vaporize, reducing its ability to convey sufficient heat to utensil surfaces.

3. During a tour of the kitchen on 12/10/12 at 2:05 p.m., two electric can openers were noted to have a build-up of black residue on the cutting blades. Also noted was an accumulation of paper can label pieces around the blades.

During a concurrent interview, Food Service Manager 2 verified the findings. He stated that the can openers appeared as though they had not been cleaned in a while. He further stated that the can openers should be cleaned after each use to prevent cross-contamination.

A review of the hospital's food and nutrition policy titled "Infection Control," dated 4/2012, revealed, "Equipment such as food grinders, choppers, mixers, etc. are to be cleaned with water, sanitized and allowed to air dry."

A review of the hospital's policy titled "Cleaning and Sanitation of Food Contact Surfaces," dated 11/2011, revealed, "Employees will clean and sanitize food contact surfaces after they are used, when switching to work with another type of food, as often as possible during the shift....and at the end of the shift."

4. During an observation in the kitchen on 12/11/12 at 11:00 a.m., Food Service Worker 3 was observed removing whole tomatoes from a sink filled with water.

During a concurrent interview, Food Service Worker 3 stated that she soaked the tomatoes in water to wash them, then emptied the water from the sink and soaked the tomatoes a second time. She verified that the tomatoes were soaked and not rinsed with running water.

During a concurrent interview with Food Service Manager 2, he stated that produce should be rinsed under running water in a sink where the produce is in a colander, not standing or soaking in the water. He was unable to explain why Food Service Worker 3 did not know the proper procedure.

A review of the hospital's policy titled "Food Preparation, Storage, Distribution and Service," dated 4/2012, revealed "Raw, unprocessed fruits and vegetables are to be washed twice under a heavy stream of cold running water and drained."

According to the 2009 US Food and Drug Administration's Food Code, pathogenic microorganisms such as Salmonella and chemicals such as pesticides may be present on the exterior surfaces of raw fruits and vegetables. Therefore, all fresh produce except commercially washed, pre-cut, and bagged produce must be thoroughly washed under running, potable water before eating, cutting or cooking.

5. During an observation in the hospital cafeteria, a refrigerated open display case was observed. A thermometer at the front of the display case registered 48 degrees F. A second thermometer registered 46 degrees F. The display case contained single portion sized containers of yogurts and cottage cheese. The temperature of a yogurt registered 42.8 degrees F. The finding was concurrently confirmed by Food Service Manager 2. He stated that the yogurt and cottage cheese were stocked in the display case before 6:00 a.m. and were replenished throughout the day as needed. There was no way of knowing how long the yogurt was at a temperature greater than 41 degrees F.

A review of the hospital's policy "Food Preparation. Storage, Distribution, and Service," dated 4/2012, revealed "potentially hazardous food shall be held at or below 41 degrees F or lower or at or above 135 degrees F.

According to the 2009 US Food and Drug Administration's Food Code, except during preparation, cooking, or cooling, refrigerated potentially hazardous food shall be maintained at 41 degrees F or less. It further explains that bacterial growth and/or toxin production can occur if potentially hazardous food remains in the temperature "Danger Zone" of 41°F to 135°F too long.

6. During a concurrent kitchen observation and interview with Food Service Worker 2 on 12/10/12 at 2:40 p.m., Food Service Worker 2 demonstrated how she tested the concentration of the sanitizer used for sanitizing food contact surfaces. She filled a spray bottle with the sanitizer solution, then immersed a test strip into the solution for approximately 30 seconds.

A review of the manufacturer's instructions on the test strip container revealed the procedure was to immerse the strip in the solution for 10 seconds, then compare the wet strip to the color chart to determine the concentration.

During an interview with Dietitian Supervisor 1, she verified that Food Service Worker 2 did not use the proper procedure for testing the sanitizer concentration which may result in a false reading. The Supervisor was unable to state why Food Service Worker 2 did not know the proper procedure.