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Based on record review and interview the facility failed to ensure that Medicare recipients received and completed "An Important Message from Medicare" (IMM) document on admission and within 48 hours of discharge in 5 of 14 Medicare recipient records reviewed (Patient (Pt) #8, 12, 13, 15, 20) in a total sample of 20.

Findings include:

A review of the facility policy #11398360, titled "Important Message From Medicare Appeal Rights", last reviewed on 3/2022, revealed: "Patient and family services will check the Important Message Monday-Friday, but after the first signature has been obtained, [either through the ED (Emergency Department) or registration], to ensure the follow up copy of the signed Important Message is given two days before planned date of discharge. Important Message form will be scanned to EPIC record upon discharge."

Review of medical records revealed Patient #15 was admitted to the facility on 6/23/2022 and discharged on 6/27/2022. Patient #15 was a Medicare recipient and did not have a documented second IMM completed prior to discharge.

Review of medical records revealed Patient #20 was admitted to the facility on 12/28/2021 and discharged on 1/1/2022. Patient #20 was a Medicare recipient and did not have a documented second IMM completed prior to discharge.

During an interview on 9/12/2022 at 3:15 PM, when asked if there should have been a second IMM notice within 48 hours of discharge for Pt #15 and Pt #20, Director of Ancillary Services N (Electronic record review navigator) stated, "Yes."


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Review of medical records revealed Patient #8 was admitted to the facility on 10/08/2022 and discharged on 10/11/2022. Pt #8 was a Medicare recipient and did not have a documented IMM completed prior to discharge.

Review of medical records revealed Pt #12 was admitted to the facility on 08/12/2022 and discharged on 09/04/2022. Pt #12 was a Medicare recipient and did not have a documented IMM completed on admission and prior to discharge.

Review of medical records revealed Patient #13 was admitted to the facility on 08/24/2022 and discharged on 09/09/2022. Pt #13 was a Medicare recipient and did not have a documented IMM completed prior to discharge.

Per interview with Chief Nursing Officer (CNO) B on 09/13/2022 at 5:00 PM, CNO B confirmed the findings for Pt #8, 12, and 13, and stated that there should be a completed IMM on admission and within 2 days prior to discharge.

Based on observation, staff interviews, and review of maintenance records between September 12 and 13, 2022, Edgerton Hospital and Health Services, did not construct, install and maintain the building systems to ensure life safety for patients.

Findings include:

The facility was found to contain the following deficiencies:
K223 Doors with Self-Closing Devices
K321 Hazardous Area - Enclosure
K353 Sprinkler System - Maintenance and Testing
K372 Subdivision of Building Spaces - Smoke Barriers
K374 Subdivision of Building Spaces - Smoke Barrier Doors
K511 Utilities - Gas and Electric
K923 Gas Equipment - Cylinder and Container Storage

Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies are not compliant with 42 CFR 485.623(c)(e) resulted in the Critical Access Hospital's inability to ensure a safe environment for the patients.

Based on record review, observation, and interview the facility failed to ensure that crash carts (emergency equipment and medications) were maintained according to facility policy in 1 of 5 areas observed (Emergency Department); and failed to follow their policies and procedures to ensure the safe use of blanket and fluid warmers in 1 of 3 blanket and fluid warmers (Medical/Surgical unit) in a total sample of 14 departments.

Findings include:

A review of the facility policy #9999271, titled "Emergency Medications and Supplies (Crash Cart), last reviewed on 1/2022, revealed: "B. Crash Carts will be inspected by nursing personnel daily and after each use. If the area is not open every day (Surgical Services/PACU (Post Anesthesia Care Unit), Stress Lab, Cardiac Rehabilitation), the Crash Cart will be inspected every day they are open."

During observation on 9/12/2022 at 10:30 AM, observed Emergency Room (ED) daily 'Adult Crash Cart Check List' for September 2022 that revealed, no documented Crash Cart check on 9/9/2022 and the 'Pediatric Crash Cart Check list' was missing checks for 2022 on 9/9, 6/26, 6/16, 4/26, 2/10, 2/25 and 2/26.

During an interview on 9/12/2022 at 10:30 AM, when asked who is responsible for the Crash Cart checks, Chief Nursing Officer (CNO) B stated, "The nurses are." CNO B confirmed the above dates were missing Crash Cart checks.


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A review of the facility policy titled, "Warming Cabinet-Fluid and Blankets", last reviewed 04/2021, revealed: "PURPOSE ...Blanket temperature must be maintained within a safe range to avoid discomfort or injury to the patient ...Blanket temperature ...1. Blanket temperature is maintained at 130 degrees or less. 2. Document the temperature weekly on the blanket warmer temperature log ..."

A review of the facility document titled, "2022 Blanket Warmer Weekly Log", revealed that there were no temperature parameters listed (per policy) on the log sheet, there was a missing temperature reading on 07/30/2022-documented as "on vac".
During an interview on 09/12/2022 at 10:13 AM with Medical/Surgical RN (Registered Nurse) E, when asked about the temperature parameters for the blanket warmer, Registered Nurse E stated, "Temperature ranges for the blanket warmer used to be hanging on the wall by the warmer, it's not there now."

During an interview on 09/12/2022 at 10:14, LPN (Licensed Practical Nurse) G stated that he/she checks the blanket warmer weekly. When asked about the "on vac" documentation for the 07/30/2022 blanket warmer reading, Licensed Practical Nurse G stated, "When I'm on vacation nobody checks the temps [temperatures], so that's why it says I was on vacation."

Based on observation, interview and record review the facility failed to monitor temperature control as per policy in 1 of 14 departments (Laboratory Department), in a total sample of 14 departments.

Findings Include:

A review of the facility policy titled, "Daily/Weekly/Monthly/Quarterly Lab Duties", last reviewed 02/2022, revealed: Policy: [Facility Name] laboratory techs [technicians] will perform regularly scheduled temperature checks ...Principle: ...All temperature checks, maintenance, and cleaning will be documented ...Notes: Record all temperature checks, cleaning and maintenance activities on the appropriate log sheets...Humidity is recorded for troubleshooting purposes ..."

During a tour of the Laboratory Department (Lab) with Lab Manager X on 09/13/2022 at 10:35 AM, "Laboratory Daily/Weekly/Monthly Temperature & Activity Log" revealed there were no temperature parameters documented for Lab Humidity % (percentage) on the temperature log sheet,

During an interview with Laboratory Manager X on 09/13/2022 at 10:42 AM, when asked what the humidity temperature % ranges are and why they are not documented on the Lab temperature log, Manager X stated that the Humidity temperature % ranges used to be listed on the temperature log sheet, "I think it just didn't get translated over when the logs were updated." Lab Manager X confirmed that the last time humidity temperature % ranges were listed on the temperature log was 01/2013. When asked what the humidity temperature % parameters are, Manager X stated "20-80%."

A review of the 2022 "Laboratory Daily/Weekly/Monthly Temperature & Activity Log" revealed, Lab Humidity temperature readings were out of range on the following dates: 01/15/2022 (18.0%), 01/16/2022 (15.8%), 01/17/2022 (17.4%), 01/20/2022 (15.5%), 01/21/2022 (15.1%), 01/22/2022 (15.0%), 01/30/2022 (17.6%), 02/03/2022 (17.5%), 02/06/2022 (15.7%), 02/07/2022 (16.9%), 03/05/2022 (19.7%) and 03/10/2022 (16.5%); there was no documentation of troubleshooting on the temperature log when humidity temperature percentages were out of range-per humidity temperature ranges stated by Lab Manager X.

Based on observation, staff interviews, and review of maintenance records between September 12 and 13, 2022, Edgerton Hospital and Health Services, did not construct, install and maintain the life safety systems for patients.

Findings include:

The facility was found to contain the following deficiencies.
K223 Doors with Self-Closing Devices
K321 Hazardous Area - Enclosure
K353 Sprinkler System - Maintenance and Testing
K372 Subdivision of Building Spaces - Smoke Barriers
K374 Subdivision of Building Spaces - Smoke Barrier Doors
K511 Utilities - Gas and Electric
K923 Gas Equipment - Cylinder and Container Storage

Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies with 42 CFR 485.623(d)(1) resulted in the Critical Access Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview staff failed to ensure patients in restraints are properly monitored, assessed, and evaluated as per policy in 2 of 2 restraint medical records reviewed (Patient (Pt) #10, #11) in a total sample of 20 medical records reviewed; and failed to ensure that staff are properly oriented to their job role/duties and competencies are assessed and evaluated as per policy in 4 of 11 staff competencies and orientations reviewed (Manager H, Food Services Manager I, Dining Services Worker K, Dietician J) in a total sample of 17 personnel files reviewed.

Findings Include:

Restraints:

Review of policy and procedure titled, "Restraint" last revised 08/2022 revealed the following:

Violent/Self-Destructive Patient Monitoring:
A. A staff member who is trained and competent monitors the patient at the initiation of restraint and every 15 minutes for violent patient thereafter for the need for:
1. Signs of injury
2. Nutrition/Hydration
3. Circulation and range of motion in the extremities
4. Vital signs
5. Hygiene and elimination
6. Physical and psychological status and comfort
7. Readiness for discontinuation of restraint
B. Relief periods for patients in restraints must occur, except when precluded for safety reasons (in which case the reason must be documented).
C. Patients must be given relief periods every 2 hours
D. When a restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff members others, the patient must be seen face to face within one hour after the initiation of the intervention by a:
1. Physician
2. Licensed Independent Practitioner
3. Trained RN
E. The face to face assessment should address:
1. Patient's immediate condition
2. Patient's reaction to the intervention
3. Patient's medical and behavioral condition (including complete review of systems and medical record)
4. The need to continue or terminate the restraint.
G. Patients must be reevaluated for continued restraint use:
1. every 4 hours for patients ages 18 years and older.

Review of medical records, revealed Pt #10 was placed in 4 point restraints (restrain both arms and both legs) in the Emergency Department (ED) on 10/20/2021 at 5:15 PM due to violent, aggressive and combative behaviors. Per review, Pt #10 did not have a documented face to face within one hour by a qualified staff member, addressing the required assessments as per policy.

Per review of Pt #10's medical record, there was no documented evidence of "relief periods" from restraints every 2 hours or documentation of the reasons this could not be initiated as per policy.

Review of Pt #10's medical record, revealed documented restraint monitoring of Pt #10 on 10/20/2021 at 5:15 PM(initial), 6:14 PM, 7:15 PM, and 8:14 PM; there was no documented restraint monitoring every 15 minutes as required per policy.

Review of Pt #10's ED notes on 10/20/2021 at 10:15 PM revealed, "Soft restraints were removed before CT (computed tomography) scan, due to patient being intubated." Per review of Pt #10's medical record, there was no documented evidence of when Pt #10's restraints were discontinued.

Review of policy and procedure titled, "Restraint" last revised 08/2022 revealed the following:

Nonviolent/Non Self Destructive Patient Monitoring:
A. At least every 2 hours the staff will provide the following cares:
1. Release of restrained extremity and provision of Range of Motion as appropriate
2. Offer of nutrition, hydration and toileting as appropriate.
3. Reposition as appropriate.
B. At least every 2 hours the staff will assess:
1. Circulatory check of extremity
2. Vital Signs as indicated
3. Signs of injury associated with application/release of restraint
4. Psychological status

Review of Pt #11's medical record revealed on 01/22/2022 at 12:35 AM, Pt #11 was placed in soft wrist restraints due to pulling on medical devices; the restraints were removed on 01/22/2022 at 4:35 AM.

Review of Pt #11's nursing flowsheet documentation revealed a "Focused Assessment" was completed on 01/22/2022 at 1:37 AM and 3:27 AM. Pt #11's focused nursing assessment did not include documentation of the following assessments as per policy:
-Range of motion of restrained extremities
-Repositioning
-Circulatory check of extremities
-Vital signs
-Assessing for signs of injury associated with use of restraints

Per interview with Director N on 09/13/2022 at 5:15 PM, nursing staff should be using the Restraint flowsheet in the electronic health record to document Restraint monitoring and this did not occur with Pt #11's nursing documentation. Director N stated that staff should be following the Restraint policy; Director N agreed with the findings for Pt #10 and Pt #11.

Competencies/Orientation:

Review of policy and procedure titled, "Competency Assessment and Education" last revised 08/2022, revealed the following:
-Orientation will consist of completion of a self assessment, the completion of the Master Competency Check List (Orientation/Competency List) and precepted shifts as deemed by the manager on assessments and orientee feedback.
-As activities or skills are obtained, the preceptor or designee validates this attainment by documentation of her/his initials and date in the appropriate column.
-An "Annual Competency Assessment" list will be developed for each clinical unit or department and for every role within each clinical unit or department.
-The completed Annual Competency Assessment list will be reviewed by departmental managers for identification of skills and/or knowledge that need review or training.
-The Orientation/Competency and Annual Competency Assessment lists and individual competencies should be available on the unit at all times...
-Validator should possess credentials for clinical practice specific to the competencies to be validated; and has documented demonstration of knowledge and skill related to defined competencies.

Review of personnel files on 09/13/2022 at 2:15 PM revealed Manager H was hired as a Registered Nurse on 08/30/2016 and became the Emergency Department Manager on 07/22/2022 and the Medical/Surgical Services Manager on 8/14/2022.

Review of the Medical Surgical Services Manager Position Summary last revised on 12/2021 revealed, "The Manager is responsible for all aspects of staff management, departmental management, annual work-plan development, budget preparation, performance reviews, quality improvement programs, professional development programs for staff, and preparation and maintenance of regulatory requirements."

Review of Manager H's personnel file revealed no documented orientation and competency assessment/check list related to the Emergency Department Manager or Medical/Surgical Services Manager.

Per interview with Chief Nurse Officer (CNO) B on 09/13/2022 at 3:30 PM, CNO B stated that Manager H does not have an orientation or competency started and/or completed for his/her job duties. Per CNO B, Manager H is the acting Manager of both the ED and Medical/Surgical unit.

Review of personnel files for Dietician J, revealed that Food Service Manager I initialed and validated Dietician J's Master Competency check list (dated 03/29/2021).

Review of the Competency check list for Dietitian J revealed that Food Service Manager I validated skills including but not limited to:
-Identifies therapeutic diet and individualized nutritional interventions
-Develops education content utilizing existing plans/protocols to include; health maintenance, disease process, pre and post procedure/treatment, discharge planning, evaluating patients/family learning, evaluates results of nutritional care plan.

Per interview with Food Service Manager (FSM) I on 09/13/2022 at 3:00 PM, when asked if he/she was qualified to validate Dietician J's skills, Food Service Manager responded, "Probably not..."

Per interview with Director of Ancillary Services N on 09/13/2022 at 5:00 PM, Food Service Manager is not qualified to validate the skills of a Dietician and should not have signed off as validating Dietician J's competency check list.

Review of personnel files for Dining Services Worker (DSW) K, revealed DSW K initialed his/her competency checklist as completed on 06/08/2022. Per review of the competency checklist, there was no documented evidence that a preceptor reviewed DSW K's competency checklist and validated his/her skills.

Review of personnel files for FSM I, revealed FSM I signed his/her name and dated 01/31/2020 under "Competency Validated" column, then drew a line down all the columns of the competency checklist. There was no documented evidence that a preceptor reviewed FSM I's competency checklist and validated his/her individual skills.

Per interview with RN Educator D on 09/13/2022 at 2:00 PM revealed that staff should be following the Competency Assessment and Education policy when orienting staff and completing competency assessments and evaluations.

Based on record review and interview the facility failed to ensure that patient consent for treatment had signatures, time, dates or a witness signature for verbal consent prior to receiving treatment in 7 of 20 medical records (Patient (Pt) #1, #2, #4, #6, #14, #15 and #20) in a total sample of 20 medical records reviewed.

Findings include:

A review of the facility policy #11624975, titled "Patient Informed Consent/Signatures", last reviewed 4/2022, revealed: "Procedure: 4. After the registration has been completed in EPIC System, the registration staff will obtain the patient/guarantor signature on the electronic pad or on the registration signature page if necessary....By obtaining the patient signature, the registration clear is assuring that the patient has been informed and consented to the treatment/procedure they are registering for..."

Review of medical records revealed Pt #14 was admitted to the facility on 7/28/2022 and discharged on 8/1/2022. Patient #14 did not sign the consent to treat form nor was verbal consent documented.

Review of medical records revealed Pt #15 was admitted to the facility on 6/23/2022 and discharged on 6/27/2022. Patient #15 did not sign the consent to treat form nor was verbal consent documented.

Review of medical records revealed Pt #20 was admitted to the facility on 12/28/2021 and discharged on 1/1/2022. Patient #20 did not sign the consent to treat form nor was verbal consent documented.

During an interview on 9/12/2022 at 3:15 PM, when asked if there should have been a signed consent to treat form or verbal consent to treat in Pt #14, 15, and 20's record, Director of Ancillary Services N (Electronic record review navigator) stated, "Yes."


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Review of medical records revealed Pt #1 was admitted to the facility on 09/10/2022 and discharged on 09/12/2022. Patient #1 did not sign the consent to treat form. Director of Ancillary Services N (Electronic record review navigator) stated that Registration staff marked that the consent form was signed by verbal consent from Patient #1, there was no verbal consent documented in the chart on the consent form.

Review of medical records revealed Pt #2 was admitted to the facility on 09/02/2022 and was inpatient on 09/13/2022 during chart review. Patient #2 did not sign the consent to treat form and there was no verbal consent documented in the chart; Director of Ancillary Services N (Electronic record review navigator) confirmed this finding.

Review of medical records revealed Pt #4 was admitted to the facility on 09/08/2022 and was inpatient on 09/13/2022 during chart review. Patient #4 did not sign the consent to treat form and there was no verbal consent documented in the chart; Director of Ancillary Services N (Electronic record review navigator) confirmed this finding.

Review of medical records revealed Pt #6 was admitted to the facility on 09/11/2022 and discharged on 09/12/2022. Patient #6 did not sign the consent to treat form and there was no verbal consent documented; Director of Ancillary Services N (Electronic record review navigator) confirmed this finding.

Based on observation, record review, and interview, staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff in 2 of 14 departments (Post Anesthesia Care Unit in the Operating Room Department and Environmental Services) in a total sample of 14 departments observed.

Findings include:

A review of the facility policy #11020973, titled, "Hand Hygiene", last revised 1/2022, revealed: "Purpose: To provide guidance for appropriate hand hygiene practices and to provide a safe environment for patients, visitors and staff by reducing the risk of transmission of infections...Indications for Hand Hygiene: 2. It is recommended that hospital and medical staff use an alcohol-based hand rub or wash hands as follows: J. After removing gloves..."

Examples in the OR (Operating Room) Department

During an observation in the OR on 9/13/2022 at 8:10 AM, observed Registered Nurse (RN) Circulator V insert a Tylenol suppository, removed gloves and donned a new pair of gloves without performing hand hygiene.

During an interview on 9/13/2022 at 9:35 AM, OR Manager T stated, "I would expect hand hygiene to be performed when removing gloves."

On 9/13/2022 at 9:30 AM during a tour of the Operating Room (OR) Suite with OR Manager T observed a full-flush hopper toilet without a cover or shield in the recovery room. Patients who have had general anesthesia come to this room after surgery for post anesthesia monitoring.

During an interview on 9/13/2022 at 9:30 AM, OR Manager T stated, "We don't use the hopper." When asked if it was functional, Manager T stated, "Yes."



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Environmental Services Department:

Review of the "Quarterly Curtain Replacement" log for the Medical/Surgical Unit revealed Quarter 1 dates are from January to March; and Quarter 2 dates are April through June. Review of the log revealed the following issues:
-No documented evidence of curtain replacement for Quarter 1 for rooms 103, 105, 107, 113, 115, 116, 117, and 118.
-No documented evidence of curtain replacement for Quarter 2 for rooms 106, 108, 109, and 113.

Per interview with Environmental Services (EVS) Manager AA on 09/13/22 at 3:10 PM, EVS AA stated that there was no policy and procedure referencing privacy curtain cleaning/replacement for patient rooms, however the protocol is for staff to replace privacy curtains at least quarterly and document evidence of this replacement on the "Quarterly Curtain Replacement" log. EVS AA stated that he/she was unable to provide evidence that curtain replacement was completed quarterly on the above patient rooms and agreed with the findings.

Based on observation, interview, and record review the facility failed to ensure the food used to prepare meals for patients was labeled, dated, and not expired; failed to ensure refrigerator and freezer temperatures are checked as per protocol to ensure food was stored at safe temperatures; and failed to complete quality control checks on the dishwasher to ensure the dishes used for patients are properly heat disinfected in 1 of 14 departments observed (Dietary) in a total sample of 14 departments observed.

Findings Include:

Food Storage:

Review of guidelines "Dry Storage Life of Foods" dated August 2018 revealed to "Use the Manufacturer's expiration date for product storage. If there is no expiration date on the package, add the time listed here to the date the food is received." Review of the above guidelines revealed the following:
-Unopened canned products: use manufacturer's expiration/best is used by date; if no date, then add 1 year from received date.
-Hot Chocolate Mix--expiration is 1 year from received date
-Canned or bottled fruit juice--expiration is 1 year from received date
-Oil and Condiments-- expiration is 4 months to 1 year unopened, from received date. 1-2 months opened refrigerated
-Grain Products (rice, flour, cereal, pasta)-- expiration is 6 months from received date.
-Seasonings (spices, herbs, sugar, flavoring extracts)-- expiration is 1 year from received date.

Review of guidelines, "Refrigerated Storage Life of Foods" dated August 2018 revealed, "Use manufacturer's expiration date for products before they are opened. If there is no expiration date on the package, add the time listed here to the date the food is received. Add the time in the 'Opened' column to the date when the food is prepared or opened. Label when product is opened." Review of the guidelines revealed the following:
-Hard Cooked eggs-- follow expiration date on package
-Sliced cheese--expires 7 days after opening.
-Non-dairy creamer--follow expiration date on package

Observations of the Dietary departments food storage on 09/12/2022 between 10:15 AM and 12:00 PM revealed the following issues:

Dry Storage foods with no opened date and/or received date:
-Opened bottles of a variety of seasoning blends (9)
-Opened Ben's Original Rice
-Opened Bag of Spaghetti
-Opened Box of dried mash potato mix
-Opened 1 gallon container of Soy Sauce
-Horseradish sauce
-Orange marmalade
-Opened bag of powdered sugar
-Opened box of pancake mix
-Opened bottle of syrup
-Opened box of Cream of Wheat
-Opened gallon of spring water

Dry Storage expired foods, no expiration date and/or received date:
-Sweet Baby Rays barbecue sauce--expired 03/28/2021
-Cans of Evaporated Milk (18)--expired 08/16/2021
-Cans of mandarin oranges (2)--expired 11/11/2020
-Box of Peanut butter packets--no expiration date
-Box of coffee creamer--no expiration date
-Containers of malted milk (2)--expired 7/2022
-Hot Cocoa mix--no expiration date
-Boxes of Swiss Miss hot cocoa (2) expired 04/15/2022

Refrigerated foods with no opened date and/or received date::
-Box of whipped spread
-Green chilies
-Jalapeno peppers
-Sundried tomatoes
-Cherry tomatoes
-Carrots
-Opened Pepper Jack cheese
-Opened American cheese
-Opened Mozzarella cheese
-Icing (no label)
-Opened bag of Tortillas
-Opened Sweet and Hot pepper relish
-Opened Plum sauce
-Jello containers (3) (No prepared date)
-Boiled eggs in plastic bag (3)

Per interview with Food Service Manager (FSM) I on 09/12/2022 during the tour from 10:15 AM to 12:00 PM, FSM I stated that food should be labeled with the date the food was received in the department and the date opened. FSM I stated that staff should be checking for outdates weekly and should follow the food guidelines listed in the policy. At the time of the observations, FSM I confirmed the food issues above and agreed with findings.

Temperature Logs:

Review of the Refrigeration Temperature Record logs for July, August, and September 2022 revealed the following missing temperature checks:

July 2022:
-On July 16, 17, and 30, there was no PM (afternoon) check for the "Walk-in Cooler".
-On July 16, 17, and 30, there was no PM check for the "Patient Cooler".
-On July 13, 17, 23, and 30 there was no PM check for the "Patient Line" cooler.

August:
-On August 4, 8, 10, 24, 29, 30, 31, there were no AM temperature checks for the "Cooler".
-On August 7, 20, and 27, there were no PM temperature checks for the "Patient Line" cooler.
-On August 4, 8, 10, 24, 29, 30, 31, there were no AM checks for the "Patient Line" cooler.

September:
-On September 1, there was no PM temperature check on the "Walk-in Cooler".
-On September 1, there was no PM temperature check on the "Patient Cooler".
-On September 1, there was no PM temperature check on the "Patient Line" cooler.

Review of the Freezer Temperature Record logs for July, August, and September 2022 revealed the following missing AM (Morning) and PM (Afternoon) temperature checks:

July:
-On July 31, there was no AM temperature check documented.
-On July 16, 17, 23, and 30, there were no PM temperature checks documented.

August:
-On August 8, 10, 24, 29, 30, and 31, there were no AM temperature checks documented;
-On August 7, 20, and 27, there were no PM temperature checks documented.

September:
-On September 1, there was no PM temperature check documented.

Per interview with Food Service Manager (FSM) I on 09/12/2022 during the tour from 10:15 AM to 12:00 PM, FSM I stated that the freezer and refrigerator temperature logs should be completed twice daily in the morning (AM) and afternoon (PM). Per FSM I, the dietary department has been very busy and sometimes these checks are missed.

Dishwasher Temperatures:

Review of the "Dish Washer Temperature" form revealed the "Wash" temperature should be at least 150 degrees Fahrenheit (F), the "Rinse" temperature should be at least 180 degrees F, and the "Test Strip" used to measure the heat disinfection process should be 160 degrees F. Per review of the form, "Internal temperature is measured using a dish washer test strip. Indicate if the dishwasher test strip reached 160 degrees F by writing YES or NO." Review of the form revealed categories for documentation of these temperatures for "Breakfast", "Lunch", and "Dinner."

Review of the Dishwasher Temperature logs for July, August, and September 2022 revealed the following missing "Breakfast", "Lunch", and "Dinner" temperature checks (Wash and Rinse):

July:
-On July 15, there was no temperature check documented for "lunch".
-On July 18, there were no temperature checks documented for "breakfast" "lunch" and "dinner".
-On July 1 through July 30, there were no "Test strip" temperatures documented indicating if the temperature (heat disinfection) reached 160 degrees F.

August:
-On July 19, there was no temperature check documented for "Breakfast".
-On July 20, there were no temperature checks documented for "Lunch" and "Dinner".
-On July 24, there were no temperature checks documented for "Breakfast" and "Lunch".
-On July 26 and 27, there were no temperature checks documented for "Breakfast", "Lunch", and "Dinner".
-On July 31, there were no temperature checks documented for "Breakfast".
-On August 1 through August 31, there were no "Test strip" temperatures documented indicating if the temperature (heat disinfection) reached 160 degrees F.

September:
-On September 1, there were no temperature checks documented for "Breakfast" and "Lunch".
-On September 2, there were no temperature checks documented for "Breakfast".
-On September 3, there were no temperature checks documented for "Breakfast", "Lunch", and "Dinner".
-On September 6 through 9, there was no temperature check documented for "Breakfast".
-On September 10, there were no temperature checks documented for "Breakfast", "Lunch", and "Dinner".
-On September 1 through 11, there were no "Test strip" temperatures documented indicating if the temperature (heat disinfection) reached 160 degrees F.

Per interview with Food Service Manager (FSM) I on 09/12/2022 during the tour from 10:15 AM to 12:00 PM, FSM I stated staff should be checking the dishwasher temperatures 3 times per day for breakfast, lunch, and dinner dishwashing cycles and documenting these checks on the Dish Washer Temperatures form. Per FSM I, the facility uses heat disinfection to ensure the proper disinfection of patient dishes. FSM I stated that staff should be using the test strips as a quality control to ensure the proper temperature is obtained during the dishwashing cycle, but FSM I stated that he/she has not been able to obtain the test strips from the manufacturer due to a back log.