HospitalInspections.org

Based on a review of documentation and an interview with staff, the medical staff failed to enforce bylaws to carry out its responsibilities.

Findings were:

During a review of reappointment documentation for 4 credentialed staff (staff #1 through #4), 3 of the 4 staff (staff #1, #2 and #4) had no current privileges delineated.

In an interview with staff #17 on 8-8-17, staff #17 stated that privileges were delineated at the time of the initial appointment but not reapplied for with each subsequent reappointment.

Facility "Medical Staff Bylaws, Rules & Regulations" (page 6) states, in part:
"Article V. Clinical Privileges
A. Clinical privileges restricted
...
2. Every application for staff appointment or reappointment must contain a request for specific clinical privileges desired by the applicant. The applicant shall have the burden of establishing his training, qualifications, demonstrated competence and experience in the clinical privileges requested."

The above was confirmed in an interview with the CEO and other administrative staff on the evening of 8-9-17.

Based on a review of documentation and an interview with staff, the medical staff bylaws failed to include a requirement that a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Findings were:

Facility document titled "Falls Community Hospital Medical Staff Rules and Regulations" states, in part:
"E. Medical Records
...
3. A complete history and physical shall be recorded within forty-eight (48) hours of admission."

In an interview with staff #17 on 8-8-17, staff #17 confirmed that the bylaws failed to include a requirement that a medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

The above was confirmed in an interview with the CEO and other administrative staff on the evening of 8-9-17.

Cross refer to:

A0620

Based on documentation, interviews with staff and a tour of the facility, the dietary director failed to be responsible for the daily management of the dietary services.

Findings were:

During a tour of the facility on 8-9-17, the following observations were made:

*Dietary Department
-2 of 3 drawers under the butcher-block counter, 1 of 1 drawer in the dessert prep area and 2 of 2 drawers in the prep area were all lined with a liner product. The edges were secured with a clear tape and had begun to peel away from the inside of the drawer. Crumbs were stuck to the sticky side of the tape. Food debris attracts vermin, which carry diseases and other microorganisms.
-The stand mixer whisk attachment had dried food residue on the wires and a sticky residue on the underside of the mixer.
-In the dishwashing area, the flaps covering the disposal system were torn away, allowing potential splashback when the disposal was in use.
-Dark, gooey residue was contained in the grout of the tile in the dishwashing area.
-The dishwasher bore a plate on the side of the unit which stated that the washing temperature for the unit should be at least 120 degrees Fahrenheit and the rinsing temperature for the unit should be at least 120 degrees Fahrenheit.
Review of the daily temperature log sheets revealed that: -
-For January 2017, the unit had been operated at temperatures less than recommended for 5 of the 30 days for which there was a record, as there was no temperature recorded for 1-17-17.
-For February 2017, the unit had been operated at temperatures less than recommended for 3 of the 26 days for which there was a record, as there was no temperature recorded for 2-15-17 or 2-19-17.
-For March 2017, the unit had been operated at temperatures less than recommended for 3 of the 25 days for which there was a record, as there was no temperature recorded for 3-5-17, 3-23-17, 3-28-17, 3-29-17, 3-30-17 or 3-31-17.
-For April 2017, the unit had been operated at temperatures less than recommended for 15 of the 25 days for which there was a record, as there was no temperature recorded for 4-1-17, 4-5-17, 4-7-17, 4-22-17 or 4-23-17.
-For May 2017, the unit had been operated at temperatures less than recommended for 23 of the 28 days for which there was a record, as there was no temperature recorded for 5-2-17, 5-10-17 or 5-16-17.
-No temperature log could be located for June 2017.
-For July 2017, the unit had been operated at temperatures less than recommended for 18 of the 31 days.
-For August, the unit had been operated at temperatures less than recommended for 8 of the 9 days recorded. In an interview with staff #13 on 8-9-17, staff #13 was asked if the dishwasher issue regarding the operating temperature had been reported to her supervisor or to the maintenance department. Staff #13 stated that the operating temperature issue had been reported to staff #18, #20 and #23 since January 2017.
When in operation, hot water sprayed out from a bent, unsealed area in the upper, left corner of the unit.
-The surface of the burner knobs in the hot food holding area contained spots of a greasy residue.
-A dark, greasy residue was stuck to the seal of the food blender.
-A sanitizer bucket was located in the food prep area, when asked to dip the solution in the bucket with a sanitizer indicator strip, the indicator strip did not change color to indicate that there was sufficient concentration of sanitizer in the solution.
-A flat, silver-colored meat pounder was found underneath a counter alongside 2 large bottles of cooking oil. When asked why the meat pounder was being stored underneath a counter and not in a utensil drawer, staff #13 stated that the item was the personal property of a member of the kitchen staff and that the kitchen staff member preferred to keep the pounder underneath the counter.
-Dishes had been stacked/nested while still wet, to include 7 half-pans, 7 full pans and 5 "third" pans.
-4 large stock pots had been turned over and were being stored upside-down on a dusty, unpainted shelf beneath a sink.
-3 48-ounce bottles of Realemon juice had expired 7-27-17 but were found on the shelf in the dry goods pantry, available for consumption.
-4 of 16 14-ounce cans of jellied cranberry sauce were not dated with the date they were received into the facility.

Facility Dietary policy titled "I. Functions of the Dietary Department" states, in part:
"Procedure:
...
10. Dishes used to serve patients, Medical Staff, guests and employees are washed in a central dish room according to acceptable sanitation standards."

Facility documentation titled "Falls Community Hospital Job Description: Food Service Supervisor" states, in part:
"Essential duties and Responsibilities:
...
B. Manages the preparation and service of nutritional food.
...
c. Monitors the sanitary conditions in food handling and preparation and compliance with infection control procedures.
...
XXVII Infection Control
Policy
It is the policy of Dietary Services that all Dietary areas will be maintained in a clean and orderly condition: all working services, utensils, and equipment will be thoroughly cleaned and sanitized after each period of use; only inspected perishable food items meeting specifications will be used.
Objectives:
1. Sanitary environment provisions to reduce sources and means for transmitting infection.
...
XXIX. Dietary Infection Control Procedures
Food Handling
1. All foods are prepared under sanitary conditions.
...
Dishwashing
Wash - 120-145 degrees Fahrenheit - 45 seconds
Final Rinse - 120-145 degrees Fahrenheit - 30 seconds with 50 PPM chlorine
...
General Cleaning and Sanitation
The highest level of sanitation shall be maintained in the department in the areas of food preparation, equipment and personnel.
...
5. Equipment such as dish machine is functioning properly at all times.
...
Procedures For Food Preparation and Handling
1. Sanitary handling procedures and techniques are applied in the preparation, transportation and serving of all foods and supplemental feedings.
...
Sanitation
1. Maintenance of Dietetic Areas
The entire dietetic area will be maintained in a clean and orderly condition. All working surfaces, utensils and equipment are thoroughly cleaned and sanitized after each period of use. Meat slicing and grinding equipment is disassembled and washed in detergent after each use. Cutting boards are washed in the dish machine after each use.
...
7. Routine Sanitation Inspections
Routine sanitation inspections are conducted weekly by supervisor as a follow-up check to daily cleaning by employees.
Rules for Dry Storage
...
11. Canned goods should be marked with the date of the delivery and the stock should be used according to the age, with the oldest first.
Cleaning Equipment
Mixing Machine:
1. Wash bowl and beater after each use.
...
3. Clean beater shaft and body of the machine with warm water and mild soap. Hard scrubbing and harsh soaps might remove the paint.
Hot Food Units
1. Remove containers; wash and dry.
2. Clean inside and outside of each unit of food table, use hot water and a washing compound; rinse and dry thoroughly.
..."

The above was confirmed in an interview with the CEO and other administrative staff on the evening of 8-9-17.

Cross refer to:

A0748

Based on documentation, interviews with staff and a tour of the facility, the infection control officer failed to develop and implement policies governing control of infections and communicable diseases. Failure to do so results in an unsanitary environment that increases the risk of illness and infection for patients, visitors and staff.

Findings were:

During a tour of the facility on 8-9-17, the following observations were made:

*Radiology Department
-2 external shipping boxes were being stored on the top shelf of the clean supply area.
-A thick, plush rug was in use on the floor of the bone density room. Stained areas were noted throughout the rug and visible debris was noted on the top surface of the rug. In an interview with staff #1, staff #1 was asked to provide documentation of the vacuuming and shampooing schedule for the rug. Staff #1 stated that, although he had no documentation of when the rug had been last shampooed, the rug was vacuumed daily prior to 12:00 pm (the facility tour was conducted beginning at approximately 1:30 pm).

*Pharmacy Department
-4 external shipping boxes were being stored on the pharmacy countertop.

*Dietary Department
-2 of 3 drawers under the butcher-block counter, 1 of 1 drawer in the dessert prep area and 2 of 2 drawers in the prep area were all lined with a liner product. The edges were secured with a clear tape and had begun to peel away from the inside of the drawer. Crumbs were stuck to the sticky side of the tape. Food debris attracts vermin, which carry diseases and other microorganisms.
-The stand mixer whisk attachment had dried food residue on the wires and a sticky residue on the underside of the mixer.
-In the dishwashing area, the flaps covering the disposal system were torn away, allowing potential splashback when the disposal was in use.
-Dark, gooey residue was contained in the grout of the tile in the dishwashing area.
-The dishwasher bore a plate on the side of the unit which stated that the washing temperature for the unit should be at least 120 degrees Fahrenheit and the rinsing temperature for the unit should be at least 120 degrees Fahrenheit.
Review of the daily temperature log sheets revealed that: -
-For January 2017, the unit had been operated at temperatures less than recommended for 5 of the 30 days for which there was a record, as there was no temperature recorded for 1-17-17.
-For February 2017, the unit had been operated at temperatures less than recommended for 3 of the 26 days for which there was a record, as there was no temperature recorded for 2-15-17 or 2-19-17.
-For March 2017, the unit had been operated at temperatures less than recommended for 3 of the 25 days for which there was a record, as there was no temperature recorded for 3-5-17, 3-23-17, 3-28-17, 3-29-17, 3-30-17 or 3-31-17.
-For April 2017, the unit had been operated at temperatures less than recommended for 15 of the 25 days for which there was a record, as there was no temperature recorded for 4-1-17, 4-5-17, 4-7-17, 4-22-17 or 4-23-17.
-For May 2017, the unit had been operated at temperatures less than recommended for 23 of the 28 days for which there was a record, as there was no temperature recorded for 5-2-17, 5-10-17 or 5-16-17.
-No temperature log could be located for June 2017.
-For July 2017, the unit had been operated at temperatures less than recommended for 18 of the 31 days.
-For August, the unit had been operated at temperatures less than recommended for 8 of the 9 days recorded. In an interview with staff #13 on 8-9-17, staff #13 was asked if the dishwasher issue regarding the operating temperature had been reported to her supervisor or to the maintenance department. Staff #13 stated that the operating temperature issue had been reported to staff #18, #20 and #23 since January 2017.
When in operation, hot water sprayed out from a bent, unsealed area in the upper, left corner of the unit.
-The surface of the burner knobs in the hot food holding area contained spots of a greasy residue.
-A dark, greasy residue was stuck to the seal of the food blender.
-A sanitizer bucket was located in the food prep area, when asked to dip the solution in the bucket with a sanitizer indicator strip, the indicator strip did not change color to indicate that there was sufficient concentration of sanitizer in the solution.
-A flat, silver-colored meat pounder was found underneath a counter alongside 2 large bottles of cooking oil. When asked why the meat pounder was being stored underneath a counter and not in a utensil drawer, staff #13 stated that the item was the personal property of a member of the kitchen staff and that the kitchen staff member preferred to keep the pounder underneath the counter.
-Dishes had been stacked/nested while still wet, to include 7 half-pans, 7 full pans and 5 "third" pans.
-4 large stock pots had been turned over and were being stored upside-down on a dusty, unpainted shelf beneath a sink.
-3 48-ounce bottles of Realemon juice had expired 7-27-17 but were found on the shelf in the dry goods pantry, available for consumption.

Facility Dietary policy titled "I. Functions of the Dietary Department" states, in part:
"Procedure:
...
10. Dishes used to serve patients, Medical Staff, guests and employees are washed in a central dish room according to acceptable sanitation standards."

Facility documentation titled "Falls Community Hospital Job Description: Food Service Supervisor" states, in part:
"Essential duties and Responsibilities:
...
B. Manages the preparation and service of nutritional food.
...
c. Monitors the sanitary conditions in food handling and preparation and compliance with infection control procedures.
...
XXVII Infection Control
Policy
It is the policy of Dietary Services that all Dietary areas will be maintained in a clean and orderly condition: all working services, utensils, and equipment will be thoroughly cleaned and sanitized after each period of use; only inspected perishable food items meeting specifications will be used.
Objectives:
1. Sanitary environment provisions to reduce sources and means for transmitting infection.
...
XXIX. Dietary Infection Control Procedures
Food Handling
1. All foods are prepared under sanitary conditions.
...
Dishwashing
Wash - 120-145 degrees Fahrenheit - 45 seconds
Final Rinse - 120-145 degrees Fahrenheit - 30 seconds with 50 PPM chlorine
...
General Cleaning and Sanitation
The highest level of sanitation shall be maintained in the department in the areas of food preparation, equipment and personnel.
...
5. Equipment such as dish machine is functioning properly at all times.
...
Procedures For Food Preparation and Handling
1. Sanitary handling procedures and techniques are applied in the preparation, transportation and serving of all foods and supplemental feedings.
...
Sanitation
1. Maintenance of Dietetic Areas
The entire dietetic area will be maintained in a clean and orderly condition. All working surfaces, utensils and equipment are thoroughly cleaned and sanitized after each period of use. Meat slicing and grinding equipment is disassembled and washed in detergent after each use. Cutting boards are washed in the dish machine after each use.
...
7. Routine Sanitation Inspections
Routine sanitation inspections are conducted weekly by supervisor as a follow-up check to daily cleaning by employees.
Cleaning Equipment
Mixing Machine:
1. Wash bowl and beater after each use.
...
3. Clean beater shaft and body of the machine with warm water and mild soap. Hard scrubbing and harsh soaps might remove the paint.
Hot Food Units
1. Remove containers; wash and dry.
2. Clean inside and outside of each unit of food table, use hot water and a washing compound; rinse and dry thoroughly.
..."

The above was confirmed in an interview with the CEO and other administrative staff on the evening of 8-9-17.