HospitalInspections.org

Based on observation, policy, document review and staff interviews, the Critical Access Hospital (CAH) failed to ensure dietary staff had a system in place to evaluate and monitor patient food temperatures in order to meet the Food and Drug Administrations Food Code requirements to prevent food bourne illness.

Failure to ensure the Foodservice Department staff had a system in place to evaluate, monitor, and maintain proper food holding temperatures during meal service could potentially result in food bourne illness, severe illness, and patient harm.

Findings include:

1. The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions, requires cold food held at a minimum of 41 degrees F or below and hot food held at a minimum of 135 degrees Fahrenheit (F) or above.

2. Review of a Food-Service policy titled "Serving Line Food Temperature Records" dated 12/15, included in part "...Temperatures of hot food items, milk and juice will routinely be measured and recorded at each meal...cook or aide will take temperatures of hot cereal, scrambled eggs...hot entree, potato, or substitute vegetables, and soup, on the hot food table immediately prior to the beginning of serving each meal...cook or aide will take the temperature of milk and juices immediately prior to the beginning of serving each meal...temperatures standards will be as follows: (in degrees)...cereal, scrambled eggs, soups, hot entrees, potatoes, vegetables...140-170 degrees...milk...juices...40 degrees or below."

3. Review of documented temperature records from January 2016 through March 17, 2016 showed dietary staff recorded food temperatures 5 days in January, 5 days in February, and 4 days in March.

4. Review of dietary meeting minutes dated 1/20/16, revealed the following in part ..."Food temps aren't good."

Review of dietary meeting minutes dated 2/12/16, revealed the following in part ..."Temperatures for food...must be documented for all meals."

Review of dietary meeting minutes dated 3/16, revealed the following in part ..."concerns that have been noted/found...holes in food temperatures...this is a violation and I have repeatedly told everyone the importance of making sure there are no holes in any documentation that we complete."

5. During an interview on 3/21/16 at 11:00 AM, Staff P, Dietary Cook reported hot and cold temperatures of food items are taken before the meal is served to patients to ensure they are at the proper temperatures and to reduce the risk of exposure to bacterial contamination.

During an interview on 3/21/16 at 2:20 PM, Staff A, dietary aide reported hot and cold food temperatures are taken and recorded before serving the meal to patients to decrease the risk of food bourne illnesses and outbreaks.

During an interview on 3/21/16 at 3:30 PM, Staff C, Dietician reported dietary staff failed to record hot and cold food temperatures 24 of 31 days in January, 23 of 29 days in February, and 12 days of 17 days in March. Staff C said hot and cold food temperatures are taken to ensure the food is the proper temperature and to prevent promotion of food bourne illnesses's. Staff C said she identified dietary staff failed to document hot and cold food temperatures when she first started working at the CAH three months ago. Staff C stated she reviewed this at their monthly meetings in January, February and March.

During an interview on 3/22/16 at 7:40 AM, Staff Q, Director of Nursing/Infection Control Coordinator said she was unaware dietary staff were not monitoring or documenting hot and cold food temperatures. Staff Q reported the hospital did not have an infection control policy specific to food temperatures and explained that it was important for dietary staff to take food temperatures to ensure the food was safe for patients to consume. Staff Q said she thought the Quality Assurance (QA) committee monitored food temperature logs to identify if the CAH had problems with food bourne illnesses.

During an interview on 3/22/16 at 7:45 AM, Staff E, Quality Services Coordinator reported the dietician presents their QA monitoring for food temperatures quarterly to the committee. Staff E said the last time food temperatures were presented to the committee was November 2015. Staff E reported they did not review food temperatures in the February 2016 committee meeting but she spoke with the dietician after the meeting and emphasized they needed to be reported on a Quarterly basis. Staff E said the dietician told her she identified concerns with dietary staff failing to monitor and document hot and cold food temperatures and she was reviewing this with staff. When asked why it was important to monitor and document hot and cold food temperatures, Staff E replied that this was a patient safety issue to ensure patients are not a risk for food poisoning. Staff E reported she had not been involved or heard anything since she'd spoken with the dietician in February but she intended to touch base with her immediately.

During an interview on 3/22/16 at 8:10 AM, Staff F, Director of General Services reported she supervised the Food Service and Dietary staff. Staff F said she was unaware the dietary staff did not take temperatures of food before the food was served to the patients. Staff F acknowledged the dietary staff failed to follow the hospital policy.

Based on document review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure 4 of 8 physicians selected for review, received outside entity peer review prior to reappointment to the Medical Staff to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH. (Staff K, L, M and O) The CAH staff identified 38 physicians credentialed to provide services to CAH patients.

The CAH administrative staff identified the practitioners provided services to patients, from 3/23/2015 to 3/23/2016, as follows:

Staff K, MD, Urology Medicine - 90 patients
Staff L, MD, Radiology Medicine - 338 patients
Staff M, MD, Radiology Medicine - 408 patients
Staff O, MD, ENT (Ears, Nose, and Throat) Medicine - 655 patients

Failure to ensure all medical staff members received an outside entity peer review affects the CAH's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of CAH Administrative Policy and Procedure titled, "Medical Staff Peer Review", dated 6/5/1995, revealed in part, ". . . 7. All peer review cases shall be placed in the physician's file for use in the reappointment process..." The policy and procedure lacks specific verbiage directed at external entity peer review.

2. Review of the Addendum to CAH's Master Network Agreement revealed in part the network hospital ". . . will assist CAH in identifying and arranging for qualified physicians and other practitioners to consult with CAH on peer review matters, including but not limited to the establishment of standards and protocols, the provision of peer review and advice with respect to individual patient records, and service on peer review committees or hearing panels..."

3. Review of CAH documentation on 3/23/16 revealed the facility failed to ensure the CAH completed outside entity peer review on the services provided to patients at the CAH for Staff K, L, M, and O, during their last full credentialing cycle.

4. During an interview on 3/24/16 at 8:00 AM, Staff E, Coordinator Quality Services, acknowledged Staff K, L, M, and O physicians lacked outside entity peer review during their last full credentialing cycle.

Based on visitation policy/procedure review and staff interviews, the Critical Access Hospital (CAH) failed to update their patient visitation policy to include the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family member or friend. The CAH had a current census of 1 swing bed patient, 2 observation patients and 2 acute care patients. The CAH administrative staff reported a census of approximately 29,610 outpatient visits last year.

Failure to update the visitation policy with the correct language in accordance with the regulation could potentially result in patient's visitors being restricted.

Findings include:

1. Review of the CAH policy titled Visitor policy last reviewed 3/21/2016 revealed the policy lacked language in accordance with the regulations to include the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family member or friend.

2. During an interview with Staff D, Chief Nursing Officer acknowledged the visitation policy lacked the language to include the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family member or friend.