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Based on observation, document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.28 Food and Dietetic Services.
Findings include:

1. The Hospital failed to ensure dietary staff followed food storage guidelines to ensure safe food storage, failed to ensure the dietary staff followed procedures for testing the dishwasher to ensure proper sanitization of dietary items, and failed to ensure daily Temperature logs were kept for all refrigerators and freezers in the dietary department.(A0619).

2. The Hospital failed to employ a Dietary Director on staff (A0620).

3. The Hospital failed to employ or contract a qualified Dietician on staff or as a consultant (A0621).

4. The Hospital failed to ensure dietary personnel were competent in their duties (A0622).

5. The Hospital failed to conduct a nutritional screening on admission and failed to ensure dietician consults were conducted. (A0630).

6. The Hospital failed to have a therapeutic diet manual. (A0631).


An investigation was conducted on 07/19/23 for Complaint #IL00160856/2310775. The Immediate Jeopardy began on 06/01/23 due to the Hospital's failure to: employ a Director of Dietary, employ/contract a dietician, employ qualified staff, maintain a therapeutic dietary manual, maintain a sanitary environment, complete nutritional screening and dietary consults as ordered, and was identified on 07/19/23, at 42 CFR 482.28, Food and Dietetic Services. The IJ was announced on 07/18/23 during a meeting with the Chief Executive Officer, Director of Quality, Infection Control Coordinator, and Informatacist, and was not removed by the survey exit date of 07/19/23.

A. Based on a request for documents, observation, and interview the hospital failed to ensure dietary staff followed food storage guidelines to ensure safe food storage. This is likely to affect all patient, staff, and visitors.

Findings include:


1. The Hospital policies for Food Storage and handling were requested on 7/18/23 at approximately 10:00 AM. Infection Control Coordinator (E #2) stated that the hospital did not have any policies for food storage or handling.

2. During an observational tour of the dietary department, conducted on 7/18/23 at 11:00 AM with the Core Measure Abstractor Quality Assurance (E #6) and Dietary Manager (E #4), it was observed the following items were expired, opened with no seal or enclosure or out-date label to ensure food quality:

In the walk-in freezer:
4 cases of chocolate pudding (expired 7-12-23)
2 meat trays open with no seal or out-date label.
1 bag of meatballs open with no seal or out-date label.

In the walk-in refrigerator:
1 container of raw chicken in liquid without an out-date label.
1 bag of mozzarella cheese with green discoloration/mold, open with no seal or out-date label
1 bag of cheddar cheese open with no seal or out-date label.

3. An interview with the Dietary Manger (E #4) on 7/18/23, during the observational tour, E #4 confirmed the above findings and stated, "I have told my staff that they must check out dates and label items that are opened."

B. Based on observation, staff interview, and a request for documents, it was determined the Dietary Manager failed to ensure the dietary staff followed procedures for testing the dishwasher to ensure proper sanitization of dietary items. This is likely to affect all patient, staff, and visitors.

Findings include:

1. During an observational tour of the dietary department, conducted on 7/18/23 at 11:00 AM with the Core Measure Abstractor Quality Assurance (E #6) and Dietary Manager (E #4), it was determined proper testing for sanitization effectiveness was not completed.

2. An interview was conducted during the observational tour with Dietary Services Worker (E #5) at approximately 12:05 PM. E #5 stated, "I just put the dishes in this side, and they come out that side clean. If the temperature gauge is working and it is at least 150 degrees it should be sanitized." When E #4 and E #5 was asked if they run sanitizing test strips or keep a sanitization log, both E #4 and E #5 stated, "we think that maintenance does that."

3. A request for Hospital policy on sanitization of dietary items and the sanitization log was made on 7/18/23 at approximately 12:15 PM. E #4 and E #2 confirmed that there was not a hospital policy for the sanitization of dietary items, that sanitization test strips were not run through the dishwasher, and that there was not a sanitization log kept.


C. Based on observation, staff interview, and document review, it was determined the Dietary Manager failed to ensure daily Temperature logs were kept for all refrigerators and freezers in the dietary department. This is likely to affect all patient, staff, and visitors.
Findings include:

1. During observational tours of the dietary department, conducted on 7/18/23 at 11:00 AM with the Core Measure Abstractor Quality Assurance (E #6) and Dietary Manager (E #4) and on 7/19/23 at 2:45 PM with Infection Control Coordinator (E #2), the Hospital refrigerator and freezer temperature logs for June 2023 and July 2023 were reviewed. The following are examples of temperatures not being taken daily:
Examples:
Freezer #1 - No temperatures recorded.
Freezer #2 - No temperatures recorded.
Freezer #3 - No temperatures recorded.
Freezer #4 - No temperatures recorded.
Freezer #5 - No temperatures recorded.
Freezer #6 - No temperatures recorded.
Behavioral Health Prep Fridge - 28 missing days on June log, no temperatures recorded for July.
Med/Surg Prep Fridge - 16 missing days on June log, 17 missing days of July log.


2. An interview with the Dietary Manger (E #4) on 7/18/23, during the observational tour, E #4 confirmed the above findings and stated, "When I started, we didn't have any logs at all. I have had to create them and am waiting for them to print now."

3. The Hospital policy for Care of Refrigerators and Ice Machines was reviewed on 7/19/23 at approximately 2:30 PM. The policy states, "A Daily Refrigerator Temperature monitor will be placed on the door of each refrigerator for documentation of refrigerator and freezer temperatures."

Based on a request for documents and interview, it was determined that the Hospital failed to employ a Dietary Director on staff. This is likely to affect all patients, staff and visitors.

Findings include:

1. A request was made for the name of Dietary Director.

2. An interview was conducted with the Infection Control Coordinator (E #2) and the Dietary Manager (E #4). E #2 stated, "We do not have a Dietary Director. We have not had one since June 1st." E #4 verbally agreed there is no Dietary Director on staff.

Based on a request for documents and interview, it was determined that the Hospital failed to employ or contract a qualified dietician on staff or as a consultant. This is likely to affect all patients, staff and visitors.

Findings include:

1. A request was made for the name of the qualified Dietician.

2. An interview was conducted with the Infection Control Coordinator (E #2) and the Dietary Manager (E #4) and Human Resources Manager (E #3). E #2 stated, "We do not have a Dietician. We have not had one since June 1st." E #3 stated, "We had one on a prn (as needed) basis for a little bit, but I believe her on the books (the previous dietician's) last day was June 1st. The hospital is working with an agency and a dietician I believe is starting next week, but I don't believe it is official yet." E #4 verbally agreed there is no Dietician available.

Based on observation, document review and interview, the Hospital failed to ensure dietary personnel were competent in their duties. This is likely to affect all patients, staff and visitors.

1. An observational tour was conducted on 07/18/23 between 10:45 AM and 11:30 AM. During the tour an interview was conducted with Food Service Worker (E #5). E #5 was asked the process for monitoring the sanitation of the dishes going through dishwasher. E #5 was unable to verbalize how/if the sanitation is monitored.

2. Personnel files were reviewed of the Dietary Manager (E #4), 3/3 Food Service Workers (E #5, E #7 and E #8) and the Lead Food Service Worker (E #9). All personnel files lacked training/education and/or competencies of dietary personnel.

3. An interview was conducted with the Human Resources Manager (E #3). E #3 stated, "We lost our dietary contract and hired several of the staff members on June 1st. We do not have a Director and are not sure who they will answer to. We are not sure how the training will be. They do not have training or competencies in their files. There was a time period that I had to do the food ordering for them."

Based on document review and interview, it was determined for 2 of 3 (Pt #4 and Pt #6) clinical records reviewed for dietary consults, the Hospital failed to ensure dietary consults were conducted. This is likely to affect all patients.


1. The clinical record of Pt #4 was reviewed. Pt #4 was admitted on 05/19/23. Pt #4 had an order for a Dietician consult on 06/06/23. The record lacked documentation of a dietician consult.

2. The clinical record of Pt #6 was reviewed. Pt #6 was admitted on 07/15/23. Pt #6 had an order for a Dietician consult on 07/15/23. The record lacked documentation of a dietician consult.

3. An interview was conducted with the Clinical Informaticist (E #1) and the Infection Control Coordinator (E #2) during the record reviews. E #1 and E #2 verbally agreed there were orders for a dietician consult and the records lacked documentation of a dietary consult. E #1 and E #2 stated, "We do not believe the Hospital had a dietician on staff at that time."

Based on a request for documents and interview, it was determined that the Hospital failed to have a therapeutic diet manual. This is likely to affect all patients, staff and visitors.

Findings include:

1. A request was made for the therapeutic diet manual.

2. An interview was conducted with the Dietary Manager (E #4). E #4 stated, "We do not have a diet manual. If we do have one, I do not know where it would be."