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Based on observation, interview and record review the Governing Body failed to ensure contracted services (Dietary and Housekeeping) were provided in a safe manner. The Dietary department was not maintained in a sanitary condition. The Housekeeping department failed to ensure equipment was clean. This practice placed patients at risk for developing and/or acquiring infections while residing in the hospital.

Findings Included:

On 10/11/11 at approximately 1:15 PM the 2 south nursing unit was observed. Three large metal housekeeping carts were observed. The three carts had a brown substance on the floor of the cart. Staff #9 stated housekeeping was to clean the entire cart everyday. Staff #9 stated the substance on the floor of the cart appeared as if it may be rust.

On 10/11/11 at approximately 2:00 PM the dining room was toured with Staff #1 and Staff #8. The following observations were made:

The dining room grill station had two soiled rags lying on the shelf where clean supplies were kept. The shelves were soiled with debris and buildup.

A mesh 10 compartment container which held paper products was rusted on the bottom of the surface. The surface was not sanitizable.

The internal swinging door to the kitchen was soiled with hand prints, grime and debris. The door surface had not been cleaned.

The rack which held pots, pans and trays was observed. Thirty eight pans used in food preparation were stacked wet on top of each other. The surveyor lifted the lip of multiple pans and water poured out onto the floor. Muffin tins (4) were rusted on the interior surface where food would have contact. Baked on debris and buildup was observed on the top and back of the tins. Staff #12 stated the dishes should not be stacked wet on top of each other and the rusted tins should be thrown away.

The walk in refrigerator unit and kitchen floors had debris, grime and buildup. Debris was observed under the equipment and work stations. Shelving throughout the kitchen was soiled and/or dusty.

The mop bucket color was yellow. The bucket was soiled with brown/black stains on the outside and inside of the bucket. The mop ringer had dirt and debris buildup and was rusted.

Two oven exterior surfaces had a collection of grease and debris. A white substance was observed on the exterior surface of the oven. Staff #8 stated he would clean the oven.

The grill station was observed. The space under the unit was observed with a large tray with a collection of grease. Lying in the grease was a stiff brush and a can of degreaser. The bottom part of the grill was soiled, dirty and greasy. Staff #8 acknowledged the space needed to be cleaned.

On 10/11/11 at 2:15 PM, Staff #8 verified the above findings. Staff #12 stated she could not provide evidence of a cleaning schedule.

The House Wide Council Minutes dated 09/07/11 reflected, "EVS (environmental services); more education may be needed on every other day linen changes...patient day rate has decreased with not using pads on the bed...Nutrition...there has been an increase in diet orders entered and changed at the tray line times...there are also trays being delivered to holdover..." No meeting discussion was documented for sanitation concerns in the dietary and housekeeping department.

The undated Hospital Plan of Care provided by Staff #1 on 10/13/11 reflected, "The hospital executive team...is responsible for developing operational objectives...reprioritizing strategic and performance improvement priorities in response to unexpected events and establishing policy. Additionally, hospital leadership is responsible to: Establish and implement policies and procedures, standards for patient care, and clinical practice guidelines; integrate processes through services...promote and provide an environment for patient safety...the hospital plans for the delivery of patient care through a systematic process of assessing, planning, implementing, and evaluating services it provides...periodically an environment assessment is conducted by the hospital....includes needs of hospital's major patient populations, and results of performance improvement activities..."

Based on observation, interview and record review the hospital failed to ensure the Dietary Director managed the dietary department in a responsible manner. The Dietary department was not maintained in a sanitary condition. This practice placed patients at risk for developing and/or acquiring infections while residing in the hospital.

Findings Included:

On 10/11/11 at approximately 2:00 PM the dining room was toured with Staff #1 and Staff #8. The following observations were made:

The dining room grill station had two soiled rags lying on the shelf where clean supplies were kept. The shelves were soiled with debris.

A mesh 10 compartment container which held paper products was rusted on the bottom of the surface. The surface was not sanitizable.

The internal swinging door to the kitchen was soiled with hand prints, grime and debris. The door surface had not been cleaned.

The rack which held pots, pans and trays was observed. Thirty eight pans used in food preparation were stacked wet on top of each other. The surveyor lifted the lip of multiple pans and water poured out onto the floor. Muffin tins (4) were rusted on the interior surface where the food would have contact. Baked on debris and buildup was observed on the top and back of the tins. Staff #12 stated the dishes should not be stacked wet on top of each other and the rusted tins should be thrown away.

The walk in refrigerator unit and kitchen floors had debris, grime and buildup. Debris was observed under the equipment and work stations. Shelving throughout the kitchen was soiled and/or dusty.

The mop bucket color was yellow. The bucket was soiled with brown/black stains on the outside and inside of the bucket. The mop ringer had dirt and debris buildup and was rusted.

Two oven exterior surfaces had a collection of grease and debris. A white substance was observed on the exterior surface of the oven. Staff #8 stated he would clean the oven.

The grill station was observed. The space under the unit was observed with a large tray with a collection of grease. Lying in the grease was a stiff brush and a can of degreaser. The bottom part of the grill was soiled, dirty and greasy. Staff #8 acknowledged the space needed to be cleaned.

On 10/11/11 at 2:15 PM, Staff #8 verified the above findings and Staff #12 stated she could not provide evidence of a cleaning schedule.

On 10/12/11 at 10:20 AM Staff #7 was interviewed. Staff #7 stated non-clinical areas are rounded once a year. Staff #7 stated dietary was completed 07/21/11 and no major issues were found.

On 10/12/11 at approximately 11:30 AM Staff #8 provided the surveyor the 09/11 and 10/11 cleaning schedules for the dietary department. The cleaning schedules indicated the dietary department was being cleaned on a daily basis.

The Food Production assessment tool dated 10/04/11 reflected, under "#5 sanitation and safety standards are met" reflected a score of 10 critical flaw..."

The Director of Food Service Job Description dated and signed, 07/02/03 reflected, "Maintains product and service quality standards by conducting ongoing evaluations and investigating complaints...inspects food and food preparation to maintain quality standards and sanitation regulations..."

Based on observation, interview and record review, the hospital Infection Control Officer failed to ensure, 1) The dietary department was maintained in a clean, sanitary condition. 2) 3 of 4 housekeeping carts were cleaned after each use. 3) The ED (Emergency Department) portable medical equipment was clean and ready for use. 4) 1 of 3 soiled linen rooms had linen stored appropriately and 5) The recovery room stored patient's belongings in a sanitary manner. These practices placed patients at risk for developing and/or acquiring infections while residing in the hospital.

Findings included:

On 10/11/11 at approximately 1:15 PM the 2 south nursing unit was observed. Three large metal housekeeping carts were observed. The three carts had a brown substance on the floor of the cart. Staff #9 stated housekeeping was to clean the entire cart everyday. Staff #9 stated the substance on the floor of the cart appeared as if it may be rust.

On 10/11/11 at 01:40 PM the 3 south nursing unit was observed. The soiled linen room had one large bag of soiled linen sitting on the floor of the room. A soiled microfiber pad was left on the counter.

On 10/11/11 at approximately 2:00 PM the dining room was toured with Staff #1 and Staff #8. The following observations were made:

The dining room grill station had two soiled rags lying on the shelf where clean supplies were kept. The shelves were soiled with debris.

A mesh 10 compartment container which held paper products was rusted on the bottom of the surface. The surface was not sanitizable.

The internal swinging door to the kitchen was soiled with hand prints, grime and debris. The door surface had not been cleaned.

The rack which held pots, pans and trays was observed. Thirty eight pans used in food preparation were stacked wet on top of each other. The surveyor lifted the lip of multiple pans and water poured out onto the floor. Muffin tins (4) were rusted on the interior surface where the food would have contact. Baked on debris and buildup was observed on the top and back of the tins. Staff #12 stated the dishes should not be stacked wet on top of each other and the rusted tins should be thrown away.

The walk in refrigerator unit and kitchen floors had debris, grime and buildup. Debris was observed under the equipment and work stations. Shelving throughout the kitchen was soiled and/or dusty.

The mop bucket color was yellow. The bucket was soiled with brown/black stains on the outside and inside of the bucket. The mop ringer had dirt and debris buildup and was rusted.

Two oven exterior surfaces had a collection of grease and debris. A white substance was observed on the exterior surface of the oven. Staff #8 stated he would clean the oven.

The grill station was observed. The space under the unit was observed with a large tray with a collection of grease. Lying in the grease was a stiff brush and a can of degreaser. The bottom part of the grill was soiled, dirty and greasy. Staff #8 acknowledged the space needed to be cleaned.

On 10/11/11 at 2:15 PM, Staff #8 verified the above findings. Staff #12 stated she could not provide evidence of a cleaning schedule.

On 10/11/11 at approximately 2:40 PM the ED was toured with Staff #1. The bladder scan machine and three vital sign machines on wheels had dust/dirt buildup on the base of the equipment. Staff #5 verified the equipment was to be cleaned every time it was used. This included the bottom of the equipment.

On 10/11/11 at approximately 2:45 PM the recovery room was toured with Staff #1. A soiled linen cart was observed in the corner. A bag of patient belongings was observed sitting on top of the soiled linen cart. Staff #1 verified the patient's belongings should not be stored on top of the soiled linen cart.

On 10/12/11 at approximately 10:20 AM Staff #7 was interviewed. Staff #7 stated the last health inspection in the dietary department was good. Staff #7 stated the non-clinical areas are looked at once a year. She stated this was done in the dietary department July 2011.

The environmental policy entitled, "Cleanup" with a date of September 2005 reflected, "Wipe down all equipment with ALPHA HP...clean equipment presents a professional image..."

The Food and Nutrition Services policy and procedures with a reviewed/revised date 04/20/11 entitled, "Storage of Perishable Food" reflected, "Maintain efficient refrigeration through proper cleaning and maintenance of the units."

The Food and Nutrition Services policy and procedures with a reviewed/revised date of 04/20/11 entitled, "Cleaning schedules" reflected, "Schedules for cleaning are established for each piece of equipment as well as for the facility..." A second policy entitled, "Procedure for Washing Doors Daily" reflected, "Apply wash solution with clean cloth. Scrub all door surfaces. Include door knobs, hinges door stop..."

The Food and Nutrition Services policy and procedures with a revision date of May 2011 entitled, "Procedure for washing pots and pans" reflected, "Remove ware from sink and place on drain board, tipped in such a way that solution will drain completely. Allow to air dry...remove ware to proper storage until next use..."

The policy and procedure entitled, "General Infection Prevention Policy" with a revision date of February 24, 2011 reflected, "Work Practice Controls include but are not limited to...separation of clean and dirty items...maintenance of a clean and safe environment...cleaning, disinfection and sterilization is to be practiced according to local, State, and National Professional Standards...general cleanliness of all facilities will be maintained...new and/or rental equipment must be wiped down with a system approved disinfectant prior to use...portable blood pressure machines, monitors and other patient care equipment must be cleaned by the healthcare worker whenever visible contamination occurs. If portable units (some with attached cuffs) are taken into isolation rooms, single patient use blood pressure cuffs must be used and the unit must be cleaned with approved germicidal wipes or spray..."