HospitalInspections.org

Based on review policy and procedure, reveiw of Dishmachine Temperature Logs, and staff interview, the hospital staff failed to ensure adequate sanitation of items placed in the automated dishmachine.

The findings include:

Review of policy #F019, "DISHMACHINE TEMPERATURES" revised 01/2017, revealed "...POLICIES:....The pressure of the final rinse water in a mechanical system shall be within the range specified on the manufacturer's data plate and may not be less than 5 nor more than 30 pounds per square inch [psi]....as measured in the water line immediately adjacent to the final rinse control valve....PROCEDURES:....High Temperature Dishmachine....Once a day, run a test strip through the dishmachine to verify the surface temperature of a dish. Attach the used test strip to the temperature log.

Review of the Dishmachine Temperature Log for December 2017, during tour on 12/13/2017 around 1400, revealed a column labeled "Test Strip Results....(Attach Test Strip)" and another column labeled "Pressure (5-30 psi)". Review of the current form did not reveal any notation in the pressure column and did not reveal test strips attached every day. Review of the November 2017 form revealed test strips showing 180 degrees attached for 11/02/2017, 11/06/2017, 11/11/2017, 11/17/2017, 11/22/2017, and 11/28/2017 (6 out of 30). Review did not reveal any test strips monitored or attached on the other 24 days in November. For October, form review revealed test strips measuring 180 degrees attached on 10/01/2017, 10/07/2017 (times two), 10/08/2017, 10/13/2017, 10/14/2017, 10/15/2017, 10/20/2017, and 10/26/2017 (8 of 31 days) but did not reveal any test strip monitoring the other days. Further review failed to reveal any pressure monitoring during October or November 2017.

Interview with Manager #1, on 12/14/2017 at 1430, revealed the policy for monitoring test strips and pressure was not followed.