HospitalInspections.org

Based on document review, observation and interview, the hospital failed to have a full-time employee who served as the food and dietetic services director and was responsible for the daily management of dietary services for 1 facility.

Findings:

1. Review of established hospital Agreement for Dietitian Services, signed 9/18/2012, indicated on page 1, under I. OBLIGATIONS OF HPR, 1.2, "HPR shall not be obligated to send a dietitian to the facility to provide service under Section 2.1 more than once each business day of a week.", and pages 2 & 3., under II. SERVICES PROVIDED BY HPR THROUGH ITS DIETITIAN, 2.1-1. (i). "upon request, provide a basic in-service educational sessions for FCCC's staff".

2. 410 IAC 7-24, for Indiana food code, effective 11/13/2004, indicated in the following sections:
A. page 28, Section 129 "When to wash hands", (a) (9) "Before touching food or food-contact surfaces." and (a) (10) "Before placing gloves on hands."
B. page 30, Section 138 "Effectiveness of hair restraint", (b) "food employees shall wear hair restraints", "worn to effectively keep hair from contacting:, (1) "exposed food"
C. pages 62 & 63, Section 254, "Accuracy of temperature measuring devices", (c) "Food temperature measuring devices shall be calibrated in accordance with manufacturer's specificiation as necessary to ensure their accuracy."

3. Personnel files for hospital staff members # 5 - # 8 (Behavioral Health Tech's), lacked documentation of training/education by dietitian for handling and serving food to patients as follows:
A. No specific documentation for handwashing prior to serving food.
B. No specific documentation for hairnets to be worn for serving food.
C. No specific documentation for standard glove type use when serving food.
D. No specific documentation for obtaining food temperatures.

4. Review of food temperature logs for August 2016, indicated the following:
A. The temperature ranges for meat should be 150 - 170 degrees Fahrenheit.
B. The temperatures documented for meat were 171 -190 degrees Fahrenheit.
C. It cannot be determined if temperatures were obtained accurately and if Thermometer had been calibrated.
D. No documentation for calibration of Thermometer was provided.

5. Review of hospital policy titled: "MAINTENANCE IFC", under Section "INFECTION CONTROL/EMPLOYEE HEALTH & EDUCATION", policy number HE 38.1.008, last revised 3/2007, lacked documentation of staff handwashing in regards to contact with and/or serving food to patients.

6. On 11/16/2016 at 12:12 pm, accompanied by hospital staff members # 1 (Sr. VP Residential/Clinical Services) and # 2 (Quality Assurance Associate), during tour of the facility, the following was observed:
A. Food temperatures taken by hospital staff member # 5 (BHT) were found not to be in range for meat (150 -170 degrees), Pork temperature = 182 Fahrenheit and Chicken/noodles = 130 degrees Fahrenheit.
(1). Temperatures were retaken by ISDH surveyor (Team Lead), with temperatures noted at 22-20 degrees difference. Pork Temperature = 146 degrees Fahrenheit and Chicken/noodles = 153 degrees Fahrenheit. Not matching those taken by above staff noted.
(2). It cannot be determined if the Thermometer utilized by hospital staff members was calibrated.
B. Three hospital staff members ( # 5, # 6 & # 8) were noted to not have performed hand hygiene prior to putting on latex gloves; before food served.
C. Two hospital staff members (# 6 & # 8) were noted to not have worn hair nets when served food to patients.

7. In interview on 11/16/2016 at 10:30 am, with hospital staff member # 1 (Sr. VP Residential/Clinical Services), the following was confirmed:
A. The contracted (under agreement) dietician only is present in facility when needed for intervention with patients on special diets. They are "short staffed".
B. The hospital staff- behavioral health techs (BHT's) have not received any training for serving food. Not certain when last training was conducted.
C. Will not find any current documentation in the BHT's files for this (food) training.

8. In interview on 11/16/2016 at 11:00 am and 12:30 pm, with hospital staff member # 2 (Quality Assurance Associate), the following was confirmed:
A. There is no current training/education for the Behavioral Health Techs for food handling/serving.
B. No one on staff is a certified food handler.
C. Staff is not aware of Thermometer needing to be calibrated.
D. Dietitian has not been present for staff training/education.