HospitalInspections.org

Based on record review and interview, the facility staff failed to provide Medicare eligible patients the second Important Medicare Message (IMM) notice within 2 days of discharge from the hospital in 2 of 3 Medicare eligible patients (pt. #21 and 22). This deficiency potentially affects all Medicare eligible patients receiving care at this hospital.

Findings include:

Review on 4/22/15 at 9:50 AM of facility policy titled "Notification of Hospital Discharge Appeal Rights" dated 2/09, states "3. Within 2 calendar days of discharge, the chart copy is to be signed by the beneficiary, or his or her representative on page 2. The staff member will sign and date, indicating that the notice was provided."

Review of Pt. #21's MR on 4/22/15 at 9:15 AM, accompanied by Nurse Informatisist (NI) VV, there in no documentation that the facility delivered a follow up IMM within 48 hours of discharge. NI VV confirmed the second IMM was not documented as given at the time of the MR review.

Review of Pt. #22's MR on 4/22/15 at 9:30 AM, accompanied by NI VV, there in no documentation that the facility delivered a follow up IMM within 48 hours of discharge. NI VV confirmed the second IMM was not documented as given at the time of the MR review.


29963


Per interview with Manager of Patient Access (MPA) WW on 4/21/15 at 11:30 AM, MPA WW stated the first IMM is given on admission with the patient rights and the second IMM is given if the hospital stay is greater than 2 days.

Based on record review and interview the facility staff failed to complete 15 minute assessment on 2 of 2 patients (pt. #17 and 18) who were placed in four-point leather restraints. This has the potential to affect all patients requiring restraint usage at this facility.

Findings include:

Per review on 4/21/2015 at 12:00 PM of policy titled Restraint Utilization (Violent, Self Destructive), dated 9/21/12 states in part under III.c. A staff member who is trained and competent assesses the patient at the initiation of restraint or seclusion and every 15 minutes thereafter for: i. Signs of any injury associated with the application of restraint or seclusion; ii. Nutrition/Hydration; iii. Circulation and range of motion in the extremities; iv. Vital signs; v. Hygiene and elimination; vi. Physical and psychological status and comfort (including pain); vii. Readiness for discontinuation of restraint of seclusion...

Per review of pt. #17's MR on 4/21/15 at 8:15 AM, pt. #17 was placed in four point leather restraints on 3/21/15 at 9:30 AM. Policy states 15 minute assessments will be completed and documented, no documentation of an assessment being completed on 3/21/15 at 10:15 AM, 10:45 AM, or at 11:00 AM while restraints remained in place.

Per review of pt. #18's MR on 4/21/15 at 9:05 AM, pt. #18 was placed in seclusion and four point leather restraints on 2/1/15 at 3:00 AM. Policy states 15 minute assessments will be completed and documented, no documentation of an assessment being completed on 2/1/15 at 11:30 AM. Documentation did not indicate that all of the required categories were completed with every 15 minute assessment. The following categories were not included in all assessments while pt. #18 was in restraints: signs of injury, vital signs, physical and psychological status and readiness for discontinuation of restraint or seclusion.

Findings were confirmed with Product Specialist (PS) O and Nurse Informaticist (NI) VV at time of record review. PS O and NI VV stated in an interview that there policy requires 15 minutes assessments on patients using restraints, which were not completed.

Based on record review and interview, the facility failed to ensure care plans were individualized to patient in 5 of 22 medical records (MR) reviewed (pt. # 25, 26, 27, 5, and 33) who would have required a care plan with a total of 30 MR reviewed. This deficiency has the potential to affect all patients served at the facility.

Findings include:

Per review on 4/22/201 at 11:30 AM of facility policy titled Care Planning, revised June 2014, states in part under Procedure: Select appropriate goals for the patient based on assessment/reassessment and involvement with patient and family. Select appropriate interventions to assist the patient with reaching the individualized goals. Modify the problem, goals and interventions as needed to ensure they are specific, individualized and measurable.

Pt. #25's medical record was reviewed on 04/21/15 at 10:50 AM, the record contains a care plan for the problem of Alteration in mood which does not define its manifestations. Goals and interventions are not individualized and do not offer concrete examples of expected outcomes or specific patient driven plans.

Pt. #26's medical record was reviewed on 04/22/15 at 9:25 AM, the record contains a care plan for the problem of Altered Thought Processes which does not define its manifestations. Goals and interventions are not individualized and do not offer concrete examples of expected outcomes or specific patient driven plans.

Pt. #27's medical record was reviewed on 04/22/15 at 9:50 AM, the record contains a care plan for the problem of Alteration in mood which does not define its manifestations. Goals and interventions are not individualized and do not offer concrete examples of expected outcomes or specific patient driven plans.

Per interview with Product Specialist O on 04/21/15 at 11:30 AM, PS O stated the care plan does not define problems that are specific to patient's diagnosis.


26390


Per review of pt. #5's record on 4/21/15 at 1:50 PM with Product Specialist O, pt. #5 was admitted on 4/19/15 with acute chronic diastolic congestive heart failure. The Plan of Care dated 4/19/15 lists heart failure as a problem which does not define its manifestations. Goals and interventions are not individualized and do not offer concrete examples of expected outcomes or specific patient driven plans.

Per interview with Product Specialist O on 4/21/15 at 2:00 PM, the plan of care is not individualized and complete. PS O stated staff are expected to include patient specific information and interventions and goals need to be individualized to meet the needs of the patient.


29972


Per review of pt. #33's MR on 4/22/15 at 10:20 AM, showed pt. #33 was admitted on 4/13/15 at 7:05 PM on Contact Isolation for MRSA (Methicillin Resistant Staph Aureus). Review of nursing care plans and assessments from 4/13/15 to 4/21/15 revealed no evidence of staff developing a plan of care for pt. #33 being in contact isolation.

Based on observation, record review, and interview, the facility failed to ensure patient records are secure and protected from unauthorized access in 1 of 1 departments in which medical records are stored (HIM).

Findings:

Facility policy "Privacy Safeguards" Number P2-v1.4 dated 9/12/2013 states in part: "9. Limit Unauthorized Access to PHI [Protected Health Information]: Limit unauthorized access to PHI by...staff members without need to know."

The HIM department was observed to contain patient medical record files on 4/21/2015 at 12:55 PM. Per HIM Dir SS, the facility scans patient records and maintains the records for 90 days. HIM Dir SS stated all clinical staff have access to the HIM department 24/7, but the department is only staffed from 6:30 AM to 7:00 PM Monday through Friday and from 8:00 AM to 4:30 PM on weekends. HIM Dir SS stated EVS staff comes in the evening to clean the department and HIM staff is not always present during the cleaning.

During an interview on 4/21/2015 at 9:00 AM, EVS Dir N stated HIM staff "are not present" when EVS staff cleans the HIM department.

Based on observation, interview and record review, the facility failed to ensure all medications are secured from unauthorized access in 1 of 2 procedure rooms (Stress Lab) and 4 of 4 crash carts (3SW, 5SW, Birthing Suites, and Family Suites) that staff were not able to monitor. This deficiency potentially affects all patients at this facility.

Findings include:

Review on 4/21/15 at 2:30 PM, facility policy titled "Medication Distribution, storage inspections and security" dated 1/15, states "2)d) On patient care units, medications are stored in automated dispensing cabinets or in secure medications carts and/or cabinets."

On 4/21/15 at 11:05 AM, observed a box containing medications used for cardiac stress tests, located in an unlocked cabinet in the stress lab room. The cabinet was not secured using the attached keypad and the door to the room was not closed or locked by the keypad. The waiting area is located right outside this room and at the time of observation two people were within the waiting area and had potential access to the unsecured medication.

Per interview with Cardio diagnostic procedure manager AA at the time of discovery, the cabinet should have been locked.


29963


On 4/20/15 at 11:45 AM, during tour of 3SW, observed a crash cart containing medications being stored in a pass through hallway, not in view of nurses station, secured with a break away plastic lock.

On 4/20/15 at 1:40 PM, during a tour of 5SW, observed a crash cart containing medications being stored in the hallway, not in view of nurses station, secured with a break away plastic lock.

Per interview on 4/20/15 at 11:45 AM, Administrator Director of Operations V confirmed the crash cart contained medications and that is was stored in an area that was not in view of the staff.


29972


Per observation on 4/20/15 at 1:30 PM, while touring 2nd floor Birthing Suites with RN E and Chief Nursing Officer (CNO) D, observed 1 Neonatal and 1 Adult crash cart in an area unattended by staff; crash carts were not locked to prevent unauthorized access. Per interview with RN E at the time of tour, RN E stated crash carts are not always in view of staff.

Per observation on 4/20/15 at 3:00 PM, while touring 3rd floor Family Suites and Pediatric unit with RN H, observed 1 Adult crash cart and 1 Pediatric crash cart in an area unattended by staff; crash carts were not locked to prevent unauthorized access. Per interview with RN H at the time of tour, RN H stated crash carts are not always in view of staff.

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. These deficiencies in all of the 74 smoke compartments would affect all of the inpatients, outpatients, staff and visitors within the facility.

FINDINGS INCLUDED:
A-701: .

A-709: The facility failed to maintain a safe environment from fire based on the following 31 K-tags.
· K-11 (building separation barrier);
· K-12 (building type construction);
· K-17 (corridor wall assembly);
· K-18 (corridor door openings);
· K-20 (vertical opening or shaft);
· K-22 (exit signs);
· K-25 (smoke barrier assembly);
· K-27 (smoke barrier doors);
· K-29 (hazardous spaces);
· K-34 (stairways used as exits);
· K-37 (dead-end corridors, aisles or passageway);
· K-38 (exit access);
· K-39 (width of aisles or corridors serving as exit access);
· K-50 (fire drill requirements);
· K-51 (fire alarm system with approved components, devices or equip. installed);
· K-52 (fire alarm testing and maintenance);
· K-54 (smoke device inspections & testing);
· K-56 (installation of automatic sprinkler system);
· K-62 (maintenance of automatic sprinkler system);
· K-64 (maintenance of portable fire extinguishers);
· K-66 (smoking regulations and policies);
· K-67 (heating, ventilating & air conditioning system);
· K-71 (rubbish and laundry chutes);
· K-72 (means of egress continuously maintained free of all obstructions);
· K-74 (portable fire extinguishers);
· K-75 (soiled linen & trash collection receptacle size);
· K-76 (medical gas storage);
· K-77 (piped-in medical gas systems);
· K-147 (electrical wiring, identification & equipment);
· K-154 (automatic fire sprinkler system out-of-service for 4+ hours/24-hours);
· K-155 (fire alarm system out-of-service for 4+hours/24-hours);

Based on the cumulative effects of the above findings, 42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.
_________________________

Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the patient life safety from fire. These deficiencies in all of the 74 smoke compartments would affect all of the inpatients, outpatients, staff and visitors within the facility.

FINDINGS INCLUDED:

A-709: The facility failed to maintain a safe environment from fire based on the following 31 K-tags.
· K-11 (building separation barrier);
· K-12 (building type construction);
· K-17 (corridor wall assembly);
· K-18 (corridor door openings);
· K-20 (vertical opening or shaft construction);
· K-22 (exit signs);
· K-25 (smoke barrier assembly);
· K-27 (smoke barrier doors);
· K-29 (hazardous spaces);
· K-34 (stairways used as exits);
· K-37 (dead-end corridors, aisles or passageway);
· K-38 (exit access);
· K-39 (width of aisles or corridors serving as exit access);
· K-50 (fire drill requirements);
· K-51 (fire alarm system with approved components, devices or equip. installed);
· K-52 (fire alarm testing and maintenance);
· K-54 (smoke device inspections & testing);
· K-56 (installation of automatic sprinkler system);
· K-62 (maintenance of automatic sprinkler system);
· K-64 (maintenance of portable fire extinguishers);
· K-66 (smoking regulations and policies);
· K-67 (heating, ventilating & air conditioning system);
· K-71 (rubbish and laundry chutes);
· K-72 (means of egress continuously maintained free of all obstructions);
· K-74 (portable fire extinguishers);
· K-75 (soiled linen & trash collection receptacle size);
· K-76 (medical gas storage);
· K-77 (piped-in medical gas systems);
· K-147 (electrical wiring, identification & equipment);
· K-154 (automatic fire sprinkler system out-of-service for 4+ hours/24-hours);
· K-155 (fire alarm system out-of-service for 4+hours/24-hours);K-18 (corridor door openings);

Based on the cumulative effects of the above findings, 42 CFR 482.41(b) Life Safety from Fire was NOT MET.
_________________________

Based on observation, interview, and policy review the hospital failed to ensure availability of spill kits for hazardous waste in 1 of 1 area (Respiratory equipment storage room #6539). The facility failed to secure biohazard waste in soiled utility rooms on 5 of the 8 floors of the southwest wing of the hospital (NICU, Ortho, Oncology, Neurosceince and Cardiac). This deficiency could potentially affects all personnel, visitors and patients.

Findings include:

Per review on 04/21/15 at 2:00 PM of facility policy entitled; "Formaldehyde Safety" dated 04/26/2013 states its purpose: "All employees working with, or having the potential exposure to, formaldehyde will be knowledgeable in the health risks associated with it and understand appropriate safe handling procedures."

The MSDS (material safety data sheet) for 10% Neutral Buffered formalin states;
"EMERGENCY OVERVIEW-Warning! May cause respiratory tract irritation. Harmful if inhaled. Harmful if absorbed through the skin. May cause lung damage. May cause pulmonary edema. May cause eye irritation and transient injury. May cause severe skin irritation. May cause reproductive and fetal effects. Contains formaldehyde which can cause cancer. May cause allergic respiratory and skin reaction."

1. Per observation, while touring room 6539 with Vice President K on 04/20/15 at 2:30 PM, approximately 30 specimen containers containing 120 ml of 10% Neutral Buffered formalin were found kept in a drawer next to the sink. VP K was interviewed at the time of the tour, K stated there was no spill kit available for a formalin spill in the area.


32670


Review on 4/21/15 at 3:50 PM, of document titled "St. Mary's Hospital Exposure Control Plan for Bloodborne Pathogens", dated 5/92, states "Biohazard labels are used to identify refrigerators, freezers, and other containers used to store or transport blood, or other potentially infectious fluids." This document does not address the securing of biohazard materials.

On 4/21/15 at 10:15 AM observed, during a tour of 2nd floor Intensive Care Unit (ICU) accompanied by Dir of ICU UU, a soiled utility room containing biohazard materials in a red bin. This utility room was not labeled as containing biohazard materials.


On 4/21/15 at 10:30 AM observed, during a tour of 5th floor ICU accompanied by Dir of ICU UU, a scolded utility room containing biohazard materials in a red bin and a sharps container full of needles. This utility room was not locked or secured and was not labeled as containing biohazard materials. Per interview with Dir of ICU UU, at the time of tours, ICU UU confirmed the soiled utility rooms are unlocked and contain biohazard material.



29963


On 4/20/15 at 11:40 AM observed, during a tour of 3rd floor Orthopedic Unit accompanied by Administrator of Director of Operations (ADO) V, a soiled utility room containing biohazard materials in a large uncovered red bin and a small rectangular plastic bin. This utility room was not locked or secured and was not labeled as containing biohazard material. Per interview with ADO V, at the time of tour, ADO V confirmed the soiled utility room is unlocked and containing biohazard material.

On 4/20/15 at 1:40 PM observed, during a tour of 5th floor Oncology Unit accompanied by Administrator Director of Medical/Surgical Services (ADMS) W, a soiled utility room containing biohazard materials in large red bin. This utility room was not locked or secured and was not labeled as containing biohazard material. Per interview with ADM S, at the time of tour, ADM S confirmed the soiled utility room is unlocked and containing biohazard material.

On 4/20/15 at 1:55 PM observed, during a tour of 7th floor Neuroscience Unit accompanied by Administrator Director of Medical/Surgical Services (ADMS) W, a soiled utility room containing biohazard materials in large red bin. This utility room was not locked or secured and was not labeled as containing biohazard material. Per interview with ADM S, at the time of tour, ADM S confirmed the soiled utility room is unlocked and containing biohazard material.


26390


On 4/20/15 at 11:55 AM observation of the 8th floor dirty utility room revealed no signage for biohazard material and the two doors for access to the room were not locked. The room contained biohazardous materials and cleaning chemicals. Per interview with Coordinator of Regulatory Compliance (CRC) A, at the time of tour, CRC A confirmed the soiled utility room is unlocked and contains biohazard material.

Based on observation, record review, and interview, the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection during 3 of 11 staff observations (RN F, G, and GG) and in 10 of 24 areas toured (3SW, 4SW, 5SW, 8SW, NICU, EVS, ED, Off site ED, 2SW, and Kitchen). These deficiencies potentially affect all patients and visitors at this hospital.

Findings Include:
Review on 4/20/15 at 3:00 PM of "Mosby's Skills Peripherally Inserted Central Lines (Neonatal) Quicksheet" provided by staff "A" states the following: Perform hand hygiene and don gloves, open equipment maintaining sterility of contents and prepare sterile field using aseptic technique; remove gloves perform hand hygiene, and don sterile gloves.
On 4/20/15 at 1:50 PM observed RN F and RN G attempting to place pt. #1's PICC (peripherally inserted central catheter) line. RN F performed hand hygiene then proceeded to open supplies sitting on keyboard, move supply cart, and move chair; RN F then donned sterile gloves, gown, and mask without first performing hand hygiene. RN G assisted RN F in performing pt. #1's PICC insertion, with gloved hands RN G silenced Vocera in scrub pocket sitting on chair, then proceeded to obtain normal saline syringe remove cap and connect syringe to a sterile syringe being held by RN F; RN G then injected normal saline into sterile syringe held by RN F allowing for potential cross contamination of sterile saline syringe used for pt. #1. RN G did not remove potentially contaminated gloves, perform hand hygiene and apply "clean" gloves prior to obtaining and opening normal saline syringe. RN G the proceeded to don sterile gloves to help hold light for RN F, RN G then touched light switch near computer potentially contaminating sterile gloves. RN G then proceeded to open clean supplies, hold pt. #1's leg under sterile field, and suction Pt. #1 without first removing gloves, performing hand hygiene, and applying new pair of gloves.

Review on 4/21/15 at 3:00 PM of policy titled, "Isolation/Transmission-Based Precautions" Infection Control Hospital Wide, dated 10/92 states when a patient is admitted with a known or suspected communicable disease appropriate isolation precautions will be implemented.

Per the Contact Precautions signage placed outside the door of patients on contact precautions provided by Staff "A" on 4/21/15 at 3:30 PM, All staff must use isolation gowns and gloves for contact with the patient, equipment, and/or the environment.

On 4/21/15 beginning at 10:45 AM, observed pt. #33 and pt. #34 receiving dialysis in the Dialysis unit. Per interview with RN GG at the time of observations, pt. #33 and pt. #34 are on contact isolation precautions for MRSA (methicillin resistant staph aureus). Per Interview, RN GG stated staff only wear isolation gowns and gloves when touching patient or patient dialysis machine. Observations showed RN HH don gloves, sit in chair, and roll directly next to pt. #34's bed to check dialysis machine without wearing an isolation gown, allowing RN HH potential exposure to infectious contaminates.


29963


Nursing Units:
Per tour on 4/22/15 at 9:40 AM, accompanied by Chief Nursing Officer (CNO) D noted the following:

3SW, room #3656, labeled staff, contained clean supplies including walkers and commodes. The room also contained a chute for the disposal of dirty laundry. There is no defined separation between clean and dirty supplies.

4SW, room #4656, labeled staff, contained clean supplies including geri-chairs, mechanical lifts and Christmas decorations. This room also contained a chute for the disposal of dirty laundry with no defined separation between clean and dirty supplies.

5SW, room unlabeled, contained clean supplies including mattresses, computers, chairs, sleeping cots and Christmas decorations. This room also contained a chute for the disposal of dirty laundry with no defined separation between clean and dirty supplies.


26390


On 4/20/2015 at 11:40 AM observation of of the 8SW floor kitchenette revealed a microwave with dry, food on all walls inside the microwave. Director of Critical Care CC observed the microwave and stated uncertainty regarding what department was responsible for cleaning the microwave.


34337


Laundry:

Per review on 4/22/2015 at 4:30 PM of the facility's "Washer and Dryer Guidelines" reviewed 6/2014 state in part: "The washer and dryer are used for: Individual patient clothing...2) Disinfection of the washer will be done after contaminated load...and at least monthly."


Dir N stated during interview on 4/21/2015 at 9:00 AM the facility uses residential-grade washer, dryer and detergent for internal laundering of patient personal clothing only. The facility uses one set of washer and dryer in the EVS department (room B520) and one set of washer and dryer in the NICU. The EVS laundry facilities were observed on 4/21/2015 at 9:45 AM accompanied by Dir M and Dir N. The dryer contained the following items: 2 dry dust mops; 2 floor cleaning pads; 1 wash cloth. Dir N stated the facility staff uses Tide detergent for laundering. No detergent was found in room B520. Dir N was unable to confirm what type of detergent the items in the dryer had been washed with or why hospital linens and not patient linens were observed in the dryer.


The washer and dryer in the NICU were observed on 4/21/2015 at 10:00 AM, per NICU Assistant II, the facility launders infant clothing for patient use. NICU Assistant II stated laundry is done "almost daily" using 7th Generation Natural Laundry Detergent and Green Works Chlorine Free Bleach with each load. NICU Assistant II wipes the interior of the washing machine with a germicidal sani-cloth after each load and runs the machine empty with bleach monthly for disinfection. The interior of the dryer is wiped with a germicidal sani-cloth monthly. When asked about a written policy for the use and disinfection of the washer and dryer, NICU Assistant II stated "I have no idea where that would be."


Dir N stated "we don't have in place" a policy or procedure on how the equipment is used or disinfected between use. There was no evidence that the detergent used was adequate to kill microbes or was reviewed and approved by the infection control committee. There is no system in place to ensure that the mechanical, thermal and chemical mechanisms used are adequate to ensure an antimicrobial effect on linens laundered within the facility. The facility does not maintain records of washer and dryer disinfection.

Emergency Department:

During a tour of the ED on 4/20/2015 at 11:25 AM, 3 of 3 clean rooms observed contained single-use patient equipment that was out of it's packaging. ED room #2 contained open oxygen tubing connected to the wall oxygen unit. ED rooms #27 and #28 contained suction tubing including Yankauer (oral suctioning tool) that was opened and not protected by packaging. These findings were verified at the time of the observation with ED Dir I. Dir I stated staff will "sometimes" open oxygen tubing and suction tubing in preparation for patients coming in. Dir I was unable to state how long the equipment had been open in the rooms or how long it would be before a patient would be roomed into any of the 3 rooms.


20878


Off-site Emergency Department:

A tour was completed on 4/21/15 at 9:50 AM, accompanied by Director of Critical Care Services CC, the following was observed:

- In room #1143 stains and sharps containers were stored under the sink allowing for contamination by plumbing leaks.
- In room #1141 a cooler and a partially used bottle of distilled water were stored under the sink.

Behavioral Health Unit 2SW:

A tour of the behavioral health unit was completed on 04/20/2015 at 12:15 PM, accompanied by Manager J and Administrator W, the following was observed:

- In the Occupational Therapy (OT) kitchen (room #2650) the top of the refrigerator was covered in a layer of dust.
- In the medication room off the Nursing station hand sanitizers, plastic bags and a plastic basin were stored under the sink allowing contamination by potential plumbing leaks.


32670


Kitchen

Per tour on 4/21/15 at 2:15 PM, accompanied by Food Services Manager Z and Dir of Food Services U, noted the following:

-Noted stainless steel rack cart containing a blender, blender parts and a toaster touching the hand washing sink allowing for contamination. Per Food Service Manager Z, the items on the cart were clean and Z stated it should be moved.
-Noted towels and aprons on the lower shelf of a stainless steel cart with splash and debris on and around the linens. A waste receptacle was noted right next to the cart. Per Food Manager Z, the towels and lines were clean stock.
-Noted thick dust and debris on rack where clean baking pans are stored.
-Noted dust and debris on shelving and tables in beverage area.
-Noted dust and debris coving shelves in the dry storage area.

Per interview on 4/22/15 at 10:30 AM, with Dir of Food Services U, the facility does not currently have a daily cleaning schedule or checklist for the kitchen. The employee assigned to each area is expected to clean as needed. They facility does a "deep clean" of the kitchen quarterly. Per U the facility is working on a checklist/cleaning schedule but it has not been implemented as of yet.

Unrestrained Hair:

Per interview of 4/21/15 at 2:00 PM, Food Services Manager Z stated this facility follows Wisconsin Food Code.

Wisconsin Food Code states:
"FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE
ARTICLES."

Per review on 4/21/15 at 3:30 PM of facility policy titled "Food and Nutrition Services" # B-1 dated 8/1/1988, it states "All employees must restrain their hair appropriately when they are in a food work area or the dish room. Employees with very short hair may wear a disposable hat providing that it is worn to cover the majority of the hair. Hair nets or bonnets must be worn to effectively cover hair which is longer. Longer hair may need to be confined in a band or braid under a hair restraint... Hair, moustaches, and beards must be clean, neatly-combed, and trimmed." This policy does not reference which standard of practice was used and has not been updated in the past 3 years.

During a tour of the kitchen on 4/21/15 at 2:15 PM, accompanied by Food Services Manager Z and Dir of Food Services U, noted the following employees in the kitchen without hair secured in bonnets that cover all hair on head: Ambassador P, Ambassador Q, Ambassador R, FSA S, FSA T, FSA X, and Cook Y. Also noted cook Y did not have a beard covered. Per interview with Cook Y at the time of discovery, Cook Y stated "I have never been required to cover my beard."

Per interview with Dir of Food Services U, this facility does not require hair nets and staff could used bonnets or hats with hair tied back.