HospitalInspections.org

Based on observations, review of Policies and Procedures and staff interviews it was determined that the facility failed to maintain a sanitary environment.

Findings included:

A tour of the Dietary/Kitchen area was conducted on 2/5/19 at 10:00 a.m. with the General Manager of Dietary Services. Rusty air vents were observed above the food service line, there was a broken ceiling light cover above the food prep area and bugs were observed in the broken lamp cover. Dirt was observed on the floor behind the ice machine in the food prep area. Two double ovens were examined and each of the double ovens had 1 broken unit, the working units had baked on grease drippings, food crumbs and dark brown residue. The walk-in freezer had condensation/ice built up on the ceiling. The freezer floor was covered with ice and was slippery when entering the freezer. The General Manager of Dietary Services indicated that the freezer had ongoing problems and had been defrosted a month ago. The General Manager of Dietary Services confirmed all the findings during the tour.

A review of the Policy and Procedures for the Department of Food and Nutrition, Policy #FNS6.7, Effective 4/29/2004, Revised 12/2014, revealed that the dietary department shall insure that their work area is clean and sanitary. The policy also revealed that employees were to maintain and follow the rule of CLEAN AS YOU GO. Further review revealed the specific procedure on:
--Convection and stacked ovens required the racks to be washed in the pots and pans sink, the inside of the oven to be wiped down with a rag, and the outside of the ovens washed with a degreaser.

A tour of the Laboratory was conducted on 2/4/19 at 2:00 p.m. with the Director of Laboratory Services. Dirty floors and dirt accumulation along the base boards was observed. The Director of Laboratory Services confirmed these findings.

A tour of the facility was conducted on 2/6/19 at 9:30 a.m. with the Director of Environmental Services and the Director of Facilities. Common areas used by staff, patients and guests were observed as having dirty floors, dirty base boards, torn wall paper, holes in walls, scuff and dirt marks on the walls. Specifically the main entry hallway, dietary/kitchen corridor, corridor from kitchen that leads to supply/engineering, and the hallway that runs from the Laboratory to Emergency Department.

A tour of the Emergency Department (ED) was conducted on 2/5/19 at 9:30 a.m. with the Director of ED Services, the adult weight scale in the triage room was observed to be covered in dust. The Registration counter was also covered with dust. ED room #4 had a hole in the wall approximately 3 inches in diameter and there were uncovered/unconnected telephone wires protruding from the wall. The ED Director confirmed these findings during the tour.

A review of the Policy and Procedures for Environmental Services, Policy #ES1.8, Effective 01/1992, Revised 12/2014, revealed that the facility would be maintained in a clean, orderly, and sanitary condition, following prescribed schedules. The Environmental Services Staff shall work together to maintain clean and aseptic conditions. The policy also revealed that cleaning would include but not be limited to:
--Patient rooms
--Lounges and public restrooms
--Library, lobbies, waiting rooms
--X-Ray, laboratory, pharmacy
--Corridors, stairwells
--Carpets
--Hallway walls and baseboards