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Based on observation, interview and record review the hospital failed to ensure the Dietary Director supervised 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 and consuming food from the hospital's only kitchen.

Findings included:


The kitchen was toured with Personnel #3 and Personnel #6 on 01/06/12 at 11:45 AM. The following observations were made:

The gas stove's exterior had dark grease and debris caked on the exterior surface.

The trays in the convection oven were observed to have scum and dirt built up.

A grey trash barrel opposite to the hand washing station did not have a lid.

During an interview on 01/06/12 at 11:47AM Personnel #6 stated the kitchen stove was "47 years old" and to be replaced. Personnel #6 stated he would provide a lid for the trash can.

A second tour of the kitchen was conducted between 2:40 PM and 3:20 PM with Personnel #2. The following observations were noted:

The grey trash barrel opposite to the hand washing station did not have a lid.

Cereals flakes identified by personnel #2 were observed on the bottom of a second bin with silverware. Next to the plastic ware was an open bag of raisin bran flakes. A cereal dispenser sat on the top of a tray covered with loose cereal.

Personnel #19 walked through the kitchen from the back hallway to the main dining area without wearing a hair cover.

During an interview on 01/06/12 at 2:40 PM Personnel #2 acknowledged that Personnel #19 walked through the kitchen without a hair cover.

The dishwasher machine spewed out water during the running wash cycle. White scummy deposit was observed on the right side of the dishwasher door close to the water leak.

Personnel #6 stated during an interview on 01/06/12 at or around 3 PM, "That ' s what it [the dishwasher] does."

A mop bucket with dark colored water was observed close to the dishwasher room; a mop was left in the bucket.

The floor freezer had thick ice coverage on the right side and a yellow and white residue was on the bottom of the freezer and identified by Personnel #2 as "pieces of vanilla ice cream, maybe one [cup of ice cream] broke."

Equipment identified by Personnel #6 as the "first module of the new stove" had water spots, food crumbs, and a long, skinny dried up spot of an orange substance.Personnel #6 stated at that time that, although the new stove module was not yet in use, staff used it for placement of kitchen items.

The gas stove revealed peeled off paint in the front, burnt on grease, scum and a greasy ladle left on the top.

Food debris was observed underneath the stove on the kitchen floor.

The floor drain in front of the stove backed up to about one inch of yellow fluid.

A can labeled "Multiquat Sanitizer Oasis 148" was observed in front of the three compartment sink.Personnel #6 did not have an explanation for the can of Sanitizer in front of the sinks.

Seven cookie sheets with dark left over build up on the outside and inside cooking surfaces were stacked on the shelf to the right of the three compartment sink.

The hospital document labeled "PM check list" provided by Personnel #6 on 01/06/12 at or around 3:15 PM reflected the assigned task of cleaning the ovens was not checked as completed four out of four days.

The hospital policy and procedure document entitled "Kitchen Sanitation and Infection Control" with a revision date of 09/20/11 reflected "all work surfaces, utensils, and equipment are sanitized with appropriate cleaning agents between uses."