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Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure consistent safe food handling practices were adhered to. The facility failed to ensure the facility's policy was implemented and failed to ensure proper daily management of the dietary services as evidenced by multiple opened food items that were stored unlabeled and undated in the kitchen and patient care areas.

The findings include:

Review of the facility's policy titled, "Food Dating Guidelines", dated 09/01/12, revealed all food items must be labeled and dated with a "use by month/day". Further review revealed, various food items have a different "use by" date after opened ranging from two (2) days to ninety (90) days. The day of preparation or container opened should be counted as day one (1). Additionally the policy stated that all non-perishable food items (dried pasta, spices...) would be labeled with the date they were opened. Observation during the kitchen tour, on 12/18/12 at 2:00 PM, revealed this policy was posted on the walk-in refrigerator in the kitchen.

During initial tour of the kitchen, on 12/18/12 at 1:50 PM, observation revealed the dry food storage area contained: One (1) opened bag of dry noodles with no label or date, one (1) opened bag of rice with no label or date, three (3) opened bottles of flavored sno-cone syrup with no label or date, one (1) bottle sesame oil opened with no date, one (1) bottle of A1 Steak Sauce opened with no date, ten (10) bottles of various spices opened with no date, one (1) opened box gluten free bread mix with no date, two (2) opened boxes of pasta with no date, one (1) opened bag of coconut with no label or date, one (1) opened bottle of cooking wine with no date, two (2) opened bottles of vinegar with no date, one (1) opened container of sliced almonds with no date, and one (1) opened box of multi-grain pancake mix with no date. Observation revealed the freezer area contained: eight (8) bags of bread with no label or date, one (1) bag of meat patties with no label or date, two (2) opened bags of pizza shells with no label or date, one (1) container of chopped tomatoes with no label or date, one (1) container of pimentos with no label or date, thirty-three (33) bags of lunch meat with no label or date, twelve (12) stacks of sliced cheese with no label or date, one (1) container of sliced tomatoes with no label or date, two (2) containers of strawberries with no label or date, one (1) container of chunked ham with no label or date, one (1) bag of unidentified contents with no label or date, and one (1) bag of lettuce with no label or date. Continued observation revealed the walk in prep area refrigerator contained: one (1) tray of individual servings of chocolate cake with no label or date, multiple opened bags of bagels with no label or date, one (1) container of sliced onions with no label or date, opened containers of chopped ham, onions, green peppers and shredded cheese with no label or date, twelve (12) trays of muffins with no label or date, one (1) container of gravy with no label or date, one (1) container of cheese sauce with no label or date, one container of mushrooms with no label or date, one (1) container of biscuits with no label or date, eight (8) containers of unidentified contents with no label or date, eight (8) containers of unknown meat with no label or date, and two (2) containers of shredded cheese with no label or date. Further observation revealed the stand up freezer by the grill area contained: two (2) opened bags of chicken strips with no label or date and one (1) opened bag of pizza shells with no label or date. Observation revealed the Chef Area contained: one (1) tray of unknown powder with no label or date, four (4) shelves of spice bottles with no opened date and two (2) bottles of vanilla extract with no opened date.

Additional observation, on 12/19/12 at 4:10 PM, in the Medical Intensive Care Unit, revealed six (6) opened bottles of soda with no opened date, one (1) opened milk carton with no date and an opened loaf of bread with no opened date. Interview, on 12/19/12 at 4:30 PM, with the Medical Intensive Care Manager, revealed the process for using a multi-serving two (2) liter soda bottles was to go by the manufacturer's expiration date for disposal. She was not aware the bottles should have been dated when they were opened.

Interview, on 12/18/12 at 2:05 PM, with the Interim System Director of Nutritional Services (ISDNS) revealed she was at the facility assisting with Dietary Services on an interim basis. She stated she had assumed the responsibility within the last few weeks. Interview further revealed staff had received training in March of 2012 related to dating of foods and the facility's process was to use a Consume by Date (CBD). The INDNS further stated that all food items should be label and dated with the CBD and that all food should be dated when it was opened. Interview further revealed there was no system in place for ensuring opened food items were dated and labeled.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure a clean and sanitary environment to prevent and control infections. Observation revealed a machine considered clean (Breath Analyzer) was sitting on a counter with soiled equipment (Urine Analyzer) at an off site health screening clinic. In addition, facility staff failed to follow the facility's policies related to hand washing and glove use during a dressing change for one (1) of fifty (50) sampled patients (Patient #27).

The findings include:

1. Review of the facility's policy titled, "Equipment: Handling/Cleaning/Disinfection", dated 09/20/12, revealed that separation of clean and dirty equipment must be maintained during processing and storage. Used and uncleaned items should be stored in soiled areas. After cleaning, these items should be moved to a clean storage area/room.

Observation during tour of the St. Elizabeth Business Health Clinic, on 12/19/12 at 1:17 PM, revealed a Breath Analyzer, considered a clean machine that a patient blows air from his/her lungs into, was located on a counter that was a soiled area designated for urine analysis. The Breath Analyzer was contained in an opened nylon case exposing the unit.

Interview, on 12/19/12 at 1:40 PM, with Clinical Supervisor #1, revealed the Breath Analyzer was stored on top of the same counter as the Urine Analyzer without a clean or soiled separation area. Clinical Supervisor #1 stated the process was to move the Breath Analyzer to the next cubical for use. Further interview reveals the unit was cleaned and disinfected between each patient use with sani-wipes; however, there was no process to clean and disinfect the unit after storage in the soiled area. Clinical Supervisor #1 stated that having a clean item such as the Breath Analyzer stored on a soiled counter containing the equipment to test urine could be an infection control issue.

Interview with the Infection Control Coordinator, on 12/20/12 at 2:45 PM, revealed the Breath Analyzer should have been stored and utilized in a clean area not in a soiled area to prevent contamination and infection control issues.


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2. Review of the facility's Hand Hygiene Practices Policy (undated) revealed hand hygiene should be performed after contact with objects in the patient environment and after removing gloves.

Review of the facility's Dry and Moist-to-Dry Dressing Policy (undated) revealed hand hygiene should be performed prior to applying a dressing.

Observation, on 12/19/12 at 10:27 AM, of a dressing change for Patient #27 revealed the facility's nurse, who was the Nurse Manager of the Wound Care Clinic, failed to sanitize her hands after touching contaminated surfaces such as keys, a cabinet door, the computer key board, a bloody pillowcase, the patient's boot, the urinary catheter bag, and a soiled urinary catheter privacy bag prior to doning gloves and initiating a dressing change. The nurse also failed to sanitize her hands after she removed her gloves after she cleansed the wound prior to applying the dressing.

Interview, on 12/19/12 at 11:21 AM, with the Nurse Manager revealed she didn't consider her hands soiled after she touched the keyboard, cabinet or keys. She stated she thought she sanitized her hands at least four (4) times. Further interview revealed everything in the room was considered soiled. After she reviewed the Hand Hygiene Policy and the Dry and Moist-to-Dry Dressing Change Policy she stated she should have used sanitizer after the gloves were removed and after she touched anything soiled.

Interview, on 12/19/12 at 11:15 AM, with the Nurse Manager of the Transitional Care Unit revealed the nurse's hands should have been washed or sanitized before the gloves were donned and after the gloves were removed for Infection Control practices and according to the facility's policies.

Interview, on 12/19/12 at 10:45 AM, with the Patient Safety and Accreditation Coordinator revealed the nurse should have sanitized her hands before donning gloves and after she removed the gloves. Further interview revealed the nurse should have changed her gloves when they were contaminated. She further stated that was an Infection Control issue.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure a clean and sanitary environment to prevent and control infections. Observation revealed a machine considered clean (Breath Analyzer) was sitting on a counter with soiled equipment (Urine Analyzer) at an off site health screening clinic. In addition, facility staff failed to follow the facility's policies related to hand washing and glove use during a dressing change for one (1) of fifty (50) sampled patients (Patient #27).

The findings include:

1. Review of the facility's policy titled, "Equipment: Handling/Cleaning/Disinfection", dated 09/20/12, revealed that separation of clean and dirty equipment must be maintained during processing and storage. Used and uncleaned items should be stored in soiled areas. After cleaning, these items should be moved to a clean storage area/room.

Observation during tour of the St. Elizabeth Business Health Clinic, on 12/19/12 at 1:17 PM, revealed a Breath Analyzer, considered a clean machine that a patient blows air from his/her lungs into, was located on a counter that was a soiled area designated for urine analysis. The Breath Analyzer was contained in an opened nylon case exposing the unit.

Interview, on 12/19/12 at 1:40 PM, with Clinical Supervisor #1, revealed the Breath Analyzer was stored on top of the same counter as the Urine Analyzer without a clean or soiled separation area. Clinical Supervisor #1 stated the process was to move the Breath Analyzer to the next cubical for use. Further interview reveals the unit was cleaned and disinfected between each patient use with sani-wipes; however, there was no process to clean and disinfect the unit after storage in the soiled area. Clinical Supervisor #1 stated that having a clean item such as the Breath Analyzer stored on a soiled counter containing the equipment to test urine could be an infection control issue.

Interview with the Infection Control Coordinator, on 12/20/12 at 2:45 PM, revealed the Breath Analyzer should have been stored and utilized in a clean area not in a soiled area to prevent contamination and infection control issues.


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2. Review of the facility's Hand Hygiene Practices Policy (undated) revealed hand hygiene should be performed after contact with objects in the patient environment and after removing gloves.

Review of the facility's Dry and Moist-to-Dry Dressing Policy (undated) revealed hand hygiene should be performed prior to applying a dressing.

Observation, on 12/19/12 at 10:27 AM, of a dressing change for Patient #27 revealed the facility's nurse, who was the Nurse Manager of the Wound Care Clinic, failed to sanitize her hands after touching contaminated surfaces such as keys, a cabinet door, the computer key board, a bloody pillowcase, the patient's boot, the urinary catheter bag, and a soiled urinary catheter privacy bag prior to doning gloves and initiating a dressing change. The nurse also failed to sanitize her hands after she removed her gloves after she cleansed the wound prior to applying the dressing.

Interview, on 12/19/12 at 11:21 AM, with the Nurse Manager revealed she didn't consider her hands soiled after she touched the keyboard, cabinet or keys. She stated she thought she sanitized her hands at least four (4) times. Further interview revealed everything in the room was considered soiled. After she reviewed the Hand Hygiene Policy and the Dry and Moist-to-Dry Dressing Change Policy she stated she should have used sanitizer after the gloves were removed and after she touched anything soiled.

Interview, on 12/19/12 at 11:15 AM, with the Nurse Manager of the Transitional Care Unit revealed the nurse's hands should have been washed or sanitized before the gloves were donned and after the gloves were removed for Infection Control practices and according to the facility's policies.

Interview, on 12/19/12 at 10:45 AM, with the Patient Safety and Accreditation Coordinator revealed the nurse should have sanitized her hands before donning gloves and after she removed the gloves. Further interview revealed the nurse should have changed her gloves when they were contaminated. She further stated that was an Infection Control issue.