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Based on observation, interview and record review the facility failed to have systems in place to ensure the facility's heat sanitizing dish washing machine is maintained in effective working condition to reach the 180 degrees Fahrenheit required to sanitize dishes;

Failed to ensure the sanitizing equipment attached to the three (3) compartment sink used for cleaning pots and pans was functional;

Failed to clean the stove, refrigerators, freezer, storage cupboards and shelves;

Failed to ensure Dietary staff preparing meals for patients and staff were knowledgeable regarding the temperature required to sanitize dishes.

This failed practice resulted in an Immediate Jeopardy being identified due to the potential for the harm of food borne illness for all patients on census and staff eating at the cafeteria. Citing all patients on census and staff that eat at the cafeteria.

Findings:

Summary: An Immediate Jeopardy was identified during observation on 4/17/2017 in the Kitchen due to:

The heat sanitizing dish washing machine was not reaching the 180 degrees Fahrenheit required to sanitize soiled dishes;

Used pots and pans were not sanitized during the washing process; Dietary staff lacked the required knowledge for sanitizing procedure of pots, pans and dishes;

There were no monitoring system in place to ensure Dietary Staff sanitized used dishes, pots and pans, and maintain dishwashing equipment in an effective working order.


Observation in the kitchen on 4/17/2017 between the hours of 12:20 p.m and 1:35 p.m revealed the following findings:

Two Dietary Staffs (L ) Cook and (M) Dietary Director were observed washing dishes, pots and pans after the lunch service.

Dietary staff (L) hand washed plates, trays and plate covers in soapy water and ran the utensils through the Hobart dishwashing machine which ran for about 3 minutes. After the rinse cycle was completed she placed the dishes on the drain tray.

The dishwasher registered 150 degrees Fahrenheit for the wash cycle and 155 degrees Fahrenheit during the rinse cycle.


The dishwashing machine had boldly printed information that the machine was a "heat sanitizing machine, wash at 150 degrees Fahrenheit and rinse at 180 degrees Fahrenheit".


There were two attached canisters on the dishwashing machine, one labeled dishwashing liquid and the other as detergent polisher. The polisher container consisted of a white rock like substance.

The soap canister was not in use. There was no sanitizing solution attached to the dishwasher.

The dishwashing procedure was repeated twice by Staff (L) and the maximum rinse temperature reached was 160 degrees Fahrenheit.

The Dietary Director was observed washing pots and pans in the three compartment sink. She hand washed the pots and pans, rinsed them under warm running water and placed them on the drain board to dry.


Observation revealed there was a set up to the back of the sink labeled "ECOLAB" with an empty container labeled "detergent" and another container two thirds full of a pink liquid labeled "Multi Quant Sanitizer". The containers had attached transparent hoses leading to the sink. The hoses were dry, there was no fluid in the line and appeared not to being used.

Stove:

Observation revealed heavy buildup of grease and food particles on stove top, forming a thick black crust on the stove top, and around the base of the burners, and in the creases of the stove.

The observation was pointed out to the Dietary Manager present at the time of the observation. She stated the stove could not be cleaned because it was more than 10 years old.

The Surveyor used a knife to demonstrate that the buildup could be removed. She used a sharp object to remove debris from the creases of the stove. The door to the oven was soiled with rust looking grease splatter. The hood over the stove had heavy grease and dust web.

Refrigerators:

Observation revealed there were two white freezers labeled #1 and 2. The outer surface of the door panel on freezer #2 was stained with small caked on rust like splatter over approximately two thirds of the surface. (The substance was removable as seen after cleaning was done 4/18/2017).

There were three (3) two (2) tier refrigerators with food items. The doors of the refrigerators were greasy and dull.

The lower section inside refrigerator #1 had a build of of slimy discolored substance on the base of the refrigerator.

Shelves and cupboards:

The stainless steel shelves and cupboards had heavy buildup of dust particles and dust webs. The shelves and cupboards were used for storing clean dishes, pans, and an array of bottled seasoning.

There was an electric can opener fixed to a counter top. It was rusty, and had a thick build up of black grimy substance at the base of the can opener and on the attachment.

Floor:

There was heavy buildup of dust and food particles in the corners of the floor along the base boards located at the back of the stove and three compartment sink. The floor tiles were dull and discolored. Black streaks were noted in the grout and some sections of the tiles.


During an interview in the kitchen on 4/17/2017 at 1:40 p.m with Staff L (Cook ) and Staff M (Dietary Director), they were both asked by the Surveyor to explain how the dishwashing machine functions and sanitizes dishes.

Both staff stated they did not know how the machine functions and did not know the required temperature the dishwasher should reach to ensure dishes were sanitized.

The Surveyor asked Staff L how the dishwashing machine was monitored to ensure the required temperature was maintained. She stated that the Maintenance staff monitors the dishwasher.

Staff M (Dietary Director) stated a temperature log was not kept for the dishwasher.
She stated daily temperature logs were kept for the freezers and refrigerators.


During the interview the Surveyor asked the Dietary Manager how pots and pans were sanitized, she stated the sanitizing setup was not working for "a while." She was not able to tell how long "a while" was.

According to the Dietary Director when the set up for the three compartment sink was working, the sink is half filled with water and three squirts of the Quant was used to sanitize the pots and pans.

She stated the mixture of water and quant solution was never tested for its effectiveness, and no logs were kept.


During an interview on 4/17/2017 at 1:55 p.m with the Dietary Director, she stated the Director of Infection Control had never visited the kitchen.

During an Interview in the kitchen on 4/17/2017 at 2:15 p.m with the Director of Nursing who is also the Infection Control Officer, she stated she had never gone into the kitchen to conduct an inspection and did not know how the dish washing equipment functions.

During an interview on 4/18/2017 at 8:39 am in the kitchen with Staff (G) Maintenance Director he gave the following information:

He was not aware the dishwasher was not reaching temperature. He was informed on Thursday (4/13/2017) that the dishwasher was leaking. He realized a pump was broken and so he reduced the heat on the dishwashing machine. He was informed afterwards by the dietary staff that the dishwasher was in use.

According to Staff (G) Director of Maintenance he was only called to the kitchen when there was a problem. He was never informed the dishwashing machine was not reaching the correct temperature.

During an interview on 4/19/2017 at 11:45 a.m. with Staff (G) Maintenance Director, he stated he had been the Director of Maintenance since 2014. He had never been in the kitchen to inspect the dishwashing equipment.

He stated no PM was done on the equipment since he became the Maintenance Director in 2014.

Staff ( G) stated he did not consider the maintenance of the dishwashing equipment as a part of his responsibility. He only responded if there was a repair problem. He stated when he was informed the dishwasher had a problem he did not develop a written plan but was going to call a repair company.

Review of temperature logs for the refrigerators and freezers revealed there were no logs for January and February 2017. Temperature logs for March 2017 had documentation for 4 - 5 days. There were no logs started for April 2017. There was no documentation that the temperature for the two freezers and the three refrigerators were done daily.

There was no evidence the temperature for the dishwashing equipment was monitored. The staff was unable to produce a temperature log.


Review of the facility's census for April 13, 2017 - April 17, 2017 when the dishwasher's temperature was lowered below the required temperature revealed there were three (3) in patients that were fed in the facility.

Review of the manufacturer's manual presented by the facility for the Hobart Dishwasher Model AM-14 /AM-14C used at the facility revealed the dishwasher is a heat sanitizing dishwasher and recommends the dishwasher be cleaned after each working shift or at least at the end of each day.

The manual gave detailed instructions for the required cleaning process. The instructions were available to the facility staff but was not utilized.

Policy and Procedure

Review of the facility's Food Service and Maintenance Policy for the dietary suite, dated 11/2016 revealed the following information:

Review of the facility's current Policy and Procedure on Food Storage directs staff as follows: "Perishable storage. Each refrigerator unit must be equipped with an indicating thermometer accuracy to + 2 degrees and situated so that it can be easily and readily observed for reading.

The temperature of all cool storage facilities shall be checked and logged on the appropriate form daily, with deviation from the norm reported and action recommended or taken recorded."

Refrigerator and Freezer Temperatures

Review of the facility's current Policy and Procedure on refrigerator and freezer temperatures, revised November 2016, directs staff as follows:

"At the beginning of each month the Dietary Director shall post log forms on each refrigerator and freezer door.

Each morning at 6:30 a.m. the Dietary Director or designee shall record temperatures on each log sheet. Completed logs will be maintained on file for one month."

Review of the Facility's Current Policy and Procedure on Maintenance directs staff as follows:

"Proper maintenance of the physical plant and all equipment in the Dietary Department shall be the responsibility of the Director of Dietary in cooperation with the Director of Maintenance of the hospital and subject to policies and procedures set forth by the hospital administration."

The dietary department will perform all cleaning of equipment in accordance with the standard procedures used and sanitation standards set forth by the hospital and for a food service established.

Dietary personnel will do routine cleaning relative to daily and periodic maintenance equipment.

The Dietary Director or Maintenance Director should be notified immediately of all equipment that is faulty or not functioning properly.

At No time will dietary employees attempt to work on or overhaul equipment in the Dietary Department.

All adjusting and setting of machines and equipment will be done by the responsible department and with the knowledge of the Supervisor.

Preventative maintenance (PM) is planned and documented by the Maintenance Department and reviewed quarterly with the Dietary Director.

Quarterly maintenance of the dishwasher: Lubricate. Clean all traps and strainers. Check temperature. Check soap and dryer dispensers. Check "O" rings and drain valve".

Review of the facility's PM records for the dishwasher revealed the last PM was done 6/22/2010 by an outside company. There was no internal maintenance done on the dishwashing machine.

Based on observation interview and record review, the Facility's Quality Assessment Performance Improvement Committee failed to monitor, identify and address
break in infection control/ sanitation practices in the facility's dietary department:
failed to have systems in place to ensure the facility's heat sanitizing dish washing machine is maintained in effective working condition to reach the manufacturer's recommended temperature of 180 degrees Fahrenheit required to sanitize dishes and utensils;

Failed to ensure sanitizing equipment attached to the three (3) compartment sink used for cleaning pots and pans was functional;
Failed to clean the stove, refrigerators, freezer, storage cupboards and shelves;
Failed to ensure dietary staff preparing meals for patients and staff were knowledgeable regarding the temperature required to sanitize dishes.
This failed practice resulted in an Immediate Jeopardy being identified due to the potential for the harm of food borne illness for all patients on census and staff eating at the cafeteria. Citing all patients on census and staff that eat at the cafeteria.

The Facility's Quality Assessment Performance Improvement committee failed to have systems in place to ensure when there is a patient death at the facility, the commitee review the death to ensure timey notification of the OPO.


Findings:

Observation in the kitchen on 4/17/2017 between the hours of 12:20 p.m and 1:35 p.m revealed the following findings:

Two Dietary Staffs (L ) Cook and (M) Dietary Director were observed washing dishes, pots and pans after the lunch service.

Dietary staff (L) hand washed plates, trays and plate covers in soapy water and ran the utensils through the Hobart dishwashing machine which ran for about 3 minutes. After the rinse cycle was completed she placed the dishes on the drain tray.

The dishwasher registered 150 degrees Fahrenheit for the wash cycle and 155 degrees Fahrenheit during the rinse cycle.


The dishwashing machine had boldly printed information that the machine was a "heat sanitizing machine, wash at 150 degrees Fahrenheit and rinse at 180 degrees Fahrenheit".


There were two attached canisters on the dishwashing machine, one labeled dishwashing liquid and the other as detergent polisher. The polisher container consisted of a white rock like substance.

The soap canister was not in use. There was no sanitizing solution attached to the dishwasher.

The dishwashing procedure was repeated twice by Staff (L) and the maximum rinse temperature reached was 160 degrees Fahrenheit.

The Dietary Director was observed washing pots and pans in the three compartment sink. She hand washed the pots and pans, rinsed them under warm running water and placed them on the drain board to dry.


Observation revealed there was a set up to the back of the sink labeled "ECOLAB" with an empty container labeled "detergent" and another container two thirds full of a pink liquid labeled "Multi Quant Sanitizer". The containers had attached transparent hoses leading to the sink. The hoses were dry, there was no fluid in the line and appeared not to being used.

Stove:

Observation revealed heavy buildup of grease and food particles on stove top, forming a thick black crust on the stove top, and around the base of the burners, and in the creases of the stove.

The observation was pointed out to the Dietary Manager present at the time of the observation. She stated the stove could not be cleaned because it was more than 10 years old.

The Surveyor used a knife to demonstrate that the buildup could be removed. She used a sharp object to remove debris from the creases of the stove. The door to the oven was soiled with rust looking grease splatter. The hood over the stove had heavy grease and dust web.

Refrigerators:

Observation revealed there were two white freezers labeled #1 and 2. The outer surface of the door panel on freezer #2 was stained with small caked on rust like splatter over approximately two thirds of the surface. (The substance was removable as seen after cleaning was done 4/18/2017).

There were three (3) two (2) tier refrigerators with food items. The doors of the refrigerators were greasy and dull.

The lower section inside refrigerator #1 had a build of of slimy discolored substance on the base of the refrigerator.

Shelves and cupboards:

The stainless steel shelves and cupboards had heavy buildup of dust particles and dust webs. The shelves and cupboards were used for storing clean dishes, pans, and an array of bottled seasoning.

There was an electric can opener fixed to a counter top. It was rusty, and had a thick build up of black grimy substance at the base of the can opener and on the attachment.

Floor:

There was heavy buildup of dust and food particles in the corners of the floor along the base boards located at the back of the stove and three compartment sink. The floor tiles were dull and discolored. Black streaks were noted in the grout and some sections of the tiles.


10802


Review of the facility's dietary temperature logs dated March 2017 for the refrigerators and freezers utilized in the dietary department revealed documentation which indicated temperature for the refrigerators and freezers were recorded for 4 - 5 days out of 31 days, although the Quality Assessment Performance Improvement data indicated temperatures were monitored and in range for 31 days.
The facility did not have temperature logs available for January and February 2017.

Review of the facility's Infection Control Surveillance forms for January 2017 - March 2017 revealed no documentation that monitoring or surveillance were done of the Dietary Department, kitchen, and general environment.

Review of the Facility's Quality assessment Performance Improvement meeting minutes and data dated January 10, 2017, February 2017, March 8, 2017 and April 2017 revealed the following documentation by the Dietary Director:
"All monitors met. The Director will continue to monitor for the next 30 days."
Review of the dietary department's Quality Assessment Improvement data and meeting minutes revealed the following documentation:
"Daily check of kitchen refrigeration temperatures to assess proper degree according to P& P.
Monitor dishwasher daily, keep between 150 &180 degrees.
Daily check of pantry temperatures to assess proper degree according to P&P."

Documentation in the Facility's Quality Assessment Performance Improvement data and minutes indicated that there was 100 % compliance in the previous and current month i.e. January, February, March and April 2017.


Review of the Facility's Quality Assessment Performance Improvement meeting minutes and data, dated January 10, 2017, February 2017, March 8, 2017 and April 2017 revealed no evidence that the Quality Assessment Performance Improvement Committee identified break in infection control and sanitation practices in the dietary department of the facility and implemented a plan to correct the deficient practice; namely the dishwasher in the kitchen not reaching and maintaining the manufacturer's recommended temperature of 180 degrees Fahrenheit for heat sanitizing of dishes and utensils, utensils washed in the three compartment sink were not washed, rinsed and sanitized with a recommended sanitizer, built up of grime, grease and dirt on the stove, counter top and refrigerator, mold and dirt in container used for storage of dried goods, slime in the refrigerator and the facility's infection control manager not integrating and monitoring sanitation in the dietary department. Dietary staff was not knowledgeable and able to demonstrate the sanitization process of dishes and utensils utilized by patients using the three compartment sink and dishwasher.


Interview on 04/18/2017 at 11:56 a.m. with the Facility's Director of Nursing revealed she is responsible for infection control which includes surveillance in the facility and Quality Assessment Performance Improvement.

The Director of Nursing said she conducts surveillance of the facility but she did not visit the dietary department and the operating room. She said she was not aware of the breakdown in sanitary condition in the facility's kitchen. She said the Dietary Manager presents information regarding the dietary department at the Quality Assessment Performance Improvement meetings but raw data such as temperature logs are not reviewed at the meetings. She said she was not aware that the dishwasher was not reaching the required temperature of 180 degrees Fahrenheit for heat disinfecting.


Interview on 04/18/2017 at 1:30 p.m. with the Facility's Dietary Director revealed she did not have documentation of the temperatures for the freezers, refrigerators or dishwashers for the former months.
She said on Thursday April 13, 2017 she observed water shooting from the connection near the dishwasher. She said she called maintenance who decreased the temperature of the water. She said staff in the kitchen continued to use the dishwasher.
She said the three compartment sink Quant automatic dispenser was not functioning for sometime and so she would mixed bleach in the water. When asked what ratio of bleach to water was used for the mixture she was unable to say.

(1) Review of the Facility's most current Policy and Procedure on Quality Assessment Performance Improvement, revised October 2016 directs staff as follows:

Procedure : "To identify organization wide concerns affecting patient care and general operations of facility through the use of all available data sources, to include but not limited to the following : Infection control department; Dietary."

"Scope: The program applies to all organized services and those services under contract, all departments and units of the organization and all healthcare professionals. It shall be ongoing and shall include effective mechanisms to monitor, identify, evaluate and resolve problems that impact on the quality of services provided"


The Quality Assessment Committee operates solely under the mandate of the Medical Staff Committee. It shall review and assess any issues, which are relative to patient care in the organization. All actions of the Quality Assessment Committee will be presented to the Medical Staff Committee."

Responsibilities:
"Review Patient care related problems. Evaluate organized services related to patient care including contract services. Receives and evaluates all reports from all organization, departments and /or units. Identifies patient care problems through reports of studies and monitoring activities/ evaluates and/ or monitors follow up to assure appropriate action has been taken and correctable problems have been resolved. "


(2) Review of the facility's policy and procedure on Infection Control Program , revised 10/2016 directs staff as follows : Objectives; To ensure all patients and employees are provided with a clean, infection free environment. To identify hospital acquired infections and those brought into the hospital from the community
To establish a procedure for reporting and gathering of data to monitor infection control activities. To ensure that there is an ongoing in-service program for all staff. "


" The infection control Program applies to all organized services and those services provided under contract . All departments of the hospital, and all healthcare professionals. It shall be ongoing and shall include effective mechanisms to monitor, identify, evaluate and resolve problems that impact on the quality of services that involve infection control. "


Lifegift:Review of the facility's Mortality Review information revealed there was documentation Lifegift was not informed of one death. There was no mention of the late notifications to life gift. There was no documented action plan for the omitted notification. This was not included in the Quality Asssessment Performance Improvement process of the facility.

Based on record review and interview, the facility failed to have systems in place to ensure when there is a patient death at the facility, the Organ Procurement Organization (OPO) is notified, and when the notification is made, it is done within the defined "timely manner" required by their agreement with the OPO;

The facility failed to comply with their responsibility to develop a policy that defines "timely manner and Imminent Death'' as required by their Agreement with the OPO.

This failed practice had the potential for the inability for Lifegift to procure organs at the facility for possible donation. Citing three (3) of four (4) death records that were reviewed. Patient #s 21, 22 and 23.


Findings:

Review of the Facility's Donor Institution Agreement, dated October 2012 revealed the following information:

"Whereas, Lifegift is an organ procurement organization ("OPO") established to perform and coordinate the recovery, preservation and transportation of organ and tissues;

For the purpose of this Agreement, the following terms shall have the meanings ascribed to them in this Article 1.

1.7 Imminent Death: A patient with severe, acute brain injury, disease or illness that may or may not be traumatic in origin; and:

(1) Who requires mechanical ventilation; and,
(2) Meets one or more of the following criteria:

(a) Has clinical findings consistent with Glasgow Coma Score (GCS) that is less than or equal to mutually-agreed-upon threshold (such as 4 or 5); or

(b) For whom physicians are evaluating a diagnosis of brain death; or

(c) For whom physicians has ordered withdrawal of life-sustaining therapies, consistent with the family's decision.

1.10 Timely Notification/Referral: Timely notification/referral means notification to Lifegift of an imminent death within one hour of the patient's meeting clinical trigger criteria for imminent death.

Notification shall be made prior to the withdrawal of any life sustaining therapies. With respect to cardiac death, timely notification means notification to Lifegift within one hour of the cardiac death".

Review of the facility's OPO policy dated October 2016 revealed the following information:

"Purpose is to outline the hospital's guidelines for routine notification of death to the Organ Procurement Organization and to outline procedures to facilitate organ and tissue donation.
It is the policy of the Hospital to report all deaths to Lifegift Organ Donation Center for evaluation of potential organ/tissue donation.

Staff involved shall cooperate and communication to the fullest extent in order to procure transplantable organs and tissue in a timely manner".

The policy did not define "timely manner, nor imminent Death".

Patient # 21

Review of progress notes dated 2/24/2017 revealed a sixty two (62) year old Patient #21 arrived at 0435 to the emergency room being bagged by Emergency Medical Services staff.

Resuscitative measures were initiated by the ER staff. There was documentation that the Physician Assistant in attendance on the patient went and discussed end of life plans with the family at 0445.

The patient was pronounced dead at 0454. At 0810 the patient's body was removed by Funeral Home Personnel.

There was documentation that Lifegift was notified at 0920(more than 4 hours after death).


Patient # 22

Review of Lifegift's Routine Notification of Death Record dated 10/29/2016, revealed Patient # 22 was pronounced dead at the facility on 10/29/2016 at 09:05. There was documentation that Lifegift was notified on 10/29/2016 at 1745, (8 hours after the patient was pronounced dead).


Patient # 23

Review of progress notes dated 12/5/2016 revealed a twenty eight (28) year old patient #23 was an inpatient at the facility since 12/3/2016. On 12/5/2016 at 09:20 the patient went into respiratory arrest and cardiopulmonary resuscitation was initiated.

Resuscitation was unsuccessful and the patient was pronounced dead at 09:54.

There was documentation the patient's body was removed from the facility by funeral home staff on 12/5/2016 at 13:20.

There was no documentation that Lifegift was informed of the patient's death, or imminent death.

Review of the facility's Mortality Review information revealed there was documentation Lifegift was not informed of one death. There was no mention of the late notifications to life gift. There was no documented action plan for the omitted notification. This was not included in the Quality Asssessment Performance Improvement process of the facility.


During an interview on 4/19/2017 at 2:30 PM with Staff (H) Registered Nurse that called Lifegift after patient (#22) was pronounced dead, she stated she was never taught a time frame to call Lifegift. She only knew the call should be made before the body is released to the funeral home.

During an interview on 4/20/2017 at 9:10 am with Staff (B) Director of Nursing, she stated that in her twenty (20) years at the facility she did not know that there was a specific time frame to call Lifegift.

She stated she would expect it to be done as soon as possible at least not waiting a complete shift before it is done.


During an interview on 4/20/2017 at 10:50 am with Staff (R) Registered Nurse, she stated she did not know there was a time factor to calling Lifegift, she stated at a minimum she thought the call should be made during the shift a patient expired and not left for the oncoming shift.