HospitalInspections.org

Based on observation, interview and record review the governing body failed to ensure the dietary department services in the main hospital and psychiatric hospital were provided in a safe and effective manner in that:

A) The main hospital:
1) Cleanliness issues were observed in the retail and kitchen production areas,
2) Lack of labeling of food items was noted in the retail, kitchen production and tray preparation areas, and
3) Food items were left at room temperature in the food storage retail area.

B) The Psychiatric Hospital Unit:
1) Cleanliness issues were observed in the patient dining and kitchen areas,
2) Food was served at unknown temperatures,
3) The dishwasher leaked and corrosive material was stored in close proximity to a patient food refrigerator, and
4) A kitchen container with yellow liquid was unlabeled.
Such practices placed patients, employees, and visitors at risk for acquiring illnesses and infections.


Findings included:

A) On 01/22/13 from 09:45 AM to 11:30 AM a tour of the Main Hospital dietary department was conducted with Personnel #12 and Personnel #46.

1) Cleanliness issues were observed in the retail and kitchen production areas.

a) Kitchen Retail Area
Behind the serving line in the retail area the two compartment sink had a leaking faucet.
The shelves under the metal serving station were soiled with dirt-like debris.
The shelf under the hot plate station was greasy and soiled with debris.
Parchment paper on the shelf used to wrap bread showed brownish debris and dirt. The parchment paper was available for use.
The steam table knobs were caked on with brown grime, dirt, and debris.
The bottom shelf of one of the work stations had a pan of "clean utensils" to be used for serving. In the pan dirt and debris were observed. The utensils were available for use on the serving line.
The refrigerator with food items had a black substance on the inside of the door and on the rubber gasket.
The freezer unit was soiled with dirt and debris.
The top, front and sides of two trash containers were covered in grime. Personnel #46 was asked if the trash disposal containers were on a cleaning schedule. Personnel #46 said he did not know and verified the interior and exterior had not been cleaned.
A ceiling tile was missing next to the main grill.
The floors, walls and baseboards behind the serving line were soiled with debris. The painted surface of the door into the kitchen was peeling. The surface of the door was soiled.

b) The Kitchen Production Area:
The storage room of the kitchen production area was observed with multiple boxes stored on the floor, two ceiling tiles missing with exposed wires. The shelf unit had black grill bricks with black residue from the bricks on the surface of the shelf and on the floor. The floor surface had dust, debris and stains. The wall surfaces were stained, scratched, and paint was missing..
A second storage room had "Clean micro-fiber pads" used to clean floors mixed with dirty rags and a soiled wet mop head. Brown stains, dirt and grime were on the walls and on the surface of the floor.
A tray rack was soiled. The surveyor took a wet paper towel and wiped the surface of the tray rack. The paper towel was brown in color.
A metal workstation was observed. The first drawer contained a collection of grime, dirt and debris. An opened box of disposable gloves was observed with dirt/debris on the gloves. The top shelf of the workstation contained a white plastic bin. The bin was soiled and dirty on the interior and exterior surface.
A large stand mixer was observed sitting on a metal work station. The mixer's connector had dried/caked on debris. The surface of the unit was greasy and dirty.
On top of a shelf a wire whisk attachment was observed. The wire whisk was covered with dust. The attachment was available for use in food preparation.
A shelf next to the ovens was observed. On the bottom shelf were (2) cast iron skillets stacked wet on top of each other. Upon inspection rust stains from the standing water was observed on the inside and exterior surface of the pan. A third large skillet was observed laying face down on the shelf. The surveyor picked up the skillet and observed a standing congealed greasy substance on the lip of the skillet and on the surface of the shelf. Personnel #47 removed the skillets and said they were dirty.
The dishwasher area was observed. 10 large trays were observed stacked wet on top of each other. Multiple pots/pans were observed stacked wet on top of each other.

2) Lack of labeling of food items was noted in the retail, kitchen production and tray preparation areas

a) Kitchen Retail Area:
A shelf under the serving station in the retail area had a pan of granola. The food item was not dated or labeled.
The refrigerator unit contained a pan of roasted garlic dated 01/09/13 with no expiration date. A pan of stir-fry mix, diced chicken, opened package of feta cheese and 25 prepared pizzas were not dated and/or labeled.
The freezer unit contained two opened bags of a meat product and a opened box of hash browns. The items were not dated and/or labeled.

b) Kitchen Production Area
A white plastic bottle of a brown substance was sitting on a metal work station in the kitchen production area. Personnel #47 stated the bottle of brown substance was caramel sauce and should be labeled.
A food prep station had two bins on rollers stored under the table. The first bin was opened and contained bread crumbs. The container was not labeled and the exterior surface and interior surface was dirty and soiled. A second container was opened and Personnel #47 identified the white powdery substance as "Diatomaceous Earth." Personnel #47 stated the substance was a filter powder used in grease. The container was not labeled and the exterior surface and interior surface was dirty and soiled. Personnel #47 stated the filter powder should not be stored next to the food product and the above items needed to be cleaned and labeled.

A material safety data sheet entitled, "Diatomaceous Earth, Silica Cement Ingredient" provided by Staff #46 reflected, "Do not mix; pour or work with this product in enclosed area without appropriate breathing protection..."

c) Tray Preparation Area:
The refrigerator in the tray preparation area contained two trays of individual salads (24) in total and a tray of green jello. The food items were not dated and/or labeled.
Inside one of the food carts was a white wet substance on the floor of the unit and a brown stain on the surface of the unit.

Personnel #45 stated when the carts were cleaned it must have been missed. Personnel #45 stated she did not know the food items were not labeled and that the production area should have labeled the items.

3) Food items were left at room temperature in the food storage retail area.
The refrigerator unit located next to the main grill in the food storage retail area was observed. The lid on top of the refrigerator unit was raised. Inside the unit were pans of sliced jalapenos, slices of ham, green peppers, mushrooms, shredded cheese and slices of white cheese exposed to room temperature. Sliced American cheese was observed in the bottom of the pan to be grease-like and not consumable. A pan of sliced tomatoes was observed. The inside of the unit was warm. No thermometer was found inside the unit. Staff #46 verified all the food items were at room temperature and not being stored properly. Staff #46 stated the food items would be discarded and said he did not know why the refrigerator did not have a thermometer. Staff #46 stated proper food handling procedures were not being followed.

On 01/23/13 at approximately 2:25 PM, Personnel #48 verified proper cleaning procedures, labeling of food products, food storage and handling were not followed.

On 01/23/13 at 01:30 PM Personnel #46 was interviewed. Personnel #46 stated he was responsible for the condition of the dietary department and verified the above findings.

The contracted dietary service policy, entitled, "Products are received and stored properly" with a date of 10/13/12 reflected, "Food temperatures of received products are taken using a digital thermometer...all food items in storage areas are labeled and dated...storage areas are neat, clean and organized...internal thermometers that are not part of the centralized system are present in all temperature-controlled equipment...foods that require time/temperature control for safety...to limit pathogenic bacterial growth...include but not limited to raw or heat-treated animal proteins...cut tomatoes..."

The contracted dietary service policy, entitled, "Prepared products are properly stored" with a date of 10/13/12 reflected, "Labels must contain the product name, date stored, discard date and associates initials..."

The contracted dietary service policy, entitled, "Sanitation and Safety Standards are met" with a date of 10/13/12 reflected, "Not leaving food "sitting out" for extended periods of time...cleaning schedule is followed for each area...all areas of the food service department including the front and back of the house sanitation level meets...standards...all equipment, work spaces, storage areas and common areas are clean, sanitary, organized and free of clutter..."


B) On 01/24/13 from 03:50 PM to 04:30 PM a tour of the Dietary Department in the Psychiatric Hospital Unit was conducted with Personnel #45 and #49. The following was observed:
1) Cleanliness issues were observed in the patient dining and kitchen areas

The patient serving line:
The metal surface of the salad bar had a collection of debris and grime on the surface.
The refrigerated unit on the serving line contained salads and desserts. The upper and lower shelves were soiled with debris.
The metal counter next to the cash register was stained, sticky and dirty.
The coffee machine area was stained with dark spots.

The dining room condiment station:
Plastic condiment containers (12) were sitting in a slotted shelf unit. The inside and outside of the containers were sticky, soiled and dirty. The containers were removed from the station and debris/caked on build-up was on the surface of the unit. The surface of the unit and the shelf on top of the unit had dust-particles which were observed falling into the bins. Staff #45 stated the condiment station had not been cleaned.

The kitchen housekeeping closet:
A yellow mop bucket filled with dirty water was observed. The bucket was stained and soiled with dirt and grime on the inside and outside of the bucket. Staff #45 stated the bucket needed to be thrown away and did not know whether the mop bucket was on a cleaning schedule.

The kitchen area:
Multiple plastic containers (10) were stacked wet on top of each other. Staff #45 verified the above observations.
A pool of water was observed next to the dishwasher.
The floor next to the dishwasher was stained with white streaks.
Metalware on the outside of the dishwasher was observed crusted and grimed over with white streaks. The side of the dishwasher closest to the entrance was covered with whitish crust-like material. Staff #46 stated at that time that it was due to "hard water" and needed to be "de-scaled."
The splashboard next to the hand washing sink was soiled with tan and brown colored areas.

The contracted dietary service policy, entitled, "Sanitation and Safety Standards are met" with a date of 10/13/12 reflected...cleaning schedule is followed for each area...all areas of the food service department including the front and back of the house sanitation level meets...standards...all equipment, work spaces, storage areas and common areas are clean, sanitary, organized and free of clutter..."

2) Food was served at unknown temperatures

On 01/29/13 at approximately 01:00 PM to 01:25 PM a second observation of the psychiatric hospital dietary department was conducted with Personnel #45 and Personnel #49. The following was observed:

The steam table on the serving line contained turkey/dressing, chicken fried chicken, mashed potatoes, gravy, green beans and vegetable soup. The lunch meal had been served to inpatients and hospital personnel previous to this observation. Personnel #59 was asked for the food temperature log. Personnel #59 opened the temperature log book. The surveyor reviewed the temperature log with Personnel #59. Personnel #59 stated the food temperatures were not taken as the temperature log was left blank. Personnel #45 stated the food temperatures should have been taken prior to the lunch meal being served. Outpatients lined up for lunch while the surveyor was speaking to Personnel #59 about the food temperatures. Personnel #59 asked one of the patients what food item they wanted. The patient requested mashed potatoes and gravy. Personnel #59 scooped the potatoes and poured gravy on top. Personnel #59 was getting ready to hand the food item to one of the patients. Personnel #45 informed Personnel #59 she needed to take the food temperatures first before serving the food.

On 01/29/13 at approximately 01:25 PM Personnel #58 was interviewed. Personnel #58 stated she did not take the food temperatures before the lunch meal. Personnel #58 stated she forgot to take the food temperatures.

The contracted dietary service policy, entitled, "Products are received and stored properly" with a date of 10/13/12 reflected, "Food temperatures of received products are taken using a digital thermometer...to limit pathogenic bacterial growth...include but not limited to raw or heat-treated animal proteins...cut tomatoes..."

3) The dishwasher leaked and corrosive material was stored in close proximity to food

On 1/29/13 at 1:04 PM a pool of water extended from the dishwasher to the patient refrigerator. Personnel #58 stated the water came from a dishwasher leak and "we reported it last Friday [01/25/13]."

Hospital Personnel #60 agreed on 01/29/13 at 1:24 PM the dishwasher leaked, a work order was initiated, and staff was "waiting for a part." Record review of work order #68125 dated 01/24/13 at 10:35 AM reflected a work order status as "closed." Personnel #60 stated on 01/29/13 at 3:15 PM he was not aware the work order was complete.

A white multi-gallon pail was placed in the kitchen area approximately 2 feet away from the housekeeping closet and in close proximity to the patient food refrigerator on 1/29/13 at 1:04 PM. Big letters had the warning "corrosive" on the outside of the pail. Personnel #46 stated on 01/29/13 at 1:06 PM the pail contained "detergent for the oven over in the hospital" and he did not "know why it is over here."

4) A kitchen container with yellow liquid was unlabeled.

An undated and unlabeled container with yellow liquid was observed on a metal shelf on 01/29/13 at 1:08 PM. Personnel #46 stated he would label it, placed it on the metal table in the middle of the kitchen, and left the area. On 01/29/13 at 1:19 PM an unidentified staff member stated, "What is this? Grease?"

The contracted dietary service policy, entitled, "Prepared products are properly stored" with a date of 10/13/12 reflected, "Labels must contain the product name, date stored, discard date and associates initials..."

On 01/23/13 at 01:30 PM Personnel #46 was interviewed. Personnel #46 stated he was responsible for the condition of the dietary department and confirmed the above findings.

The Dietary Management Services Agreement (contract) was signed 01/09/12.

Based on record review, interviews and observations the hospital's psychiatric unit failed to provide a safe patient care environment by securing a medical gas cover that was accessible to patients. The psychiatric unit had a known incident that included 1 of 1 patient's (Patient #27) removal of the hard plastic cover. This failure could place 28 patients on three adult units at risk for access to a weapon or for self-harm.

Findings included:

Review of Patient #27's Psychiatric Discharge Summary dated 07/28/12 at 1:09 PM reflected the patient was admitted on 07/12/12 and discharged on 07/16/12. Her admission diagnoses included Bipolar Disorder, Manic, With Psychosis. The summary noted Patient #27 "remained manic...disruptive to the milieu...and physically aggressive, tearing things off the wall..."

The Nursing Psychiatric Progress Notes dated 07/13/12 at 6:14 AM reflected Patient #27 took "everything out of the refrigerator and cabinets...threw cups of water at staff...started taking things off the wall."

Nursing Psychiatric Progress Notes dated 07/16/12 at 5:04 AM noted Patient #27 was "destructive throughout the unit and in her room. She removed the plastic covering from the medical gas system control valve."

The Discharge Referral summary dated 07/16/12 at 5:03 PM noted Patient #27 had a "known history of destructive and manic behavior."

Review of the hospital Safety Action Learning Tool (SALT) document dated 07/13/12 at 5:40 AM reflected the activation of an emergency code when Patient #27 "started taking everything out of the refrigerator and cabinets...threw cups of water at staff...started taking things off the wall." Management's review of the incident dated 07/13/12 concluded "no further action [was] required."

Hospital Employee #11 stated on 01/19/13 at 9:30 AM the incident was not reviewed by the EOC (Environment of Care) committee.

During an interview on 01/29/13 at 11:05 AM, Personnel #19 acknowledged the incident was not addressed as a safety concern before but "should have been." He stated he was not aware of the incident as a safety issue.

Observations on 1/24/13 at 3:40 PM on the hospital's psychiatric CD (chemical dependency) unit and at 3:52 PM on the hospital's adult psychiatric unit reflected a hard plastic cover over Medical Air, Oxygen, and Vacuum dials. Hospital Employee #49 pulled the cover off by a metal ring.

Observations on 01/29/13 at 9:30 AM with Personnel #11 and Personnel #49 reflected plastic covers easily removable on the hospital's adult psychiatric unit and the psychiatric CD units. Observations on the Gero-Psychiatric unit reflected the plastic cover broken on the top, leaving a sharp edge. Employee #49 stated the cover broke when she pulled it off the wall.

The American Psychiatric Nurse Association (http://www.apna.org/i4a/pages/index.cfm?pageid=3859#sthash.JsESfCH2.dpbs) implemented a mental health environment of care checklist which noted that "items must be secured to the wall in a manner that prevents removal or use as a weapon or for self-harm."

Based on observation, interview and record review the Hospital failed to ensure the Director of Food Service supervised and maintained the dietary department in the main hospital and psychiatric hospital unit in a responsible manner in that

A) The main hospital:
1) Cleanliness issues were observed in the retail and kitchen production areas,
2) Lack of labeling of food items was noted in the retail, kitchen production and tray preparation areas, and
3) Food items were left at room temperature in the food storage retail area.

B) The Psychiatric Hospital Unit:
1) Cleanliness issues were observed in the patient dining and kitchen areas,
2) Food was served at unknown temperatures,
3) The dishwasher leaked and corrosive material was stored in close proximity to a patient food refrigerator, and
4) A kitchen container with yellow liquid was unlabeled.
Such practices placed patients, employees, and visitors at risk for acquiring illnesses and infections.


Findings included:

A) On 01/22/13 from 09:45 AM to 11:30 AM a tour of the Main Hospital dietary department was conducted with Personnel #12 and Personnel #46.

1) Cleanliness issues were observed in the retail and kitchen production areas.

a) Kitchen Retail Area
Behind the serving line in the retail area the two compartment sink had a leaking faucet.
The shelves under the metal serving station were soiled with dirt-like debris.
The shelf under the hot plate station was greasy and soiled with debris.
Parchment paper on the shelf used to wrap bread showed brownish debris and dirt. The parchment paper was available for use.
The steam table knobs were caked on with brown grime, dirt, and debris.
The bottom shelf of one of the work stations had a pan of "clean utensils" to be used for serving. In the pan dirt and debris were observed. The utensils were available for use on the serving line.
The refrigerator with food items had a black substance on the inside of the door and on the rubber gasket.
The freezer unit was soiled with dirt and debris.
The top, front and sides of two trash containers were covered in grime. Personnel #46 was asked if the trash disposal containers were on a cleaning schedule. Personnel #46 said he did not know and verified the interior and exterior had not been cleaned.
A ceiling tile was missing next to the main grill.
The floors, walls and baseboards behind the serving line were soiled with debris. The painted surface of the door into the kitchen was peeling. The surface of the door was soiled.

b) The Kitchen Production Area:
The storage room of the kitchen production area was observed with multiple boxes stored on the floor, and two ceiling tiles missing with exposed wires. The shelf unit had black grill bricks with black residue from the bricks on the surface of the shelf and on the floor. The floor surface had dust, debris and stains. The wall surfaces were stained, scratched, and paint was missing.
A second storage room had "Clean micro-fiber pads" used to clean floors mixed with dirty rags and a soiled wet mop head. Brown stains, dirt and grime were on the walls and on the surface of the floor.
A tray rack was soiled. The surveyor took a wet paper towel and wiped the surface of the tray rack. The paper towel was brown in color.
A metal workstation was observed. The first drawer contained a collection of grime, dirt and debris. An opened box of disposable gloves was observed with dirt/debris on the gloves. The top shelf of the workstation contained a white plastic bin. The bin was soiled and dirty on the interior and exterior surface.
A large stand mixer was observed sitting on a metal work station. The mixer's connector had dried/caked on debris. The surface of the unit was greasy and dirty.
On top of a shelf a wire whisk attachment was observed. The wire whisk was covered with dust. The attachment was available for use in food preparation.
A shelf next to the ovens was observed. On the bottom shelf were (2) cast iron skillets stacked wet on top of each other. Upon inspection rust stains from the standing water was observed on the inside and exterior surface of the pan. A third large skillet was observed laying face down on the shelf. The surveyor picked up the skillet and observed a standing congealed greasy substance on the lip of the skillet and on the surface of the shelf. Personnel #47 removed the skillets and said they were dirty.
The dishwasher area was observed. 10 large trays were observed stacked wet on top of each other. Multiple pots/pans were observed stacked wet on top of each other.

2) Lack of labeling of food items was noted in the retail, kitchen production and tray preparation areas

a) Kitchen Retail Area:
A shelf under the serving station in the retail area had a pan of granola. The food item was not dated or labeled.
The refrigerator unit contained a pan of roasted garlic dated 01/09/13 with no expiration date. A pan of stir-fry mix, diced chicken, opened package of feta cheese and 25 prepared pizzas were not dated and/or labeled.
The freezer unit contained two opened bags of a meat product and a opened box of hash browns. The items were not dated and/or labeled.

b) Kitchen Production Area
A white plastic bottle of a brown substance was sitting on a metal work station in the kitchen production area. Personnel #47 stated the bottle of brown substance was caramel sauce and should be labeled.
A food prep station had two bins on rollers stored under the table. The first bin was opened and contained bread crumbs. The container was not labeled and the exterior surface and interior surface was dirty and soiled. A second container was opened and Personnel #47 identified the white powdery substance as "Diatomaceous Earth." Personnel #47 stated the substance was a filter powder used in grease. The container was not labeled and the exterior surface and interior surface was dirty and soiled. Personnel #47 stated the filter powder should not be stored next to the food product and the above items needed to be cleaned and labeled.

A material safety data sheet entitled, "Diatomaceous Earth, Silica Cement Ingredient" provided by Staff #46 reflected, "Do not mix; pour or work with this product in enclosed area without appropriate breathing protection..."

c) Tray Preparation Area:
The refrigerator in the tray preparation area contained two trays of individual salads (24) in total and a tray of green jello. The food items were not dated and/or labeled.
Inside one of the food carts was a white wet substance on the floor of the unit and a brown stain on the surface of the unit.

Personnel #45 stated when the carts were cleaned it must have been missed. Personnel #45 stated she did not know the food items were not labeled and that the production area should have labeled the items.

3) Food items were left at room temperature in the food storage retail area.
The refrigerator unit located next to the main grill in the food storage retail area was observed. The lid on top of the refrigerator unit was raised. Inside the unit were pans of sliced jalapenos, slices of ham, green peppers, mushrooms, shredded cheese and slices of white cheese exposed to room temperature. Sliced American cheese was observed in the bottom of the pan to be grease-like and not consumable. A pan of sliced tomatoes was observed. The inside of the unit was warm. No thermometer was found inside the unit. Staff #46 verified all the food items were at room temperature and not being stored properly. Staff #46 stated the food items would be discarded and said he did not know why the refrigerator did not have a thermometer. Staff #46 stated proper food handling procedures were not being followed.

On 01/23/13 at approximately 2:25 PM, Personnel #48 verified proper cleaning procedures, labeling of food products, food storage and handling were not followed.

On 01/23/13 at 01:30 PM Personnel #46 was interviewed. Personnel #46 stated he was responsible for the condition of the dietary department and verified the above findings.

The contracted dietary service policy, entitled, "Products are received and stored properly" with a date of 10/13/12 reflected, "Food temperatures of received products are taken using a digital thermometer...all food items in storage areas are labeled and dated...storage areas are neat, clean and organized...internal thermometers that are not part of the centralized system are present in all temperature-controlled equipment...foods that require time/temperature control for safety...to limit pathogenic bacterial growth...include but not limited to raw or heat-treated animal proteins...cut tomatoes..."

The contracted dietary service policy, entitled, "Prepared products are properly stored" with a date of 10/13/12 reflected, "Labels must contain the product name, date stored, discard date and associates initials..."

The contracted dietary service policy, entitled, "Sanitation and Safety Standards are met" with a date of 10/13/12 reflected, "Not leaving food "sitting out" for extended periods of time...cleaning schedule is followed for each area...all areas of the food service department including the front and back of the house sanitation level meets...standards...all equipment, work spaces, storage areas and common areas are clean, sanitary, organized and free of clutter..."

The Job Description for the Food Service Director reflected, "Plans, directs and controls all unit operations...maintains product and service quality standards...establishes and maintains applicable preventative maintenance programs to protect the physical assets of the unit...inspects food and food preparation to maintain quality standards and sanitation regulations..."



B) On 01/24/13 from 03:50 PM to 04:30 PM a tour of the Dietary Department in the Psychiatric Hospital Unit was conducted with Personnel #45 and #49. The following was observed:
1) Cleanliness issues were observed in the patient dining and kitchen areas

The patient serving line:
The metal surface of the salad bar had a collection of debris and grime on the surface.
The refrigerated unit on the serving line contained salads and desserts. The upper and lower shelves were soiled with debris.
The metal counter next to the cash register was stained, sticky and dirty.
The coffee machine area was stained with dark spots.

The dining room condiment station:
Plastic condiment containers (12) were sitting in a slotted shelf unit. The inside and outside of the containers were sticky, soiled and dirty. The containers were removed from the station and debris/caked on build-up was on the surface of the unit. The surface of the unit and the shelf on top of the unit had dust-particles which were observed falling into the bins. Staff #45 stated the condiment station had not been cleaned.

The kitchen housekeeping closet:
A yellow mop bucket filled with dirty water was observed. The bucket was stained and soiled with dirt and grime on the inside and outside of the bucket. Staff #45 stated the bucket needed to be thrown away and did not know whether the mop bucket was on a cleaning schedule.

The kitchen area:
Multiple plastic containers (10) were stacked wet on top of each other. Staff #45 verified the above observations.
A pool of water was observed next to the dishwasher.
The floor next to the dishwasher was stained with white streaks.
Metalware on the outside of the dishwasher was observed crusted and grimed over with white streaks. The side of the dishwasher closest to the entrance was covered with whitish crust-like material. Staff #46 stated at that time that it was due to "hard water" and needed to be "de-scaled."
The splashboard next to the hand washing sink was soiled with tan and brown colored areas.

The contracted dietary service policy, entitled, "Sanitation and Safety Standards are met" with a date of 10/13/12 reflected...cleaning schedule is followed for each area...all areas of the food service department including the front and back of the house sanitation level meets...standards...all equipment, work spaces, storage areas and common areas are clean, sanitary, organized and free of clutter..."


2) Food was served at unknown temperatures

On 01/29/13 at approximately 01:00 PM to 01:25 PM a second observation of the Psychiatric Hospital Unit dietary department was conducted with Personnel #45 and Personnel #49. The following was observed:

The steam table on the serving line contained turkey/dressing, chicken fried chicken, mashed potatoes, gravy, green beans and vegetable soup. The lunch meal had been served to inpatients and hospital personnel previous to this observation. Personnel #59 was asked for the food temperature log. Personnel #59 opened the temperature log book. The surveyor reviewed the temperature log with Personnel #59. Personnel #59 stated the food temperatures were not taken as the temperature log was left blank. Personnel #45 stated the food temperatures should have been taken prior to the lunch meal being served. Outpatients lined up for lunch while the surveyor was speaking to Personnel #59 about the food temperatures. Personnel #59 asked one of the patients what food item they wanted. The patient requested mashed potatoes and gravy. Personnel #59 scooped the potatoes and poured gravy on top. Personnel #59 was getting ready to hand the food item to one of the patients. Personnel #45 informed Personnel #59 she needed to take the food temperatures first before serving the food.

On 01/29/13 at approximately 01:25 PM Personnel #58 was interviewed. Personnel #58 stated she did not take the food temperatures before the lunch meal. Personnel #58 stated she forgot to take the food temperatures.

The contracted dietary service policy, entitled, "Products are received and stored properly" with a date of 10/13/12 reflected, "Food temperatures of received products are taken using a digital thermometer...to limit pathogenic bacterial growth...include but not limited to raw or heat-treated animal proteins...cut tomatoes..."

3) The dishwasher leaked and corrosive material was stored in close proximity to food

On 1/29/13 at 1:04 PM a pool of water extended from the dishwasher to the patient refrigerator. Personnel #58 stated the water came from a dishwasher leak and "we reported it last Friday [01/25/13]."

Hospital Personnel #60 agreed on 01/29/13 at 1:24 PM the dishwasher leaked, a work order was initiated, and staff was "waiting for a part." Record review of work order #68125 dated 01/24/13 at 10:35 AM reflected a work order status as "closed." Personnel #60 stated on 01/29/13 at 3:15 PM he was not aware the work order was complete.

A white multi-gallon pail was placed in the kitchen area approximately 2 feet away from the housekeeping closet and in close proximity to the patient food refrigerator on 1/29/13 at 1:04 PM. Big letters had the warning "corrosive" on the outside of the pail. Personnel #46 stated on 01/29/13 at 1:06 PM the pail contained "detergent for the oven over in the hospital" and he did not "know why it is over here."

4) A kitchen container with yellow liquid was unlabeled.

An undated and unlabeled container with yellow liquid was observed on a metal shelf on 01/29/13 at 1:08 PM. Personnel #46 stated he would label it, placed it on the metal table in the middle of the kitchen, and left the area. On 01/29/13 at 1:19 PM an unidentified staff member stated, "What is this? Grease?"

The contracted dietary service policy, entitled, "Prepared products are properly stored" with a date of 10/13/12 reflected, "Labels must contain the product name, date stored, discard date and associates initials..."

The Job Description for the Food Service Director reflected, "Plans, directs and controls all unit operations...maintains product and service quality standards...establishes and maintains applicable preventative maintenance programs to protect the physical assets of the unit...inspects food and food preparation to maintain quality standards and sanitation regulations..."

On 01/23/13 at 01:30 PM Personnel #46 was interviewed. Personnel #46 stated he was responsible for the condition of the dietary department and confirmed the above findings.

Based on observation, interview and record review the infection control office failed to provide a system to identify, report, investigate, control and avoid sources and transmission of infections and communicable diseases in the maintenance of a sanitary hospital environment in that clean and contaminated items were stored in close proximity, used linens were stored in an open bag and placed on the floor for pick up, equipment ready for patient use was soiled, and trash was stored in an unsanitary manner.
Findings included:

A) Observations during a hospital tour on 01/22/13 between 1:20 PM and 3:05 PM reflected the following:

An open multi-gallon sharps container sat on the floor in the ED Triage Room with open access to tubes with blood and sharp objects while an unidentified pediatric patient was treated by ED staff in a triage room in close proximity.

The soiled utility room on the cardiac step down unit had a metal tray with crumbs, an oximeter, two dusty towels, some red plastic bags and black plastic bags identified by Personnel #10 "for general trash." On the shelf above the sink was a black plastic basket with shoe covers identified by Hospital Personnel as "new." An open bag with clean face masks was observed next to the trash gondola and close to a red biohazard box with yellow-whitish content identified by Personnel #10 to be "solidified NG tube (naso-gastric tube)" material.

In the pantry, an uncovered cup with ice was observed on the metal grid of the ice dispenser; the metal back splash had several strawberry-colored spots and light-colored streaks.

The unit's clean utility room had pieces of trash on the floor between stored wheel-chairs. One wheel-chair had dusty, grimy spokes. Hospital Personnel #8 agreed at that time that it was "dusty." A computer on wheels had a dust particle covered key board, and a cart with boxes of clean gloves had a soiled bottom shelf.

The oncology unit soiled utility room had a dust pan with some trash in it, a tray with spilled milk and items of trash. Hospital staff #7 was not able to determine whether two microfiber pads on the shelf were clean or used and stated a folded baby blanket "should not be here." The clean linen room stored two "wet floor" warning signs which Hospital Personnel #18 identified to belong in the utility room.

One plastic bag with trash and a blue open bag with linen were observed in the hallway in front of the x-ray department on 01/22/13 at 3:05 PM. Hospital Personnel #18 was observed to close the bag with ungloved hands at that time.

B) A second hospital tour was conducted on 1/23/13 between 11:15 AM and 11:30 AM. The cardiac step down unit clean utility room had a wheel chair with dusty spokes.

Observation on 1/23/13 at 2:55 PM in the third floor utility closet Room 3.271 reflected two blue bags filled with soiled linen on the floor in front of the blue gondola. Hospital Personnel #20 stated she did not know why the bags were there. On 1/23/13 around 3 PM an unidentified housekeeper was observed opening the unlocked Room 3.206A labeled "Trash" when a bag fell off the bin piled high with trash bags and landed on the floor in the hallway in front of staff. The house keeper touched the bag with ungloved hands in an attempt to move it.

Hospital Personnel #20 was interviewed on 01/23/13 at 1:30 PM. When asked how wheel-chairs were cleaned she stated possibly by hospital volunteers. When asked about trash or linen bags on the floor, Hospital Personnel #20 stated bags should be in a cart.

Hospital Personnel #1 agreed on 01/23/13 around 1:40 PM it was hospital administration's expectations to not have open trash or linen bags on the floor.

Hospital Policy TJC IC.02.01.01; NIAHO IC.1 issued January 2012 reflected "soiled linen shall be bagged on the patient care units and placed in the soiled linen room for pick up."

Hospital Policy HMHEB IC-02 dated 09/11 reflected "eating...is prohibited in work areas where there is potential for exposure to bloodborne pathogens. The policy noted "All used laundry...is considered contaminated and is handled and bagged in a manner to prevent occupational exposure. Appropriate PPE (personal protective equipment) is to be worn when handling soiled laundry, and handling is kept to a minimum. Used laundry is placed in closed blue plastic bags for transport by EVS..." and "Waste containers are...not allowed to overfill." The policy noted the expectations that health care workers demonstrate "compliance with...Standard Precautions..."

During an interview on 1/23/13 at 9:45 AM Hospital Personnel #15 stated infection control practitioners and the environment of care members visited clinical areas twice a year and non clinical areas once a year.

Hospital Policy THHEB IC-01 dated 2/11 noted as "duties of the Infection Prevention Committee...(to) maintain surveillance over the program..."