HospitalInspections.org

Based on record review, observation, and interview the facility's governing body failed to ensure quality assessment and performance improvement activities, including performance improvement projects, were carried out in a formal, cohesive and functional quality assessment and performance improvement program which defined, tracked, monitored and analyzed data which was used to improve the quality of patient care. (refer to A0263 and A0273)

The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Governing Body.

Based on a review of facility documentation, observation and staff interviews, the facility failed to ensure that all patients receiving care at the facility were provided the names and contact information of regulatory entities where they could file a patient care complaint or grievance.

Findings were:

Facility policy entitled, "Patient Grievance/Complaint Process," included the following:
" ...It is the policy of the Governing Board of Falls Community Hospital and Clinic that patients [sic] and their authorized representatives' grievances will be resolved in a timely, reasonable and consistent manner ...
Patients are informed of the Grievance/Complaint process through written notice in their admission packet explaining how to file a complaint or grievance.
Other patients are made aware of the grievance/complaint process through notices posted in high traffic areas throughout the hospital ..."

A review of the hospital admission packet provided to patients revealed the following:
"Your Information. Your Rights. Our Responsibilities ...

File a complaint if you feel your rights are violated
-You can complain if you feel we have violated your rights by contacting us using the information on the back page.
-You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/..."

The back page of the packet included the following:
" ...This Notice of Privacy Practices applies to the following organizations.
Falls Community Hospital and Clinic
322 Coleman St
Marlin, TX 76661
254-803-3561"

No other complaint or contact information was included in the information provided to patients. There was no information identifying Texas Health and Human Services as the regulatory agency responsible for investigation of patient care complaints, and no contact information as follows:

Health Facility Compliance
Health and Human Services Commission
Complaint and Incident Intake
Mail Code E-249
P.O. Box 149030
Austin, Texas 78714-9030
Complaint hotline: 1-800-458-9858, Option 5
Email: hfc.complaints@hhs.texas.gov



A tour of the facility on the morning of 11/3/22 revealed only one posting of a hospital document entitled, "Patient Rights and Responsibilities." The posting was inside the x-ray waiting area. The sign did not contain information identifying the Texas Health & Human Services Commission as the regulatory entity responsible for investigation of patient care complaints.

A subsequent tour of the hospital in the early afternoon on the same date revealed there was a hospital document entitled, "Patients Rights and Responsibilities," posted in a hallway leading away from the hospital ER toward the administrative offices. While there were three main entrances into the hospital, none of them would have necessarily led an individual past this sign.

In an interview with Staff #2, Director of Nursing, on the morning of 11/2/2022 at approximately 11:30 a.m., she stated the patient rights signs had been posted, but were removed because staff had been painting all of the hospital interior walls. The sign in the hallway between the ER and administrative offices appeared after this discussion.

In an interview with Staff #3, Assistant Director of Nursing, at 2:00 p.m. on 11/2/2022, after observation of the Patient Rights sign hanging on the wall leaving the ER, she stated, "That sign was just hung back up a little while ago. All the signs have been down for about 2 months while we were painting. I think there may be another one hanging somewhere." Observations revealed there were no signs hanging at any entrance of the hospital.

Based on a review of facility documentation and staff interviews, the facility failed to provide each patient making a grievance with written notice of the outcome of that grievance for all patient grievances reviewed for 2022 [3 of 3 complaints].

Findings were:

A review of the three patient grievances the hospital had received thus far in 2022 revealed no documented evidence of a written response to the complainant regarding the outcome of the grievance. Approximately 10 patient grievances the hospital received in 2021 also included no documentation of patient notification of investigation outcomes.

Facility policy entitled "Patient Grievance/Complaint Process," included the following:
" ...It is the policy of the Governing Board of Falls Community Hospital and Clinic that patients and their authorized representatives' grievances will be resolved in a timely manner ...
Patients will be informed that they have the right to file a complaint directly with the State agency, Texas Department of Health, as well as or instead of utilizing the hospital grievance process. Falls Community Hospital and Clinic employees will direct to the patient [sic] to the flyer on the wall that lists the state agency address and phone number where they may file a complaint.

The Governing Board has delegated responsibility for the patient grievance process to the QAPI Committee. The QAPI Committee is responsible for overseeing the grievance process and investigating and resolving patient grievances, when necessary.

Falls Community Hospital and Clinic believes that through the evaluation of patient complaints, patient satisfaction may be enhanced and opportunities for improvement may be identified. These improvements may further enhance the quality of patient care and service provided. The QAPI [Quality Assessment and Performance Improvement] Committee will report grievance to Governing Board as part of our continuous quality improvement activities ...

The patient or his or her authorized representative will be notified in writing of the investigative outcome of all grievances (oral or written). This will be done within 7 days unless additional time is needed for resolution. If additional time is needed, the patient or representative will be notified of that in writing ...

Grievances/Complaints that are require [sic] extensive investigation into patient care will be forwarded to the Medical Staff Peer Review Committee for handling the investigation. In these cases, the QAPI Manager will send a response to the patient explaining that the hospital is still working to resolve the grievance and that we will follow-up with another written response within 30 days ..."

In an interview with Staff #34, the Clinical Risk Manager and the individual identified as responsible for patient complaints, on the afternoon of 11/3/22 at 1:40 p.m. in the hospital conference room, he stated, "I didn't realize we needed to keep any of that stuff. We have a letter form to send to people who make complaints, but we haven't kept any copies of what we've sent out. So, from here going forward, we'll keep those ..."

Based on review of facility documentation and staff interviews, Falls Community Hospital and Clinic failed to meet the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by:

A. Failing to ensure a functional QAPI program existed which was organized and effectively coordinated, and implemented. (refer to A0273 and A0309)

B. Failing to define and monitor Performance Improvement Projects (PI) were defined and monitored by hospital leadership. (refer to A0273 and A0309)

C. Failing to ensure that quality indicators currently in place as defined by each individual department were being tracked, trended and analyzed by hospital leadership to improve the quality of patient care. (refer to A0273 and A0309).

The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Quality Assessment and Performance Improvement (QAPI).

Based on a review of facility documentation and staff interview, the facility failed to ensure the hospital developed and implemented a functioning, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program, as the hospital staff could provide no documented evidence of such a program.

Findings were:

On the morning of 10/31/22, a review of QAPI meeting minutes for 2022 revealed many entries which indicated the committee, rather than primarily addressing quality issues, was being used as a staff meeting. For example, recent committee meeting minutes indicated discussion of topics such as:
August 23, 2022 meeting: current job titles around the room along with responsibilities, the hospital TB policy being reviewed and updated, and meeting frequency.
September 2022 meeting: "Dove was here Sept 6-8, and met with all department head to make recommendations and updates on billing concerns," and "Flu vaccines are in."

In an interview with Staff #2, DON and Quality Management Coordinator, on the morning of 11/1/22 at approximately 2:28 p.m., when surveyor mentioned the staff meeting nature of the minutes, she replied, "I understand what you're saying ..." When asked if the board was involved with quality for the hospital as a whole and the performance improvement projects, she stated, "Each of our departments has just kind of been doing its own thing ... Each area might have some quality that they're doing on their own ..." When surveyor said minutes reviewed in the quality notebook were inconsistent from department to department, Staff #2 stated, "I hear you. We're in agreement that we don't really have a quality program right now ..." She agreed there appeared to be inconsistent data reported to the committee, but also that for some departments, there was no documentation to indicate use of the data to improve patient care. Staff #2 said, "I know. There's just not really a program." When asked who was responsible for the QAPI program, she stated, "Well, I guess I am. I've only been DON since October 1st [2022], and we're all still figuring out who's doing what. We had some people leave."

On the morning of 11/1/22 at approximately 11:08 a.m., Staff #2, Quality Management Coordinator, provided a document entitled, "2021 Plan Quality Assurance Performance Improvement (QAPI)." She stated, "This was all I could find." When surveyor asked if there was nothing for 2022, Staff #2 stated, "No, that was the most recent we could find. It looks like maybe someone who was doing that [QAPI] and who is no longer here maybe did it. So now, with knowing what the regs are, we'll be able to address that ..."

Review of the 2021 QAPI plan revealed it was unsigned, despite approval signature blanks made available on the last page of the plan.

In a subsequent interview with Staff #2 on the morning of 11/2/22, she stated, "I found this document. I don't know if it's just an update, or what it is exactly." She provided a document entitled, "Quality Assessment Performance Improvement Plan Proposed Policy Update." This document appeared to contain wording which was more congruent with regulatory requirements than the 2021 plan had, but the update included priorities for 2020-2021, indicating it was yet an older document than the plan. When Staff #1, CEO, was asked on the morning of 11/2/22 if the update had ever been approved, she said she was not sure if it had been. She identified the 2021 QAPI Plan as what was currently being used as the hospital QAPI program, but added, "I can't find a signature page where it was signed and approved."

A statement signed by Staff #2, DON and Quality Management Coordinator, on 11/2/22 read as follows:
"Falls Community Hospital and Clinic does not currently have a hospital wide, formalized, Quality program."

Based on a review of facility documentation and staff interview, the facility failed to ensure the hospital developed and implemented a functioning, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program, as the hospital staff could provide no documented evidence of such a program.

Findings were:

On the morning of 10/31/22, a review of QAPI meeting minutes for 2022 revealed many entries which indicated the committee, rather than primarily addressing quality issues, was being used as a staff meeting. For example, recent committee meeting minutes indicated discussion of topics such as:
August 23, 2022 meeting: current job titles around the room along with responsibilities, the hospital TB policy being reviewed and updated, and meeting frequency.
September 2022 meeting: "Dove was here Sept 6-8, and met with all department head to make recommendations and updates on billing concerns," and "Flu vaccines are in."

In an interview with Staff #2, DON and Quality Management Coordinator, on the morning of 11/1/22 at approximately 2:28 p.m., when surveyor mentioned the staff meeting nature of the minutes, she replied, "I understand what you're saying ..." When asked if the board was involved with quality for the hospital as a whole and the performance improvement projects, she stated, "Each of our departments has just kind of been doing its own thing ... Each area might have some quality that they're doing on their own ..." When surveyor said minutes reviewed in the quality notebook were inconsistent from department to department, Staff #2 stated, "I hear you. We're in agreement that we don't really have a quality program right now ..." She agreed there appeared to be inconsistent data reported to the committee, but also that for some departments, there was no documentation to indicate use of the data to improve patient care. Staff #2 said, "I know. There's just not really a program." When asked who was responsible for the QAPI program, she stated, "Well, I guess I am. I've only been DON since October 1st [2022], and we're all still figuring out who's doing what. We had some people leave."

On the morning of 11/1/22 at approximately 11:08 a.m., Staff #2, Quality Management Coordinator, provided a document entitled, "2021 Plan Quality Assurance Performance Improvement (QAPI)." She stated, "This was all I could find." When surveyor asked if there was nothing for 2022, Staff #2 stated, "No, that was the most recent we could find. It looks like maybe someone who was doing that [QAPI] and who is no longer here maybe did it. So now, with knowing what the regs are, we'll be able to address that ..."

Review of the 2021 QAPI plan revealed it was unsigned, despite approval signature blanks made available on the last page of the plan. The document included the following:

" ...Falls Community Hospital and Clinic's Quality Assurance Performance Improvement (QAPI) committee has developed, implemented, and maintains an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital's governing body has reviewed the program and ensured that it reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. Our hospital maintains documentation and can demonstrate evidence of our QAPI program for review by CMS.

The plan, design, measurement, assessment, and improvement of important functions and processes can help to achieve organizational effectiveness ...

AUTHORITY AND RESPONSIBILITY
The Board of Directors of Falls Community Hospital and Clinic has full legal authority and ultimate responsibility for care and services. The Board delegates authority and responsibility for Quality Assurance Performance Improvement to the Administrator and the Medical Staff and QAPI Committee. The Board of Directors strives to assure these activities by requiring and supporting the establishment and maintenance of a comprehensive Quality Assurance Performance Improvement Program.

BOARD OF DIRECTORS ...
Establishes priorities in conjunction with organization leaders, for organization wide improvement and requires that QAPI committee perform and [sic] annual review to determinate [sic] the number of distinct improvement processes necessary ...
Receives regular reports of Quality Improvement activities, using this information to evaluate all improvement processes and insure compliance with the intent of process in achieving desired priorities and goals ..."

In a subsequent interview with Staff #2 on the morning of 11/2/22, she stated, "I found this document. I don't know if it's just an update, or what it is exactly." She provided a document entitled, "Quality Assessment Performance Improvement Plan Proposed Policy Update." This document appeared to contain wording which was more congruent with regulatory requirements than the 2021 plan had, but the update included priorities for 2020-2021, indicating it was yet an older document than the plan. When Staff #1, CEO, was asked on the morning of 11/2/22 if the update had ever been approved, she said she was not sure if it had been. She identified the 2021 QAPI Plan as what was currently being used as the hospital QAPI program, but added, "I can't find a signature page where it was signed and approved."

A review of the "Bylaws of Falls Community Hospital and Clinic Board of Directors," revealed no mention of specific Board responsibilities. A review of the Board Minutes for 2022 indicated a heavy emphasis on financial topics. For example, in the board meeting minutes of January 25, 2022, the only mention of QAPI was the one item:
"A motion was made to approve QA/PI. The motion was seconded, and the motion carried ..."
The same held true for the February 22, 2022 meeting minutes, as well as for the March 29, 2022 meeting minutes.

A statement signed by Staff #2, DON and Quality Management Coordinator, on 11/2/22 read as follows:
"Falls Community Hospital and Clinic does not currently have a hospital wide, formalized, Quality program."

Based on review of facility documentation and staff interview, the facility failed to ensure each member of the medical staff was re-appointed to membership by the governing body according to the medical staff bylaws of the facility for 1 of 12 Physician and mid-level credentialing files reviewed.

Findings were:

A review of the credentialing file for Staff #16 revealed a Delineation of Privileges Sheet -Emergency Medicine Privileges signed and dated 2/18/2010. There was no current credentialing letter included in the file, nor was there a current list of facility privileges for Staff #16.

Review of the facility's medical staff coverage schedule reflected Staff #16 was scheduled 11 days during the month of August, 2022, 10 days during the month of September 2022, and 10 days during the month of October, 2022.

Review of the Medical Staff Bylaws of Falls Community Hospital and Clinic revealed the following:
"B. Responsibilities
The responsibilities of the Medical Staff shall be to:
1.Develop and monitor compliance of the Medical Staff Bylaws, the Rules and Regulations of the Staff and other related Hospital policies.
2.Assure the qualifications and competence of Practitioners through a credentialing procedure, including mechanisms for appointment, reappointment, delineation of clinical privileges, and appeals in adverse findings.
C.Reappointment
1.Medical Staff members are appointed based upon two-year contracts that are self renewing (other than probationary contracts). Said contracts, however, are subject to modification or termination by either Physician or the Governing Board, without cause, with proper, advance notice as provided in the Physician's contract..."

Review of Medical Executive Committee meeting minutes did not reveal any evidence of a current credentialing letter or privileges for Staff #16.

In an interview with Staff #33, the individual identified as responsible for credentialing, on the morning of 11/2/2022, in the facility conference room reported "I think we have it, but the last surveyor may have taken it. We can't find it. We will get it today."

At approximately 3:30 pm 11/2/2022, Staff #2 presented a Medical Staff Reappointment form for Staff #16 signed and dated 11/2/2022, an Appointment Determination letter signed and dated 11/2/2022 and Delineation of Medical Privileges signed and dated 11/2/2022.

The hospital failed to have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care, as the Director of Nursing failed to be responsible for the operation of the service by ensuring that facility guidelines and best practice were followed regarding nursing qualifications.

Findings were:

Review of nursing personnel files revealed the following:
o Staff #18 was employed by the facility as a Licensed Vocational Nurse. Staff #2 confirmed that staff #18 worked in the emergency department as well as on the patient care unit. Facility job description titled "LVN" required (in addition to current licensure) BCLS [basic cardiac life support], successful completion of an arrhythmia course and certification in the NIH [National Institute of Health] stroke scale. Facility job description titled "Emergency Department Licensed Vocational Nurse" required (in addition to current licensure) BCLS, ACLS [advanced cardiac life support] and PALS [pediatric advanced life support]. Staff #18 had been employed at the facility since 12-20-90. Staff #18 is currently working on an as-needed basis, both on the patient care unit and in the emergency department. The personnel record for staff #18 contained no documentation of BCLS, ACLS, PALS, successful completion of an arrhythmia course or certification in the NIH stroke scale. Timesheets revealed that staff #18 had worked numerous shifts at the facility thus far in 2022, with 12 of those shifts in the emergency department.
o Staff #19 was employed by the facility as a Licensed Vocational Nurse. Staff #2 confirmed that staff #19 worked in the emergency department as well as on the patient care unit. Facility job description titled "LVN" required (in addition to current licensure) BCLS [basic cardiac life support], successful completion of an arrhythmia course and certification in the NIH [National Institute of Health] stroke scale. Facility job description titled "Emergency Department Licensed Vocational Nurse" required (in addition to current licensure) BCLS, ACLS [advanced cardiac life support] and PALS [pediatric advanced life support]. Staff #18 had been employed at the facility since 1-5-21. Staff #18 is currently working on a full-time basis, as an infection control assistant, on the patient care unit and in the emergency department. The personnel record for staff #19 contained documentation of online BCLS, but no documentation of ACLS, PALS, successful completion of an arrhythmia course or certification in the NIH stroke scale. Timesheets revealed that staff #19 had worked numerous shifts at the facility thus far in 2022, with 14 of those shifts in the emergency department.
o Staff #20 was employed by the facility as a Registered Nurse, with primary duties as the Infection Control Nurse. Staff #2 confirmed that staff #20 worked on the patient care unit when needed, in addition to the primary duties of infection control nurse. Facility job description titled "Registered Nurse" required (in addition to current licensure) BCLS, ACLS (within 6 months of hire), successful completion of an arrhythmia course and certification in the NIH [National Institute of Health] stroke scale. Facility job description titled "Infection Control Nurse" required (in addition to current licensure) BCLS certification. Staff #2- had been employed at the facility since 4-5-07. Staff #20 is currently working on a full-time basis, both on the patient care unit and as the infection control nurse. The personnel record for staff #20 contained no documentation of BCLS, ACLS, successful completion of an arrhythmia course or certification in the NIH stroke scale. Timesheets revealed that staff #20 had worked numerous shifts at the facility thus far in 2022, with 8 of those shifts on the patient care unit.
An individual with only the written portion of basic cardiac life support, who has not provided a return demonstration of skills, may not be qualified to provide emergency care.

Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, "No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements." Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=28541.

A signed letter from the Director of Nursing attested to the above individuals' hire dates and missing certifications.

The hospital failed to have an organized dietary service that was directed by an adequately qualified personnel, as the dietary department was not properly cleaned, expired food was available for patient use, food was improperly stored and personnel were inappropriately dressed.

Cross refer to A0620

Based on a review of documentation, observation and an interview with staff, the hospital failed to have a full-time employee qualified by experience or training that was responsible for the the daily management of the dietary services.

Findings were:

During a tour of the facility on 11-2-22, the following was noted:

o In kitchen refrigerator #1 were 18 of 18 ½ pint cartons of fat-free milk that had expired 10-29-22 but were available for patient use.
o In kitchen refrigerator #1 were 11 of 25 ½ pint carts of 2% milk that had no stamp indicating a "best by" date, but were available for patient use.
o In kitchen refrigerator #1 was a gallon of whole milk that had expired 11-1-22 but was available for patient use.
o In kitchen refrigerator #1 were 2 of 2 8-ounce containers of sour cream that had both expired 10-20-22 but were available for patient use.
o In kitchen refrigerator #1 was 1 of 1 16-ounce container of cottage cheese that had expired 10-30-22 but was available for patient use.
o In kitchen refrigerator #1 was 1 of 37 chocolate pudding cups that had expired 10-21-22 but was available for patient use.
o In kitchen refrigerator #1 were 56 of 56 4-ounce containers of orange juice that had expired 10-20-22 but were still available for patient use.
o In kitchen refrigerator #1 was a plastic container marked "chicken salad" with a prepared date of 10-29-22.
o The 2 kitchen freezers contained the following: a plastic bag that held approximately 50 pre-made hamburger patties, a 22-quart plastic container of ears of corn, 30 pounds of frozen fish fillets, a large bag of chicken patties and a 10-pound bag of sausages-on-a-stick. None of the listed items were appropriately sealed in a manner that would prevent freezer burn.
o 3 storage bins with clear lids were located outside the dry storage room. One bin contained a white, granular substance, another a yellow, granular substance and the third bin contained a white, powdered substance. None of the 3 bins were labeled to identify the contents.
o 4 of 4 kitchen ovens were soiled on the interior with substances that had the appearance of baked-on and splattered food.
o 1 of 1 attached can opener was observed with a brownish, sticky substance adhering to the puncture tooth.
o 1 of 2 cabinets above the rinsing sink had a lower shelf that was sticky and greasy to the touch.
o Staff #24 was observed wearing 2 necklaces, as well as a ring set on her left, ring finger that contained stones in a raised setting.
o In the dishwasher area, staff #23 was asked to run the dishwasher so that the wash/rinse temperatures could be observed. Appropriate wash water temperature was achieved, but the dial on the rinse temperature sensor did not move during the cycle. Staff #23 stated that the manufacturer had been contacted previously to repair the dial but the repair had not yet occurred. Staff #23 was asked how the rinse water temperature was verified and he demonstrated that the water was hot enough with the use of a temperature-indicator strip used during the cycle. Staff #23 was asked to dip an indicator strip in the sanitizer water to show that the sanitizer water contained at least 50 ppm [parts per million] of sanitizer, but the indicator strip did not change color to indicate such. Observation of the indicator strip package stated that the strips should turn 1 of 5 different colors that would indicate strengths of 10ppm, 25 ppm, 50ppm, 100ppm and 200ppm. Review of the dish machine log for October revealed that 36 of the 93 checks performed (3 times daily for 31 days) were recorded in values for which the package provided no color indication. The values listed were 55ppm, 60ppm and 65ppm.
o The emergency room patient nourishment refrigerator contained 4 of 4 cartons of orange juice that had expired 10-20-22 and 2 of 2 cartons of fat-free milk that had expired 10-29-22 but were still available for patient use.
o The patient care unit nourishment refrigerator contained 2 of 2 cartons of 2% milk that had expired 10-29-22 and 3 of 3 cartons of orange juice that had expired 10-20-22 but were still available for patient use.

Review of refrigerator and freezer temperature logs for October 2022 revealed the following:
o The temperature log for the #1 refrigerator (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the #2 freezer (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the #3 refrigerator (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the #4 freezer (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the emergency room patient nourishment refrigerator contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 28 of 62 had not been documented.
o The temperature log for the 2nd floor nurse's station patient nourishment refrigerator) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 38 of 62 had not been documented.

Facility policy titled "Receiving and Storage" states, in part:
"Policy: Food and supplies are received into the dietary department in a safe and organized way to minimize food safety risks. Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination.
...
Receiving:
...
4. All shipper/packer boxes will be opened and contents will be removed in the receiving area. A cart will be used to transfer the contents of the boxes from the receiving area to dry, refrigerated and freezer storage areas. Contents will be placed on open shelving or in plastic storage bins that have been cleaned, sanitized and labeled with the receiving date.
...
Storage:
...
4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of bulk foods ...All containers must be legibly and accurately labeled.
...
13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2 days or discarded.
...
15. Refrigeration:
a. Temperatures for refrigerators should be between 35-39 degrees Fahrenheit. Thermometers should be checked at least three times each day. (See freezer and refrigerator temperature form)
...
c. Each nursing unit with a refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures.
...
16. Frozen Foods:
...
c. Foods should be covered, labeled and dated."

Facility policy titled "Food Storage" states, in part:
1. Store Room:
...
D. Staples, after opening are stored in plastic or metal food safe containers. With tight fitting lid and labeled for contents and dated."

Facility policy titled "Cleaning Schedules" states, in part:
" ...
2. Monthly Cleaning:
a. Items requiring monthly cleaning include ovens (1st and 3rd week) ..."

Facility policy titled "Dish Washing Procedures" states, in part:
"Procedure:
...
C. Temperature of Dish Machine:
Dish Machine temperatures must be recorded each meal to assure adequate sanitation (see dish machine temp log sheet).
D. Concentration of Sanitizer:
To assure dilution of sanitizer is 50ppm to rinse water will be tested each meal. The test strip will be attached to the dish machine temperature/sanitizer record to document proper sanitizer dilution."

Facility policy titled "Infection Control" states, in part:
" ...
Food Handling:
...
6. Foods that readily support bacterial growth such as locally prepared salad dressings, ham, eggs and chicken or tuna salad are not prepared more than three hours in advance of serving and are not held over for(sic) one meal to another. However, if these foods are held at 41 degrees Fahrenheit or below during service in the cafeteria, they may be utilized safety for 48 hours as leftovers. (TFER)
...
General Cleaning and Sanitation:
The highest level of sanitation shall be maintained in the department in the areas of food preparation, equipment and personnel.
The dietary supervisor shall see that:
1. All employees are properly dressed when on duty, (no jewelry on hands except plain bands, no dangling jewelry of any kind, uniforms, shoes and protective covering for hair."

Facility policy titled "Left Over Food" states, in part:
" ...
Procedure:
...
5. All foods that have been properly and safely handled during preparation and service may be kept as left over for up to 48 hours. These foods must be properly cooled, labeled, dated and stored."

The above findings were confirmed with the Dietary Director on 11-2-22, who accompanied the surveyor on the tour.

The hospital failed to have active, hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, as the facility was not maintained in a manner to prevent the entry of dirt and insects and the dietary department was not maintained in a safe and sanitary condition.

Cross refer to A0749

Based on a review of documentation, observation and an interview with staff, the hospital infecton prevention and control program failed to employ methods for preventing and controlling the transmission of infections within the hospital.

Findings were:

During a tour of the facility on 11-2-22, the following was noted:
o The exterior, kitchen hallway door leading to the outside did not reach the floor and a space of approximately ¼ inch was present. This space allows bacteria, dirt, dust and insects to enter the facility.
o In kitchen refrigerator #1 were 18 of 18 ½ pint cartons of fat-free milk that had expired 10-29-22 but were available for patient use.
o In kitchen refrigerator #1 were 11 of 25 ½ pint carts of 2% milk that had no stamp indicating a "best by" date, but were available for patient use.
o In kitchen refrigerator #1 was a gallon of whole milk that had expired 11-1-22 but was available for patient use.
o In kitchen refrigerator #1 were 2 of 2 8-ounce containers of sour cream that had both expired 10-20-22 but were available for patient use.
o In kitchen refrigerator #1 was 1 of 1 16-ounce container of cottage cheese that had expired 10-30-22 but was available for patient use.
o In kitchen refrigerator #1 was 1 of 37 chocolate pudding cups that had expired 10-21-22 but was available for patient use.
o In kitchen refrigerator #1 were 56 of 56 4-ounce containers of orange juice that had expired 10-20-22 but were still available for patient use.
o In kitchen refrigerator #1 was a plastic container marked "chicken salad" with a prepared date of 10-29-22.
o The 2 kitchen freezers contained the following: a plastic bag that held approximately 50 pre-made hamburger patties, a 22-quart plastic container of ears of corn, 30 pounds of frozen fish fillets, a large bag of chicken patties and a 10-pound bag of sausages-on-a-stick. None of the listed items were appropriately sealed in a manner that would prevent freezer burn.
o 4 of 4 kitchen ovens were soiled on the interior with substances that had the appearance of baked-on and splattered food.
o 1 of 1 attached can opener was observed with a brownish, sticky substance adhering to the puncture tooth.
o 1 of 2 cabinets above the rinsing sink had a lower shelf that was sticky and greasy to the touch.
o Staff #24 was observed wearing 2 necklaces, as well as a ring set on her left, ring finger that contained stones in a raised setting.
o In the dishwasher area, staff #23 was asked to run the dishwasher so that the wash/rinse temperatures could be observed. Appropriate wash water temperature was achieved, but the dial on the rinse temperature sensor did not move during the cycle. Staff #23 stated that the manufacturer had been contacted previously to repair the dial but the repair had not yet occurred. Staff #23 was asked how the rinse water temperature was verified and he demonstrated that the water was hot enough with the use of a temperature-indicator strip used during the cycle. Staff #23 was asked to dip an indicator strip in the sanitizer water to show that the sanitizer water contained at least 50 ppm [parts per million] of sanitizer, but the indicator strip did not change color to indicate such. Observation of the indicator strip package stated that the strips should turn 1 of 5 different colors that would indicate strengths of 10ppm, 25 ppm, 50ppm, 100ppm and 200ppm. Review of the dish machine log for October revealed that 36 of the 93 checks performed (3 times daily for 31 days) were recorded in values for which the package provided no color indication. The values listed were 55ppm, 60ppm and 65ppm.
o The emergency room patient nourishment refrigerator contained 4 of 4 cartons of orange juice that had expired 10-20-22 and 2 of 2 cartons of fat-free milk that had expired 10-29-22 but were still available for patient use.
o The patient care unit nourishment refrigerator contained 2 of 2 cartons of 2% milk that had expired 10-29-22 and 3 of 3 cartons of orange juice that had expired 10-20-22 but were still available for patient use.

Review of refrigerator and freezer temperature logs for October 2022 revealed the following:
o The temperature log for the #1 refrigerator (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the #2 freezer (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the #3 refrigerator (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the #4 freezer (located in the kitchen) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 9 of 62 had not been documented.
o The temperature log for the emergency room patient nourishment refrigerator contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 28 of 62 had not been documented.
o The temperature log for the 2nd floor nurse's station patient nourishment refrigerator) contained blanks for documenting the refrigerator temperatures in the morning and in the evening. Of the checks, 38 of 62 had not been documented.

Facility policy titled "Receiving and Storage" states, in part:
"Policy: Food and supplies are received into the dietary department in a safe and organized way to minimize food safety risks. Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination.
...
Receiving:
...
4. All shipper/packer boxes will be opened and contents will be removed in the receiving area. A cart will be used to transfer the contents of the boxes from the receiving area to dry, refrigerated and freezer storage areas. Contents will be placed on open shelving or in plastic storage bins that have been cleaned, sanitized and labeled with the receiving date.
...
Storage:
...
4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of bulk foods ...All containers must be legibly and accurately labeled.
...
13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2 days or discarded.
...
15. Refrigeration:
a. Temperatures for refrigerators should be between 35-39 degrees Fahrenheit. Thermometers should be checked at least three times each day. (See freezer and refrigerator temperature form)
...
c. Each nursing unit with a refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures.
...
16. Frozen Foods:
...
c. Foods should be covered, labeled and dated."

Facility policy titled "Food Storage" states, in part:
1. Store Room:
...
D. Staples, after opening are stored in plastic or metal food safe containers. With tight fitting lid and labeled for contents and dated."

Facility policy titled "Cleaning Schedules" states, in part:
" ...
2. Monthly Cleaning:
a. Items requiring monthly cleaning include ovens (1st and 3rd week) ..."

Facility policy titled "Dish Washing Procedures" states, in part:
"Procedure:
...
C. Temperature of Dish Machine:
Dish Machine temperatures must be recorded each meal to assure adequate sanitation (see dish machine temp log sheet).
D. Concentration of Sanitizer:
To assure dilution of sanitizer is 50ppm to rinse water will be tested each meal. The test strip will be attached to the dish machine temperature/sanitizer record to document proper sanitizer dilution."

Facility policy titled "Infection Control" states, in part:
" ...
Food Handling:
...
6. Foods that readily support bacterial growth such as locally prepared salad dressings, ham, eggs and chicken or tuna salad are not prepared more than three hours in advance of serving and are not held over for(sic) one meal to another. However, if these foods are held at 41 degrees Fahrenheit or below during service in the cafeteria, they may be utilized safety for 48 hours as leftovers. (TFER)
...
General Cleaning and Sanitation:
The highest level of sanitation shall be maintained in the department in the areas of food preparation, equipment and personnel.
The dietary supervisor shall see that:
1. All employees are properly dressed when on duty, (no jewelry on hands except plain bands, no dangling jewelry of any kind, uniforms, shoes and protective covering for hair."

Facility policy titled "Left Over Food" states, in part:
" ...
Procedure:
...
5. All foods that have been properly and safely handled during preparation and service may be kept as left over for up to 48 hours. These foods must be properly cooled, labeled, dated and stored."

The above findings were confirmed with the Dietary Director, who accompanied the surveyor on the tour.