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Based on observation, interview, document review and policy review, the Hospital failed to ensure the Dietary Services Department was directed in its operations to maintain acceptable hygiene practices of food storage, food preparation, personnel hygiene, and kitchen sanitation.

The cumulative effects of this deficient practice could lead to transmitting food-borne pathogens (a bacteria, virus, or other microorganism that can cause disease) to all patients, visitors, and staff members receiving meal service at the facility, with possible negative outcomes, including illness and death.

Findings Include:

Observations during a tour of the hospital Dietary Department (kitchen, food preparation areas, storage areas) on 09/15/20, showed the following:

1. An open plastic bin filled with bread ends, a garbage disposal sink full of waste food from breakfast.

2. An open laundry bin filled with dirty rags.

3. Multiple open and undated items in the "reach-in freezer" and the "Grab and Go"(cafeteria) freezer: one box of beef and bean burritos, one box of breaded shrimp, one bag of potato slices, one box of battered cod fillets, one box of "veggie burgers," one box of beef patties, one bag of shredded hash browns, two bags of tater tots, and one bag of chicken tenders.

4. An unidentified staff member working on the patient lunch tray preparation line wearing a long ponytail and no hairnet from 11:15 AM to 11:30 AM.

During interviews with 10 kitchen staff members on 09/15/20 and 09/16/20, eight of the ten reported being instructed to change expiration date labels on perishable and/or leftover foods to extend the expiration dates. Six of the ten staff members reported having changed the labels. Two of the ten staff members stated they had witnessed Staff H, DD Mgr. change the expiration date labels. Three of the ten staff members stated they had also washed mold from produce in order to use the produce, at the direction of Staff H, DD Mgr.


1. The hospital failed to ensure staff followed policy expectations for storage of perishables and leftovers with strict adherence to expiration dates;

2. The hospital failed to ensure staff followed cafeteria infection control requiring closed and dated containers and prompt disposal of food in the garbage disposal;

3. The hospital failed to ensure staff followed the General Healthcare Laundry policy, by leaving a laundry bin full of dirty rags opened;

4. The hospital failed to ensure staff followed the dress code policy requiring hair nets for staff preparing and/or serving food;

5. The hospital failed to ensure staff complete temperature checks for each meal on 24 of 92 days; and

6. The hospital failed to ensure the dietary manager completed the daily "Food Service Manager Self-Inspection Checklist," for the dates of 08/10/20 through 08/31/20.

(Refer to A-0620 for further detail)





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Based on observation, interview, document review, and policy review, the Hospital failed to ensure the Dietary Director followed safe practices for maintaining perishable foods within their expiration dates, for serving only quality produce, and for oversight of staff safety practices in the kitchen. This deficient practice could lead to transmitting food-borne pathogens to any and all patients, visitors and staff members receiving meal service at the facility, with possible negative outcomes, including illness and death.

Findings Include:

Review of a hospital policy titled, "Storage of Perishables and Leftovers," effective date 08/09/16, showed, " Any food removed from the original container is to be placed in a clean container, covered, labeled, and dated ...Potentially hazardous foods (those containing chopped or ground food with mayonnaise or eggs) should be discarded after 48 hours. Other protein items such as cooked meat ...should be discarded when the expiration date is up. Dairy products will be discarded when the expiration date is up. Frozen food that have been kept frozen may be stored in the freezer for up to one (1) year from the purchase date ...Poor quality produce having spots, mold, or is off-colored will be discarded immediately ...Any food that has been cooked (leftovers) can be reheated once before discarding. Leftover foods containing a protein food (meat, eggs, milk) should be discarded after 72 hours in the refrigerator. Leftover vegetables and non-protein foods at the proper temperature may be kept up to 7 days before discarding. This includes fruits, juices, salads, breads, and non-protein sweets."

Review of a hospital policy titled, "Unused Food Portions," effective date 08/17/16, showed, "Any prepared food which has been reheated once is discarded. Any prepared food is refrigerated in a covered container, labeled, and dated."

Review of a hospital policy titled, "Cafeteria Infection Control," effective date 08/17/16, showed, "Foods that are stored in the Cafeteria refrigerator are covered, labeled, and dated between meals ...Waste food should be run through the garbage disposal as soon as possible."

Review of facility policy titled, "Dress Code," effective date 08/09/16, showed, "Hairnets should be worn when in the food production and serving areas."

Review of a hospital policy titled, "Taste/Temperature Record," last revised 08/2019, showed, "TEMPERATURES...Two temperatures must be noted on the form, a beginning and either a mid-point or an ending temperature ...to verify that the food is at the appropriate service temperature. Completed logs are maintained on file for one year."

Review of a hospital policy titled, "Laundry: General Healthcare Laundry Policy Guidelines," effective date 12/04/19, showed, "Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location: these bags are then securely tied or otherwise closed to prevent leakage."

An observation tour was conducted of the hospital Dietary Department (kitchen, food preparation areas, storage areas) on 09/15/20 from 9:00 AM to 11:30 AM, attended by Staff H, Dietary Department Manager (DD, Mgr.) and Staff C, Director of Quality and Infection Preventionist (QAIP). Before starting the tour, Staff H, DD Mgr. reported conducting a self-check inspection of the Dietary Department on a daily basis. Observed during this tour were the following:

1. An open plastic bin filled with bread ends, a garbage disposal sink full of waste food from breakfast,

2. An open laundry bin filled with dirty rags,

3. Multiple open and undated items in the "reach-in freezer" and the "Grab and Go"(cafeteria) freezer: one box beef and bean burritos, one box breaded shrimp, one bag of potato slices, one box battered cod fillets, one box "veggie burgers," one box beef patties, one bag of shredded hash browns, two bags tater tots, one box of beef patties, and one bag of chicken tenders.

4. While observing the patient lunch tray preparation line on 09/15/20 from 11:15 AM to 11:30 AM, an unidentified staff member was seen wearing a long ponytail and no hairnet.

During a brief interview with Staff H, DD Mgr. on 09/15/20 at 11:30 AM, while conducting the tour, Staff H, DD Mgr. was asked to comment on the issues of concern noted above and stated, "Not okay, you came on a bad day," and, "All hair should be covered."

1. During an interview on 09/15/20 at 1:40 PM, Staff R, Kitchen Supervisor, reported changing expiration dates on labeled perishable foods in the Dietary Department, at the direction of Staff H, DD Mgr., on numerous occasions. Staff R also reported witnessing Staff H, DD Mgr. change expiration date labels. Staff R, Kitchen Supervisor (Sup), denied reporting this activity for fear of job loss.

2. During an interview on 09/15/20 at 2:13 PM, Staff O, Dietary Aide (DA), reported being asked to change expiration dates on labeled perishable foods in the Dietary Department by Staff H, DD Mgr., on multiple occasions. Staff O, DA denied reporting this activity for fear of job loss.

3. During an interview on 09/15/20 at 2:43 PM, Staff M, Cook, reported changing expiration dates on food labels of items sold in the cafeteria to visitor and staff after being told to do so by Staff H, DD Mgr. Staff M denied reporting this activity for fear of job loss.

4. During an interview on 09/15/20 at 3:37 PM, Staff S, Dietary Aide and Ambassador (staff that delivers food trays to patients), reported changing expiration date labels on food items sold in the cafeteria to visitors and staff after being told to do so by Staff H, DD Mgr. Staff S denied reporting this activity for fear of job loss.

5. During an interview on 09/15/20 at 3:45 PM, Staff L, Cook, Dietary Aide and Ambassador, reported changing expiration date labels on sandwich meat and cheese after being told to do so by Staff H, DD Mgr. and/or Staff R Sup. Staff L also reported being instructed by Staff H, DD Mgr., to wash the mold from grapes and strawberries and to use these items in meals. Staff L, denied reporting this activity for fear of job loss.

6. During a telephone interview on 09/15/20 at 4:10 PM, Staff J, Cook, reported witnessing Staff H DD Mgr. and Staff R, Sup., change expiration date labels. Staff J stated, "At least once a week, they walk through the freezer and refrigerator to change dates on things getting close to expiration, or sometimes just write over the dates." Staff J also reported witnessing a fellow (now former) employee wash mold from squash and use it in meal preparation at the direction of Staff H, DD Mgr. Staff J denied reporting this activity for fear of job loss.

7. During a telephone interview on 09/15/20 at 4:30 PM, Staff N, Cook, reported being told to change expiration dates on labeled food, "by (name of DD Mgr.) a number of times," in the "Grab and Go" coolers located in the cafeteria. Staff N stated, "He doesn't let us throw anything away and sometimes he says change the date." Staff N denied reporting this activity for fear of job loss.

8. During an interview on 09/16/20 at 8:15 AM, Staff K, Ambassador, reported being instructed by Staff H, DD Mgr. to re-label expired "Grab and Go" foods sold in the cafeteria, adding, "That happens every day." Staff K also reported witnessing another staff member being told, by Staff H, DD Mgr. to wash the mold from strawberries and use them in a meal. Staff K reported witnessing Staff R, Sup. go into the freezer and refrigerator and, "...re-date things ...I saw the dates before and after." Staff K denied reporting this activity for fear of job loss.

Review of documents titled, "Trayline Temperature Monitoring Form," dated 06/01/20 through 08/31/20 showed temperature checks were missed for at least one meal per day on each of the 24 dates as follows:

1. 06/01 Lunch;
2. 06/04 Lunch;
3. 06/05 Breakfast and Lunch;
4. 06/09 Lunch;
5. 06/11 Breakfast and Lunch;
6. 06/12 Breakfast and Lunch;
7. 06/19 Breakfast and Lunch;
8. 06/26 Breakfast and Lunch;
9. 07/03 Breakfast and Lunch;
10. 07/24 Breakfast and Lunch;
11. 07/20 Breakfast and Lunch;
12. 07/28 Breakfast and Lunch;
13. 07/29 Breakfast and Lunch;
14. 07/30 Breakfast and Lunch;
15. 07/31 Breakfast and Lunch;
16. 08/06 Lunch;
17. 08/07 Breakfast and Lunch;
18. 08/14 Breakfast and Lunch;
19. 08/17 Lunch;
20. 08/18 Breakfast and Lunch;
21. 08/19 Lunch;
22. 08/21 Breakfast and Lunch;
23. 08/28 Breakfast and Lunch;
24. 08/31 Dinner.

During an interview on 09/16/20 at 12:15 PM, Staff H, DD Mgr. was asked the significance of the use of the "Trayline Temperature Monitoring Form." Staff stated the form is to maintain patient safety, to maintain safe temperatures of foods prior to and to check for quality of taste and appearance. Staff H, DD Mgr. stated that, "Patients could get sick," if "Someone didn't check." When asked if Staff H, DD Mgr. is responsible for oversight and review of the documents, Staff H, DD Mgr. stated that it was Staff H's responsibility to review the log sheets weekly. When asked why the gaps in the log sheets had not been found during this review process, Staff H, DD Mgr. was unable to answer.

Review of documents titled, "Food Service Manager Self-Inspection Checklist," dated daily for 08/10/20 through 08/31/20 were all found to be blank.

During an interview on 09/16/20 at 12:15 PM, Staff H, DD Mgr. was questioned about the blank inspection documents and was unable to answer whether or not the inspections had been completed on those dates.

During a follow-up interview on 09/17/20 at 8:00 AM, Staff H, DD Mgr. correctly stated policy expectations for storage of perishables and leftovers with strict adherence to expiration dates, cafeteria infection control requiring closed and dated containers and prompt disposal of food in the garbage disposal, linen control including covering dirty linen bins, and dress code requiring hair nets for staff preparing and/or serving food. Staff H, DD Mgr. denied ever failing to follow these policies or instructing staff to ignore policies. Staff H, DD Mgr. reported collecting no data for quality review in the Dietary Department. When asked if Staff H, attends Quality Assurance Performance Improvement (QAPI) meetings, Staff H reported attending, "some," meetings but reported no participation. Staff H, DD Mgr. stated that they have had no QAPI projects for the Dietary Department until 09/16/20, when findings of concern were discussed during the survey observation.

Based on interview, policy review, document review, and review of CDC (The Centers for Disease Control and Preventions) guidelines, the facility failed to adhere to nationally recognized infection prevention and control guidelines to ensure all staff are actively screened for fever prior to starting work. This failure could lead to the spread of the COVID-19 virus from Health Care Professionals (HCPs) to patients, visitors, and other facility employees, with possible negative outcomes, including illness and death.


Findings Include:


Review of the most current CDC Guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," last updated 07/15/2020, showed the following recommendations:

"Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19.

Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented ...

Limit and monitor points of entry to the facility.

Consider establishing screening stations outside the facility to screen individuals before they enter ...Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control.

Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature >100.0°F or subjective fever.

Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection."

Review of a hospital policy titled, "Employee Health-General Policy," effective date 07/10/16 showed, "Employee Health Activities will be monitored by the Infection Control/Employee Health Nurse or designee in his/her absence. All pertinent findings will be referred to the Quality
Assurance Committee Chairman for consultation on an as needed basis."

Review of a hospital policy titled, "Employee Illness Reporting," effective date 10/26/18, showed, "If there is a possibility that the employee's health state may put others at risk for
exposure to a communicable disease, a mandatory absenteeism may be required
for the employee."

Review of the hospital memo, "Interim Guidelines SARS Cov2 (COVID-19) Employee Health and Safety," dated 08/27/20, showed, "Self-monitoring for symptoms including but not limited to the attestation that being on the clock at (hospital name) is indicating that the employee feels healthy and free of illness. Any healthcare worker that develops fever or the symptoms of SARS Cov2 (COVID-19) without a known exposure should report the illness to their supervisor at the earliest opportunity. This employee should not report to work. The employee should follow the return to work after illness guidelines."

Review of the memo titled, "Employee attestation of health," dated 04/18/20, showed, "Every employee when that (sic) arrive at work and clock in attest to the following: 1. They have checked their temperature and have no fever, 2. They do not have symptoms of COVID including cough or shortness of breath, 3. They have not traveled to a restricted area based on the KDHE (Kansas Department of Health and Environment) travel guidelines posted by the time clock."

During an interview on 09/18/20 at 10:00 AM, Staff C, Director of Quality and Infection Preventionist (QAIP), as part of the COVID-19 Focused Infection Control Survey, was asked to describe the screening process for employees presenting to work daily. Staff C, QAIP stated that employees are expected to self-check their temperature at home daily prior to arrival to the facility. Staff C, QAIP stated all time clocks in the facility now have a sign posted notifying all employees that by clocking in for work, this serves as an attestation that they have completed a self-check of their temperature and are not febrile (see "COVID Task Force memo dated 04/18/20). Staff C QAIP stated the facility is not currently actively checking the temperatures of staff reporting to work, nor is the facility documenting the screening process.