HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure regular equipment maintenance occurred for overhead lights in patient halls and the kitchen; and the cleaning of the hood vent above the range and grill. These deficient practices had the potential to affect all patients using the hallway which led to the CT scanning area at the facility and/or affect all patients eating meals from the kitchen, at the facility. Findings include:

1. During kitchen observations on 9/13/21 at 2:42 p.m., 9/14/21 at 3:49 p.m., and 9/15/21 at 7:05 a.m., two sets of double tube lights were observed with no protective covers encasing the lights.

-One set of the uncovered tube lights was above the clean dishes area runner, which exited the dish machine. A rack of plastic glasses was on the dishwasher runner, under the unprotected set of lights.

- The other set of uncovered tube lights was on the ceiling, to the right of the wood preparation table.

During an interview on 9/15/21 at 7:05 a.m., staff member D stated the wood preparation table was used by staff to prepare foods and drinks for meals.

During an interview on 9/15/21 at 8:05 a.m., staff member C stated the maintenance crew was aware of the lights not having covers on. The staff member stated the maintenance department was to be ordering covers for the two sets of uncovered lights. The staff member agreed that food being prepared on the wood preparation table could be contaminated if the lights broke/burst, small shards of glass would go unnoticed, mixed in or on top of any food being prepared. The staff member agreed that if the lights above the clean dish rack were to break, shards of small pieces of glass could contaminate the dishes and go unnoticed.

During an interview on 9/15/21 at 8:10 a.m., with staff members R and S, staff member R stated he was aware of all the ceiling lighting that did not have protective covers on them. Staff member R stated he had trouble finding covers to fit. Staff member stated there were different sizes for the fixtures.

Staff member S stated all the tubes in the ceiling light fixtures had been replaced with LED lights and they didn't break as easy. Staff member S stated the lights really didn't need protective covering.

2. During an observation on 9/13/21 at 3:15 p.m. and 9/15/21 at 7:05 a.m. the fan filters, in the hood cover, over the range and grill, had greasy black dust dangling from them and the fire suppressant piping hanging down. The pipes, connecting the oven/grill/range to the gas also had the black, greasy dust hanging off the metal. The dust was observed moving from the air drafts of the air and fans.

During an interview on 9/15/21 at 7:05 a.m., staff member D stated staff member C did not want kitchen staff to get up and remove the hood fan filters, to clean. Staff member D stated staff member C or the maintenance staff cleaned the hood vents and the surrounding area.

During an interview on 9/15/21 at 8:05 a.m., staff member C stated the kitchen staff was to clean the hood vent covers and surrounding area, and all pipes connected to the range and vent, weekly. Staff member C stated the kitchen had been short staffed, and the area had not been cleaned.

Review of the "Cleaning Duties," dated 2/12/21, with the dietary manager's name on the bottom right-hand corner, showed Thursdays, the "PM AIDE" was to clean the hood filters.

Review of the cleaning schedule, dated July 2021 and August 2021, showed no one had cleaned the hood filters for at least one month and three weeks.