HospitalInspections.org

Based on observation and interview the Hospital failed to provide an accessible copy of the diet manual to all medical, nursing, and food service personnel.

Findings include:

The Surveyor interviewed the Clinical Nutrition Manager at 10:45 A.M. on 10/15/14. The Clinical Nutrition Manager said the current diet manual was available to medical and nursing staff by requesting a copy from one of the Hospital Dieticians.

The Senior Director of Support Services was interviewed at 1:05 P.M. on 10/15/14. Director of Support Services said the manual was available by request from the Hospital Dieticians. However, the Senior Director of Support Services said the Dieticians worked seven days per week, but not during the evening or night and the diet manual would not be available during those times.

Based on observation, record reviews and staff interview, the staff failed to follow the Hospital procedure for monitoring dish machine temperature, donning personal protective equipment, improper use of biohazard transport receptacles, and maintaining a sanitary environment of care.

Findings include:

1.) The Policy titled Sanitation and Infection Control for Dishmachine Temperatures, revision date 1/14, indicated temperatures for the low temperature dish machine are to be recorded during each period of use.

The Surveyor reviewed the dish machine log on 10/15/14 during tour of the Kitchen #1 between 8:30 A.M. and 10:00 A.M., while monitoring of the sanitizer concentration was documented for each cycle of the dish machine, the log lacked temperature monitoring for the month of October 2014.

The Senior Director of Support Services was interviewed at 1:05 P.M. on 10/15/14. The Senior Director of Support Services said staff only monitored the parts-per-million concentration of the sanitizer.

2.) The Policy titled Transmission Based Precautions indicated gloves are to be worn when entering a patient on Contact Precaution's room and hand hygiene was to be performed when exiting. The Surveyor observed a patient in ICU #8 on Contact Precaution in the Surgical Intensive Care Unit at 9:40 A.M. on 10/16/14. The Contact sign was attached to the entry door. The Surveyor observed an Electroencephalography technologist in the contact precaution room without gloves and he failed to perform hand hygiene upon exit.

Approximately five (5) minutes later, a Neurosurgical Fellow entered ICU #8 without donning personal protective equipment and exited the room without performing hand-hygiene.

3.) The Surveyor observed the clean distribution section of the Central Processing Department at 8:45 A.M. on 10/20/14 where approximately six (6) red receptacles with biohazard stickers contained wrapped sterile supplies on top of the operating room clean case carts.

The Surveyor interviewed the Director of the Central Processing Department at 8:50 A.M. on 10/20/14. The Director said the red receptacles were clean and used to hold supplies during transport to the operating room. However, in the Hospital red biohazard receptacles are to be used for soiled biohazardous transport only.

4.) The Surveyor observed the dish machine area on 10/15/14 during tour of the Kitchen #1 between 8:30 A.M. and 10:00 A.M. A large fan was in use and observed to have dark dusty debris on the fan blades.