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Based on observation, record review, and interview, the facility failed to ensure that the quality assessment and performance improvement program involves all hospital departments and services, in that,

A) there were no quality checks completed on the floor to ensure warm food at the bedside for the patient; and

B) no quality data for the dietary department being reported through the Quality program.

Findings included

During a tour of the dietary kitchen on 4/12/18 at 11:10 AM with Personnel #10 and visualized by Personnel #1, once the carts of patient trays were delivered to the floor, the nurses were visualized while delivering them to the patients without delay. There were no temperatures checked of the food on the patient floor.

There were no records of temperature checks on the patient floors to ensure warm food at bedside.

During an interview on 4/12/18 at 12:20 PM, Personnel # 8 was asked if the nurses always deliver the patient trays. Personnel #8 stated, "Yes."Personnel #8 was asked how they make sure the food is at the right temperature. Personnel #8 stated, "We don't. We don't even have a thermometer to check. I don't know."

During a patient interview on 4/12/18 at 1:01 PM, Patient #5 was asked about food temperature (door was open). Patient #5 stated, "The food is cold sometimes. The soup sometimes like cream of chicken."

During an interview on 4/12/18 ending at 1:03 PM, Personnel #1, #3, and #4 was informed the patient said food was sometimes cold. They were reminded the nurses stated they pass the trays and dietary does not. They were asked what was done to ensure warm food to patients at the main hospital. Personnel #1 stated, "They (main campus) do checks to ensure." Personnel #1 was reminded whatever is done at the main campus needs to be completed here as well. Personnel #1 stated, "Yes. I know." Personnel #1 was asked for the policy and quality metrics for dietary.

During an interview on 4/12/18 ending at 2:05 PM, Personnel #5 (Personnel #1 was present) was asked about no quality checks on the floor to ensure warm food at bedside for the patient. Personnel #5 stated, "At the main campus, my FAN (Food and Nutrition) manager completes monthly temperature checks on the (patient) floors to ensure warm food at the bedside. The FAN had not done that (temperature checks on the floor) at this campus. There is not a policy, just our practice."

During an interview on 4/12/18 at 2:22 PM, Personnel #6 (Personnel #1 and #5 were present) was asked what quality metrics dietary collected and reported through the quality process. Personnel #6 stated, "We realized that we don't report up to quality. We collect patient satisfaction survey data that is reviewed thru the EOC (Environment of Care) meeting but it doesn't go through Quality. We have done a PI Project for dining on demand but it was not reported through Quality."

Based on observation, record review, and interview, the facility failed to ensure the administrative and technical personnel competent to conform to food handling techniques, in that,

A) the gravy was poured out of the heating container into a plastic salad dressing container;
B) gloves were not changed with hands washed after completing and documenting food temperatures prior to food plating;
C) gloves were not changed with hands washed after using a marker to write on Styrofoam cups; and
D) no quality checks completed on the floor to ensure warm food at the bedside for the patient.

Findings included

During a tour of the dietary kitchen on 4/12/18 at 11:10 AM with Personnel #10 and visualized by Personnel #1, the process of receiving food delivery including checking temperatures, plating food, and the cart delivery to the floor was visualized. The dietary tech took the temperatures of each food in the heating pan and document them with a pen on the paper log. The dietary tech did not change gloves or wash her hands. The dietary tech poured the gravy into a plastic salad dressing dispenser from the silver heating pan. During the plating of food, the dietary tech would reach for a marker and use it to write on Styrofoam cups. The dietary tech did not change gloves or wash her hands and continued to plate food. Once delivered to the floor, the nurses were visualized while delivering them to the patients without delay. No temperatures were checked on the floor.

There were no records of temperature checks on the patient floors to ensure warm food at bedside.

During an interview on 4/12/18 at 12:20 PM, Personnel # 8 was asked if the nurses always deliver the patient trays. Personnel #8 stated, "Yes." Personnel #8 was asked how they make sure the food is at the right temperature. Personnel #8 stated, "We don't. We don't even have a thermometer to check. I don't know."

During a patient interview on 4/12/18 at 1:01 PM, Patient #5 was asked about food temperature (door was open). Patient #5 stated, "The food is cold sometimes. The soup sometimes like cream of chicken."

During an interview on 4/12/18 ending at 1:03 PM, Personnel #1, #3, and #4 was informed the patient said food was sometimes cold. They were reminded the nurses stated they pass the trays and dietary does not. They were asked what was done to ensure warm food to patients at the main hospital. Personnel #1 stated, "They (main campus) do checks to ensure." Personnel #1 was reminded whatever is done at the main campus needs to be completed here as well. Personnel #1 stated, "Yes. I know." Personnel #1 was asked for the policy and quality metrics for dietary.

During an interview on 4/12/18 ending at 2:05 PM, Personnel #5 (Personnel #1 was present) was asked about the gravy in the plastic salad dressing container, not changing gloves/washing hands after completing temperatures and documenting them, not changing gloves/washing hands after using a marker to write on Styrofoam cups, and no quality checks on the floor to ensure warm food at bedside for the patient. Personnel #5 stated, "She should have left the gravy in the pan in the water bath to maintain the temperature. She should have changed gloves and washed her hands both times. At the main campus, my FAN (Food and Nutrition) manager completes monthly temperature checks on the (patient) floors to ensure warm food at the bedside. The FAN had not done that (temperature checks on the floor) at this campus. There is not a policy, just our practice."

During an interview on 4/12/18 at 2:22 PM, Personnel #6 (Personnel #1 and #5 were present) was asked what quality metrics dietary collected and reported through the quality process. Personnel #6 stated, "We realized that we don't report up to quality. We collect patient satisfaction survey data that is reviewed thru the EOC (Environment of Care) meeting but it doesn't go through Quality. We have done a PI Project for dining on demand but it was not reported through Quality." Personnel #1 added, "No. They don't now, but they will bi-annually."