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Based on observation, interview, and record review, the hospital failed to maintain mechanical facility equipment in a safe operating condition when the ice machine located on the third floor north medical surgical unit (provides general medical care for a wide variety of acute illnesses) was not maintained per manufacturer's instructions.

This failure had the potential for exposing patients, visitors and staff to contaminated ice and water.

Findings:

During an observation on 3/21/19, at 9:02 a.m., on the third floor medical surgical unit nutrition room, the ice machine collection tray was found with standing water in the collection tray with brown substance on the bottom of the collection tray with white floating particles.

During a concurrent observation and interview with the Director of Special Projects (DSP), on 3/21/19 at 9:05 a.m., she verified the standing water and the brown substance at the bottom of the collection pan and the floating white particles. The DSP stated there should not be standing water in the collection tray and their might be a draining issue. She stated if staff had noticed the water not draining it should have been reported immediately.

During a concurrent interview and observation with Licensed Facility Associate (LFA), on 3/21/19 at 9:15 a.m., he stated there had been no work orders reported for this ice machine. The LFA stated nutritional services is responsible for the exterior cleaning of the machine.

During a concurrent observation and interview, with an employee of Nutritional Services (NS), on 3/21/18 at 11:15 a.m., stated he performs cleaning of the exterior of the ice machine regularly. The drain was unclogged by the LFA and the water that was standing was no longer in the collection tray. The NS was observed cleaning the exterior of the ice machine after the drain was unclogged. The NS did not clean the collection tray where the brown substance was noted. He stated the collection tray was still wet and when the tray is wet he does not clean the collection tray.

During an interview with the Director of Nutritional Services (DNS), on 3/21/19 at 11:20 p.m., he stated the NS did not perform the proper cleaning of the exterior of the ice machine. He stated the steps that should be followed are listed on the document "Nutritional Services Competency Ice Machine Cleaning." He stated the competency is the step by step process per manufacture guidelines on how to clean the exterior of the ice machine and the steps were not performed correctly.

During an interview with the Director of Nutritional Services (DNS), on 3/22/19 at 9:15 a.m., he stated nutrition services are responsible for stocking the refrigerator in the pantry daily but do not perform any additional inspections of the ice machine. The DNS stated the ice machines are cleaned once a week and he obtains the monthly log but does not verify the ice machines are clean or if the process is being done correctly. The DNS stated all persons who request ice or water are affected by the improper cleaning of the ice machine. The DNS stated it is important to ensure proper cleaning techniques to prevent exposure of dirty ice or water. The DNS stated the ice machines need to be checked on a daily basis and cleaning should be weekly and as needed.

The hospital policy titled, "Ice Machine Use in Food Service Areas" dated 10/14/18, indicated "Policy: Compliance- Key Elements A. Ice which is used in connection with food or drinks shall be form a sanitary source and shall be handled and dispensed in a sanitary manner. B. Facilities Services Deep Cleaning, Sanitation and Servicing of Ice Makers: ...3. Deep cleaning and disinfecting of interior and exterior surfaces will follow manufacturer's recommendations or as often as needed to maintain cleanliness. This will be completed on a scheduled basis for all ice machines where ice is used for human consumption."

During review of the document titled, "Nutritional Services Competency Ice Machine Cleaning" undated indicated, " ...Ice Machine Cleaning Instructions per Manufacture Guidelines: ...1. Press and release the splash panel switch located to the left of the water sprout. 2. Remove the grill and place in dirty tub 3. Remove the protective ice shoot/ water chute by pulling them down and place in the sanitary bucket for no less than one minute. 4. Spray Orange Force on a clean paper towel and wash. 5. Get another clean paper towel, place into sanitation solution, ring it out, sanitize surface and let air dry. 6. Clean the exterior of the ice machine with Orange force and then sanitize. 7. Fill water pitcher with to water from sink and flush sink with hot water 2 times. 8. Spray orange force on towel and clean in sink area, clean and follow steps to sanitize and let air dry. 9. Clean and sanitize grill and put back in place. 1. When panel is clean, re- push the clean switch or allow 2 minutes for system to reset. Repeat Weekly."

The Service Manual titled, "Dispense Area Sanitation, "dated 2001, indicated "The dispense area; spouts, sink, grill and splash panel will need periodic cleaning and maintenance. 1. The ice chute may be pulled down to remove it from the ice dispenser. Wash and sanitize it. 2. Sink grill may be removed for washing and sanitizing. 3. The sink should be flushed with hot water and wiped clean and sanitizer. 4 ...Wash the splash panel and wipe with sanitizer ..."