HospitalInspections.org

Based on staff interviews and document reviews, the hospital's governing body and administrative officials failed to ensure the Quality Management (QM) Plan for the Nutrition Services Department was updated to include food safety/services criteria based on recent deficient practices cited and food and nutritional procedures which addressed patient safety. This resulted in the potential for, and actual repeat deficient practices in this department to continue when QM data based on recent specific deficient practices cited in the department was not compiled and reported to the Governing Body.

Findings:

During the previous CMS Validation Survey of 7/23/10, multiple areas of deficient practice were identified related to food service systems to ensure patients, staff and visitors were served safe/quality food. Deficient food safety practices cited included ensuring:

1. The proper cool down procedures were carried out and monitored for previously cooked potentially hazardous foods which lead to the potential for food borne illness.

2. The can opener and pans used for cooking were maintained in a clean and sanitary manner which lead to the potential for cross contamination and food borne illness.

3. Expired prepared food and nutritional supplements were not stored in the food services department to ensure safety and quality.

A review of the survey plan of correction, completion dated 11/2010, "Production staff (was) re-educated on cooling procedures and record keeping (cooling logs), Can opener cleaning responsibility (was) assigned to (the) lead cook....(and for the) Expired foods the responsibility was clarified on Job Task lists for production staff." It further stated, "Monitoring of all interventions (was) ongoing since August 2010 by Sanitation checklist twice a month by supervisors and environmental rounds followed by random checks by the department director. Sanitation checklists are reviewed by nutritional services director twice a month, they are quantified and reported to (the) quality management committee quarterly."

A review of the hospital's "Quality Management Plan 2010" revealed that, "The Quality Management Program (QMP) is designed to assess the dimensions of performance (as it relates to) safety." According to the plan, the "Hospital and Medical Staff Leaders...have the responsibility for ensuring that there is a planned, systematic hospital-wide approach for designing, measuring, assessing and improving care, patient safety and service. In addition, the leaders are also responsible for creating an environment that encourages...the implementation of process to reduce the likelihood of reoccurrence.

The plan showed the prioritization of the QM Plan should include high risk, high volume, event/safety issues and regulatory requirements to ensure that the delivery of patient care was safe and optimal...the monitoring and evaluation process was designed to assist the organization in focusing on high priority quality of care and safety issues.

A review of the Nutrition Services Plan for Quality Management, dated 5/2010, revealed that the department was reporting on performance indicators related to food safety as a "Food Sanitation Score" that was an accumulation of many items as it related to sanitation in the kitchen. There were no indicators for the monitoring of the specific deficient practices identified in the 7/23/10 survey.

A review of the Quality Management Committee Meeting minutes dated 3/2/11 revealed that the Nutritional Services Dashboard was presented for approval by the committee and the members approved the dashboard. There was no action/recommendation by the committee requiring data collection and analysis to ensure the plan of correction in Nutrition Services had been implemented, was effective, and improvements were sustained over time.

During an interview with the Quality Improvement Director on 5/4/11 at 1:00 PM, she confirmed that there were no indicators from the Nutrition Services Department or any other department addressing food safety as it related to the plan of correction for the deficient practices identified during the 7/23/10 survey. The Director was unable to state how the hospital leadership and the Governing Body would be able to determine if the plan of correction in Nutrition Services had been implemented, was effective, and if improvements were sustained over time without data collection and analysis.