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1 MEDICAL CENTER DRIVE

MORGANTOWN, WV 26506

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observation, interview and document review the hospital failed to maintain a sanitary environment in one (1) of one (1) salad bars contaminated with a consumers Band-Aid. This failure has the potential for all persons who consume the salad bar to be at risk for infectious disease by contamination.

Findings include:

1. Observation on 7/24/18 at approximately 11:50 a.m. by surveyor #1, revealed she was standing in line in the hospital cafeteria to purchase her meal, when an unknown female came to the register with a salad from the salad bar and asked the clerk if she could get something else to eat because she found a Band-Aid in her salad. The clerk told her she could get something else to eat. The clerk put out her closed sign and finished ringing up two lines of customers. Surveyor #1, noted the Band-Aid was nude in nature and folded up. At 12:01 p.m. she contacted the patient service supervisor by telephone to explain a visitor had found a used Band-Aid in her salad. At 12:08 p.m. this surveyor asked the clerk if the supervisor was coming to the cafeteria to check the salad bar and she stated in part, "I called but, that's all I can do, but, it needs closed down." This surveyor asked her to contact the supervisor and at 12:08 p.m. a second call was made to ask the supervisor to come to the cafeteria. At 12:10 p.m. the Retail manager of nutrition services came to the cafeteria and the clerk explained to him about the Band-Aid and he immediately came to our table. When asked if he was aware of the first phone call about contamination of the salad bar by a used Band-Aid he stated in part, "Yes, I was coming out to find out what happened when the clerk said you wanted to talk to me. I am on my way to close the salad bar and replace the contents right now."

2. A joint interview was conducted on 7/24/18 at 1:05 p.m. with the Director of Nutrition Service and the Retail Manager of Nutrition. When asked what the procedure was for contamination of food by a foreign object was the Director of Nutrition stated in part, "The area contaminated would be shut down and investigated and the health department would be contacted." When asked if the clerk had the ability to shut down the salad bar? He stated in part, "Yes, she does and there is also a lead in the cafeteria that should have shut it down immediately." When asked if the procedure was followed? He stated in part, "No, the salad bar was not immediately closed. I have contacted our point of contact with the health department to notify them of the incident. We did find that the Band-Aid was nude in color so we know our employees did not contaminate the salad bar because our employees are supplied with blue Band-Aid for any injuries."

4. A review of a policy titled "Scope of Service" with a last revision date of 03/17, states in part: "Prepare and serve meals following sanitary food handling practices according to the standards of Monongalia County and the state of West Virginia."

5. Review of the website for Monongalia Health Department revealed the health department uses the 2005 Food and Drug Administration (FDA) food code.

6. Review of the 2005 FDA Food Code 3-701.11 states in part: "Food that is contaminated by food employees, consumers, or other persons through contact with their hands, bodily discharges, such as nasal or oral discharges, or other means must be discarded."

7. An interview was conducted on 07/25/18 at 9:40 a.m. with the Director of Regulatory. When asked if he found the point of sale on the salad bar for the time of contamination, he stated in part: "The point of sale can only be conducted at fifteen minute intervals. The weighted items that sold on 7/24/18 between 11:45 a.m. and 12:00 p.m. was thirty (30) and between 12:00 p.m. and 12:15 p.m. was thirty-seven (37) for a total of sixty-seven (67) weighted items sold on the salad bar."

8. An interview was conducted on 7/25/18 at 8:45 a.m. with the Director of Nutrition service. He concurred the salad bar should have immediately have been closed down.