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Based on observation, interview and document review the hospital failed to ensure that dietary services met the needs of all patients as evidenced by failure to:

1. Provide effective dietetic services as evidenced by findings of unsafe food handling practices and supervision of the dietary department (Cross Reference A620, A749).

2. Ensure comprehensive disaster planning. (Cross Reference A701).

3. Ensure the development of comprehensive policies and procedures that reflected the scope and nature of services. (Cross Reference A620)

4. Ensure that physician ordered diets were followed and a system to ensure the nutritional needs of patients were met. (Cross Reference A630).

The cumulative effect of these systemic problems resulted in the inability of the hospitals' food and nutrition services to direct staff: 1) To provide safe food handling practices and supervision; and 2) To ensure that the nutritional needs of patients were met in accordance with practitioners' orders and acceptable standards of practice.

Based on foodservice observations, contracted staff interview and dietary document review, the hospital failed to ensure comprehensive management of dietetic services as evidenced by 1) lack of comprehensive system to identify and monitor potentially hazardous foods requiring time/temperature control for food safety; and 2) lack of standardized recipes that provided adequate food production to ensure food safety.

PHF's are foods capable of supporting bacterial growth associated with foodborne illness. Safe food handling practices would ensure that time/temperature control parameters were maintained during preparation and storage of PHF's. PHF's that are cooked must be cooled to 70?F within 2 hours and to below 41?F within an additional 4 hours (Food Code, 2009)

Failure to ensure implementation of effective food safety systems relative to the scope of food services may put patients at risk for foodborne illness, further compromising medical status and in severe instances may result in death.

Findings:

1. During foodservice observations on 10/26/11 beginning at approximately 10:30 a.m., the following issues were identified: 1) lack of effective systems with respect to the handling of PHF's (Cross Reference A749). In an interview on 10/26/11 at 3:30 p.m., with Contracted Staff (CS) A stated that she was recently assigned to the hospitals' contract as the Director of Food Service. The surveyor asked CS A to provide the departments' policy and procedure manual. It was noted that the departmental policies and procedures were reviewed and approved in January 2008 by hospital administrative staff. The manual also contained an updated table of contents dated 2/2010. She stated that the approved manual was developed by the hospital and was not the manual provided by the contracted food service company. Review of hospital document titled, "Statement of Deficiencies and Plan of Correction" dated 9/20/11, revealed that on page 10 the hospital documented that the contractor's policy and procedure manual was adopted. There was no indication that this plan of correction was implemented.

Review of the manual revealed that while the department had some policies related to food procurement, receiving, storage, and handling of potentially hazardous foods (PHF's) the procedures did not consistently provide staff comprehensive procedural guidance. An example included the policy titled, "Two Stage cooling of Food" dated 11/09. It was noted that the purpose of the policy was to, "ensure foods cooked and cooled for later service remain free of contamination and foodborne illness" as well as temperature parameters; however it did not provide specific guidance on which foods would require cooldown monitoring, rather provided general statements.

2. Food storage observations on 10/26/11 beginning at 10:30 a.m., revealed that the hospital was preparing chicken salad, a potentially hazardous food, for use at a later time (Cross Reference A749). In an interview on 10/27/11 at 10:30 a.m., with CS A and DS B they stated that there was no standardized recipe for this item.

Review of additional standardized recipes revealed that while there was an ingredient list with quantities as well as basic preparation instructions there was no guidance listed to ensure safe food handling practices such as guidance for cooldown of those recipes that contained potentially hazardous foods. CS A acknowledged that the standard of practice would be to ensure that each menu item had an associated standardized recipe that provided guidance to staff for item preparation.

Based on staff interview, and medical record review, the hospital failed to ensure that all diets were ordered by the physician as evidenced by a doctor's order for a , "liberal calorie diet" being translated as an 1800 calorie diet without any clarification with the doctor.

Findings:

Record review on 10/26/11 at 3:45 p.m., revealed that Patient 3 was admitted with multiple medical problems including a diagnosis of diabetes. The physician's admission orders dated 10/23/11 indicated that the patient was to be given a, "liberal calorie diabetic diet." The dietary request form dated 10/23/11 indicated that the patient was to receive a 2000 calorie diabetic diet. There was no documentation of a physician's order for the 2000 calorie diet.

During a concurrent interview 3 of 3 licensed nursing staff at the nursing station were unable to say what a "liberal calorie diabetic diet" was and did not know who made the decision to give the patient a 2000 calorie diet.

During an interview on 10/27/11 at 10 a.m., Dietary Staff N produced a list of the diabetic calorie diets. The list included the following calorie count diets: 1400 calorie, 1500 calorie, 1800 calorie, 2000 calorie, 2200 calorie, 2500 calorie, and no concentrated sweets diets. Staff N reviewed the diet order for Patient 5 and stated that she did not know which calorie count should be selected for a, "liberal calorie diabetic diet" and that she did not make the decision to convert the, "liberal calorie count diet" to a 2000 calorie diet. Staff N stated that she usually called the nursing station or talked with the dietician when she received an unclear order.

The Registered Dietician stated during an interview on 10/27/11 at 10:20 a.m., that she did not enter the diet orders and was unaware of how the liberal calorie diet was converted to a 2000 calorie diet.


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Based on food service observations, contract staff interview and dietary document review, the hospital failed to ensure regular and therapeutic diets met patient nutritional needs as evidenced by the development and implementation of menus that did not meet physician ordered diets and the hospitals' defined parameters for fat and sodium restricted diets. Failure to ensure that menus met physician ordered diets and/or estimated nutritional requirements' may further compromise the medical status of patients which may result in extended hospital stays and poor patient outcomes.

Findings:

1. During trayline observation on 10/26/11 at 11:45 a.m., the entree items for regular and therapeutic diets consisted of items such as a breakfast burrito, commercially prepared breaded tilapia, with potatoes and a commercially prepared chicken melt for a wide variety of therapeutic diets.

In an interview on 10/26/11 at 4 p.m., CS A was asked to describe how the hospital ensured the physician ordered therapeutic diets were met, in particular for those patients with low sodium (2000 milligrams sodium) and cardiac diets (50 grams of fat). CS A stated she was new to the hospital and stated that in her discussions with the previous food service director the previous director developed the menu. CS A was unable to demonstrate that the menu was reviewed and approved by a Registered Dietitian. She also stated she believed there were issues with the menu, however she had not had an opportunity to complete a comprehensive analysis that evaluated recipes and items purchased.

During a review of the nutritional analysis prepared by CS A at the request of the surveyor, on 10/27/11 at 10 a.m., in the presence of CS A, it was noted that the sodium content of the lunch and dinner meals on 10/26/11 was approximately 2,900 milligrams of sodium. Similarly the fat content for the lunch and dinner meals for 10/26/11 was 73 grams of fat. CS A acknowledged that the addition of the breakfast items would have contributed additional sodium and fat to the menu totals.

Additional review of the selected menu items for 10/27 and 10/28/11 noted the sodium content of the meals was 5900 and 4800 milligrams respectively. Similarly the fat restricted diets for 10/27 and 10/28/11 were 78 and 52 grams of fat respectively.

Review on 10/27/11 at 11 a.m., of dietary policy titled. "Sodium Restricted Diets" dated 12/09 indicated that the low sodium diet would not exceed 2 grams of sodium/day. Concurrent review of the undated, unreferenced hospital document titled, "Section J. Fat controlled Diets" indicated that a fat controlled diet would limit dietary fat to 50 grams/day. CS A acknowledged that the menu as served did not meet the physician ordered therapeutic diets with respect to fat and sodium content. She also acknowledged without a comprehensive nutritional analysis of the menu it was not possible to determine if patient nutritional needs were met.

2. In an interview on 10/26/11 at 10:30 a.m., CS A stated the hospital had a menu that included a designated main entree as well as a patient select alternate. During document review beginning on 10/27/11 at 9:15 a.m., in the presence of CS A and RD D, the hospital's patient select menu was reviewed. CS A stated that several months earlier she was assigned as the Director of Food Service at the hospital. She stated that the previous Director had developed the menu and that to her knowledge the menu was not reviewed and/or approved by a Registered Dietitian. RD D stated that she was given a nutritional analysis of the menu that she used while doing clinical nutrition care.

The hospital document presented titled, "SVH Production Chart Calories" revealed an estimated calorie count of the menu using food groupings such as juice, starches, proteins and vegetables but was not menu specific. Similarly the undated hospital document titled, "Week Three-Production Chart" for Wednesday, Thursday and Friday was more specific with respect to food items; however the patient menu and production chart were not consistent with one another.

On 10/26/11 CS A developed a nutritional analysis of the menu that included calories, fat, cholesterol, sodium, carbohydrates, and protein of 2-1/2 days during the survey. CS A acknowledged there was no nutritional analysis of the menus served and that without a nutritional analysis it would not be possible to ensure patient nutritional needs were met.

Review on 10/27/11 at 11 a.m., in the presence of CS A, of the hospital's standardized recipes revealed there was no comprehensive nutritional analysis of the recipes and/or prepared food items that were utilized. It was noted that while some of the recipes provided basic consumer nutritional labeling there was no analysis of the vitamins/minerals that the product or recipe contained. CS A acknowledged that it would not be possible to ensure that the menus met standards if there was no nutritional analysis of the recipes. CS A stated that the contracted vendor had comprehensive menus, recipes, and nutritional analysis of regular and therapeutic diets but the system was not currently implemented.

It would be the standard of practice to ensure that menus met standards of practice such as the Dietary Reference Index or the Recommended Dietary Allowances (Institute of Medicine of the National Academies, 2011) that was comprehensive. A comprehensive menu would also include an analysis of macronutrients such as fat, fiber, and carbohydrates but also included micronutrients such as vitamins and minerals.

Review of the hospital document titled, "Production Charts and Portion Control" dated 12/10, indicated that the purpose of the chart was to, "ensure that each patient receives ...nutrient intake according to their physician ordered-diets."

Based on observation, staff interviews, and document review, the hospital failed to ensure comprehensive maintenance of the physical environment as evidenced by: 1. Inadequate disaster food supplies to meet the needs of patients and staff during a disaster and, 2. Failure to maintain the ice machines according to manufacturer guidance, and ensure that each machine had an air gap in the drain resulting in the possible contamination of manufactured ice.

Findings:

1. During food storage observations, concurrent dietary management staff interview, and dietary document review on 12/26/11 at 3 p.m., the hospitals' disaster meal planning was reviewed. DMS A stated that the hospital was planning to provide food for a total of 120 people including patients and staff. It was noted that the hospital developed a menu for a total of 4 days. Three of the days menus included canned supplies as well as some supplies such as pasta that required cooking.

The surveyor conducted a spot check of the items. It was noted that the hospital did not have adequate supplies of the canned entrees including beef stew, corned beef hash, and chili con carne, and had a limited supply of ravioli. In a concurrent interview, DMS A stated stated that the items were outdated and were discarded and not yet replaced. It was also noted that the hospitals' stoves were natural gas and in the event of a disaster this supply might be unavailable. DMS A stated that she was told the hospital had a propane barbeque that was in a storage unit away from the hospital campus. DMS A acknowledged the shortage of the staple food supply. The standard of practice would be to ensure that that hospital maintained all disaster supplies in the general acute care licensed hospital building.


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2. During a tour and observation of the ice machines on 10/26/11 at 12 p.m., Maintenance Staff X explained the process for cleaning the ice machines. He stated that there were two types of machines in the facility but that the process was the same for each type. Both were cleaned first with one type of solution and then disinfected with another type of solution.

Staff X also described how he mixed the cleaning solutions. Staff X stated that he had a one liter clear plastic graduated container. He stated that he put 50 ml of the cleaning solution in the container and then added enough water to reach the 850 ml line. The container had no measurement mark for 50 ml. Staff X stated that he, " guesstimated " how much was 50 ml.

When asked what solution he was using Staff X produced a bottle labeled " Metal Safe Ice Machine Cleaner. " Staff X stated that the two types of ice machines in the facility each required a different cleaner per the manufacturer. He wanted to simplify the process and to reduce costs, so he contacted the manufacturers and asked for suggestions on what else could be used.

Staff X stated that he was told by both manufacturers that, "Metal Safe Ice Machine Cleaner "would work as well as the cleaners recommended by the manufacturers. Staff X obtained the product and had been using it to clean both types of ice machines.

When asked what solution he used to disinfect the machines Staff X stated that he used a household bleach solution. He mixed an unmeasured amount of household bleach with water in the same plastic container. When asked what the concentration of the bleach solution he was making was, Staff X could not say.

During an interview on 10/26/11 at 11:45 a.m., Administrative Staff Y was asked to provide the policy and procedure for the ice machine cleaning, Review of the documents titled, " Follet Ice Machine Cleaning " and another titled Maintenance and Cleaning -Scottsman Ice Machines " indicated the following:

The Scottsman Ice Machine procedure indicated " monthly cleaning, "Prepare the cleaning solution by diluting it in a plastic container with 2.1 quarts (2 liters) of warm water (113-122 deg F) with 7 ounces (0.2 liters ) of Scotsman Ice Machine Cleaner" and under, Sanitization, "A possible sanitizer can be obtained by mixing 1 ounce of liquid household bleach with 2 gallons of warm water."

The document titled, " Follett Ice Machine Cleaning " indicated that the process required three separate solutions, " Prepare a cleaning solution (200 ppm of available chlorine content) of Ecolab Mikro-chlor Cleaner or equivalent chlorinated detergent ....Prepare a sanitizing solution (50 ppm of available chlorine content) of Ecolab Mikro-chlor cleaner or equivalent chlorinated detergent ' ...and " a solution of one cup ...of household bleach mixed with one gallon ...hot water ... "

In a follow up interview on 10/27/11 at 9 a.m., Administrative Staff Y and Staff X both acknowledged that the instructions for mixing cleaning solutions provided in the two written procedure did not match what Staff X was doing and that there was no written guidance for Staff X to use in the preparation of the " Metal Safe Ice Machine Cleaner. " Additionally, both agreed that it was not possible to determine what the actual concentration of the bleach disinfecting solution was when mixed the way Staff X was mixing it.

During an interview on 10/27/11 at 11 a.m., Administrative Staff M reviewed the ice machine cleaning procedures. When asked if the procedures had been reviewed by the infection control committee, Staff M stated that because they were not in the hospital format for policies and procedures she did not think they had been reviewed by the committee.

During an observation on 10/26/11 at 12 p.m., of the ice machine in the emergency department, it was noted that the drain from the ice machine was placed inside the down drain. There was no air gap between the ice machine drain and the sink drain. Maintenance Staff X and Administrative Staff Y stated that there were a total of 8 ice machines in the hospital excluding the kitchen and the skilled nursing unit.

Observation of the ice machines located on the ambulatory care unit, 2 ice machines located on the medical units, and one on the intensive care unit revealed that in every case the ice machine drains were positioned in contact with the drain. There was no air gap in any of the five ice machines observed.

Based on food storage observations, dietary staff interview, and dietary document review, the hospital failed to ensure time/temperature monitoring of potentially hazardous foods for food safety. Failure to ensure comprehensive safe food handling practices may result in foodborne illness and in severe instances may result in death.

Findings:

During initial tour on 10/26/11 beginning at 10:30 a.m., it was noted that in the walk-in refrigerator there was chicken salad with an expiration date of 10/28/11 with a temperature of 42?F. In a concurrent interview Dietary Management Staff (DMS) A stated that an item with a 10/28 date was prepared on 10/25/11.

Chicken is considered a potentially hazardous food (PHF). PHF's are foods capable of supporting bacterial growth associated with foodborne illness. Safe food handling practices would ensure that time/temperature control parameters were maintained during preparation and storage of PHF's. PHF's that are cooked must be cooled to 70?F within 2 hours and to below 41?F within an additional 4 hours (Food Code, 2009).

In an interview on 10/26/11 at 11:15 a.m., Dietary Staff (DS) B was asked to describe how the item was prepared. She stated that she cooked the chicken on 10/24/11 at approximately 5 a.m. by placing it in the steamer. She further stated that she remove the chicken from the steamer at approximately 5:30 a.m., at which time the item was 165?F. She then covered, dated the item, and placed it in the refrigerator. At approximately 12:30 p.m. (7 hours after heating), DS B rechecked the temperature and noted it to be 39?F. The surveyor asked if the temperatures were recorded; she stated they were not. She also acknowledged that the 12:30 p.m., was the only temperature taken.

In an interview on 10/26/11 at 12:30 p.m., DS C was asked to describe the foods that would be cooked and held for later use. He stated the only item that was monitored for cooldown was flank steak that was cooked on a weekly basis for service the following day.

In an interview on 10/26/11 at 2 p.m., DMS A was asked to describe how safe food handling practices were ensured. She stated that on a monthly basis a food safety audit was completed. DMS A stated that she ordered pre-cooked chicken for chicken salad and was unaware that dietary staff was routinely cooking it prior to preparation. She also stated that there were additional items such as Salad Nicoise, Chinese chicken salad and egg salad that contained heated potentially hazardous foods that would require time/temperature monitoring to ensure food safety. She also acknowledged that she had missed the necessity to monitor temperatures during the production of these menu items.

Hospital document titled, "Food Safety Audit" dated 8/15/11, indicated in Section 4a that staff was not preparing any PHF's that required time/temperature control. Review of dietary staff training on 10/26/11 beginning at 1 p.m., for training dated 6/30 - 10/26/11 revealed that while dietary staff received training on the cooldown of PHF's it was limited to temperature control while thawing raw meat under running water.

Review on 10/27/11 at 10 a.m., in the presence of DMS A and the RD, of a hospital document titled, "Statement of Deficiencies and Plan of Correction" dated 9/20/11 indicated that the hospital, "developed and implemented a checklist for the cooling of food involving critical control points from HACCP standards: ..." Both DMS A and the RD acknowledged that the system developed focused on the temperature monitoring of raw foods during thawing.

The hospital document titled, "Two Stage Cooling of Food" dated 11/09, revealed that while the hospital had a policy for cooling previously cooked foods the policy was not comprehensively implemented.



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