HospitalInspections.org

At the time of the revisit this deficiency had not been corrected.

Based on review of personnel files, contracts, policies and procedures the facility failed to provide a full-time qualified, competent, dietary manager. The facility has a contract with a consultant dietitian. There is no documentation the Dietary Manager is a certified dietary manager or a registered dietary technician as required by State licensure standards. This finding was verified with administration at the exit conference.

At the time of the revisit on 5/14/2012 this deficiency had not been corrected.

Based on interviews, review of personnel records, hospital contracts, and policies the hospital failed to provide appropriately trained and competent dietary staff. According to dietary staff, hospital documents, and surveyor observation patient's dietary trays are prepared by nursing personnel on occasion. There is no documentation in any of the nursing personnel files the nursing staff have been trained in food handling safety and appropriate preparation of patient diets. This finding was verified with administration on the afternoon of 5/14/2012.

Based on review of policy and procedures the facility failed to provide policy and procedures specific to the perioperative processes at the facility.

Findings:

1. On 5/14/12 surveyors requested operating room policies. The manual did not have policies covering all of the required elements. There were no policies regarding current infection control and all sterilization practices.

2. There were no policies and procedures for the use of the Sterrad sterilizer.

3. There was no documentation of monitoring for adequate sterilization of loads run in the Sterrad sterilizer.

4. There was documentation that indicated eye instruments were flash sterilized between cases on a routine basis.

5. There was no documentation sterile processing of surgical instruments was performed by trained and competent staff.

6. The above findings were provided to the administration at the exit conference on 5/14/2012. No further documentation was provided.