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Based on observation and staff interview it was determined that the facility failed to maintain the kitchen in a manner consistent with food safety and sanitation standards. Failure to maintain a sanitary environment has the potential to impact the safety and well-being of patients and staff.

Findings:

On 1/9/17 the kitchen inspection began at approximately 11:45 AM. The surveyor asked the contracted kitchen staff member (Staff C) on duty if he used the automatic dishwasher to sanitize dishes and utensils. The Staff C replied yes. When asked if the dishwasher uses chemicals for sanitation, Staff C said no, it relies on hot water for sanitation. The surveyor then asked Staff C what temperatures are required for hot water sanitation. Staff C stated 150°F for wash cycle and 180°F for rinse cycle. The surveyor confirmed that these temperatures are consistent with the manufacturers instructions.

Staff C was then asked to demonstrate a wash cycle. During the first cycle the wash temperature reading on the dishwasher gauge was 140°F and the rinse temperature was 148°F. Staff C then ran the dishwasher again. On the second cycle the wash temperature reading was 148°F and the rinse temperature was 158°F. Staff C stated that he had noticed that the temperatures had been running lower than required. When asked how long they had been running low Staff C said he had noticed it about two weeks ago.

The Chief Operating Officer (Staff D) who was present at the time of inspection, was not aware of this issue, and confirmed the observations at the time of inspection.

See also: C273, C278, C279

Based on interview and document review, the CAH did not maintain patient care policies and procedures that describe the Food Safety Standards that will be adhered to in the provision of Food Service.

Findings:

The Contractual Agreement for Food Services was reviewed on 1/9/17. The contract does not include any details related to food safety or any references to food safety and sanitation regulations. All kitchen staff are employed by the Food Service Contractor.

During the kitchen inspection on 1/9/17 at approximately 12:30 PM Staff C was asked if there were any hospital policies or procedures that were to be followed with regard to food safety or service. Staff C replied "not that I am aware of". When asked if he was familiar with any of the policies or procedures used by his employer Staff C replied "I don't know what they do over there".

These findings were confirmed by Staff D at the time of the kitchen inspection.

Based on observation and interview, the facility failed to remove outdated drugs from the emergency drug supply.

Findings:

On 1/9/17, at 3:00 PM, on a tour of the Infusion Center, it was noted that the Emergency Drug Box contained dopamine for infusion. The medication had expired in December 2016. Staff who were present on the tour, agreed that the medication was expired. Staff stated that the pharmacist was responsible to check the Emergency Box on a monthly basis and to remove expired medications.

On 1/11/17, at 1:30 PM, on a tour of the Westport Health Center, observations included review of medication in the Emergency Drug Box. Two vials of 1:1000 epinephrine solution had expired in September of 2016. Staff who were present on the tour agreed that the medication was outdated. Staff stated that pharmacist was responsible to check the Emergency Box and remove expired medications.

Based on observation and staff interview the facility did not maintain the kitchen in a manner consistent with food safety and sanitation standards to prevent infections and communicable diseases.

Findings:

On 1/9/17 at approximately 12:15 PM during the kitchen inspection, it was observed that the contracted kitchen staff member (Staff C) on duty had a full beard approximately six inches long and a full mustache. Staff C was not wearing any facial hair covering. When asked if he wore facial hair covering, Staff C replied no.

Staff C moved from task to task in the kitchen, including taking food temperatures and demonstrating the dishwasher, then went to the storage room and retrieved disposable cup lids, and carried the cup lids against his apron. Staff C's apron was soiled with grease and food stains. All of these tasks were done without changing gloves or performing hand hygiene.

The surveyor asked the Staff C to take a temperature of the meatballs that were in the oven. Staff C approached the food without sanitizing the probe thermometer. When asked by the surveyor if he was going to sanitize the probe, Staff C replied "oh you want me to do it before I stick it in?"

Staff C was then asked how he tested the effectiveness of the solution used for sanitizing. He demonstrated using test strips. It was then observed by the surveyor that the test strips being used expired in April 2016.

The above findings were confirmed by Staff D at the time of inspection.

Based on interview and document review the facility did not ensure that the orders of the practioner are being followed.

Findings:

During interview on 1/11/17 at approximately 1:00 PM Staff C was asked how he prepared therapeutic diets. Staff C said that patients choose from a special menu for diabetic, cardiac or low sodium diet. During review of the special menus it was noted that the there is a choice at the top of each menu where the patient can choose "small", "medium" or "large" portion size.

The surveyor then asked Staff C how the size of a portion of green beans was determined. Staff C replied that small is about a half of a spoon, medium is about one spoon, and large is about one and one half spoons. When asked if he used the same method to portion mashed potatoes he replied yes. When asked how he measured tuna fish he said he uses a scoop, that is either 3 or 4 ounces. He was not sure. When asked how he measured chicken breast he said he gives one piece. When asked what size the chicken breasts were, he did not know. When asked if he ever used measuring cups, or a scale, to portion food he replied no. Staff C was asked if the Hospital had any policies or procedures related to patient diets. He replied "not that I am aware of".

These findings were confirmed by Staff F at the time of interview.

Based on observation and interview, the facility failed to display a current Clinical Laboratory Improvement Amendment (CLIA) certificate.

Findings:

On 1/11/17 at 1:15 PM on a tour of the Westport Health Center, it was noted that the CLIA certificate, which was being displayed in the laboratory, had expired in July of 2015. Staff noted that it was expired and that they had requested an updated certificate, but had never received one. When contacted by telephone, on 1/11/17 at 1:14 PM, Staff V stated that the facility had misplaced the current certificate and had never replaced it. Staff V stated that the facility CLIA certification was valid through July of 2017.

Based on interview and document review, the CAH's medication administration policy failed to include "Timing of Medication Administration" guidelines.

Findings:

During review on 1/12/17, of the "Medication Administration, Medication Safety and Error Prevention" policy (revised 3/10/16 and 11/4/16), it was noted that the policy failed to address the accepted standards of practice for medication administration timing guidelines. Specifically, the policy failed to identify the following:

Medications not eligible for scheduled dosing time
Medications eligible for scheduled dosing times
Administration of eligible medications outside of their scheduled dosing time
Time critical and non-time critical medications
Missed or late medication administration
Evaluation of medication timing policies

The Staff A verified the above findings on 1/12/17 at 2 PM.

Based upon interview and document review, Pharmacy policies were not reviewed or revised annually.

Findings:

The pharmacy has policies that are printed and different policies that are maintained online. The printed policies were not reviewed or revised since 2004. Policies that were online were not reviewed or revised since 2010.

The above findings were verified upon interview with Staff A on 1/12/17 at 11 AM.