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Based on observation of the facility's kitchen and two meal services, review of the Dietary Supervisor's job description, and interviews with the Driver/Host, the Registered Dietitian (RD), the Chief Nursing Officer (CNO), the Chief Executive Officer (CEO), the Director of Nursing Operations (DON), a Representative of Sodexo, and five in-house patients, the facility failed to operate an effective food service department when they did not employ a full-time Director of Food and Dietetic Services which resulted in a problematic food service department and a general lack of organization.

The findings include:

1. Observation of facility's kitchen on 5/3/10 at 9:30 AM revealed the kitchen did not contain the essential equipment to prepare the meals for their patients or staff. There was only one employee in the kitchen at that time and she stated she had recently been hired to supervise the cafeteria at this facility.

Interview with the DON on 5/3/10 at 10:00 AM revealed the facility had contracted their food service out to a local hospital. The contracted hospital was to cook the food, prepare the individual meal trays, place them in transportation carts, drive the food to this facility via a rented truck, and serve breakfast, lunch, and dinner to their patients. They were also contracted to supply the food to the cafeteria.

Observation of the lunch meal on 5/3/10 from 11:45 - 1:30 PM revealed the meal service was disorganized and potentially hazardous. The food was to be delivered to the facility around 11:30 AM, but it did not arrive until 12:40 PM.

Interview with a newly hired employee, the driver/host for the contract food service company, on 5/3/10 at 12:40 PM revealed the meals were over an hour late because he had a accident with one of the transportation carts. He stated he had failed to secure the carts appropriately and one of the carts tipped over during the transportation process.

The contract food service company had hired him approximately one week ago, and it was his responsibility to prepare the meal trays, drive them to this facility via rented truck, and then serve the meals to the patients.

Observation of the transportation carts located in the back of the rented truck, revealed one of the carts had a broken latch that allowed the door to fly open exposing the ready to eat foods to potential contaminants. The driver/host stated he had not secured the transportation carts before he drove away and one of the carts fell over which broke the latch. Six meal trays fell out of the cart, landed on the floor of the truck, and ruined the food.

When interviewed about how the truck was to be cleaned and sanitized in-between meal services the newly hired driver/host stated he had yet to be trained on how to complete that task.

Observation of the individual meal trays located inside all three of the transportation carts on 5/3/10 at 12:45 PM revealed many, if not most, of the entrees did not have a securely fitting dome. Because the domes did not fit properly, the food was exposed to potential contaminates. The domes were laying sideways in the food that created a potentially hazardous product and one that was not ascetically pleasing. Some of the meal trays had spilt beverages that saturated the napkins and the condiments which were lying on the bottom of the trays.

Interview with the Sodexo Representative on 5/3/10 at 1:30 PM revealed the newly hired dietary staff, in this facility's kitchen, was a Dietary Supervisor and not the Director of the Food and Dietetic Services.

Review of the job description for the position of a Dietary Supervisor revealed she was responsible for the food served in the cafeteria, cleanliness and sanitation of the environment. She was not the Director of the Food and Dietetic Services and she did not prepare, serve, or ensure the patient's food was served in a safe fashion, timely, and palatable.

Interview with the RD on 5/4/10 at 2:30 PM confirmed she was a clinical dietitian and was not involved with the food service aspect of this facility.

2. Observation of the breakfast meal on 5/4/10 at 7:30 AM revealed many of the entree domes did not fit the plates securely and the food was exposed to potential contaminates during the transportation process.


Interview with an in-house patient on 5/4/10 at 8:00 AM revealed she/he was very dissatisfied with the food served at this facility. She stated she does not receive the food she requested, the meals are always late, does not get a beverage with her breakfast, has the same food for dinner that was served for lunch the previous day, and the food is not served at an acceptable temperature.


Interview with an in-house patient on 5/4/10 at 8:10 AM revealed he/she would be probably be satisfied with the meals if he/she "ever got one". He/stated the meals are routinely late.



Interview with a patient in 104 on 5/4/10 at 8:45 AM who had an uneaten breakfast tray on the bedside table for approximately one hour revealed the patient had not eaten breakfast yet; when a PCT approached the room and stated he was just going in to feed the patient.

Interview with a patient in 107 at 9:20 AM revealed breakfast was warm " not hot " and meals were never served hot.

Interview with a patient in room 109 on 5/4/10 at 9:00 AM revealed the breakfast "wasn't what I ordered " ; it was served cold and no one offered anything else.


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Observations of the breakfast meal on 5/4/10 at approximately 7:45 AM revealed breakfast trays were placed in patient rooms (133 and 138) out of reach of the sleeping patients. Patients were not awaken or positioned to eat, nor were the trays placed within reach of the patients. These patients were awaken approximately 30-60 minutes later to eat, without the food being reheated.

Observation on 5/4/10 at 8:26 AM of room 106 revealed a breakfast tray which had been placed previously on the bedside table for approximately 40 minutes, when a PCT arrived to set up the tray and feed the patient. The tray consisted of scrambled eggs, pancakes, butter and an empty covered coffee cup; there was no syrup for the pancakes on the tray. The PCT did not offer to get syrup for the pancakes or coffee for the patient to drink instead just he just poured a glass of water. After eating one bite the patient refused the meal, the plate which contained the entree was cool to touch.

Observation of the lunch meal on 5/3/10 at approximately 12:45 PM revealed a facility person delivering a lunch tray to room 136 and placing it on the bedside table. The bedside table was out of reach for the patient and the patient had to yell out for someone to come in and bring the table within reach and help set up the tray.

Interview with the DON, the CEO, the CNO, and the Sodexo Representative on 5/4/10 at 2:30 PM revealed the facility did not have a person designated to be the Director of the Food and Dietetic Services. There was no one at the facility that had the responsibility to ensure the food would be delivered timely, safely, in a sanitary fashion, ascetically pleasing, and acceptable to the patients. The Sodexo Representative stated she was a full time employee at the hospital, the contract food service company; therefore, she could not spend 40 hours each week ensuring the food service department at this facility was well organized and the food was safe for consumption.
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Based on observations, and interviews, the facility infection control officer failed to ensure an effective infection control program was in place that would prevent or reduce the spread of infections including MRSA and food borne illnesses. Observations made during meal delivery and patient set up, revealed that staff handling of meals put patients at risk for contacting and spreading infections.

The findings include:

1. On 5/4/10 at 8:26 AM, a patient care technician (PCT) wearing a gown and gloves walked into room 106 where the patient was on contact isolation due to MRSA and C-diff . The gloved PCT proceeded to prepare the patient for breakfast, positioning the bed in an upright position, bringing the over bed table closer to the patient's bed which had the patient's tray on it, arranging the articles on the table to make additional space and sliding it out. The gloved PCT then removed the dome from the plate and picked up a pancake with his gloved hand placed it flat in his hand and then buttered the pancake with his other hand and returned it back to the plate. The PCT then began to feed the patient with the same gloved hand but after one bite the patient refused the meal.

2. During the breakfast meal on 5/4/10 a PCT was observed walking into room 132, where a patient was on isolation due to C-Diff with a breakfast tray without gowning or gloving and setting up the tray.



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3. Observation of the lunch meal on 5/3/10 at 11:30-1:30 PM revealed the newly hired driver/host, that was responsible for delivering the food to this facility, via rented truck, had much difficulty handling the large transport carts independently.


He was observed during the delivery of the meals on 5/3/10 at 12:45 PM sweating and rubbing his face and hair with un-gloved hands. He was allowed to enter the facility's kitchen at 12:50 PM. He walked through the kitchen to the cafeteria area without a hair restraint and without washing or sanitizing his hands. He reached for a pair of plastic gloves and placed them on his hands. Because he did not first wash his hands the plastic gloves were potentially contaminated. Before he took the food temperatures, the surveyor intervened.


4. Observation of the food filled transportation carts, located in the back of the rented truck, on 5/3/10 at 12:40 PM revealed one of the carts had a broken latch that allowed the door to fly open exposing the ready to eat foods to potential contaminates.

The driver/host stated at 12:40 PM on 5/3/10 that the latch had broken during the transportation process when he failed to secure the carts. One of the carts fell over during transportation which resulted in a broken latch. Six meal trays fell out of the cart, landed on the floor of the truck, and consequently the food was ruined.

When interviewed about how the truck was to be cleaned and sanitized in-between meal services the newly hired driver/host stated he had not yet been trained on how to complete that process.

Observation of the individual meal trays located inside all three of the transportation carts on 5/3/10 at 12:45 PM revealed many, if not most of the entrees did not have a securely fitting dome. The food was exposed to potential contaminates and the dome was laying sideways in the food which created a potentially hazardous product.