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Based on a review of documents, observations and interviews, the facility failed to ensure that services were provided in a safe, effective manner according to facility policy, as current standards in infection control, kitchen services, and personnel training were not followed. These deficient practices had the potential to affect all patients.

Findings included:

The facility failed to identify areas for potential transmission of infections. The infection control nurse did not have training or experience in infection control, policies and references did not reflect current standards in infection control and prevention, staff training in infection control was not conducted, and the facility failed to ensure a sanitary environment in all areas of the facility. Cross refer: CFR 485.635(a)(3)(vi)

The facility failed to ensure that dietary services were provided in accordance with recognized dietary standards, as the kitchen manager had no documented education or training as a kitchen manager, the sanitizing solution did not contain the minimum concentration of sanitizer to prevent cross contamination, there was food residue on kitchen cooking pans, food was stored improperly, and portions of the diet manual were outdated. Cross refer: CFR 485.635(a)(3)(vii)

The facility failed to ensure that staff were competent as nursing orientation was not documented and 3 nursing employees were not current in CPR. Cross refer: CFR 485.635(d), (d)(1)

Based on a review of documents, observations and interviews, the facility failed to identify areas for potential transmission of infections. The infection control nurse did not have training or experience in infection control, policies and references did not reflect current standards in infection control and prevention, staff training in infection control was not conducted, and the facility failed to ensure a sanitary environment in all areas of the facility.

Findings included:

Review of facility policy, Infection Control, Department Plan for Providing Care and Service, Policy number 1998-02, last revised 8/21/04 provided to the surveyor stated, in part,
General functions of the Infection Control Program include but are not limited to: ...
2. Establishing and implementing the policies and procedures related to control of infections within the hospital ...
V. Qualifications of Staff. A medical technologist or RN is required by Iraan General Hospital to accomplish infection control responsibilities. This Practitioner must have management experience, experience in sterilization procedures as well as experience or education in infection control techniques. The individual selected is strive (sic) to meet the required qualifications as defined by the JCAHO standards.
VI. Inservice as Continuing Education to Maintain or increase Competency. The Infection Control Coordinator is an active member of TSICP [Texas Society for Infection Control and Prevention] and as such receives information and updates on infection control issues and programs. Additionally, the coordinator receives the most recent documents available as well as attending local seminars to acquire knowledge of practices in the community and surrounding communities.
VII. Communication, Collaboration and Functional Relationships with other Departments.
A. Internal The department interacts on a daily basis with all departments of the hospital in search of prevention of infections and assurance of understanding of the standards of practice of infection control ...
X. Standards of Practice Adopted/Adapted by the Department. The department depends upon the standards of practice of CDC and APIC Standards of Practice.

In an interview with Staff #2, Infection Control Nurse the afternoon of 8/5/15 in the facility conference room, when asked by the surveyor if she had any training or experience in infection control, she stated, "No, I haven't." When asked by the surveyor if she was a member of any organization such as TSICP or APIC [Association for Professionals in Infection Control and Epidemiology], she stated that she was not a member of any organization and had not attended any seminars or training for infection control. Staff #2 stated that she did not conduct Environment of Care rounds of the various departments at the hospital.

During a tour of the facility the morning of 8/4/15, accompanied by Staff #1, facility administrator, the following was observed:
· There was a layer of dust on the large ceiling mounted light in the Emergency Department treatment room, indicating a need for cleaning. This presents a risk for cross contamination.
· There was uncovered linen observed in the radiology department and the physical therapy department. This presents a risk for cross contamination.
· There were corrugated external shipping containers in the central supply room, including a dirty corrugated shipping container on a wire shelving unit above patient care items such as procedure masks, oxygen tubing and NaCl irrigation solutions, available for patient use. Storing patient use items in proximity to and below contaminated external shipping boxes makes cross contamination likely by dirt, dust, or insects. 
· There were two external doors that had insufficient door seals or weather stripping, leaving a gap between the doors and the frame with outside light visible seen from inside the building. The lack of weather stripping or seals prevents a risk for contamination from the weather and the entry of insects and other environmental contaminants such as dust and debris.
· In the kitchen food prep area, the sanitizing solution did not contain the minimum concentration of sanitizer to prevent cross contamination, there was dried food on kitchen cooking pans, and food stored in the walk-in refrigerator was not dated. This presents a risk for cross contamination which could result in a food-borne illness.

The above findings were confirmed with Staff #1 during the tour the morning of 8/4/15.

Review of the personnel records of 14 out of 14 clinical staff revealed no documented evidence of Infection Control training. In an interview with Staff #2, Infection Control Nurse, she stated that she had not conducted Infection Control Training since she began employment at the facility in January of 2014.

Review of facility policy, "Infection Control Program Roles and Responsibilities" Policy number 1998-03, last revised 7/29/04, stated, in part,
"1. Department Manager Responsibilities
A. Implement infection control program policies and procedures in the areas of responsibility and assure that personnel comply with the policies and procedures within the department and throughout the hospital ...
E. Maintain a clean and safe environment for the patients, staff and visitors.
F. Assist in presenting infection control programs for the department and document attendance/participation.
G. Assure that employees receive infection control education annually."

Review of facility policy, "Infection Control Orientation and Inservices" Policy number 1998-08, last revised 8/23/04, stated, in part, "All new staff members will be orientated to the hospital infection control program. All patient care area staff members will be inserviced on infection control practices specific to their clinical area at least annually."

Review of facility policy, "Personnel Records" Policy number 1215, last reviewed 4/30/14, stated, in part, "The contents of the Personnel File include the following: ...
Skills Competency Checklists ...
In-service and Continuing Education ..."

Review of the Infection Control Policy and Procedure Manual revealed that the manual included the publication, "Definitions/Criteria for Nosocomial Infections" (Policy number 1998-11), which had not been revised since 8/17/04, despite more recent definitions and criteria for healthcare acquired infections. The latest publication from the CDC [Center for Disease Control and Prevention] for Surveillance was published in January 2015, with a modification in April 2015, entitled, "CDC/NHSN Surveillance Definitions for Specific Types of Infections ", available at http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf.

Review of facility policy, "Multiple Dose Vials," Policy number 1998-23, last revised 8/18/04, stated, in part,
1. All multiple dose vials, once opened are good until the manufacturer's expiration date ..." Current guidelines from the CDC state that "If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."
http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html

The above findings were confirmed in an interview with the facility administrator the afternoon of 8/5/15 in the facility conference room.

Based on observation, review of documentation, and interviews, the hospital failed to ensure that dietary services were provided in accordance with recognized dietary standards, as the kitchen manager had no documented education or training as a kitchen manager, the sanitizing solution did not contain the minimum concentration of sanitizer to prevent cross contamination, there was dried food on kitchen cooking pans, food was stored improperly, and portions of the diet manual was outdated.

Findings included:

A tour of the dietary and kitchen areas was conducted the morning of 8/4/15 accompanied by the facility administrator Staff #1 and the kitchen manager Staff #5. The following was observed:
· In the Kitchen, there were two dirty knives hanging on the knife rack, available for use in food preparation This presents a risk for cross contamination.
· There were food items (cheese and meat in baggies) in the walk-in refrigerator available for use in food prep for patients, which were not dated to indicate expiration date. This presents a risk for food-borne illness using food beyond the expiration date.
· There were 2 metal cooking pans on the metal shelving for clean cookware which were in need of cleaning as one pan had approximately 2 inches of a brown food substance adhered to the inside of the pan and the second pan had a layer of grease inside the pan. This presents a risk for cross contamination.
· There was no indication of the safe food temperature ranges on the temperature log form for the walk-in refrigerator and the walk-in freezer. When the Kitchen Manager was asked what the safe temperature ranges were, she stated that she was not sure. The temperature log form also did not provide instructions outlining the steps to be taken if the temperature was out of range. This presents a risk that food in the refrigerator or freezer could be outside of the safe temperature range due to a lack of staff knowledge of safe temperatures, and food could be maintained outside a safe range, which presents a risk for food-borne illness.
· In the food prep area, the surveyor requested that the kitchen manager test the sanitizer solution in the sink, which was used for washing dishware and cleaning food prep and food service areas in the kitchen. When the sink of sanitizer concentration was tested on request of the surveyor, there was no color change registered on the strip to indicate any concentration of the disinfectant/sanitizer in the liquid, or less than 50 PPM, indicating the sanitizer did not have the proper solution to sanitize or disinfect the food preparation area.
· During a second tour of the kitchen food prep area the afternoon of 8/5/14, the surveyor requested the sanitizer log for the sanitizing solution. There was no log provided; staff #5 stated that a log was not maintained. The surveyor requested that Staff #5 test the sink of water containing sanitizing solution. Again, when the sink of sanitizer concentration was tested on request of the surveyor, there was no color change registered on the strip to indicate any concentration of the disinfectant/sanitizer in the liquid, or less than 50 PPM, indicating the sanitizer did not have the proper solution to sanitize or disinfect the food preparation area. Approximately 30 minutes later, Staff #5 told the surveyor that the sanitizer dispensing device had been malfunctioning and had not dispensed the sanitizer solution into the sink. Staff #5 was unsure how long it had been malfunctioning. Pathogenic microorganisms can survive and contaminate food products if food-contact surfaces or dishes are not properly cleaned and sanitized with a sanitizing agent maintained at the proper level. When asked, Staff #5 stated that a log was not maintained to demonstrate sanitizer solution testing; there was no documented evidence provided to the surveyor to indicate that sanitizing solutions were being tested.

Review of the personnel record for Staff #5, Kitchen Manager, revealed no documented evidence of training or qualifications as a food service or kitchen manager. In an interview with Staff #1 and Staff #5, these findings were confirmed.

Review of Dietary Policy, "Infection Control" last revised 6/28/04, stated, in part,
"A. The Food and Nutritional Services Director is responsible for: ...
2. Preventing and controlling food borne disease ...
3. Maintaining good food handling and sanitation standards in the Department.
4. Maintaining proper documentation on the maintenance and temperatures of equipment.
5. Including personal hygiene, food handling, and sanitation in the inservice education program for department employees ...
E. Care of Equipment ...
All working surfaces, utensils, and equipment are cleansed thoroughly and sanitized after each period of use ...
G. Education
In-service schedule includes subjects relative to infection control throughout the year such as Personal Hygiene, Infection Control, Food Safety, Sanitation."

Review of the Dietary Policy, "Food Handling", last revised 6/28/04, stated, in part,
"Employees are trained during orientation and through ongoing in-services on safe food handling practices."

Review of the Dietary Policy, "Temperatures/Food Equipment", last revised 6/28/04, stated, in part,
"Temperatures of equipment, i.e., refrigerators, freezers and dish machine will be maintained as follows:
Refrigerators: Meat/Dairy and Reach-In - 38-45 degrees F
Produce - 38 - 45 degrees F
Freezers: Below 0 degrees F
If chemical sanitizer is used, a temperature of 120 degrees shall be maintained.

Review of Dietary Policy, "Leftovers" last revised 6/28/04, stated, in part,
"Leftover cooked foods will be utilized within 24 hours.
1. All leftover foods are placed in appropriate containers which are covered and labeled. The label must include the name of the item and the date of storage ...
3. The leftovers are to be used per expiration time of within 24 hours."

Review of Dietary Policy, "Equipment Temperature Monitoring", last revised 6/28/04, stated, in part,
"1. It is the responsibility of the Supervisor in Charge to check all units and record their temperature on the Temperature Check Sheet ...
4. Temperatures must be as follows:
Refrigerators 38 - 45 F
Freezers -10 - 0 F ...
5. Any variance to these temperatures must be investigated and Maintenance must be contacted if the problem can not easily be determined and fixed."

Review of Dietary Policy, "Manual Cleaning and Sanitizing" last revised 6/28/04, stated, in part,
"Proper procedure for manual cleaning and sanitizing equipment or dishware will be followed ...
A. A three (3) compartment sink shall be used if washing, rinsing and sanitizing of utensils and equipment is done manually; ...
G. When chemicals are used for sanitization, a test kit or other device that accurately measure the parts per million concentration of the solution shall be provided and used."

Review of the Dietary Policy Manual revealed the Texas Department of Health "Rules on Food Service Sanitation" dated 11/30/77. The current Texas Food Establishment Rules were last revised September, 2006. Facility failed to have current guidelines in place.

The above findings were confirmed in an interview with the facility administrator the afternoon of 8/5/15 in the facility conference room.

Based on interview, and review of records, and review of facility policies, the facility failed to ensure that staff were competent as nursing orientation was not documented and 3 nursing employees were not current in CPR. This presents a risk that nursing staff may not be assigned based on their competence and ability, particularly in situations requiring specialized training, and also presents a risk that staff may not be competent to respond in a medical emergency.

Findings included:

Review of the personnel records for 5 nursing employees revealed no documented evidence of job specific competency training or evaluation. The competency training was not provided to the surveyor for Staff #2 (RN), Staff #4 (RN), Staff 8 (RN), Staff #11 (RN) and Staff #12 (nursing assistant). This

Review of the personnel records for 3 nursing employees revealed no documented evidence of current CPR training. Current CPR documented was not provided to the surveyor for Staff #10 (nursing assistant), Staff #11 (RN), and Staff #12 (nursing assistant). Staff #2 Director of Nursing stated that these employees were scheduled to attend CPR training this week, but the class had been postponed and their training had expired.

Review of facility policy, "Personnel Records" Policy number 1215, last reviewed 4/30/14, stated, in part, "The contents of the Personnel File include the following: ...
Skills Competency Checklists ...
In-service and Continuing Education ..."

Review of facility policy, "Initial Employment Period" Policy number 1220, last reviewed 4/30/14, stated, in part, "The first 180 days of employment for all employees with Iraan General Hospital is considered to be an initial employment period...Performance, competency and conduct will be evaluated during this time. Human Resources will notify the department director when the initial period is over and remind them to complete the six-month evaluation and skills competency checklist."

Review of facility policy, "Hospital Wide-Competency Program" Policy number 1250, last reviewed 4/30/14, stated, in part, "It is the policy at Iraan General Hospital to ensure that staff are selected, prepared, and determined competent for their responsibilities through pre-employment interviews, hospital-wide and department-specific orientation, in-service training, continuing education, and annual competence assessment and verification. New employees are required to successfully pass a comprehensive skills competency checklist within their initial employment period (first 180 days). 2. The director of Human Resources is responsible for the following: a. Overseeing overall competency assessment program; b. Ensuring timely completion of all job descriptions, annual performance evaluations and competence assessment checklists; Ensuring a completed current competence assessment checklist for each employee (including contract staff) is maintained in the employee's personnel file"

The expired CPR and lack of job specific competency training and evaluation was confirmed in an interview with Staff #2, Director of Nursing at approximately 2:30 PM on 8/5/15 in the facility conference room.