The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|UF HEALTH LEESBURG HOSPITAL||600 E DIXIE AVE LEESBURG, FL 34748||March 31, 2017|
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based on observation, facility policy and interview, it was determined the facility failed to ensure the department is designed and equipped to facilitate the safe, sanitary provision of food service to meet the nutritional needs of the patients and to maintain appropriate infection control standards, potentially affecting the entire hospital patient population, (308 licensed beds) .
An observation of the food service operation at the conclusion of breakfast and the production for lunch was conducted on 3/31/2017 beginning at 9:05 AM with Nutritional Services staff members and the Risk Manager. Areas of concern were identified.
a.) An observation of the preparation area was conducted at 9:10 AM with the facility Risk Manager, Kitchen Supervisor and Chef. The staff member had been in the process of panning vegetables for the noon meal. A bucket was sitting on the table labeled, "Sanitizer/Disinfectant." The staff was asked to provide test strips for the check of proper sanitizing solution (Parts Per Million). The test strips provided were for a Quaternary solution. When the strip was immersed in the bucket, the test strip failed to change color, indicating no sanitizer was in the bucket (or wrong test strips utilized). The cook spoke up and stated, "oh that is soapy water which we use to wash our tables down with." When asked what sanitizer was used, there was confusion as to what was being used. The staff went to a back room, and came back with a spray bottle of disinfectant. The staff was asked to clarify the contents of the bucket marked, "Sanitizer" and then having to search for an unopened bottle of sanitizer. The sanitizer bottle was then placed on top of the work counter, near the food production.
A follow-up observation of the production area at 9:40 AM confirmed the bucket now contained a 200+ Parts Per Million (PPM) of sanitizing solution.
Two rags were noted on the work table, one near each end of the table. The rags were visibly dirty and had not been stored in a bucket with soap and water for cleaning the tables. The production staff member was observed picking up the rag from the table, wiping the surface of the table (not washed or sanitized) and replaced the rags onto the table top and not into any wash bucket.
Follow-up observation revealed the production person is now panning baked fish from the oven and placing the pieces into steamtable pans for service. Once again, the rags were on the table, not in any solution and picked up and wiped the table with the cloth for cleaning, spreading the fish juice onto the table and not removing effectively. The table was not sanitized. The production staff person was asked when the tables are disinfected. His reply was, "at the end of the shift."
b.) Food was observed at 9:22 AM in a portable steamtable located off to the side of the production area and patient tray line. Pans of food had been placed in this steamtable prior to this observation and was prepared for the lunch meal to be served beginning at approximately 11:00 AM per the kitchen staff. It was confirmed six pans were in the steamtable at that time to include creamed chicken with another being rice.
Interviews with the kitchen staff at 9:25 AM, confirmed they use this steamtable as a holding unit due to insufficient warming/heating cabinets available to hold all food that needs to be produced for the meals. It was confirmed food had been placed into the steamtable at a minimum of 2 hours in advance of the actual serving of the food. It was confirmed the steamtable is to be used for service and not for extended holding of hot food product.
c.) The walk-in refrigerators and freezers were observed at 9:45 AM with the Director of Food & Nutritional Services and Risk Manager. It was confirmed the staff had placed raw bacon on the top shelf above pans of seasoned raw chicken breast and creamed soup. It was confirmed with the Director the 5 boxes of raw bacon should have been positioned below the pans of prepared food product.
d.) Equipment was observed with the Food Services Director during the kitchen review on 3/31/2017. Areas of concern included the excessively dirty double deck oven near the production area. The oven floors (upper and lower) both had an extensive baked-on, thick layer of encrusted burnt food dropping that had not been cleaned.
The ovens near the steam table were observed to have an excessively thick burnt layer of build-up on the floor of each unit.
e.) An observation of the dish room operation was conducted during the morning of 3/31/2017 beginning at 10:05 AM with the Food Services Director. There was one food service worker in the dish room at this time. There was no handwashing sink near the dish room, and no sanitizing bucket observed for which the staff member to utilize for sanitizing hands between tasks. The staff person was observed to go from the dirty side to the clean side without washing or sanitizing her hands.
f.) The dish room observation revealed the possibility of the dish machine dryer not functioning effectively. Plastic meal trays were removed from the dish machine that remained excessively wet. The staff person in the dish room who was unloading the clean dishes proceeded to stack the wet trays on top of each other without letting them air dry in preparation of the next meal served.
The rack used for stacking domes once they exit the clean side of the dish machine, was found to have spilled debris on it that had not been wiped off prior to putting the clean dishes on it.
g.) Throughout the tour of the kitchen to include the walk-in and reach in refrigerators and stockroom shelving, the shelving was found to have a tacky residue and unclean and dusty shelves where food was stored.
h.) An observation of the floor model food mixer was conducted with the Infection Control Nurse on 3/31/2017. The under base where the beater attachment connects to the unit was checked for cleanliness. Excess dried debris was found to be remaining on the contact portion. It was confirmed vibration of the machine and beater function would loosen debris dried on the plate and fall into the beater bowl while mixing.
Further interviews with the Food Services Director and Risk Manager at 10:33 AM confirmed the facility has an "Environment of Safety (EOC)" procedure which inspects the kitchen operation twice yearly. These reports are then forwarded back to the department for review and action, then to the Quality Department for review and further action. It was confirmed the last review had been conducted in December of 2016 and confirmed with the Infection Control, Registered Nurse. The identified areas of concern were discussed with the Infection Control nurse.
It was confirmed there is no follow-up performed by the Environment of Care (EOC) committee once areas of concern area identified to ensure corrective action and then compliance has performed by the identifying department.