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.

SUN BEHAVIORAL HOUSTON 7601 FANNIN STREET HOUSTON, TX 77054 Nov. 16, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review the facility failed to ensure an RN (registered nurse) supervise and evaluate the nursing care for 3 of 8 patients' care. (Patient #36, #37, #39).


Findings include:


Patient #36

Record review on 11/14/17 of Patient #36's medical record failed to reveal that consult was done as ordered dated 11/07/17.


Interview on 11/14/17 at 11:00 am with RN Supervisor #23 stated that it was nursing responsibility to update orders, and ensure that they were carried out. She was unable to find documentation of the consult.


Patient #37


Record review of medical record on 11/ 14/17 of Patient #37 revealed that a form titled "Diabetic Clinical Record" November 2017 revealed several blank spaces.


Interview on 11/14/17 at 1:30 p.m with RN #18 reported the blank spaces means it was not documented.


Patient #39


Record review 11/14/17 of Patient #39's medical record revealed a nursing progress note dated 11/12/17,"patient's home medications will be brought in by family member(niece)". Another nursing progress Note, dated 11/15/17 revealed home med had not followed up on order to have home medications brought in.


Interview on 11/14/17 at 10:30 am with RN #19 reported nursing was responsible to carry out all orders received and to see that medications that are coming from home were brought in.


Record review on 11/14/17 at 1:00 PM of policy titled, "Plan of Care- Protocol For The Use Of The Multidisciplinary Format" read:

PROCEDURE:

Phase I
Nursing will complete an Admission Assessment within eight (8) hours of admission.

... The RN will then initiate the initial Plan of Care reflecting Standards of Nursing Care.
These plans will guide provision of care until the first multidisciplinary plan of care session. ... these plans should be evaluated and integrated into the multidisciplinary plan of care when necessary.

Phase II Plan of Care Development: Formulating the Multidisciplinary Plan of Care

Members (nursing) of the treatment team will give additional and/or new findings.
Representatives/members will meet weekly to discuss, review and update the plan...on each problem-specific plan of care.

Record review on 11/14/17 at 2:00 pm of policy titled: Master Treatment Plan, dated 12/14/15 read:
A. Every patient shall have an individualized , comprehensive Master Treatment Plan
E. Goals are time-limited, measurable and achievable.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation,interview, and record review, the governing body failed to ensure staff' adherence to facility policies regarding Patient Rights and Food & Dietetic Services.


Patient Rights: care in a safe setting: The governing body failed to ensure:


A. Hazardous items were not readily available to ten (10) patients currently placed on suicide/self-harm precautions.


B. An effective process to communicate patient precaution levels: Inconsistent understanding among two (2) Mental Health Techs (MHT) and the Chief Nursing Officer regarding process to communicate suicide/self-harm precautions.


C. Adequate documentation of suicide/self harm precaution levels on "Patient Safety Observation Sheets": Document review revealed 11 current patients who had been placed on suicide/self harm precautions did not have this listed per policy on their "Patient Safety Observation Sheets".


D. Complete environmental safety rounds: Document review of the environmental rounding sheets for November 2017 for the second and third floors revealed numerous shifts in which the environmental rounds were not documented. On the third floor (adolescent boys & adolescent girls): 39 required shift inspections were not documented.


These 4 deficient practices had the likelihood to effect all patients in the hospital placed on suicide/self-harm precautions. Cross refer : A-0144



Food & Dietetic Services : the governing body failed to ensure staff' adherence to facility policies related to compliance with federal regulations and State licensure requirements for food service standards, laws and regulations.


A. Observation on 11-14-17 at 12:00 p.m. revealed the dishmachine was not reaching required temperatures for washing/ rinsing dishes per dishmachine manufacturer name plate (operating parameters).


B. Required concentration and availability of chemical sanitizer was not met per dishmachine manufacturer name plate (operating parameters) and state regulations.


Further observation revealed no markings on the bulk sanitizer container to indicate "fill line" and no alarm to signal if sanitizer volume was low.


Dietary Manager was unable to provide documentation of measurements of dishmachine water temperatures & sanitizer concentration for 2017. She stated water temperatures should have been checked and documented at least twice daily per policy.

Cross refer A-0620


Based on observation, interview, and record review, the facility failed to ensure 4 of 4 dietary staff were trained and competent to perform their job duties .

Interviews on 11-14-17 with 4 current Dietary Staff revealed they all operated the dish machine. None were able to state required temperatures or chemical sanitizer levels. None of the 4 were able to state how often and if the temperatures and sanitizer concentration levels were checked and documented.

Cross refer A-622
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interviews, and document review, the hospital failed to uphold patients' right to recieve care in a safe setting. The facility failed to ensure:


A. Hazardous items were not readily available to patients currently placed on suicide/self-harm precautions as evidenced by observations made on the second & third floors on 11-14-17 and 11-15-17.


Observation on 11-14-17 on the second floor revealed hazardous items in six (6) patients' rooms who were currently placed on suicide/self harm precautions (Patients # 20, 21, 22, 23, 24, 25). Items included pencils, a canvas bag with straps, scrub pants with a long drawstring tie, multiple hygiene products such as bottles of body wash, lotions, combs, brushes, toothpaste/toothbrushes, and roll on deodorant.


Observation on 11-15-17 on the second and third floors revealed hazardous items in four (4) patients' rooms who were currently placed on suicide/self harm precautions (Patients # 26, 46, 47, 48) . Items included pencil, cloth headband, multiple hygiene products such as bottles of body wash, lotions, combs, brushes, and toothpaste/toothbrushes.



B. Effective process to communicate patient precaution levels:


Interviews on 11-15-17 with Mental Health Tech ( MHT) # 12 she stated there were no patients on her unit on suicide/self harm precautions. Interview with charge nurse of same unit, Registered Nurse (RN ) # 41, she stated there were 2 patients on suicide/self harm precautions precautions on their unit.


Interviews on 11-14-17 & 11-15-17 with MHT # 11 and MHT # 15 revealed 2 different processes for communication of information related to suicide/self harm precautions.

Interview on 11-15-17 with the Chief Nursing Officer (CNO) she stated a third process was the one MHT and nursing should be following: this information should be communicated at the end of shift report.


C. Adequate documentation of suicide/self harm precaution levels on "Patient Safety Observation Sheets":


Document review on 11-14-17 & 11-15-17 revealed 11 patients who had been placed on suicide/self harm precautions did not have this listed per policy on their "Patient Safety Observation Sheets"; some for multiple days while on these precautions (Patient # 20, 22, 23, 24, 25, 26, 27, 45, 46, 47, 48).


D. Complete environmental safety rounds:


Interview on 11-15-17 with CNO # 2 she stated the MHTs conducted environmental safety rounds every 8 hours.


Document review of the environmental rounding sheets for the second and third floors revealed :


Second floor ( Mood/Anxiety Unit): 27 of the 42 required shifts for environmental safety rounds were documented.


Third floor ( adolescent boys & adolescent girls): 3 of the 42 required shifts for environmental safety rounds were documented.


These 4 deficient practices had the likelihood to effect all patients in the hospital placed on suicide/self-harm precautions. Cross refer: A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure patients' right to receive care in a safe setting on 2 of 3 patient floors (2nd & 3rd floors). The facility failed to ensure:


1. Hazardous items were not readily available to patients currently on suicide /self harm precautions.


2. An effective process to communicate patient precaution levels (particularly suicide /self harm precautions).


3. Documentation of suicide/self-harm precaution levels on "Patient Safety Observation Sheets".


4. Environmental safety rounds were conducted / documented each shift by the mental health techs(MHTs).


Findings include:


Review of facility reports revealed on August 2017, a [AGE] year old male with a history of swallowing objects and impulsive behavior was admitted . After admission, he was sent to ER from facility 3 times within 4 days. This patient chewed and swallowed a shampoo bottle cap ; and 2 golf pencils (on 2 separate dates). Facility reviewed the incidents. Preventative measures included "soap bottles discontinued and packets of soap in place for patient use".



1. Hazards in Rooms of Patients on Suicide/ Self Harm Precautions:


Day 1:

Observation on 11-14-17 during initial tour between 9:30 a.m. and 10:30 a.m. on the second floor revealed, six (6) patients on suicide/self-harm precautions had identified hazards in their rooms:


Room 217 (Patient #25 ): 2 pencils; hairbrush, lotion, 2 bottles of body wash.


Room 222 ( Patient #21): large canvas bag with 2 strap handles; comb/brush; bottle of lotion, bottle of body wash.


Room 215 (Patient # 22) : paper bag that contained "scrub pants" with a long heavy, drawstring tie; 2 bottles of body wash, bottle of lotion, toothbrush & paste


Room 219 ( Patient #24) : 2 bottles of body wash; comb, toothbrush / toothpaste; bottle of lotion.


Room 214 (Patient # 20) : a comb,brush, 2 bottles of bath wash, 1 roll-on deodorant.


Room 216 (Patient # 23) : 2 bottles of body wash, comb, toothbrush, toothpaste.


Record review on 11-14-17 of the clinical records of Patients # 20, 21, 22, 23, 24, and 25, revealed all the patients had current physician orders for suicide/self-harm precautions.


Interview on 11-14-17 at 9:50 a.m. with MHT #11 she stated none of the patients should have"hygiene buckets" in their rooms. After the patients shower, the buckets were to be kept locked in cabinets near the nurses' station. MHT # 11 went on to say "patients on suicide precautions should not have soap bottles, lotions, toothpaste, toothbrushes and definitely not anything with straps or ties on it. These are safety issues"


Day 2:

Second floor:

Observation on 11-15-17 between 10:50 a.m. and 11: 30 a.m. revealed the following:


Room 204 : shampoo, bodywash, toothbrush, deodorant


Room 202 B: ( Patient # 26 ) deodorant, body wash, toothpaste, shampoo ( patient on suicide/self harm precautions)


Room 214 : 2 bottles of body wash, toothpaste/toothbrush


Interview on 11-15-17 at 11:30 a.m. with CNO # 2, she stated "I was told the hygiene products had all been picked up this morning. This is the only floor that doesn't lock the hygiene buckets up in a cabinet near the nurse's station. The 3rd floor has a better system."


Third Floor:

Observation on 11-15-17 at 11:55 p.m. on the third floor revealed three (3) patients on suicide/self harm precautions who had identified hazards in their rooms:


Patient # 47: physician order dated 11-08-17 for suicide /self harm precautions: had a pencil, body wash, deodorant, and toothbrush/paste in her room.


Patient # 46: physician order dated 11-09-17 for suicide /self harm precautions: had cloth headband, deodorant; body wash x 2 , deodorant, and toothbrush/paste in her room.


Patient # 48: physician order dated 11-13-17 for suicide /self harm precautions: had toothbrush/paste, brush and comb in her room.


Interview with CNO # 2 at the time of observation, she stated none of the patients should have these things in their rooms.


Record review of facility policy titled "Suicide Precautions, dated 12-01-15, read:"...Policy...All harmful objects shall be removed from the patient's possession..."


Record review of facility policy titled "Contraband & Restricted Articles", dated 01-03-17 read: "...The following is a list of items not allowed during the hospital stay..This is a guide and not all inclusive. Items to be restricted: ...3. anything that may jeopardize patient safety..4...pencils..9...clothing containing strings or ties..."


Review of facility policy titled "Patient Rights & Responsibilities", dated 12-14-15, read: Purpose: To ensure all hospital staff and contract staff observe these patient's rights..The Statement of Patient Rights shall include, but is not limited to, the patient's right to ..considerate...care provided in a safe environment.."



2. Ineffective communication process for patient precaution levels



Interview on 11-15-17 at 10:55 a.m. with MHT # 12, she stated there were no patients on her unit currently on suicide/self harm precautions.


Interview on 11-15-17 at 10:30 a.m. with charge nurse on same unit, RN # 41, she stated there were 2 patients on suicide/self harm precautions.


Interview on 11-14-17 at 9:30 a.m. with MHT # 11, she stated the night shift documented the precaution levels on the observation sheets and that is what they followed.


Interview on 11-15-17 at 11:30 a.m. with MHT # 15 she said the MHTs give each other a report between the shifts.


Interview on 11-15-17 at 11:45 a.m. with the Chief Nursing Officer (CNO) # 2 she stated the MHTs were supposed to attend shift report to obtain this information from the nurses but they often did not do this.


3. Inadequate documentation of suicide/self-harm precaution levels on "Patient Safety Observation Sheets":

Day 1:

Record review on 11-14-17 of the following patient's clinical records and "Patient Safety Observation Sheets" (Observation Sheets) revealed the following:


Patient # 20: physician order dated 11-13-17 for "suicide/self harm precautions"; one Observation Sheet was undated; observation sheet dated 11-13-17 did not have suicide /self harm precautions listed as current.


Patient #22 : physician order dated 11-11-17 for "suicide/self harm precautions"; Observation sheet dated 11-14-17 did not have suicide /self harm precautions listed as current.


Patient #23 : physician order dated 11-13-17 for "suicide/self harm precautions"; Observation sheet dated 11-14-17 did not have suicide /self harm precautions listed as current.


Patient #24 : physician order dated 11-11-17 for "suicide/self harm precautions"; Observation sheets dated 11-12-17, 11-13-17, and 11-14-17 did not have suicide /self harm precautions listed as current.


Patient # 25 : physician order dated 11-13-17 for "suicide/self harm precautions"; Observation sheets dated 11-13-17 and 11-14-17 did not have suicide /self harm precautions listed as current.



Day 2: second floor

Record review on 11-14-17 of the following patient's clinical records and "Patient Safety Observation Sheets" (Observation Sheets) revealed the following:


Patient # 45: physician order dated 11-14-17 for "suicide/self harm precautions"; Observation sheets dated 11-14-17 and 11-15-17 did not have suicide /self harm precautions listed as current.


Patient # 27: physician order dated 11-10-17 for "suicide/self harm precautions"; Observation sheets dated 11-10-17, 11-11-17, 11-12--17, 11-13-17, and 11-14-17 did not have suicide /self harm precautions listed as current.


Patient # 26: physician order dated 11-10-17 for "suicide/self harm precautions"; Observation sheets dated 11-10-17, 11-12-17, 11-13-17, and 11-14-17 did not have suicide /self harm precautions listed as current.


Day 2: third floor

Record review on 11-15-17 of the following patient's clinical records and "Patient Safety Observation Sheets" (Observation Sheets) revealed the following:


Patient # 46: physician order dated 11-09-17 for "suicide/self harm precautions"; Observation sheets dated 11-09-17, 11-10-17, 11-11-17, and 11-12-17 did not have suicide /self harm precautions listed as current.


Patient # 47: physician order dated 11-08-17 for "suicide/self harm precautions"; Observation sheets dated 11-08-17, 11-09-17, 11-10-17, 11-11-17, 11-12-17, and 11-13-17 did not have suicide /self harm precautions listed as current.


Patient # 48: physician order dated 11-13-17 for "suicide/self harm precautions"; One observation sheet was undated.


Record review of facility policy titled "Levels of Observation & Precaution Levels", dated 01-17-17 , read: "..5. Staff will complete the patient observation rounds as rounds are made using the patient safety observation codes described on the patient observation record...Staff will initial, document appropriate safety observation codes in the designated areas on the..record.."


Record review of facility policy titled "Patient Observation Rounds", dated 12-14-15, read: "...A staff member will be assigned by the Charge Nurse each shift to be responsible for the Patient Check Sheet..The Charge nurse reviews and signs the rounds sheets at the end of each shift.."



4. Incomplete environmental safety rounds:


Interview on 11-15-17 at 11:30 a.m. with CNO # 2, she reported the MHTs conducted environmental rounds every 8 hours.


Interview on 11-16-17 at 1:00 p.m. with MHT # 40 she stated the MHTs making walking rounds every shift looking for environmental hazards, contraband, infection control missies, etc... She said all MHTs use the same form and the completed forms are kept on a binder at the nurses station.


Third Floor:

Record review on 11-15-17 of binder titled " Environmental Daily Rounds" [third floor Binder -Adolescent Unit] for November 2017 revealed:

*Girls: only 3 of 42 environmental rounds forms completed for November 2017.

*Boys: only 3 of 42 environmental rounds forms completed for November 2017.


Second Floor:

Record review on 11-15-17 of binder titled " Environmental Daily Rounds" [second Floor Binder : Mood/Anxiety Unit] for November 2017 revealed:

*There was only 2 days in which the form was completed for all 3 shifts.

*Two (2) days: form not completed for all 3 shifts ( November 4 & 10, 2017)

* Seven (7) days in which one shift was missing ( November 1, 2, 5, 7, 11, 12, and 15, 2017 ).

*Four (4) days in which 2 shifts were missing (November 3, 8,13,15)


Record review of facility policy titled "Behavioral Health Unit Safety", dated 10-03-17, read: "Purpose...To ensure a safe and secure environment of care...Safety rounds on the physical environment...will be conducted daily by a member of the multidisciplinary treatment team..."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, and record review the facility failed to ensure that individual treatment plans contained a list of specific nursing related needs for 4 of 12 patients (Patient ID #2, # 34, #36, #38, # 34 ).


Findings included:


Patient ID # 2:

Record review of medical record of Patient ID#2 on 11/12/17 failed to reveal a treatment plan.

Interview on 11/14/17 at 1:45 p.m. with RN (registered nurse) #18 stated that treatment /nursing care plan is kept in the medical record of each patient. When asked to locate it for this Patient#2 it was not found.


Patient ID # 34:

Record review of Patient # 34's clinical record revealed, he was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizophrenia. Review of Patient # 34's Master Treatment Plan , dated 11-10-17 revealed his active medical diagnoses were diabetes and hypertension.

Further review of Patient 34's clinical record revealed a physician order, dated 11-09-17 that read:" diabetic patient, insulin sliding scale protocol." Patient # 34 was having blood sugar checks 4 times a day.

Continued review of Patient #34's Master Treatment Plan failed to reveal diabetes or hypertension listed as a nursing problem.

Interview on 11-16-17 at 1:15 p.m. with Registered Nurse(RN) # 31, she was unable to locate diabetes and hypertension listed as nursing problems on Patient #34's treatment plan. She stated they both should have been addressed, as they were active medical diagnoses.


Patient ID #36:

Record review on 11/14/17 of medical record of Patient ID#36 revealed that the newly diagnosed Acute Bronchitis was not contained on care plan.

Interview on 11/14/17 at 10:45 am with RN, ID#23, Nursing Supervisor, stated that the care plan should have been updated with Acute Bronchitis.


Patient ID # 38

Record review on 11/14/17 of medical record of Patient ID#38 revealed that nursing failed to remove from the care plan the discontinuation of 1 on 1 monitoring specific for this patient.

Interview on 11/14/17 at 1:30 pm with RN ID#18 about Patient #38 one on one status being discontinued. Who's responsibility is to update the care plan with that new information she said,"nursing". When asked to locate that in the care plan she could not find it. Is it suppose to be in the care plan, she stated, "yes".


Record review on 11/14/17 of facility policy titled, "Plan of Care- Protocol For The Use Of The Multidisciplinary Format" read:


PROCEDURE:
Phase I
Nursing will complete an Admission Assessment within eight (8) hours of admission.

... The RN will then initiate the initial Plan of Care reflecting Standards of Nursing Care.
These plans will guide provision of care until the first multidisciplinary plan of care session. ... these plans should be evaluated and integrated into the multidisciplinary plan of care when necessary.

Record review on 11/14/17 of policy titled: Master Treatment Plan, dated 12/14/15 read:
A. Every patient shall have an individualized , comprehensive Master Treatment Plan
E. Goals are time-limited, measurable and achievable.
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
Based on observation, interview, and record review, the facility failed to ensure adherence to facility policies related to compliance with federal regulations and State licensure requirements for food service standards, laws and regulations.


A. Observation on 11-14-17 at 12:00 p.m. revealed the dishmachine was not reaching required temperatures for washing/ rinsing dishes per dishmachine manufacturer name plate (operating parameters).


Required wash temperature was 140 degrees (F); actual wash temperature measured by Dietary manager was 64 degrees F.

Required rinse temperature was 120 degrees F; actual rinse temperature measured by Dietary Manager was 60 degrees F.


B. Required concentration and availability of chemical sanitizer was not met per dishmachine manufacturer name plate (operating parameters) and state regulations.


Required concentration of chemical sanitizer was at least 50 ppm (parts per million); actual sanitizer concentration measured by Dietary manager was less than 50 ppm.

Further observation revealed no markings on the bulk sanitizer container to indicate "fill line" and no alarm to signal if sanitizer volume was low.

Interview at time of observation with Dietary Manager # 6 she stated she was unaware a visual check or alarm was required for chemical sanitizers.

Dietary Manager was unable to provide documentation of measurements of dishmachine water temperatures & sanitizer concentration for 2017. She stated water temperatures should have been checked and documented at least twice daily per policy.

Cross refer A-0620



Based on observation, interview, and record review, the facility failed to ensure 4 of 4 dietary staff were trained and competent to perform their duties (Dietary Staff 7, 8, 9, 10).


Interviews on 11-14-17 with Dietary Staff # 7, 8, 9, 10 revealed, they all operated the dish machine. None were able to state required temperatures or chemical sanitizer levels. None of the 4 were able to state how often and if the temperatures and sanitizer concentration levels were checked and documented.


Observation on 11-14-17 of Dietary Staff # 7 demonstrated checking the water temperature in the 3 compartment sink using a test strip meant for checking chemical sanitizer concentration. He stated he always used these strips and verified, "yes, it is for measuring water temperature". Dietary Staff #9 also said he used these same strips to measure temperature in the 3 compartment sink.

Cross Refer A-0622
~~~
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, interview, and record review, the facility dietary manager failed to ensure:


Required temperatures for washing / rinsing dishes were maintained to sanitize patient dishware for 10 of 10 months in 2017.


Required concentration and availability of chemical sanitizer was maintained to sanitize patient dishware for 10 of 10 months in 2017.


Findings include:


Observation on 11-14-17 at 11:30 a.m. in the facility kitchen revealed an "Auto-Chlor" dish machine.


Interview at the time of observation with Dietary Manager # 6 , she supplied the names of staff currently on duty who operated the dish machine.


Interview on 11-14-17 at 11:40 a.m. with Dietary staff # 8 he stated he operated the dish machine. He went on to say "I think the sanitizer is checked ." He was unsure where this was recorded. Dietary Staff # 7 said the dish machine temperatures were not documented.


Interview on 11-14-17 at 11:45 a.m. with Dietary staff # 7 he stated he operated the dish machine. He went on to say "the temperature could be checked with paper strips." He was unable to state what the correct temperatures should be or show where the temperatures were recorded.


Observation on 11-15-17 at 12:00 p.m. revealed "Auto-Chlor" dishmachine, data plate operating instructions posted on the machine that read: "NSF DATA PLATE...Chemical Sanitizing:

Wash tank minimum temperature 140 degrees Fahrenheit (F)
Final rinse minimum temperature: 120 decrees F
Sanitizer required: minimum 50 ppm ( parts per million) available chlorine".


Interview at the time of observation with Dietary Manager # 6 she stated the dish machine was a chemical sanitizer dish machine.


Continued observation revealed Dietary Manager # 6 checked the temperatures on the dish machine twice. The highest of the temperatures readings were as follows:

Wash cycle: 64 degrees F (required 140 degrees F)
Rinse cycle : 60 degrees F (required 120 degrees F)


Dietary Manager # 6 went on to check the sanitizer concentration with a test strip. It was less then the required 50 ppm.


Continued interview with Dietary Manager # 6 she stated she was aware the temperatures were not at required levels. She had been in her position for 7 weeks. Shortly after she started , Ecolab was called because the dishmachine temperature booster was broken. She went on to say it had not been repaired yet because in the interim, the facility changed vendor contracts for the dish machine.


Dietary Manager # 6 said the dish machine temperatures should be measured at least twice a day and recorded. She was unable to produce documentation of dish machine temperature recordings or chemical sanitizer levels for 2017.


She went on to say she was not aware the facility was required to have an alarm or visual means to verify detergents and sanitizers were being delivered to the machine. She said the facility did not have an alarmed machine or maintain a log to indicate a visual inspection of the sanitizer level. The required level on the sanitizer container was not marked. Dietary Manager # 6 said she was unsure what the level should be but she would find out and mark the sanitizer container.


Record review of the facility census report for 11-14-17 revealed a total patient census of 83.


Record review of facility policy titled "Dishwasher Compliance", dated 12-14-16, read:...lll. Dishwashing:...2. Dishwasher water temperature will be maintained at 150-160 degrees F and a sanitizing solution of sodium hypchorite will be used in the wash cycle...3. The final rinse cycle will operate with a water temperature of 120 F ... Monitoring: 1. The dishwasher temperature is monitored: a. after breakfast..b after dinner..C follow manufacturer's instructions.."


Record review of the Texas Food Establishment Rules (TFER) dated October 2015, [25 Texas Administrative Code (TAC) 228.106(m) ]read: "..Warewashing (dishwashing) machine, data plate operating specifications. A warewashing machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operating specifications including the:(A) temperatures required for washing, rinsing, and sanitizing;..."


Continued review of TFER, October 2015, [25 Texas Administrative Code (TAC) 228.106(q) (2) ] read : "...Warewashing machines shall be equipped to ...(2) incorporate a visual means to verify detergents & sanitizers are delivered or a visual or alarm to signal if the ..sanitizers are not delivered ..."
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on observation, interview, and record review, the facility failed to ensure that 4 of 4 dietary staff were trained & competent in their duties (Dietary Staff # 7, 8, 9, 10).

Facility failed to ensure staff had training/ knowledge of food safety measures related to the dishwashing machine and 3 compartment sink.


Findings include:


Dish Machine:


Observation on 11-14-17 at 11:30 a.m. in the facility kitchen revealed an "Auto-Chlor " dish machine.


Interview at the time of observation with Dietary Manager # 6 , she supplied the names of staff currently on duty who operated the dish machine.


Interview on 11-14-17 at 11:40 a.m. with Dietary staff # 8 he stated he operated the dish machine. He went on to say he did not know if it was a high temperature or chemical sanitizer machine. "I think the sanitizer is checked ." He was unsure where this was recorded. Dietary Staff # 7 said the dish machine temperatures were not documented.


Interview on 11-14-17 at 11:45 a.m. with Dietary staff # 7 he stated he operated the dish machine. He was unsure if the dish machine was a high temperature or chemical sanitizer machine. He went on to say "the temperature could be checked with paper strips." He was unable to state what the correct temperatures should be or how often they should be checked. He was not aware if the dish machine temperatures were recorded.


Interview on 11-14-17 at 11:50 a.m. with Dietary staff # 9 he stated he sometimes operated the dish machine. He was unsure if the dish machine was a high temperature or chemical sanitizer machine. He said he did not think the temperatures were recorded for the dish machine; just the 3 compartment sink.


Interview on 11-14-17 at 12 p.m. with Dietary staff # 10 she stated she usually worked as a cook, but operated the dish machine sometimes. She said "I think they check the temperatures but not sure of this."


3 Compartment Sink:


Observation on 11-14-17 at 11:30 a.m. in the facility kitchen revealed a 3 compartment sink. Further observation revealed a clipboard with forms hanging on the wall over the sink. A plastic tube of some type of test strips was located on a shelf right above the 3 compartment sink.


Record review of the forms on the clipboard read: title " 3 Compartment Sink Temperature Log"...* Test strips should read 200-400 ppm [parts per million]...".


Interview on 11-14-17 at 11:45 a.m. with Dietary staff # 7 he stated he often checked the temperature for the 3 compartment sink. When asked to demonstrate; he took a test strip from the plastic bottle on the shelf placed it into the sink compartment at the far right. He read the strip and said "it is 200 degrees." Surveyor clarified he was measuring temperature. Dietary Staff # 7 said "yes" and said he compared the strip to the color coding on the side of the test strip bottle that showed "200 ppm". "This indicated the temperature was 200."


Interview on 11-14-17 at 11:50 a.m. with Dietary staff # 9 he stated he used the strips (QAC OR Test Strips) to check the temperature of the 3 compartment sink. He said he recorded it on the " 3 Compartment Sink Temperature Log".


Record review of label of the plastic bottle of test strips used by Dietary Staff # 7 read" QAC QR Test Strips." Review of manufacturers instructions stated: " QAC test strips (for quaternary ammonia compounds) are used to confirm if QAC sanitizers are at the appropriate concentration for use in sanitizing..."


Interview on 11-14-17 at 12:20 p.m. with Dietary Manager # 6 , she stated she was unaware staff was using sanitizer test strips and thinking they were measuring temperature.



Record review on 11-16-17 of the personal and training records of Dietary Staff # 7, #8, #9, # 10 revealed the following:


Dietary Staff # 7: "Food Service Service Worker "job description , signed 08-08-17, read : "Demonstrates Competency in the Following Areas:..."Loads and operates dishwashers..Operates equipment safely and correctly...Supports and maintains a culture of safety and quality.." Further review of the training file for this employee failed to reveal documented training/competency specific to the processes related to the dish machine and 3 compartment sink.


Dietary Staff # 8: "Food Service Service Worker "job description , signed 11-07-17, read : "Demonstrates Competency in the Following Areas:..."Loads and operates dishwashers..Operates equipment safely and correctly...Supports and maintains a culture of safety and quality.." Further review of the training file for this employee failed to reveal documented training /competency specific to the processes related to the dish machine and 3 compartment sink.


Dietary Staff # 9: "Food Service Service Worker "job description , unsigned, read : "Demonstrates Competency in the Following Areas:..."Loads and operates dishwashers..Operates equipment safely and correctly...Supports and maintains a culture of safety and quality.." Further review of the training file for this employee failed to reveal documented training / competency specific to the processes related to the dish machine and 3 compartment sink.


Record review of facility policy titled "Dishwasher Compliance", dated 12-14-16, read:...lll. Dishwashing:...2. Dishwasher water temperature will be maintained at 150-160 degrees F and a sanitizing solution of sodium hypochlorite will be used in the wash cycle...3. The final rinse cycle will operate with a water temperature of 120 F ... Monitoring: 1. The dishwasher temperature is monitored: a. after breakfast..b after dinner..C follow manufacturer's instructions.."


Record review of facility policy titled "3 Compartment Sink", dated 12-16-16, read:"...6...This sink must contain...a. QUAT 40/Oasis 146 Multi-Quat sanitizer of a range of 150-400 ppm. This is verified by the Quat 40 test strip...submerge in water for 10 seconds and verify color is within acceptable range...b. Hot water of at least 170 degrees F (check periodically with thermometer for 30 seconds every 10-20 minutes, or..c. Water with chlorine strength of 100 ppm.."


Record review of the Texas Food Establishment Rules (TFER) dated October 2015, [25 Texas Administrative Code (TAC) 228.106(m) ]read: "..Warewashing (dishwashing) machine, data plate operating specifications. A warewashing machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operating specifications including the:(A) temperatures required for washing, rinsing, and sanitizing..."