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Based on observation, interview and review of documents, it was determined that the facility failed to provide food and dietetic services to patients in a safe and therapeutic manner and maintain acceptable food practice hygiene measures.

These identified unsafe dietary practices put all patients at risk for potential poor nutritional outcomes and food borne illness conditions.

Findings include:

See citations under:
Tag A 620
Tag A 622
Tag A 629

Based on observation, staff interview and review of dietary policy and procedures, it was determined that the Director of the Food and Dietetic Services did not ensure that food safety practices are followed and that the department's Quality Improvement Program (QAPI) is incorporated in the hospital-wide QAPI Program.

Findings include:

1. A tour of the hospital kitchen was conducted on 7/16/15 at approximately 10:30 AM. The following issues were identified in the presence of the Food Service Director and Assistant Director of Food Service, who were present during the tour:

a. Refrigerated foods were not kept at a safe temperature to maintain food safety.

Examples include the following:

A mini fridge freezer located on a counter adjacent to the tray line had a 10 degree temperature (Fahrenheit) and the food found in this freezer was not frozen. (Standard temperature for a freezer is 0 degrees and below). This freezer was in use despite the findings documented in the Infection Control Committee Meeting Minutes dated September 24, 2014, which noted that all mini fridge freezers, have been closed off for non-use, because they were unable to keep the freezer at the required temperatures.

The Director of Food Services acknowledged that this freezer was put back in use and was not closed off for non-use.

Two (2) tall reach-in refrigerators had torn gaskets which may affect the temperature on the refrigerator and food safety.

Two (2) insulated lids, located beneath the sliding lid cover on the third (3rd) compartment freezer, had duct tape holding the insulated lids to the sliding lid cover. This would affect the temperature of the freezer and the ability to maintain food at the correct temperature.



b. All foods in the refrigerator and freezers that were removed from original packages, were labeled with a date only. In addition, the foods were not identified on the label.
When the surveyor asked about the expiration date, the Assistant Director informed the surveyor that food is discarded after 3 days.

The facility does not have a policy on food labeling to validate this statement and a policy to provide guidance to the staff.



2. A review of the Temperature Logs completed on 7/20/15, identified the department did not meet its own temperature requirements for dietary refrigerators and freezers.

Examples include the following:

a) The Dishwashing Temperature Logs for June and July 2015 showed:
In the month of June, the Wash Temperature (Normal range = 140 degree Fahrenheit) was not met 2 of 88 times or 2%; Rinse Temperature (Normal range = 160 degree Fahrenheit) was not met 67 of 88 times or 76%; Final Rinse Temperature (Normal range = 180 degree Fahrenheit) was not met 54 of 88 times or 61%.

Similar findings were documented for the month of July, 2015.

The department did not meet its own minimum temperatures required to sanitize dishes and equipment and there was no evidence that corrective action was taken.

b) The Cooks Freezer Temperature Logs for June 2015 documented that the temperature for the freezer was not met 58 of 85 times or 68%. (Standard temperature for freezer is 0 and below degrees Fahrenheit). Examples: 6/1/15 (AM) 12.1 degrees, Noon 19.7 degrees: 6/4/15 (Noon) 22 degrees; 6/21/15 (PM) 18.6 degrees.

Walk-in Freezer temperature was not met 79 of 86 times or 92% (Standard temperature for freezer is 0 and below degrees Fahrenheit). Examples: 6/2/15 (Noon) 26 degrees; 6/6/15 (AM) 19 degrees, 6/8/15 (PM) 30 degrees.

Walk-in Refrigerator temperature was not met 25 of 86 times or 29%. Examples: 6/3/15 (PM) 50 degrees, 6/8/15 (AM) 44 degrees, 6/11/15 (PM) 45 degrees.

Similar findings were documented in July when the standard temperature for these freezers/refrigerators were not met, and the findings showed an increase in non-compliance with their required temperatures for that month.

There was no evidence that these logs were reviewed, and a Manager's signature was not documented, as required on the logs.
There is no evidence that corrective action was taken.



3. A review of the Food and Nutrition Quality Improvement Program was conducted on 7/17/15 at approximately 1:00 PM. The Performance Improvement Indicators for 2015 are; Indicator #1: "Acceptable temperature for Hot Food Items." The Benchmark for this indicator is 85%. Indicator #2: "Acceptable temperature for Cold Food Items." The Benchmark for this indicator is 85%.

The findings for Indicator #1 showed that on 1/15, 2/15, 4/15 and 5/15/15, the benchmark for the temperature for hot foods was not met; for Indicator #2, the benchmark for acceptable temperature for cold food was not met in May 20215.

There was no corrective action documented for this report.

A review of the Clinical Nutrition Performance Improvement Indicators for 2015 identified that the second (2nd) quarter data (April to June) was missing on the report. No corrective actions were documented when the data showed the indicator for Diabetic Teaching did not meet the benchmark of 90% on 2/15, and Clinical Productivity also did not meet the benchmark.

The Director of Regulatory was interviewed on 7/17/15 at approximately 2:30 PM. The Director stated that the Food and Nutrition Department Quality Improvement Program had never reported to the hospital-wide Quality Improvement Program and the department was not yet on the agenda to report for 2015.

Review of the report for Environmental Care Rounds for 2011 and 2014, identified: "All Windows were dirty." In 2014 it noted, " Soap dispenser empty, Window sills in kitchen dirty."
These findings were observed during the present survey and were validated by of the Food Service Director.
There is no documentation that the food services department corrected these identified issues. This was confirmed at interview with the Director of Safety on 7/17/15 at 10:30 AM.

Based on staff interview and review of personnel files and other documents, it was determined the hospital did not follow its policy and regulatory requirements to have Registered Diet Technicians who are qualified to perform patient nutrition assessments.

Findings include:
An interview with the Clinical Nutrition Director was conducted on 7/16/15 at approximately 12:00 PM, and the director indicated that the staff included three (3) Registered Diet Technician (one perdiem). When asked by the surveyor if the Registered Diet Technicians performed patient nutrition assessments, the Director of Clinical Nutrition stated that these technicians performed nutrition assessment on "lesser floors" such as cardiac and medical/surgical floors. She also informed the surveyor that the diet technicians did not have the State Certified Dietitian Nutritionist (CDN) credential mandated by the state of New York.

Review of the 2 Registered Diet Technician Personnel file identified the following:
The hospital's Job Description for a Registered Diet Technician was the same as for a Clinical Graduate Dietitian (4 year college and CDN) and this Job Description stated, a "Bachelor of Science in Nutrition/Dietetics" is required to work as a technician.
These 2 Registered Diet Technicians had only an Associate Degree (2 years of college) not a Bachelor degree (4 years of college) which does not meet the requirement, as stated in the facility's policy, to work as a Registered Diet Technician.
In addition, there was no evidence in the personnel file that these 2 Registered Diet Technicians had a state Certified Dietitian Nutritionist credential (CDN).

The New York State Office of Professions Website states only a CDN can practice dietetics. It states Dietitians and Nutritionist must register as a CDN every three years to practice in New York.




32522

Based on staff interview, and review of documents, it was determined that the department did not ensure that physician prescribed diets and menus met the therapeutic nutritional needs of the patients. Specifically, diets were not reviewed to ensure that all physician prescribed diets and menus met the therapeutic needs of patients; the diet order formulary was incomplete; physician prescribed diets were transcribed on the menu abbreviated, and there were diets on the menus which were not in the diet prescription formulary.

Findings include:

a) A review of the hospital master menus and physician's diet order formulary, conducted on 7/16/15 at approximately 1:00 PM, identified the following: The hospital has 29 diets on the physician diet order formulary, which is created by the nutrition division for the use of the physician in prescribing diets. When asked by the surveyor if a nutrient analysis of the diets was performed to validate that the menu conformed to all the different diet restrictions, the Clinical Nutrition Director informed the surveyor that she did not have the nutrient analysis for any of the 29 diets. Without the nutrient analysis it is unknown whether the diets on the menu met the physician diet order, or if the diets on the menus met the therapeutic nutritional needs of patients.
In addition, nine (9) out of the 29 diets in the physician's diet formulary were incomplete and the amount of the restriction was not noted.

b) A review of the menus identified that the physician prescribed diet was not transcribed to the patient's menu as written (ordered) by the physician, but was abbreviated. In addition, the abbreviation was not legible.
Example:
i) Pro40, 2 gm NAlosalt, LoPhos, Lok
ii) Dysph3
The use of abbreviations will not allow the patient or the medical/clinical staff to understand the diet ordered.

The master menu contained diets that were not on the physician diet formulary. As a result, the diets on the menu did not match the physician diet formulary.
Examples of these diet are:
- Cardiac
- There are three renal diets (not diabetic) on the physician formulary yet only one diet listed on the menu titled " Renal "
- Low Potassium Lo Na
- 1200, 1500, 1800 and 2000 calories Low Sodium
- Dysphagia Diet
- Dysphagia Low Sodium
- Dysphagia Diabetic

The hospital's master menus do not have the size of the food portion next to the food item. Standard practice requires portion size be stated next to the food item on the menu.

These findings were acknowledged by the Clinical Nutrition Director, who was present at the time of the review.

Based on observation and staff interview, the hospital did not maintain the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.

Findings are:

A tour of the hospital kitchen was conducted on 7/16/15 at approximately 10:30 AM. The following issues were identified in the presence of the Food Service Director and Assistant Director of Food Service:

1. A hand sink located at the entrance of the kitchen was blocked by 4 cases of bleach and an extra-large plastic garbage receptacle. This prevented staff access to the sink
for handwashing.
2. The kitchen ceiling vents were very dirty with black dust.
3. All plastic garbage receptacles in the kitchen had no lids.
4. The floor throughout the kitchen had black dirt stains.
5. An open, unscreened window adjacent to the food tray line was left open and served
as potential for the entry of flies and dirt. The food services director, who was present
during the tour, gave the directive to have the window closed.
6. The dry storeroom containing canned and boxed food items also had food equipment
stored in this area. The equipment was unused and soiled with dirt.


During tours of the hospital on the period from 7/20-7/24/2015, the following issues were identified in the presence of the Director of Engineering who accompanied the surveyor throughout the survey time.


During a tour of the Emergency Department (ED) on the morning of 7/20/2015, the following issues were identified:

1. The audio annunciation function of nursing call system of the bathrooms in the ED did not work and there was no audible signals at the nurse stations when the nurse call was pulled.
2. At least two chairs at the nurse station in the ED were found to have a torn and ripped surfaces.
3. The floors in some parts of the ED were not clean and there was black material coming out of the seams between the floor tiles. During an interview with the Director of Engineering, he said that that black material is the glue of the floors and that the hospital will try to wax the floor and to fix this issue.
4. The doctor's desk at Core-D of the ED was found to have sharp wooden edge and that the staff fixed cotton and gauze at that sharp edge to prevent injury. The sharp edge of the desk impose a potential hazard of injury for the staff. Also, fixing the problem using gauze and plaster to create a safer situation is a potential of infection.

Emergency Department -Psychiatric (Psych):
1. An exposed cable and wiring of the TV was observed in the waiting area of the ED Psych unit which is a potential for looping risk.
2. The Air supply vents are not from the secure and OMH approved type and they are potential of looping.
3. The door handles throughout the unit including the patient rooms and bathrooms are from the L shape (regular type), that impose a risk of looping.
4. There was over-bed table observed in some patient areas with metal handles which is potential for looping risk. Also, the shape and configuration of the over-bed table imposed looping risk.
5. The strike plates on the frames of all doors on the psych unit had protruded metal pieces that impose safety risk for the patients.
6. There was a stretcher in patient room 4 with multiple features of its sides and head of the stretcher that can be used for looping.
7. The patient bathrooms had multiple looping hazards that include but are not limited to the following:
a- The flush meter and its pipes
b- The door handles
c- The faucets and the hand-wash sinks
8. All the doors of the patient bathrooms had regular hinges, not piano hinges, which are potential of looping.
9. The fire alarm bells and strobes are not of the OMH approved ones and are potential of looping.

Operating Rooms - Main Floor:
During a tour of the Operating Rooms on the morning of 7/21/2015, the following were identified in the presence of the Director of Engineering who was accompanying the surveyor and acknowledged the findings.

1. The nursing call system in the recovery area did not have an audio annunciation.
2. The hand wash sink in procedure room #1 was found to be blocked by supply cart and was not accessible for use.
3. The way to the sharp container in procedure room #4 was blocked by garbage cart and it was observed being mounted in very close proximity to the clean supplies.
4. The hospital does not have a policy and procedure on the pre-cleaning of the scopes and the amount of the enzozyme or the water used for the pre-cleaning of the scope and or the concentration of the enzozyme used for this process.
5. There was a stainless hood in the processing room on top of the hand wash sink and that hood was observed to be rusty.

Acute Dialysis Unit- East Wing (3rd floor):
During a tour of the Acute Dialysis Unit on the morning of 7/22/2015, it was observed that the hospital has stored a clean (ready for use) portable Reverse Osmosis unit in the Hepatitis B isolation room. It should be noted that the isolation room is considered not clean and should not be used for storage of clean supplies or equipment which is potential for the spread of infection.


During a tour of the West Wing- 2nd floor (Medical Surgical Unit) on the afternoon of 7/22/2015, it was observed that the clean utility room did not have the required positive air flow as required for this type of room.

During a tour of the Central Sterile Area on the morning of 7/23/2015, it was observed that the Decontamination room did not have a hand wash sink for the staff to wash hands.

During a tour of the Catheterization Laboratory (Cath Lab) Suite on the afternoon of 7/23/2015, it was observed that the air flow of the Cath Lab room was negative instead of the required positive air flow that is required for this room.

The water faucets of the scrub sink outside the Cath Lab room was not working and there was no water available to the staff for scrubbing.

Radiology Suite:
During a tour of the Radiology Suite and review of the documentation on the morning of 7/24/2015, the following was identified in the presence of the Director of Engineering who was accompanying the surveyor.

The annual physicist reports of the two Ultrasonic machines of the hospital (Ultrasonic machines Serial #s 113701 and 113703) were overdue for the year of 2015.

Kitchen:
During a tour of the kitchen on the afternoon of 7/24/2015, the following were identified:

1. A Cook who was chopping raw meat (Red Top Round Beef) and then, there was
another bin inside the oven that had cooked meat, the cook with the same glove on his hands and without washing his hands, took the cooked meat from the oven and put it on the counter behind him. Also, the Cook after grabbing the cooked meat, removed his gloves, and washed his hands.

It should be noted that touching the cooked meat with dirty gloves and un-washed hands is a potential of transmitting microorganism from the raw meat to the ready cooked meat.

2. The back of the chest freezer which was facing the food preparation counter was found to be very dirty and dust laden.

3. The temperature of the walk-in freezer was 28 degree Fahrenheit, and the food items that included but were not limited to: fish, meat, vegetables, and chicken were not solid frozen. The Staff told the surveyor that the hospital is aware of the problem and that this problem is because of a failing of the compressor of that freezer and that a technician was working to fix this problem at the time of finding this problem.

4. Additionally, the temperature of the walk-in refrigerator was found to be 47 degree Fahrenheit, contrary to the CDC recommendation of 40 o Fahrenheit.

The above findings were identified in the presence of the Director of Engineering and the Kitchen Administrator who acknowledged them and that the facility will implement the proper corrections.