HospitalInspections.org

Based on review of the Human Resources Manager job description, observation of the kitchen and interview with staff (EMP), it was determined EMP6 was not knowledgeable to perform the duties needed to oversee the Food and Nutrition Department.

Findings include:

A review of the job description for EMP6, Senior Care officer for the Food and Nutritional Department revealed the job description was for "Position Title: Human Resources Manager." The job description failed to reveal any position requirements for Infection Control training or Food and Nutrition training.

1) A tour on August 21, 2014, from 9:45 AM to 10:00 AM of the kitchen refrigerator revealed a black slimy residue in the door jam.

An interview conducted on August 21, 2014, at 10:00 AM with EMP1 and EMP2 confirmed the presence of the black slimy residue in the door jam.

2) A tour on August 21, 2014, from 10:00 AM to 10:15 AM of the dish room revealed a moist black/brown substance along the caulk line between the wall and the top edge of the dishwashing work table, black residue and dust on the pipes below the dishwashing work table, a moist black/brown residue on the underside of the dishwashing work table, a moist yellow/white substance on the dishwasher, dust and dirt on a cart containing clean dishes
and a large amount of dust on the fan.

An interview on August 21, 2014, at 10:15 AM with EMP1 and EMP2 confirmed the above findings.

3) A tour on August 21, 2014, from 9:15 AM to 9:45 AM of the kitchen walk-in cooler revealed the following items that were not labeled with either a received or opened date: a bowl of fruit salad, a gallon container of fat free Italian salad dressing, a small bag of shredded carrots, a small bag of shredded red cabbage, a large bag of broccoli, a gallon jar of red sweet pepper strips, two large bags of spring mix, two bags of romaine lettuce, and a jar of capers. The tour also revealed three quart containers of yogurt with an expiration date of August 15, 2014, three soft and decaying tomatoes, nine soft and decaying cucumbers, two honeydew melons with black residue noted on the bottom, and moist black residue on moist paper towels on the bottom of the containers holding fresh fruit and vegetables.

An interview conducted on August 21, 2014, at 9:45 AM with EMP1 and EMP2 confirmed the above.

4) A tour on August 21, 2014, from 9:45 AM to 10:00 AM of the kitchen refrigerator revealed the following items: an open jar of garlic and an open jar of horseradish with black moist residue noted around the lid, an unlabeled red onion in a plastic bag, three soft tomatoes, an unlabeled chunk of provolone cheese in a plastic bag, an open and unlabeled bag of whipped topping and two aluminum pans with a creamy yellow substance on wet paper towels lining the bottom of the container which held unsliced lunch meat.

An interview conducted on August 21, 2014, at 10:00 AM with EMP1 and EMP2 confirmed the above.

An interview conducted on August 29, 2014, at 12:30PM with EMP6 revealed, "It falls under my umbrella. It was my responsibility to make sure people were doing what they are suppose to."

Based on review of facility policies, observation and interview with staff (EMP), it was determined the facility failed to implement policies to ensure a safe and sanitary environment was provided in the food and nutrition department.

Findings include:

A review on August 29, 2014, of Patient's Bill of Rights reviewed 2011 revealed "...You have the right to: ...Receive kind, respectful, safe, quality care delivered with the highest quality of service. ..."

A review of facility policy "Equipment care and cleaning" last revised in October 2010 revealed, "Cleaning of Stainless Steel ... X. Kitchen Rack Shelving ... 1. ... Obvious food spills/debris will constitute immediate sanitation. ..."

A review of facility policy "Cleaning Schedules" last revised June 2008 revealed, "Purpose: To designate the regular and proper sanitation of all areas and facilities of the Food & Nutritional Services Department. ... Procedure ... Individual employees are assigned cleaning tasks which they initial upon completion. The supervisor is to check to assure that each task is completed and done correctly. ..."

A review on August 21, 2014, of the cleaning log for the previous six months failed to reveal any evidence that the supervisor ensured the cleaning tasks were completed.

An interview conducted on August 21, 2014, with EMP1 confirmed the cleaning log contained no evidence that the supervisor checked to ensure the cleaning tasks were completed.

1) A tour on August 21, 2014, from 9:45 AM to 10:00 AM of the kitchen refrigerator revealed a black slimy residue in the door jam.

An interview conducted on August 21, 2014, at 10:00 AM with EMP1 and EMP2 confirmed the presence of the black slimy residue in the door jam.

2) A tour on August 21, 2014, from 10:00 AM to 10:15 AM of the dish room revealed a moist black/brown substance along the caulk line between the wall and the top edge of the dishwashing work table, black residue and dust on the pipes below the dishwashing work table, a moist black/brown residue on the underside of the dishwashing work table, a moist yellow/white substance on the dishwasher, dust and dirt on a cart containing clean dishes
and a large amount of dust on the fan.

An interview on August 21, 2014, at 10:15 AM with EMP1 and EMP2 confirmed the above findings.

3) A tour on August 21, 2014 from 10:15 AM to 11:00 AM of the general kitchen area revealed the following items: dust/dirt buildup in the corners of the kitchen, an unidentifiable dried substance noted on the clean muffin tin, a thick black residue under the cook stove, a brown/black sticky substance on the bottom of a plastic container under the griddle holding various opened plastic condiment bottles, black debris in the clean utensil storage drawer, and dust/dirt in the bottom of a dish warmer cart.

An interview on August 21, 2014 at 11:00 AM with EMP1 and EMP2 confirmed the above findings.

A review of facility policy "Guidelines for food storage" last revised in July 2012 revealed, "Purpose: To ensure ... Policy: All food ... must be stored according to state, local and federal guidelines for proper, safe and sanitary holding. ... When food items are received, they will be dated with the receiving date by using a white labeling gun. ... All partially used, opened, or leftover foods must be placed into a clean container or re-wrapped and covered, labeled and dated. ..."

4) A tour on August 21, 2014, from 9:15 AM to 9:45 AM of the kitchen walk-in cooler revealed the following items that were not labeled with either a received or opened date: a bowl of fruit salad, a gallon container of fat free Italian salad dressing, a small bag of shredded carrots, a small bag of shredded red cabbage, a large bag of broccoli, a gallon jar of red sweet pepper strips, two large bags of spring mix, two bags of romaine lettuce, and a jar of capers. The walk-in cooler also contained three quart containers of yogurt with an expiration date of August 15, 2014, three soft and decaying tomatoes, nine soft and decaying cucumbers, two honeydew melons with black residue noted on the bottom, and moist black residue on moist paper towels on the bottom of the containers holding fresh fruit and vegetables.

An interview conducted on August 21, 2014, at 9:45 AM with EMP1 and EMP2 confirmed the above.

5) A tour on August 21, 2014, from 9:45 AM to 10:00 AM of the kitchen refrigerator revealed the following items: an open jar of garlic and an open jar of horseradish with black moist residue noted around the lid, an unlabeled red onion in a plastic bag, three soft tomatoes, an unlabeled chunk of provolone cheese in a plastic bag, an open and unlabeled bag of whipped topping and two aluminum pans with a creamy yellow substance on wet paper towels lining the bottom of the container which held unsliced lunch meat.

An interview conducted on August 21, 2014, at 10:00 AM with EMP1 and EMP2 confirmed the above.

Based on observation and interview with staff (EMP), it was determined the infection control nurse failed respond immediately to the unsanitary conditions found upon inspection of the kitchen and to immediately implement a successful corrective action plan for cleaning the kitchen.

Findings include:

1) A tour on August 21, 2014, from 9:45 AM to 10:00 AM of the kitchen refrigerator revealed a black slimy residue in the door jam.

An interview conducted on August 21, 2014, at 10:00 AM with EMP1 and EMP2 confirmed the presence of the black slimy residue in the door jam.

2) A tour on August 21, 2014, from 10:00 AM to 10:15 AM of the dish room revealed a moist black/brown substance along the caulk line between the wall and the top edge of the dishwashing work table, black residue and dust on the pipes below the dishwashing work table, a moist black/brown residue on the underside of the dishwashing work table, a moist yellow/white substance on the dishwasher, dust and dirt on a cart containing clean dishes
and a large amount of dust on the fan.

An interview on August 21, 2014, at 10:15 AM with EMP1 and EMP2 confirmed the above findings.

3) A tour on August 21, 2014 from 10:15 AM to 11:00 AM of the general kitchen area revealed the following items: dust/dirt buildup in the corners of the kitchen, an unidentifiable dried substance noted on the clean muffin tin, a thick black residue under the cook stove, a brown/black sticky substance on the bottom of a plastic container under the griddle holding various opened plastic condiment bottles, black debris in the clean utensil storage drawer, and dust/dirt in the bottom of a dish warmer cart.

An interview on August 21, 2014 at 11:00 AM with EMP1 and EMP2 confirmed the above findings.

4) A tour on August 21, 2014, from 9:15 AM to 9:45 AM of the kitchen walk-in cooler revealed the following items that were not labeled with either a received or opened date: a bowl of fruit salad, a gallon container of fat free Italian salad dressing, a small bag of shredded carrots, a small bag of shredded red cabbage, a large bag of broccoli, a gallon jar of red sweet pepper strips, two large bags of spring mix, two bags of romaine lettuce, and a jar of capers. The tour also revealed three quart containers of yogurt with an expiration date of August 15, 2014, three soft and decaying tomatoes, nine soft and decaying cucumbers, two honeydew melons with black residue noted on the bottom, and moist black residue on moist paper towels on the bottom of the containers holding fresh fruit and vegetables.

An interview conducted on August 21, 2014, at 9:45 AM with EMP1 and EMP2 confirmed the above.

5) A tour on August 21, 2014, from 9:45 AM to 10:00 AM of the kitchen refrigerator revealed the following items: an open jar of garlic and an open jar of horseradish with black moist residue noted around the lid, an unlabeled red onion in a plastic bag, three soft tomatoes, an unlabeled chunk of provolone cheese in a plastic bag, an open and unlabeled bag of whipped topping and two aluminum pans with a creamy yellow substance on wet paper towels lining the bottom of the container which held unsliced lunch meat.

An interview conducted on August 21, 2014, at 10:00 AM with EMP1 and EMP2 confirmed the above.

An interview conducted on September 3, 2014, at 9:30AM with EMP5 revealed that on August 14, 2014, between 6:00PM and 6:30PM EMP5 toured the kitchen. One of the staff showed EMP5 the dark substance growing on the the wall in the walk in refrigerator and dark material growing on the seal door for the walk in refrigerator. EMP5 was told by staff that the dietary carts were not cleaned after every meal pass. The employee went over concerns regarding hand hygiene for certain staff that were not present. EMP5 stated that they felt the staff wanted to point out things that would get someone in trouble. EMP5 said that they came into the kitchen at the end of the shift and the facility does not allow overtime. EMP5 stated that they called EMP6 the next morning because they were going on vacation and explained their concerns regarding the unsanitary condition of the kitchen.

An interview with EMP1 confirmed that The Department of Health entered the facility on August 21, 2014, and nothing was done to improve the unsanitary conditions of the kitchen.