HospitalInspections.org

Based on document review and interview, the Governing Body failed to exercise oversight and responsibility for the Specialty Hospital.
This failure placed all patients at increased risk of injury and adverse outcomes.

Findings:
The Governing Body failed to:

(a) Ensure a Physician coverage at all times for patients in the Specialty Hospital

See Tag A067

(b) Ensure that all departments and services within hospital participated in the QAPI Program.
Specifically, Food and Dietetics Department could not provide any data on any specific QI project to surveyor.

See Tag A308

(c) Ensure the Specialty Hospital has been incorporated in the Governing Body and the Medical Staff Bylaws

See Tag A347

(d) Develop a comprehensive Emergency Preparedness program that meet the needs of the population of inpatients
in the Specialty Hospital. Specifically, the facility failed to ensure:
(a) that mechanisms for timely response to an emergency medical event was in place. Specific reference is
made to the facility's lack of communication systems for staff to summon help in the event of a medical
emergency
(b) that all equipment is maintained in a manner to function appropriately.

See Tag A724

Based on observation, document review, and interview, the facility failed to maintain an Infection Control (IC) Program for the purpose of minimizing infections and communicable diseases.

These breaches in infection control practices are potential of causing cross contamination and transmission of pathogens.

Findings:

The facility failed to:

a. Appoint a qualified Infection Control and Prevention Director to oversee the IC Program

See Tag A748

b. Ensure a safe environment consistent with infection control practices and prevention of cross contamination to prevent the spread of infection.

(a)Specific reference is made to the following:
(1) The Environmental Services (EVS) staff did not wear appropriate PPE while cleaning the patient floors
(2) The Environmental Services (EVS) staff did not perform hand hygiene in between glove changes
(3) The Environmental Services (EVS) staff did not follow a specific pattern of cleaning from clean to dirty
(4) The patient care staff did not clean and disinfect patient care equipment after use.


(b) On 11/2/2021 at approximately 11:00 AM, a tour of the hospital kitchen was conducted.
The surveyor observed and an overall unsanitary condition.

See Tag A749

Based on document review and interview, the facility failed to ensure there was a physician covering the care of patients at all times at the Specialty Hospital.


Findings include:

Review of the physician schedules for September to November 2021 revealed the following timeframes for weekday coverage:
7:00 PM to 7:00 AM
9:00 AM to 2:00 PM
9:00 AM to 5:00 PM
12:00 PM to 7:00 PM.

Timeframes for weekend coverage:
9:00 AM to 9:00 PM
9:00 AM to 7:00 PM

On Wednesday September 1st, 2021, the schedule stated:
NP -9:00 AM to 2:00 PM
Physician -9:00 AM to 5:00 PM
Physician - 10:00 PM to 7:00 PM
Physician - 7:00 PM to 7:00 AM (overnight)

There was no physician scheduled coverage from 7:00 AM to 9:00 AM when the previous overnight shift ended at 7:00 AM.

On Thursday September 2nd the schedule read:
Physician - 9:00 AM to 2:00 PM
NP - 9:00 AM to 5:00 PM
Physician - 12:00 PM to 7:00 PM
Physician - 7:00 PM to 7:00 AM (overnight)

There was no physician scheduled to cover from 7:00 AM to 9:00 AM after overnight coverage ended at 7:00 AM.

On Friday September 3rd the schedule read:
Physician - 9:00 AM to 2:00 PM
NP - 9:00 AM to 5:00 PM
Physician - 12:00 PM to 7:00 PM
Physician - 7:00 PM to 9:00 AM (overnight)

There was no physician scheduled to cover from 7:00 AM to 9:00 AM after overnight coverage ended at 7:00 AM.

On Saturday September 4th: the schedule read:
Physician - 9:00 AM to 9:00 AM (on call)

On Sunday September 5th:
Physician - 9:00 AM to 7:00 AM.

Monday September 6th the schedule read:
Physician - 9:00 AM to 2:00 PM
Physician - 12:00 PM to 7:00 PM
Physician - 7:00 PM to 7:00 AM

There was no physician scheduled to cover from 7:00 AM to 9:00 AM after overnight coverage ended at 7:00 AM.

On Monday September 7th the schedule read:
Physician - 9:00 AM to 2:00 PM
NP - 12:00 PM to 7:00 PM
NP - 7:00 PM to 7:00 AM

On September 8th the schedule read:
NP - 9:00 AM to 2:00 PM
Physician - 12:00 PM to 7:00 PM
Physician - 7:00 PM to 7:00 AM (overnight)

There was no physician scheduled to cover from 7:00 AM to 9:00 AM after overnight coverage ended at 7:00 AM, and from 2:00 PM on September 7th to 12:00 PM on September 8th, 2021

Similar findings were noted throughout the schedules for September, October, and November 2021.

The facility's policy titled "Amended and Restated Bylaws for Terence Cardinal Cooke Health Care Center" approved by the Board of Trustees of The Catholic Health Care System dated December 17, 2014 section 7.2 states: " ... the Board of Directors shall serve as the governing board of the Nursing Home, shall oversee its property and affairs, develop and preserve the assets of the Nursing Home, and oversee the quality of care of patients through the appointment of a qualified medical staff. The Board shall have power to hold meetings, appoint committees, appoint an Advisory Council, employ necessary medical and administrative staff and employees and to suspend, censure or expel any of them subject to the personnel policies of the Nursing Home without prejudice to their contract rights, if any."

Review of facility's "Bylaws of the Medical and Dental Staff of Terence Cardinal Cooke Health Care Center" Revised and Restated effective June 26, 2014 in Article V, Professional Associate Staff, Section 5.1 Qualifications states: "The Professional Associate Staff shall consist of those Allied Health Professionals authorized to practice their professions at the Nursing Home including psychologists, optometrists, physician assistants, acupuncturists and nurse practitioners. Professional Associate Staff shall not be considered members of the Medical and Dental Staff."

During interview on 11/8/21 at 12:00 PM, Staff V, Medical Director stated: "During COVID we had two (2) resignations. The Nurse Practitioner occasionally helped out. Since you spoke to me, we decided to adjust the schedule. I am updating the November schedule now to reflect coverage."

Based on observation, interview and document review, the facility did not ensure that patients or their representatives are informed of the patient's rights.

Findings include:

On 11/9/2021 at approximately 1:00PM, a tour of the Specialty Hospital Unit 2C and 3C was conducted with Staff G, Program Manager. Patient Unit 3C has a census of 29 patients and three (3) patient's have Medicare. The Unit 2C has a census of 28 patients and five (5) patients have Medicare. Review of medical records on both units had no acknowledgement of notice of rights, or medicare beneficiary notice.

The admission packet consists of a folder with xerox loose paper in the folder. Some of the documents in the folder were not legible due to the multitude of xeroxing of these documents. Documents were not secure. They were loose in the folder and could easily get lost.
The Admitting Packet was in English with no title identifying the purpose of the packet.
There was no Bill of Rights or numbers to call for questions the representative may have.

On 11/9/2021 at approximately 10:10AM, an interview was conducted with Staff P, Social Worker to discuss facility's policies on patient rights, process of complaints. Staff P informed the surveyor she was unaware of the Notice of Rights, and the facility has no policies on patient rights. Social worker informed the surveyor she only interview patient family members if there is a problem. She also fills out documents at the request of the family member.

Based document review and interview, the facility did not ensure that patient grievance was thoroughly investigated and that a written response was provided to complainant.

Findings include

A. On 11/9/2021 at approximately 11:00 AM, Staff G, Program Manager presented the surveyor the facility policy on Complaints and Grievances. The title of the policy, "Grievances/Complaint Reporting and Response". This policy was last revised on 8/21/2014. The policy states they will acknowledge a grievance 7-14 days.
They will investigate and report back to the complainant 14 to 21 days afterward.

The timeframes do not meet the federal regulations criteria set fourth for timely response to complaints.

Staff G provided surveyor with 2 grievances they received for Patient #21 and Patient #22.
Both grievances were about missing belongings. There was no documented evidence that the complainant was provided a written acknowledgement or that the finalization of the investigation/outcome was mailed to the complainant.

There was no quality improvement program addressing Complaints and Grievances.

The findings were discussed with Staff G at the time of the finding.

Based on document review and interview, the hospital failed to ensure that all departments and services within the hospital participated in the QAPI Program.

Findings include:

Review of the hospital's QAPI data revealed there was no data for the Food and Dietetics Department. The Food and Dietary Department did not have a QAPI project to identify, track, analyze and improve food services in the hospital.

During tour of the facility's kitchen on 11/2/21 at approximately 11:00 AM, Staff B, Director of Food and Dietary, was asked to show and explain to surveyor the QAPI project implemented by the department. Staff B stated: "I check the diet trays for accuracy. I give it to them monthly." Staff B did not have any available projects, tracking or trending data for surveyor to review.

During interview on 11/3/21 at approximately 11:00 AM, Staff A, Dietician was asked to show surveyor the projects she was working on. Staff A stated that she checked the new admissions to ensure they were receiving a high calorie diet. Staff A could not provide any data on any specific QI project to surveyor.

These findings were shared with Staff S, Executive Director on 11/9/21 at approximately 3:00 PM.

Based on observation and document review, the facility failed to ensure there is adequate staffing in the Medical Records Department to conduct QAPI activities.

Findings include:

A tour of the Medical Record Department was conducted on 11/8/21 at approximately 1:00 PM. Present during interview was Staff I, Nurse Practitioner. Staff D, Medical Record Manager was interviewed regarding her role in the Department and Medical record audits. She informed the surveyor that the Medical Record Director had retired 3 months ago (August 2021) and that medical record audits have not been done since June 2020. She showed the surveyor a copy of the last Closed Record Documentation Audit performed in June 2020. She also showed a copy of the last QAPI performed on 6/2020. Deficiency Analysis Form resulting from this QAPI was blank. Staff D informed the surveyor that besides her there was only one (1) clerk.

Based on document review and interview, the facility failed to ensure the Specialty Hospital has been incorporated in the Governing Body and the Medical Staff Bylaws


Findings include:

Surveyor requested a copy of the facility's Organizational Chart at Entrance Conference on 11/2/21 at approximately 9:30 AM. Surveyor requested the Organizational Chart repeatedly and received it at approximately 3:45 PM,while leaving on 11/3/21. Surveyor was told by Staff Y, Senior Administrator "I just made this one."

Review of the Governing Body Bylaws and the Medical Staff Bylaws reveal the Specialty Hospital operates with a unified Medical Staff and Governing Body shared with the Nursing Home as "Terence Cardinal Cooke Health Care Center" although they are two (2) separate entities.

The Amended and Restated Bylaws for Terence Cardinal Cooke Health Care Center effective January 1, 2015 Article 1-Purposes, Section 1 states: "Certificate of Incorporation. The name and purposes of Terence Cardinal Cooke Health Care Center (the "Nursing Home") shall be as set forth in its Certificate of Incorporation. These Bylaws, the powers of the Nursing Home and of its Members and Directors and Officers and all matters concerning the conduct and regulation of the affairs of the Nursing Home shall be subject to such provisions in regard thereto, if any, as are set for the in the Certificate of Incorporation."

Section 4. Purpose of the Nursing Home. The Nursing Home is devoted to caring for the sick and disabled with compassion in the tradition of Catholic Health Care ..."

There is no reference to the Specialty Hospital.


Review of the Medical Staff Bylaws titled "The Bylaws of the Medical and Dental Staff of Terence Cardinal Cooke Health Care Center" Revised and restated. Effective June 26, 2014. States: Preamble - "The Terence Cardinal Cooke Health Care Center ("the Nursing Home") is a not-for-profit voluntary corporation sponsored by the Archdiocese of New York." The Nursing Home was organized under the Not-for-Profit Corporation Law of the State of New York and operates a Skilled Nursing Facility.
Article II states: "The purposes of these Medical and Dental Staff Bylaws ("Bylaws") and of the Medical and Dental Staff shall be: 1. To ensure all patients treated at the Nursing Home receive high quality compassionate care ..."

There is no reference to the Specialty Hospital.

The Bylaws of the Medical and Dental Staff does not separate out the specific Medical Staff Rules and Bylaws of the Specialty Hospital or the quality of care of patients in the Specialty Hospital.

During interview on 11/8/21 at approximately 11:00 AM Staff G, Program Manager stated: "I checked and according to one of our corporate lawyers, there's no separate bylaws. No separation because we're a corporation and it's quite legitimate."

Based on observation and interview, the facility failed to properly store patient's medical record to protect from potential damage from fire or water.

Findings include:

A tour of the Medical Record Department was conducted on 11/8/2021 at approximately 1:30PM.
Present during this tour was Staff D, Medical Record Manager. The Medical Record Department is in the basement of the facility. It contains over 500 medical records. These medical records were found to be unprotected. They are stored in open metal shelves on the walls, and others were in slidable open carts.


Staff D acknowledged the findings.

Based on observation, interview, and document review, it was determined, (a) recognized standards of practice was not followed for documenting diets on the menus, and (b) the facility did not ensure that diet menus met the nutritional needs of patients.

Findings include:

A. A tour of the area of clinical nutrition was performed on 11/3/21 while touring the kitchen. Present during this tour was Staff B, Food Service Director and Staff A, Clinical Nutrition Manager.
Surveyor observed menus were being sorted. Surveyor observed that prescribed diets were abbreviated, and the full name of the diet prescribed by the physician was not documented.
Example: Consistent Carbohydrate Diet was abbreviated with CCU. Abbreviation of diets is not a recognized dietary practice because the diets have a name in the facility's diet manual, and the physician orders the diet with a name, not an abbreviation.

The diets were missing the component addressing the amount of the restriction.
Example: Consistent Carbohydrate Diet did not list the total amount of carbohydrate (grams of Carbohydrate) the physician prescribed for the patient. Amounts on restrictive diets were not listed on the patient menu.

When the Staff A, Clinical Nutrition Manager was question on this matter, she did not respond.

B. Review of a posted menu was conducted while in the kitchen:
1. The Master Menu 2021 that was posted in the kitchen did not have signatures of approval or date that it was posted.

2. The Master Menu consists of five diets on a week menu and there is a 4-week cycle menu.

3. The menu posted did not have a complete diet. Example: Regular No added Salt Diet did not specify the amount of Sodium (3gm or 4 gm of Sodium).

4. The Renal Diet on the Master Menu did not have the restrictions required by this diet. This diet also did not list the amount to be provided for these restrictions. Example: 60 gms Protein, 2 gms sodium etc.

When the surveyor asked the Staff A, Clinical Nutrition Manager for the reason the restrictions ware not listed on the menu and what were the amounts in this Renal Diet, the Clinical Nutrition Manager shrugged. All questions asked by the surveyor pertaining to the Master Menu went unanswered.

C. The Master Menu nutrient analysis numbers were assessed to be incorrect. The nutrient analysis included the master menu food items plus alternate entrees available as substitutes. RDA/ RDI could not be assessed with the numbers provided in the nutrient analysis. Therefore, diets such as Regular, No Added Salt, Puree, Mechanical Soft and Renal diet could not be validated for its nutrient content, therefore there was no Nutrient Analysis to validate these diets.

D. Diets on the Food Service Menu Software titled "GeriMenu" had physician diet formulary abbreviated which did not match with the diet manual. The Diets did not read as the physician prescribes them and as listed in the facility diet manual.

Based on observations, staff interview and document review, the facility failed to ensure:
(a) that mechanisms for timely response to an emergency medical event was in place. Specific reference is made to
the facility's lack of communication systems for staff to summon help in the event of a medical emergency
(b) that all equipment is maintained in a manner to function appropriately.

Findings include:

(a) During the tour of the Specialty Hospital patient rooms and the ancillary spaces on 11/02/21 between 11:00 AM and 1:30 PM, the surveyors noted that the patient rooms did not have any code call bell system and the staff did not have any means to summon for help in the event of a medical emergency in the patient rooms. It was observed that all patient rooms are not in the near vicinity of the nurse's station.

Upon interview of the Executive Director for Speciality Hospital, Staff S, on 11/04/21 at approximately 12:00 noon, it was stated that in the event, a staff member notices a patient undergoing cardiac arrest, that staff member would run to the door of the patient room and yell out for "Help" into the corridor.

Upon request for a written policy and procedure on Handling Medical emergencies, a policy titled "Clinical, CARDIOPULMONARY (CPR) BASIC LIFE SUPPORT Protocol, Policy and Procedure (ALL Nursing Homes)" of Recharge was provided to the surveyors. Review of this policy revealed that this policy was not specific to the Specialty Hospital and it did not demonstrate the method of communication to summon for help when a staff member and/or a patient family member notices a patient undergoing a medical emergency.

In addition, the hospital was not able to demonstrate how a code cart is summoned to the bedside during an event of cardiac arrest. Review of the above-mentioned policy provided to surveyors on 11/03/21 at approximately
11:00 AM, revealed that the security guard was responsible to bring in the code cart. This policy was later changed by hospital administration to indicate that the code cart would be brought in by the nursing staff. However, the policy did not mention the mechanism or the means of communication between a patient room and the nurses' at the nurses station, and the method by which a staff member in any ancillary space (medication room, soiled utility room, clean storage) at that critical moment will be alerted of a patient code.

Therefore, the lack of a call bell system to alert staff during medical emergencies poses a risk in delay of treatment, which may result in injury/harm to patients.

(b) During the tour of the kitchen on 11/03/21 at approximately 10:30 AM, the surveyors noted a stream of water flowing from the exhaust of the dishwasher machine onto the cleaned dishes coming through the dishwasher. The surveyors noted that the inverted cups and dishes coming out of the dishwasher had puddles of water collected onto the flat surfaces and they were stored away without drying properly.

Upon interview of the Director of Food Services, Staff B, on 11/03/21 at approximately 10: 30 AM, it was stated that this staff member was not aware of the problem and that the maintenance vendor would be contacted to repair the machine.

The problem of not obtaining dry dishes after cleaning from the dishwasher poses an infection control risk, due to the fact that collection of water and wet surfaces on the dishes promotes bacterial growth.

Based on document review, and interview facility failed to follow appoint and approve an Infection Control Prevention Specialist certified in Infection Control and Prevention

Findings:

- Review of job description for an Infection Control Nurse revealed that the employee must be "licensed to practice as a Registered Nurse in New York State" and must have a "Certificate in Infection Prevention and Control (CIC)."

Review of personnel file for Staff H, Infection Control Nurse, revealed that the employee is licensed in New York State to practice as Licensed Practical Nurse, and has no valid CIC certificate.

On 11/03/2021, at 12:00noon, these findings were brought to the attention of Staff M, Human Resources Coordinator.

On 11/08/2021, at 1:00 PM, during an interview with Staff G, Program Manager, she stated that Staff H is not CIC certified. She said that Staff G, Infection Control Nurse, reports information related to infection control to physicians Staff T, MD, Infectious Diseases and Staff U, MD, Infectious Diseases.

Review of personnel files revealed that Staff T and Staff U, Physicians, have infection control privileges in the facility; however, none is CIC certified.

Based on observation, document review and staff interview, the facility did not ensure a safe environment consistent with infection control practices and prevention of cross contamination to prevent the spread of infection.

A.Specific reference is made to the following:
(1) The Environmental Services (EVS) staff did not wear appropriate PPE while cleaning the patient floors
(2) The Environmental Services (EVS) staff did not perform hand hygiene in between glove changes
(3) The Environmental Services (EVS) staff did not follow a specific pattern of cleaning from clean to dirty
(4) The patient care staff did not clean and disinfect patient care equipment after use.

B. The Food and Nutrition Depart Department failed to conform to generally acceptable infection control practices.
Specifically, the kitchen had unsanitary conditions.


Findings include:

(1) During observation of cleaning and disinfection of 2nd Floor patient rooms on 11/04/21 at approximately
11:00 AM, the surveyors observed:

a. Housekeeping staff cleaning patient room #s 224 and 222 without wearing gowns.

b. EVS Staff Z and Staff Aa were observed cleaning room #224 at approximately 11:05 AM without a gown or apron. During the cleaning process of the patient's bathroom, Staff Z's clothes were observed to be rubbing against the toilet while cleaning. These staff members were observed cleaning room after room without any gowns or aprons.

c. Staff Aa was observed at 11:15 AM to push the big biohazard container while mopping the floor of biohazard room without any gown and then was observed to enter another patient room without any gown.

Upon interview of the Director Of Environmental Services (EVS), Staff K, on 11/04/21 at approximately
11:15 AM, the surveyors were informed that the policy of the Specialty Hospital does not require EVS Staff to wear gowns when cleaning regular patient rooms. Gowns were worn by EVS staff only while cleaning isolation rooms.

Upon review of "ARCHCARE AND AFFILIATED ENTITIES POLICY" titled "Environmental Services-Infection Control and Prevention policy" on 11/04/21, it was noted that it states "Facility will provide appropriate PPEs in accordance with OSHA's PPE standards (29 CFR 1910)"

However, the policy did not specify the appropriate PPE required for EVS staff to wear during general cleaning of patient rooms.

Upon interview of the Executive Director Staff S, on 11/04/21 at approximately 12:30 PM, it was stated that the Specialty hospital was in compliance with CDC and that the policy did not require EVS Staff to wear gowns while cleaning the patient rooms on the 2nd floor, as these rooms were not isolation rooms.


(2) During the observation of the cleaning procedures, the surveyors noted that the EVS Staff did not perform hand hygiene between glove changes. For example, EVS Staff Z was observed cleaning in Room # 222 on 11/04/21 at approximately 11:45 AM. This staff member was observed cleaning and wiping the outer surface of the toilet bowl in the patient bathroom and then was observed to remove her gloves, don a new pair of gloves, open the container of clean wipes located on the EVS cart parked by the room door and pull out a new wipe and then clean the handwashing sink in the patient room.

This practice was observed multiple times while wiping and disinfecting different surfaces in the room. This staff member washed hands after removing gloves only when exiting the room. This practice was also observed by the Director Of Environmental Services, Staff K, who acknowledged the findings.

Upon request for the in-service for EVS staff regarding hand hygiene on 11/04/21 at approximately 11:15 AM, the surveyors were informed that the Director was new to the position and to the facility and had not been able to provide any specific training to the staff.


(3) Observation of the Cleaning and disinfecting process used by the EVS Staff in patient rooms, it was noted that the staff member randomly chose the different surfaces to be cleaned without following any specific pattern or sequence.
On 11/04/21 at approximately 11:30 AM in Room #222, the surveyors observed that EVS Staff Z wiped and disinfected the side rails of the bed after wiping and disinfecting the outer surface of the toilet bowl in the patient bathroom. This staff member was observed to remove her gloves and without performing hand hygiene donned a new pair of gloves to obtain clean wipes from the wipe container to wipe the bed side rails.
This practice was observed while cleaning patient room #224 between 11:00 AM and 11:30 AM also, whereby the staff member went back and forth cleaning and wiping down the various surfaces between the patient room and the bathroom.

Review of the "ARCHCARE AND AFFILIATED ENTITIES POLICY" titled "Environmental Services-Infection Control and Prevention policy" on 11/04/21, revealed that the policy did not specify any particular pattern or flow to be followed during the patient room cleaning process.

(4) During the tour of the 2nd Floor on 11/04/21 at approximately 11:45 AM, the surveyor noted a hoyer lift being used to transfer a patient from the bed to the wheelchair in room #.226. After the transfer, the hoyer lift was pushed out into the corridor by the Staff X, Certified Nursing Assistant (CNA),without wiping and disinfecting the surfaces of the hoyer lift. At approximately 11:55 PM, the surveyor observed EVS Staff Aa, roll the hoyer lift and store it away in a room.

Upon interview the CNAs that were present in room #226, Staff X and Staff Y on 11/05/21 at approximately
1:00 PM, confirmed that on 11/04/21 at approximately 11:45 AM, hoyer lift after being used to transfer the patient was put out into the corridor without wiping and disinfecting it, due to lack of adequate space in the room to move around and change the bedsheets.

In addition, an infusion pump with an empty Intravenous (IV) Solution bag hanging on it was observed in room #222 on 11/04/21 at approximately 11:30 AM. The surveyors noticed that infusion pump was not cleaned or disinfected.

Upon interview of the EVS Staff M,at approximately 11:30 AM, the surveyor was informed that the patient care related equipment were wiped down and disinfected by the CNAs.

Upon interview of the Executive Director for Specialty Hospital, Staff S, on 11/05/21 at approximately 1:15 PM, it was stated that the EVS Staff were expected to clean the base and stand of the infusion pump stand and the remaining portion of the pump would be cleaned and disinfected by the patient care staff.

Upon request for policies for cleaning patient care equipment, the facility was not able to provide a policy for the Specialty Hospital that laid out the roles and responsibilities of staff in cleaning and disinfecting patient care equipment between patient use.

These breaches in infection control practices is potential of causing cross contamination and transmission of pathogens.


On 11/2/2021 at approximately 11:00 AM, a tour of the kitchen was conducted. Present during the tour was Staff B, Food Service Director and Staff A, Clinical Nutrition Manager. The Food and Nutrition Department is managed by a contractual company.
The surveyor observed and an overall unsanitary condition. Findings were as follows:

A.1.The floor was dirty and had black grime.
2. Food carts with lunch meals were lined up beside the dirty side of the dishwasher. Some entrée covers were lope-sided due to the moving of the cart. Temperature is lost when covers are not anchored to the plate. The carts had no cover on them hence exposing the trays to dust while parked and when traveling throughout the units in the hospital. These food carts reach the patient unit via a freight elevator without being covered.
3. In the dish room was a large garbage plastic container with at least a hundred cereal bowls just swimming in water. When the surveyor asked if the dish machine was not working, she was informed by the Director that the cereals attached itself to the bowls to the extent that they do not come out clean.
4. There were three large carts with boxes, aprons and paper all disorganized in the shelves on the cart. Two of the carts were in the clean area where clean dishes were located.
5. Dirty dry flatware was lying on a plastic container.
6. A dirty fan was blowing air at the dish machine. The top of the dish machine was full of dust.
7. Food Service employees on the tray line were missing their hospital identification.
8. Walls throughout the kitchen were dirty and had dry grease stains. Small windows in the kitchen were so laden with dust you could not see through the windows.
9. The grill had approximately ¼ inch of dried grease accumulated with time.
10. The floor mixer was full of dust. Director informed the surveyor that he does not use this equipment.
11. The same finding was observed with the equipment named Robo-Coupe.
12. The lighting throughout the kitchen, pot washing area and prep area was very dim.
13. Florescent lighting was out and needed to be replaced.
14. Food warmers and two refrigerator handles were just swing when touched. They required replacement or fixing.
15. Three ovens not in use were found dirty and employees were using the ovens as lockers with clothes and
miscellaneous items.
16. Stainless steel cart next to a refrigerator had notebooks and all kinds of personal items on the shelves.
17. All cooking equipment were stained with old grease stains.
18. Below the cook's table was a shelf being used for miscellaneous personal items, t-shirt, deodorant etc.
19. Windows in the pot washing and prep areas were very dirty.
20. Floor of the refrigerators, walls of freezers and warmers were extremely dirty.
21. Food thermometer were placed in front of all refrigerators (easier to read) and not in the back as required.
22. Gaskets on warmers and reach-in refrigerators were detached, torn, discolored and brittle. All were in poor
condition yet never changed.
23. Plastic garbage cans found throughout the kitchen had no closed lids. The lids had a hole in the middle of the lids
exposing the odor of foods to fly's present during the tour.

Overall, this was a very dirty kitchen requiring oversight by the facility Infection Control Department. Staff F, Infection Control Nurse informed the Surveyor that he does not tour the kitchen nor does anyone else tours the kitchen. The kitchen has no oversight.

Staff B, Food Service Director was informed of findings throughout the tour. He acknowledged the findings.












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