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Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in 7 of the 7 smoke compartments, and would affect all of the 28 patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies. K11 (common walls), K12 (building type), K17 (corridor walls), K18 (corridor doors), K20 (vertical openings), K21 (door hold opens), K27 (smoke doors), K33 (exit construction), K34 (stair enclosure), K36 (travel distance), K38 (exit discharge), K43 (egress locking) , K56 (fire protection sprinkler function), K62 (fire protection sprinkler maintenance), K67 (ventilation), K103 (combustible construction), K106 (essential electrical) and K147 (fixed wiring). Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41.

______________________________________

Based on MR review, hospitals policy and procedures, and interview with facility staff, in 3 of 5 MR reviewed (#6, 19, 32) of patients with unwitnessed falls, a total of 33 medical records reviewed, the staff failed to adhere to hospital policy and procedure, ensuring the patients with unwitnessed falls receive immediate neurological assessments.


26390


On 9-8-2011 at 10:14 AM review of hospital Policy & Procedure (P&P) titled, " Hospital Nursing Follow-Up After Falls ", (revised 8-2010) was completed. P&P states in part, " For all unwitnessed falls, a Neurological Assessment flow sheet is to be initiated immediately following the fall. A full neurocheck is to be done and documented at least every 2 hours for the first 12 hours, every 3 hours for the next 24 hours, and every 4 hours for the following 24 hours. "

On 9-7-2011 at 1:50 PM the closed record for pt. #6 was reviewed. The record showed pt. #6 was admitted on 2-11-2011 for Chronic Kidney Disease. Nurses notes dated 2-13-2011 showed pt. #6 suffered a unwitnessed fall. Documentation states in part, " Pt. found on floor next to bed by CNA. Writer assessed pt. and found no injury or distress, fall documented and new floor mat and bed alarm in place. No treatment needed, as no injury. Pt taught to position closer to wall while in bed. " No other assessment related to the unwitnessed fall was completed.

Interview with DQA, B on 9-8-2011 at 1:00 PM revealed the hospital was aware the procedure for pt. #6 ' s unwitnessed fall was not followed. DQA, B explained there were other unwitnessed falls after pt. #6 ' s fall, in which the neurocheck was not completed. On 6-27-2011 an in service was completed to re educate staff to the fall P&P ' s.

On 9-8-2011 from 1:45 PM through 2:45 PM MR's for pt. ' s # 27, 32 and 33 were reviewed by surveyor #26390. Record for pt. # 32 showed an unwitnessed fall on 7-30-2011 was not followed up immediately with a Neurological Assessment. This was confirmed by DQA, B at 3:15 PM.



26711

Findings by Surveyor #26711:

A MR review was conducted on Pt. #19's open MR on 9/8/2011 at 2:00 p.m. Pt. #19 fell out of bed on 8/12/2011 approximately 9:10 a.m. Neurological checks (level of consciousness, pupil response, hand grasps, movement of extremities, pain and vital signs) were not initiated until 8/13/2011 at 8:00 a.m., almost 24 hours after the fall. This is not in accordance to the facility's policy.

An interview with RN P and RN Q was conducted on 9/8/2011 at 1:45 p.m. RN P was hired in October of 2010 and RN Q, "about 5 months ago." Neither RN recall a recent formal type education regarding patient falls and their responsibility other than the education they received in their orientation as new hires.
RN P stated that there was verbal communication that this was an area the facility needed to improve on and RN P did recall a mock fall demonstration P had to perform which was then critiqued and the results placed in P's mailbox for improvement suggestions.

Based on MR review 3 of 31 MR reviewed, Pt.s #3, 4, 24, review of facility forms (1 of 1 form), and staff interview, this facility fails to ensure that all documents are appropriately authenticated with signature, time, and date of the person who is initiating/writing the entry, and also that all entries are legibly entered and easily identifiable.

Findings by Surveyor #26711:

Facility form titled, "Physicians Daily Orders for Safety Interventions," with an implementation date of 2/2011, was discussed with Dir. B, CNO C, and RN P 9/8/11 at 8:30 a.m. The form is meant to be a Medical Doctor (MD) order form and it has three separate sections on the page.
One section is for Supervision Level which addresses if the patient needs more intensive supervision, such as 1:1 for pulling out tubes or lines, frequent falls, elopement risk, etc.
The next section is for Safety Interventions and includes interventions such as use of bed alarm, having a low bed, video monitoring, and other types of alarms.
The last section is the Restraint section which is reserved for more stringent restraints to prevent self harm or harm to others.
At the bottom of the order form is a place for the MD to sign, date, and time and also for a staff member to sign on the "orders noted by" line. The staff signing this form does not sign it until after the MD indicating that the new orders are noted.
According to RN P, the night shift nursing staff goes through all of the MRs nightly and prepares these forms for the MDs to sign. The night shift staff circle the pertinent interventions that are needed, however they are not to write in the Restraint section.

There is no place on the form to indicate who initiated the form, who indicated the interventions are still warranted, or the date or time the form was initiated.
Dir. B, CNO C, and RN P agreed, at the time of the discussion, this form is misleading and is not being authenticated by the staff initiating the form.

A MR review was completed on Pt. #3's open MR on 9/7/2011 at 8:35 a.m. Pt. #3 was admitted to the facility on 9/1/2011.
On 9/6/11 two separate telephone orders were taken 9 hours apart, one at 2:00 p.m., another at 11:15 p.m. The two orders are written closely together and do not allow space for the physician to co-sign the first order.
On 9/7/11 at 6:30 a.m. a telephone order (TO) was taken by an RN. The order reads: "Order clarification for 9/7 labs: CBC, BMP/read back and noted 9/7/11 0630." There is no indication by the RN that it is a telephone order or that a physician was contacted for this order.
These findings were confirmed by QCM H on 9/7/11 at 10:05 a.m.

A MR review was completed on Pt. #4's open MR on 9/7/2011 at 10:00 a.m. Pt. #4 was admitted to the facility on 5/7/2011. The chart review was done on records from 8/1/11 through 9/7/11 for orders and progress notes.
A physician progress note for 8/13/11 is not signed, dated, or timed by the physician. Two consults done by the same MD, one on 5/12/11 and one on 6/19/11, do not include a date or time for the MD signature. These findings were confirmed on 9/7/11 at 11:00 a.m. by QCM H.

A MR review was completed on Pt. #24's open MR on 9/7/2011 at 3:12 p.m. Pt. #24 was admitted to the facility on 8/15/2011.
There are 4 MD progress notes in the MR that do not indicate a time the MD signed them: 9/1/11, 8/31/11, 8/19/11, and 8/17/11. These findings were confirmed on 9/7/11 at 3:55 p.m. by QCM H.

Based on MR review 8 of 31 MRs reviewed, Pt.s #3, 4, 17, 18, 20, 23, 24, 29, Medical Staff Rules and Regulations, and staff interview, this facility fails to ensure that telephone orders (TO) and verbal orders (VO) are promptly reviewed and co-signed by the Medical Doctor (MD).

Findings by Surveyor #26711:

Review of facility Medical Staff Rules and Regulations 2011 by surveyor #29963 on 9/6/2011 at 1:15 pm. C .2. "The responsible practitioner shall authenticate such orders within forty-eight hours, and failure to do so shall be brought to the attention of the Medical Executive Committee for appropriate action".

An interview with Health Information Maintenance staff (HIM) R was completed on 9/6/2011 at 3:33 p.m. HIM R stated that MD's have 48 hours to co-sign TO's and VO's.

A MR review was completed on Pt. #3's open MR on 9/7/2011 at 8:35 a.m. Pt. #3 was admitted to the facility on 9/1/2011.
A VO taken on 9/4/11 and has not been co-signed by the physician. This finding was confirmed on 9/7/11 at 10:05 a.m. by QCM H.

A MR review was completed on Pt. #4's open MR on 9/7/2011 at 10:00 a.m. Pt. #4 was admitted to the facility on 5/7/2011. The chart review was done on records from 8/1/11 through 9/7/11 for orders and progress notes.
A VO taken on 8/23/11 was not co-signed by the MD. This finding was confirmed on 9/7/11 at 11:00 a.m. by QCM H.

A MR review was completed on Pt. #23's open MR on 9/7/2011 at 2:35 p.m. Pt. #23 was admitted to the facility on 8/15/2011.
There is a TO dated 9/2/11 from a dietician that has not been co-signed by the MD (Medical Doctor). This finding was confirmed on 9/7/11 at 3:10 p.m. by QCM H.

A MR review was completed on Pt. #24's open MR on 9/7/2011 at 3:12 p.m. Pt. #24 was admitted to the facility on 8/15/2011.
A TO was taken on 9/3/11 which is not co-signed by the MD. Also, at the bottom of this order page another TO was taken on 9/5/11 but is in amongst 4 entries that are indicated as "chart reviews" by the facility staff and therefore almost unidentifiable as a TO.
These findings were confirmed on 9/7/11 at 3:55 p.m. by QCM H.

A MR review was completed on Pt. #29's open MR on 9/8/2011 at 8:50 a.m. Pt. #29 was admitted to the facility on 8/29/2011 and transferred to an acute care facility on 9/4/11 for a change in 29's medical condition. Pt. 29's bed is currently being held pending return from acute care.
Between 9/2/11 and 9/3/11 there are 6 TOs that are not co-signed by the MD. The 3 TOs from 9/2/11 are written so closely together, or in amongst "chart reviews" that they are almost unidentifiable as separate TOs.
These findings were discussed with and confirmed by Dir. B on 9/8/11 at 2:15 p.m.

Findings by surveyor #20878:

Per review of patient #17's clinical record on 09/07/2011 at 2:30 PM the following orders were incomplete; A TO written on 08/15/2011 at 11:00 AM was not counter-signed by the physician. another TO written on 08/23/2011 at 1:30 PM was not counter-signed by the physician until 08/29 (no year was indicated). another TO on that same day at 5:30 PM is not counter-signed at all. A TO written on 08/27/2011 at 11:00 AM is counter-signed and timed by the physician but there is no date.

Per review of patient #18's clinical record on 09/07/2011 at 2:50 PM the following orders were incomplete; A TO written on 08/31/2011 at 4:00 PM was counter-signed and timed by the physician but there was not date indicated. A TO written on 09/04/2011 at 6:50 AM was not counter-signed by the physician.

Per review of patient #20's clinical record on 09/07/2011 at 3:30 PM the following orders were incomplete; A TO written on 08/26/2011 at 12:30 PM was not counter-signed by the physician until 08/29/2011. A TO written on 09/02/2011 at 10:00 PM was not counter-signed by the physician until 09/06/2011.

The preceding findings were confirmed per review by QCM H on 09/07/2011 at 4:00 PM.

According to the 2009 Food and Drug Administration (FDA) Food Code, food employees shall clean their hands using a cleaning compound in a handwashing sink. Food employees are to wash their hands with soap and water " before donning gloves for working with FOOD " . Hand antiseptics are applied only to hands that are cleaned (washed with soap and water), immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles.

Based on observations and interview, employees do not wash hands with soap and water prior to putting on gloves.

On 9/07/2011, surveyor 29302 made the following observations during tray line set-up and service:

11:34 a.m., Cook W was setting up tray line. Cook W changed left hand disposable glove, did not wash hand with soap and water and put on a new disposable glove.

11:36 a.m., Cook W removed both disposable gloves from hands, put on hand antiseptic, then put on new disposable gloves without washing hands with soap and water.

11:38 a.m., Dietary Aide V, assisting with tray line, put on disposable gloves without first washing hands with soap and water.

11:39 a.m., Cook W removed disposable gloves, applied hand antiseptic, then put on new pair of disposable gloves without washing hands with soap and water.

11:43 a.m. Dietary Aide V removed disposable gloves, applied hand antiseptic, then put on new pair of disposable gloves, without washing hands with soap and water.

11:44 a.m., Dietary Manager (DM) T, assisting Cook W with tray line, put on pair of disposable gloves without washing hands with soap and water.

11:46 a.m., Dietary Aide V removed disposable gloves, applied hand antiseptic, then put on pair of disposable gloves without washing hands with soap and water.

11:47 a.m., Cook W removed disposable gloves, applied hand antiseptic, then put on pair of disposable gloves without washing hands with soap and water.

11:48 a.m., Dietary Aide V removed disposable gloves, applied hand antiseptic, then put on pair of disposable gloves without washing hands with soap and water.

11:49 a.m., Cook W removed disposable gloves, applied hand antiseptic, then put on pair of disposable gloves without washing hands with soap and water.

11:51 a.m., Cook W removed disposable gloves, applied hand antiseptic, then put on pair of disposable gloves without washing hands with soap and water.

11:52 a.m., DM T put on pair of disposable gloves without washing hands with soap and water.

On 9/7/2011, 3:15 p.m., surveyor 29302 interviewed RD G regarding use of hand antiseptic instead of washing hands with soap and water prior to putting on disposable gloves. RD G stated was not aware handwashing with soap and water was required prior to putting on disposable gloves. RD G reported understanding for washing of hands prior to putting on disposable gloves was only necessary when hands were visibly soiled.

Hair Restraints
The 2009 FDA Food Code states that " FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observations, two employees did not have mustaches covered and one employee had front section of hair exposed.

Findings are as follows:

On 9/6/2011, 1:35 p.m.-2:20 p.m., Surveyor 29302 observed Cook U and Dietary Manager (DM) T without a mustache restraint when present in the kitchen.

On 9/7/2011, 10:45 a.m.-noon and 2:27 p.m.-2:45 p.m., surveyor 29302 observed DM T without a mustache restraint when in the kitchen.

On 9/7/2011, 10:56 a.m., surveyor 29302 observed Cook V with approximately 2 inches of hair along front hairline not covered.

Cleaning of Equipment and Utensils
The 2009 FDA Food Code states 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.
(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf
(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations.
(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free
of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observations, oven hoods and walls were dirty.

Findings are as follows:
On 9/6/2011, 1:35 p.m.-2:20p.m., surveyor 29302 toured kitchen with Registered Dietitian G (RD G). The following observations were made:
· Both range hoods in kitchen have an accumulation of dust inside.
· Edge of wall, next to ceiling, above fire extinguisher there is an accumulation of dirt that covers approximately a 12 inch area.
· There is an accumulation of dust located above sign " Cut-N-Carry " which is also above foodservice film used to cover food.

Dishwashing Machine Temperature Monitoring
According to the 2009 FDA Food Code, an irreversible registering temperature indicator is to be used to validate that the utensil surface temperature of 160 o Fahrenheit is achieved for hot water mechanical operations. Based on interview, this procedure is not being done.

Findings are as follows:
On 9/6/2011, during the initial kitchen tour conducted 1:35 p.m. - 2:20p.m., surveyor 29302 observed dishwashing procedures. Facility ' s dish machine uses hot water for sanitizing. According to surveyor 29302 ' s discussion with Registered Dietitian G (RD G) and Dietary Manager T (DM T) temperatures are logged based on the external temperature gauge and documented. RD G and DM T do not have a system in place for checking the internal temperatures of the machine as indicated by the food code. This is only done when the EcoLab representative comes in during monthly visits.

Based on observation, staff interviews and review of maintenance documents, the facility failed to construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. This deficiency occurred in 7 of the 7 smoke compartments, and would affect all of the 28 patients in the facility on the day of the survey.

FINDINGS INCLUDE:
It was observed that the facility had the following life safety deficiencies. K11 (common walls), K12 (building type), K17 (corridor walls), K18 (corridor doors), K20 (vertical openings), K21 (door hold opens), K27 (smoke doors), K33 (exit construction), K34 (stair enclosure), K36 (travel distance), K38 (exit discharge), K43 (egress locking) , K56 (fire protection sprinkler function), K62 (fire protection sprinkler maintenance), K67 (ventilation), K103 (combustible construction), K106 (essential electrical) and K147 (fixed wiring). Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 482.41.

______________________________________

Based on observations 3 out of 7 observations completed, (2 observations for Pt. #4, #11 ), policy and procedure review, review of professional infection control standards, and staff interview, this facility fails to maintain a sanitary environment and deliver care in a manner that would prevent the spread of infection.

Findings by Surveyor #26711:

Facility policy titled, "Hand Washing/Cleansing," dated 8/2010, was reviewed on 9/8/2011 at 12:15 p.m. On page 1, #1. Procedure A. Hand Hygiene indications, #5. states, "Before moving to clean body site from a contaminated body site during patient care."
#7 states, "After contact with body fluids, or excretions, mucous membranes, nonintact skin, or wound dressings or items contaminated with these body fluids."
#8. states, "During performances or normal duties/procedures."
On page 2., #15. states, "Before donning and after gloves are removed."
#17. states, "It may be necessary to wash/cleanse hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites."

Contracted service policy titled, " Treatment initiation procedure," dated 6/2006 and revision date 9/2010, was reviewed on 9/8/2011 at 2:00 pm. On page 1, procedure #3 states, "Wash hands. Put on PPE (personal protective equipment - face protection, gloves, fluid resistant/fluid impervious barrier garment).

On page 3 of this same policy, F. 3. states, "Double and triple gloving during patient/resident care may be appropriate depending on the circumstances to maintain clean procedures rather than attempting to wash/cleanse hands between tasks."

In a publication dated 7/22/2004 from the Association for Professionals in Infection Control (APIC), it states, "When double gloving, the inner glove is not a substitute for hand washing. Change both gloves and wash hands before proceeding to another task or another patient."

A tour of the East Wing was completed on 9/6/2011 at 1:55 p.m. by Surveyor #26711, accompanied by Admin A. The following findings were noted by Surveyor and confirmed by Admin A at the time of discovery:

*Clean items on the floor in the linen closet (room 2040)
*The "Day Room" had paint peeling from the walls, laminate missing from counter tops, and chips and breaks in dry wall exposing porous uncleanable surfaces.
*Pt. room 2039 had breeches in the painted surface of the wall exposing the porous drywall surface underneath.
*Pt. room 2048 had chips in the drywall exposing the porous drywall surface underneath.
*Room 2048 A, linen closet, had a clean sweatshirt on the floor.
*Pt. room 2050 has a door frame that is being loosened from the wall due to the Pt. assigned to that room slamming the door, exposing dry wall. A work order has been initiated.
*Room 2053, Janitor closet, missing pieces of laminate from the door causing a non-smooth uncleanable surface.
*Room 2056, Soiled Utility room, extensive damage to the walls with missing paint, numerous small holes in the walls, missing kickboard exposing a non-smooth surface and a gap between the floor and the wall.
*Medication Administration room had broken tiles on the floor. An open pudding cup was sitting on the counter and fragments of a pill were also laying on the counter next to the pudding cup.

An observation of a bed bath procedure was conducted on Pt. #4 by Surveyor #26711 on 9/7/2011 at 9:03 a.m. The bed bath and repositioning was performed by CNA I and CNA J. Pt. #4 is on droplet precaution isolation.

With gloved hands CNA I cleaned a small amount of stool from Pt. #4. With the same gloves CNA I applied lotion to Pt. #4's back and legs and then applied a cream to the buttock area (nutrashield). CNA I then removed the gloves and did not wash hands before applying a new pair of gloves.

Pt. #4 had more stool that required cleaning, which CNA I, with gloved hands, proceeded to clean, and then with the same gloves handled a bottle of peri-wash, lotion, and body wash and put them back in the cabinet thereby contaminating all clean items with the soiled gloves.

After the second stool, with gloved hands CNA J applied the cream to Pt. #4's buttock area and then with the same gloves assisted CNA I to change the bedding, thereby contaminating the clean bedding with the same gloves used to apply the buttock cream.

With the same gloves CNA J reattached the tube feeding, which was removed for bathing purposes, to the gastrostomy tube site and put away supplies, thereby contaminating those items as well.

These findings were discussed with CNO C and ICP F on 9/8/2011 at 9:15 a.m. Both C and F agreed this is poor practice.

An interview with RT L was conducted on 9/7/2011 at 1:40 p.m. in the RT office. A room off of the office area contained clean RT supplies on shelving units.

It was noted that in the center of this room there were insulated pipes that were missing protective covering over the insulation at the bottom of the pipes exposing the insulation and rusted connectors to the floor. Also, several areas of tile were cracked and broken and chunks of the kickboard were missing.

These areas would not be able to be cleaned effectively on the porous surfaces. These findings were confirmed by RT L at the time of discovery.

An observation of tracheostomy (trach) care and suctioning was conducted by Surveyor #26711 on 9/7/2011 at 2:16 p.m. with RT L on Pt. #4. Pt. #4 is on droplet precautions for isolation. After washing hands and applying the proper personal protective equipment (PPE), RT L put a pair of sterile gloves on over the clean gloves for the deep trach suctioning process. On three separate occasions RT L removed the top pair of gloves and applied a new pair of sterile gloves over the original pair of clean gloves without removing the original pair or performing hand washing between the glove changes.

These findings were discussed with CNO C and ICP F on 9/8/2011 at 9:15 a.m. ICP F stated the facility does not encourage double gloving and was not aware of this practice. ICP F stated that there is not a double gloving policy for the facility that F is aware of.



26390


On 9-7-2011 at 11:05 AM a tour of the hospital supply areas on the patient care units was completed with ICP, F. In clean equipment room # 2.019 an accumulation of dust, dirt and packaging material was observed under the supply racks. Dirt and dust was noted behind the door to the room.

The Soiled Equipment room had breaks in the drywall, broken and loose floor tiles and a air vent with a build up of dirt.

The clean supply room contained a ice/water machine for pt.s. The dispensing spout had a thick white coating on the outside of the spout. The inside of the spout (where the water and ice comes out) contained a thick coating of gray and white substance. The nutrition rack that held supplements contained 5 bottles of Nepro supplement that expired in April of 2011, 20 cans of Nutren Replete liquid nutrition that expired in November 2010 and 9 single serving boxes of Boost Glucose control that expired in August 2011. In addition the boxes of Boost had a layer of dust on top of the boxes. ICP, F confirmed all of the above findings at the time the observations were made.

In regards to the expired supplements ICP, F explained that while rounds are completed for Infection Control, F does not look for expiration dates or check for cleanliness of the supplement containers.


29963

An observation of the initiation of dialysis was conducted on Pt. # 11 by surveyor #29963 on 9/7/2011 at 10:50 am. The initiation of dialysis was completed by contracted staff M.

Staff M washed hands, applied gloves and a gown. Face protection was not utilized by staff M. Surveyor #29963 interviewed Staff M, on 9/7/2011 at 11:20 am, regarding the use of face protection, staff M stated "I normally do wear face protection, I know what I am suppose to do".

These findings were discussed with DQA B on 9/7/2011 at 4:00 pm. DQA B stated the staff should be following the policy.











29302

Employee Health
According to the 2009 Food and Drug Administration (FDA) Food Code, the facility " shall require FOOD EMPLOYEES and CONDITIONAL EMPLOYEES to report to the PERSON IN CHARGE information about their health and activities as they relate to diseases that are transmissible through FOOD. A FOOD EMPLOYEE or CONDITIONAL EMPLOYEE shall report the information in a manner that allows the PERSON IN CHARGE to reduce the RISK of foodborne disease transmission, including providing necessary additional information, such as the date of onset of symptoms and an illness, or of a diagnosis without symptoms. " There are specific requirements for specific symptoms/illnesses that a facility shall adhere to when " removing, adjusting, or retaining the exclusion or restriction of a food employee. "

Based on interview and record review, the facility does not have a system in place to identify, restrict and exclude ill employees working in the food service department.

Findings are:
On 9/7/2011, 1:48 p.m., surveyor 29302 interviewed Register Dietitan G (RD G) regarding what would happen if a food service employee calls in with vomiting or diarrhea? RD G stated would tell employee to stay home until symptoms subside. Surveyor 29302 asked if there is a specific timeframe employee would need to follow prior to return - depending on what the illness is? RD G did not know but went to check facility ' s infection control policy and procedure.

On 9/7/2011, 1:54 p.m., surveyor 29302 received from RD G " POLICY: Food Service/Sanitation. " " Purpose: To identify techniques and procedures, which prevent the spread of communicable diseases through prepared foods. " Surveyor 29302 ' s review of this policy demonstrates that the facility does not have a system in place to identify, restrict and exclude ill employees that work in the food service department.