HospitalInspections.org

Based on observation, interview and record review the hospital failed to ensure the Dietary Director managed the dietary department in a responsible manner. The Dietary department was not maintained in a sanitary condition. This practice placed patients at risk for developing and/or acquiring infections while residing in the hospital.

Findings included:

On 02/02/12 from 10:00 AM to 11:00 AM the kitchen and dining room were toured with Staff #2, Staff #3 and Staff #4. The following observations were made:

The dish rack identified as clean by Staff #4 contained 9 perforated pans, 27 holding pans and 16 small pans. The pans were stacked wet on top of each other and not allowed to air dry. The bottom shelf of the dish rack contained 3 large lids used to cover food on the steam table. Dust, debris, grime and grease buildup was observed on the lids. Staff #4 stated the lids were not clean and should not be on the shelf.

The walk-in refrigerator contained yellow cheese slices, swiss cheese slices, various items in individual small metal pans, broccoli, shredded cheese, onions, beets and bacon bits covered with plastic wrap. The food items had no label which identified when the food was prepared. The floor of the room was soiled with dirt and debris.

The walk-in freezer contained an open bag of french fries with no label when opened. The freezer floor was soiled with debris and grime on the floor.

The dry storage room had a bag of coconut, an open container of picante sauce, a bag of pasta shells, spirals, egg noodles and opened cake mix. The above items were not labeled with date opened.

A large metal fan was sitting on the floor of the Dietary Director's office. The fan had large amounts of dust, grime and debris. Staff #4 was asked what the fan was used for. Staff #4 said the fan was used to dry the floor after mopping.

The hand sink behind Serving Line #1 was loose and falling off the wall. The sink was soiled and did not appear to be cleaned. The soap dispenser for the hand sink was sitting on top of the serving line counter. Staff #4 stated it broke off the wall next to the hand sink.

At 10:50 AM Staff #5 was asked to do food temperatures for food items on the serving line. Staff #5 took one of the two soiled cloths sitting on the steam table and proceeded to pick up the digital thermometer. Staff #5 then wiped the digital thermometer with the soiled cloth and reached over to measure the food temperature for the turkey meat. The surveyor stopped Staff #5 before the food item was contaminated. Staff #5 stated the cloth was clean. The surveyor asked Staff #5 to look at the cloth used to wipe the digital thermometer. Staff #5 said it was soiled. Staff #4 obtained alcohol pads and gave the pads to Staff #5 to use.

The lids which covered the food items on Serving Line #1 were dusty and soiled.

The table which housed the coffee/tea urns had two plastic containers on the second shelf which contained, lemon, sugar and artifical sweeteners. The containers were soiled with grime, grease and debris both inside and out.

At 10: 57 AM, the #2 serving line's hand sink was soiled with buildup. Five small plates of cookies were sitting on the top shelf of the serving line. The cookies were not labeled.

The salad bar table had two plastic bottles of salad dressing sitting on ice. The bottles were soiled with dried debris on the outside and around the spouts of the two containers. The inside surface of the table had debris stains. The exterior surface of the table had debris, dirt and grime collected on the sliding door tracks on the left and right side of the table. The plexi glass cover for the table was dusty and had not ben cleaned.

On 02/02/12 at approximately 11:00 AM Staff #4 was interviewed. Staff #4 stated the kitchen and dining room were not usually in this condition. Staff #4 verified the above findings.

The policy entitled, "Testing Food Temperatures and Use of Thermometers" with an edit date of 07/10 reflected, "Food temperatures will be taken using a standardized procedure to ensure accuracy and consistency...to assure food temperatures are always taken in a safe, accurate and sanitary manner...sanitize thermometer with an alcohol prep swab. Allow to air dry...before taking the temperature of the next item, sanitize thermometer again with alcohol swab..."

The policy entitled, "Infection Control Guidelines-Food Preparation Areas" with an edit date of 07/10 reflected, "All kitchenware and food contact surfaces used in the preparation or serving of food and beverages will be disinfected after each use...clean cloths are used in conjunction with approved sanitizing solutions and kept in the solution when not in use. Cloths are not to be left on counters...all food contact surfaces of equipment and utensils, will be handled and stored in a manner to protect them from contamination...non-food contact surfaces or equipment will be cleaned after each use and at the end of each shift to keep them in a clean and sanitary condition..."

The policy entitled, "Infection Control Guidelines-Pot and Pan Washing" with an edit date of 07/10 reflected, "Items are air dried, not towel dried for sanitation reasons and stored in a sanitary manner.."

The policy entitled, "Food Storage within the Dietary Department" with an edit date of 07/10 reflected, "Dry storage food and non-food supplies are clearly labeled..."

The policy entitled, "Food Storage Safety/Infection Control" with an edit date of 07/10 reflected, "Food is dated and rotated to ensure first in-first out...opened food items will be labeled/dated and refrigerated...leftovers are accounted for and disposed of after two days."

Based on observation, interview and record review the hospital failed to ensure the physical plant environment was maintained to ensure the safety and well-being of patients for 1 of 1 dietary department and for 4 of 7 nursing units (Chemical Dependency Unit, Adult Unit, Trauma Unit, and Children's Unit).

Findings included:

1) On 02/02/12 from 10:00 AM to 11:00 AM the kitchen and dining room were toured with Staff #2, Staff #3 and Staff #4. The following observations were made:

The hand sink behind Serving Line #1 was loose and falling off the wall. The sink was soiled and did not appear to be cleaned. The soap dispenser for the hand sink was sitting on top of the serving line counter. Staff #4 stated it broke off the wall next to the hand sink. Paint was peeling off the wall surface behind the hand sink.

On 02/02/12 at approximately 11:00 AM Staff #4 was interviewed. Staff #4 stated the kitchen and dining room were not usually in this condition. Staff #4 verified the above findings.

2) On 02/02/12 at approximately 11:10 AM the Chemical Dependency Unit was toured with Staff #2. The following was observed:

The nursing station wall had peeling paint.

3) On 02/02/12 at approximately 3:20 PM the adult unit was toured with Staff #2 and Staff #3. The following was observed:

The unit snack room ceiling vent had no cover on it. Staff #3 stated he did not know where the vent cover was.

The upper wood cabinets next to the juice machine were stained with red matter. The wall behind the juice machine was covered with red matter. The upper and lower cabinets wood surface was splintered and the veneer surface was peeling away. The wall surfaces in the room had peeling paint. The wall behind the hand sink had red matter on it. Cabinet handles were loose and/or missing.

The conference room/storage room ceiling vents (4) were observed. The exterior vent surface had a collection of black colored dirt, and grime buildup.

The dining room/activity room was observed. The ceiling four bulb fluorescent light fixture did not have a cover. A second light fixture's cover was bowing and falling out of the ceiling.

Staff #3 was asked by the surveyor if he had any work orders for the previous items found. Staff #3 stated "no."

4) On 02/03/12 at 11:15 AM, the Trauma Unit was toured with Staff #2. The following was observed:

The cover over the light fixture in the patient laundry room was falling off the fixture.

5) On 02/03/12 at approximately 10:30 AM, the Children's Unit was toured with Staff #3. The following was observed:

The housekeeping closet floor appeared dirty with dark stains and grime. The housekeeping floor sink also appeared dirty with dark stains and grime. The ceiling fluorescent light fixture did not have a cover.

At approximately 11:00 AM on 02/03/12, Staff #3 agreed that the housekeeping room needed to be taken care of and cleaned.

The undated signed Job Description for the Director of Plant Operations reflected, "The Director of Plant Operations is responsible for all aspects of maintaining the physical plant of the hospital...paint, wall and floor finishes...portable equipment...sanitation..."

Based on observation, interview and record review the hospital failed to ensure hospital equipment 1 of 4 wheelchairs, 4 of 4 geri-chairs, 5 of 7 wheelchair cushions and 2 of 2 B/P (blood pressure) machines and 1 of 1 Dietary Hand Sink were not maintained and ready for use.

Findings included:

1) On 02/02/12 from 10:00 AM to 11:00 AM the Dietary Department was toured with Staff #2, Staff #3 and Staff #4. The following was observed:

The hand sink behind Serving Line #1 was loose and falling off the wall. The sink was soiled and did not appear to be cleaned. The soap dispenser for the hand sink was sitting on top of the serving line counter. Staff #4 stated it broke off the wall next to the hand sink.

2) On 02/03/12 at 11:00 AM the Geriatric Unit was toured with Staff #2. The following observations were made:

Four wheelchairs were observed in the middle of the dayroom. One of the wheelchair's vinyl arm rests were torn and not able to be sanitized.

Four geri-chairs were soiled with debris and had a collection of dust on the back of the chair. The chairs smelled of urine.

Five of the seven wheelchair cushions were heavily stained and smelled of urine. One of the cushion's interior foam padding was sitting outside of the cushion cover.

Two blood pressure machines on wheels were soiled. The face plates of the equipment and metal base of the machines were dusty, dirty and soiled.

On 02/03/12 at approximately 11:10 PM Staff #3 was interviewed. Staff #3 acknowledged all the above findings were observed.

The undated Director of Plant Operations Job Description reflected, "The Director of Plant Operations is responsible for all aspects of maintaining the physical plant of the hospital...sanitation...portable equipment...ensures...housekeeping standards are met..."