HCA Florida Sarasota Doctors Hospital

Based on medical record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) that was within the capability and capacity of the hospital's emergency department (ED) to determine whether or not an emergency medical condition existed for 1 patient (Patient #2) of 21 sampled patients for emergency treatment. Refer to findings in A2406.

Based on review of medical records, the Electronic Central Log, in-service training, and interviews, the facility failed to accurately maintain the central log for an individual who comes to the emergency department seeking medical assistance for 1 patient (Patient #2) of 21 sampled patients.

The findings included:

A record review on 11/25/13 revealed documentation for Patient #2 of a late entry dated 11/4/13 for an evaluation that took place on 11/3/13 at 2:00 p.m. The evaluation by the physician documented her primary discharge diagnosis as facial swelling. The treating physician documented, The patient reports a fall and facial injury 2 days ago for which she was seen and evaluated here at hospital. She states since she is taking anticoagulants, that she had CT head/brain done at that time, which was negative for any intracranial injury.

She states that the swelling on her chin has gotten larger since that time and 'isn't sure what to do about it.' She denies any/all other complaints/symptoms at the time of the initial H & P (History & Physical), specifically denying any changes in visual acuity or neurological changes/symptoms. The patient was discharged home.

During an interview on 11/25/13 at 5:13 p.m., the Director of the Emergency Department (ED) stated, I sent out a bullet list about EMTALA about how they should approach patients coming to the ED. I explained the situation that we are self-reporting,... I explained about completing the entry into the Central Log and to include all individuals that came to the ED seeking assistance. I reminded them that it must be accurate, that anytime a person requested medical care they must be added to log, every individual coming to the ED even if they leave should be recorded into the log as 'John/ Jane Doe' if they don't give identifying information. ED providers will not advise patients in the lobby or provide any type of exam to any individual in the lobby who has not been logged into the system. Education for EMTALA is done every 2 years. I sent this out to everybody in nursing to be done, and the Medical Director sent out a notice to his providers to do the education on-line.

During an interview on 11/26/13 at 2:24 p.m., Employee A stated, The niece and the patient (#2) came in with papers in her hand. She said 'I was here on Friday.' When I saw what her face looked like, I offered her a wheelchair; the niece kept saying 'she doesn't need to be here.' The patient said she didn't need to be here but wanted to know if the swelling is what the doctor had said she could expect. I told her to go ahead to sit in the chair and I would register her. She refused to be registered and then said she just wanted to validate what the doctor said. She showed me the discharge papers. I then went to the back and asked the doctor to come and talk to her. I was just asking the physician to validate the instructions by the physician who discharged her, so I asked him to come up. I am not allowed to bring a person back that isn't registered. The ED physician came up to the triage area. I was standing there, but I wasn't observing what he was doing; I was speaking with the niece. I was physically standing in the entrance, but I was turned to the niece. I have since received education, if they refused to be registered I will put them in as John/Jane Doe; every patient will be registered. I would then complete an incident report and get in touch with my supervisor. Now everybody will be registered.

On 11/25/13 review of the Electronic Central Log revealed Patient #2 was logged in on 11/1/13 (her original visit). The electronic central log documented on 11/3/13 for Patient #2 recheck - late entry at 1400. Documentation of the Electronic Central Log revealed that on 11/3/13 at 2209 Patient #2 was admitted with a subdural hematoma.

A medical record review on 11/25/13 revealed documentation for Patient #2 as a late entry dated 11/4/13 at 12:50 p.m., for an evaluation by the ED physician that took place on 11/3/13 at 2:00 p.m. Patient #2 was originally seen and evaluated by a physician for this medical issue on 11/1/13. According to interview with Employee A, Patient#2 was seen on 11/3/13 at 2:00 p.m., in the triage area and not was registered in the Electronic Central Log.

The surveyor checked the Electronic Central Log for accuracy, completeness, gaps in entries or missing information in the records. The second encounter for Patient #2 was documented as a late entry and there was no documentation of a disposition for the 11/3/2013 2:00 p.m. visit. There was no record of registration or collection of required information at the time Patient #2 presented in ED at 2:00 p.m. on 11/3/13. Interviews with facility staff revealed the patient was seen in the ED without documenting the encounter.

A review of the hospital records finds the ED nursing staff was provided in-service training on the requirement to document all patient visits to the ED on 11/15/13. All hospital nursing staff received an in-service on 11/7/13, including information on EMTALA requirements and the requirement to initiate a record for all patients presenting at the ED. The medical staff department minutes for emergency physicians documented Employee F had a department meeting with the ED physicians on Tuesday, 11/19/13 and reviewed the requirement to document all patient encounters.

Based on record review and interview, the facility failed to provide an appropriate medical screening examination (MSE) that was within the capability and capacity of the hospital's emergency department (ED) to determine whether or not an emergency medical condition existed for 1 patient (Patient #2) of 21 sampled patients for emergency treatment.

The findings included:

A record review on 11/25/13 revealed documentation for Patient #2 of a late entry dated 11/4/13 at 12:50 p.m. for an evaluation that took place on 11/3/13 at 2:00 p.m. The evaluation by the physician documented her primary discharge diagnosis as facial swelling. The treating physician documented, The patient reports a fall and facial injury 2 days ago for which she was seen and evaluated here at hospital. She states since she is taking anticoagulants, that she had CT head/brain done at that time, which was negative for any intracranial injury.

She states that the swelling on her chin has gotten larger since that time and 'isn't sure what to do about it.' She denies any/all other complaints/symptoms at the time of the initial H & P (History & Physical), specifically denying any changes in visual acuity or neurological changes/symptoms. The patient was discharged home.

The facility failed to ensure that on 11/3/13 at 2:00 p.m., Patient #2 received a formal medical screening examination. An informal medical screening examination for patient #2 was not documented until 11/4/13 at 12:50 p.m. Further review of the medical record indicated that Patient #2 returned to the ED on 11/3/13 at 22:09 for continued facial swelling, confusion, and vomiting. Review of the History and Physical dated 11/4/13 revealed in part, Patient #2 had an emergent CT scan of the brain, which showed a large subdural hematoma (a collection of blood outside the brain usually caused by severe head injury). By the time the patient came out of the CT scanner, back to the emergency room , he/she was rapidly becoming obtunded and could not maintain her airway and therefore he/she was electively intubated by the ER physician ... The patient expired shortly before I saw her on the Medical Surgical Department, but had been discussed with the patient's family and been made a DNR (do not resuscitate) and comfort measures. Cause of death is from the subdural hematoma with a midline shift and intracranial pressure.

During an interview on 11/25/13 at 5:13 p.m., the Director of the Emergency Department (ED) stated, ED providers will not advise patients in the lobby or provide any type of exam to any individual in the lobby who has not been logged into the system.

During an interview on 11/25/13 at 5:50 p.m., Employee B stated I am aware of her (Patient #2) swelling and she was taking Coumadin (an anti-coagulant). She had questions about her facial swelling; she wanted to know what she could to make it go down faster. I gave her a brief exam and found her to be neurologically intact. I didn't think the CT (computed tomography) scan needed to be repeated based on focal exam, neurologically intact and given the clinical picture; it just wasn't warranted.

Based on record review and interview, the hospital failed to maintain the facility's fuel supply for the emergency generator to ensure reliable use of the generator in an emergency. The failure to ensure emergency power puts the health and safety of patients at risk in the event of a power failure, not an uncommon event in southwest Florida. The facility failed to ensure the smoke dampers were operable.

The findings include:

1. The fuel analysis for Doctor's Hospital's emergency generator was taken on 2/25/13 from a 10,000 gallon tank. FOI Laboratories identified the presence of heavy sediment particles in the diesel fuel for the hospital's only emergency generator. The report stated that sediment in the fuel tank can cause clogged filters and may lead to failed fuel injectors. The fuel analysis was released to the facility 3/11/13.

As of 3/27/13, the facility had no plan in place to correct this condition. See standard citation at A703 and A724 for details of the deficiency.

The failure of the emergency power generator has the potential to adversely affect many patients (scope) and to result in serious injury or death (severity).

2. The fire life safety (FLS) surveyor reviewed reports to find the facility failed to maintain the fire/smoke dampers in reliable operating condition. See standard citation at A709 and A724 for details of the deficiency. This situation could place the lives of the occupants in smoke-filled environment, should a fire occur and the fire/smoke dampers failed to respond.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to maintain the facility's fuel supply for the emergency generator to ensure reliable use of the generator in an emergency. The failure to ensure emergency power puts the health and safety of patients at risk in the event of a power failure, not an uncommon event in southwest Florida.

The findings include:

On 3/27/13, the fire life safety (FLS) surveyor reviewed documentation of the fuel analysis for Doctor's Hospital's emergency generator. The diesel fuel sample was taken on 2/25/13 from a 10,000 gallon tank. The documents revealed the diesel fuel had the presence of heavy sediment particles. This diesel fuel is for the hospital's only emergency generator. The company that did the fuel analysis is FOI Laboratories. This report states that sediment in the fuel tank can cause clogged filters and may lead to failed fuel injectors. The fuel analysis was released to the facility 3/11/13.

In an interview on 3/27/13, the Director of Facility Management said he had not seen this report. Some 16 days after release of the report, the facility had no plan in place to correct this condition.

On 3/27/13, a review of the facility records revealed the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with National Fire Protection Association (NFPA) 101 and NFPA 110 Standard for Emergency and Standby Power Systems (ESPS). NFPA 110-8.4.9 requires Level 1 ESPS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months.

The generator was tested on [DATE]. The 4-hour run test is only required every three years.

Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8, A fuel quality test shall be performed at least annually using tests approved by American Society for Testing and Materials (ASTM) standards.

After the surveyor brought the problem with the fuel to the attention of the facility staff, they called an outside vendor. This company cleaned the fuel and holding tanks. This was completed on 3/27/13 at 7:00 p.m.

Based on review of the facility records and interviews with the Director of Facility Management, the facility failed to maintain the fire/smoke dampers in reliable operating condition. This situation could place the lives of the occupants in smoke environment should a fire occur and the fire/smoke dampers failed to respond.

The findings include:

During the survey on 3/27/13, the fire life safety surveyor reviewed documentation of fire/smoke dampers which revealed a few of the dampers were noted as not accessible. The report was from an outside vendor.

In an interview at 11:20 a.m., the Director of Facility Management admitted the hospital staff has no plan in place to correct these dampers noted as they were not accessible.

Reference: National Fire Protection Association (NFPA) 101 Life Safety Code (2009) 18.5.2.1, 19.5.2.1, 9.2.1, 8.4.6.2 & NFPA 90A or B (2009 editions).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to maintain the facility's fuel supply for the emergency generator to ensure an acceptable level of safety. The failure to ensure emergency power puts the health and safety of patients at risk in the event of a power failure. Smoke dampers not inspected.

The findings include:

1. On 3/27/13, the fire life safety (FLS) surveyor reviewed documentation of the fuel analysis for Doctor's Hospital's emergency generator. The diesel fuel sample was taken on 2/25/13 from a 10,000 gallon tank. The documents revealed the diesel fuel had the presence of heavy sediment particles. This diesel fuel is for the hospital's only emergency generator. The company that did the fuel analysis is FOI Laboratories. This report states that sediment in the fuel tank can cause clogged filters and may lead to failed fuel injectors. The fuel analysis was released to the facility 3/11/13.

In an interview on 3/27/13, the Director of Facility Management said he had not seen this report. Some 16 days after release of the report, the facility had no plan in place to correct this condition.

On 3/27/13, a review of the facility records revealed the facility failed to provide documentation that all of the generators and ancillary equipment were tested and certified at an optimal state in accordance with National Fire Protection Association (NFPA) 101 and NFPA 110 Standard for Emergency and Standby Power Systems (ESPS). NFPA 110-8.4.9 requires Level 1 ESPS shall be tested for the duration of its assigned class for at least 4 hours at least once within every 36 months.

The generator was tested on [DATE]. The 4-hour run test is only required every three years.

Reference: NFPA 110-Standard for Emergency and Standby Power Systems 8.3.8, A fuel quality test shall be performed at least annually using tests approved by American Society for Testing and Materials (ASTM) standards.

2. During the survey on 3/27/13, the fire life safety surveyor reviewed documentation of fire/smoke dampers which revealed that a few of the dampers were noted as not accessible. The report was from an outside vendor.

In an interview at 11:20 a.m., the Director of Facility Management admitted the hospital staff has no plan in place to correct these damper noted as they were not accessible.

Reference: NFPA 101 Life Safety Code (2009) 18.5.2.1, 19.5.2.1, 9.2.1, 8.4.6.2 & NFPA 90A or B (2009 editions).

Based on interviews, the facility failed to comply with the Condition of Care for EMTALA.

The facility failed to medically screen Patient #21 when presented at the Emergency Department Bay by EMS transport (refer to 2406); failed to stabilized Patient #21 when presented at the Emergency Department Bay by EMS transport (refer to 2407); failed to ensure an appropriate transfer with hospital to hospital communication (refer to 2409) and failed to maintain a medical record for Patient #21 (refer to 2403).

Based on interview, the facility failed to maintain a record of a patient who presented at the Emergency Department for 1 (Patient #21) of 21 sampled patients reviewed.

The findings include:

Record review revealed Patient #21 was listed on the ED log as Jane Doe on 7/10/11; however, there was no medical record available as this patient was never examined in the hospital ED.

Based on interviews, the facility failed to ensure that an individual patient presenting at the Emergency Department was medically screened before transfer for 1 (Patient #21) of 21 patients reviewed.

The findings include:

1. During an interview with the Risk Manager (RM), on 8/19/11 at 3:35 p.m., she revealed she was informed the charge nurse was speaking to Emergency Medical Services (EMS) personnel on the phone and she told them if the patient was stable, they should take the patient to another hospital with obstetric capabilities because they did not have obstetrical (OB) services. The medic was not sure whether the patient was stable and they would call back. They did not get a call back and 10 minutes later showed up in the hospital Bay. The physician went out to the ambulance bay and spoke to the medic before the patient was unloaded and the medic stated the BP was stable. The physician stated twice he would take the patient but would then have to transfer the patient to the other hospital for fetal monitoring. The medic then took the patient to the other hospital.

2. Interview with Registered Nurse (RN), on 8/19/11 at 3:51 p.m., who received the call revealed she received a phone call from Rescue 12, or 15, and they called to say that they were coming in with a 6 month pregnant female who had fallen on her belly. She asked if the patient was stable and they said she was and she explained to them they did not have a fetal monitor at the hospital and it would probably be in the patient's best interest to go to another hospital with OB capabilities. But, they would take the patient if they felt they needed to come to Doctor's Hospital. At no time did she refuse to take the pt. The guy that called was not the paramedic and he relayed the info to the paramedic who said they would call back. They never called back and just showed up at the hospital EMS bay. The physician was told about the call and they had not called back and she assumed they were going to the other hospital. They showed up at the back door and she informed the physician and he stated he wanted to talk to them. They went outside and the patient had not been unloaded and when they opened the door to the rig the physician stated she needed to go to the other hospital where she needed to be monitored; but, he also said if she's unstable we'll take her but she probably needs to go to the other hospital and said to the medic it's your call. They took her to memorial. The RN stated they all took the EMTALA education and it's all important to them now. This re-education is very valuable. Took it within the past month. They have a crystal clear understanding of EMTALA.

3. Interview with the physician involved on 8/19/11 at 4:02 p.m., revealed he was told by the ER nurse that she received a call from EMS that a mother who was 6 months pregnant had fallen on her stomach and they were possible en route to Doctor's Hospital. She told the physician that they were going to be calling them back because she informed who she spoke to that they do not have the capability of fetal monitoring and it would probably be in the best interest of the patient to be taken straight to the other hospital. They had not heard anything back and then he was called out to the ambulance entrance where it was learned the mother was in the truck. He stated he told the medics he would treat the patient but he did not have the ability to do fetal monitoring; the best he could do would be an ultrasound and then would probably have to send her to the other hospital. He stated at no time did he refuse to take the patient; he felt it was in the best interest of the patient to be taken to the other hospital but never refused to take her. He walked back into the ER and the medics took her to the other hospital. He stated he has been addressed by the ED Medical Director, for this bad decision and has just recently taken another extensive course in EMTALA for which he has learned a valuable lesson.

Based on interviews, the facility failed to ensure that any patient presenting at the Emergency Department was medically stabilized before transfer for 1 (Patient #21) of 1 patients reviewed for transfer.

The findings include:

1. During an interview with the Risk Manager (RM), on 8/19/11 at 3:35 p.m., she revealed she was informed the charge nurse was speaking to EMS on the phone and she told them if the patient was stable, they should take the patient to another hospital with obstetric capabilities because they did not have OB. The medic was not sure whether the patient was stable and they would call back. They did not get a call back and 10 minutes later showed up in the Bay. The physician went out to the ambulance bay and spoke to the medic before the patient was unloaded and the medic stated the BP was stable. The physician stated twice he would take the patient but would then have to transfer the patient to the other hospital for fetal monitoring. The medic then took the patient to the other hospital.

2. Interview with Registered Nurse (RN), on 8/19/11 at 3:51 p.m., who received the call revealed she received a phone call from Rescue 12, or 15, and they called to say that they were coming in with a 6 month pregnant female who had fallen on her belly. She asked if the patient was stable and they said she was and she explained to them they did not have a fetal monitor at the hospital and it would probably be in the patient's best interest to go to another hospital with OB capabilities. But, they would take the patient if they felt they needed to come to Doctor's Hospital. At no time did she refuse to take the pt. The guy that called was not the paramedic and he relayed the info to the paramedic who said they would call back. They never called back and just showed up at the hospital EMS bay. The physician was told about the call and they had not called back and she assumed they were going to the other hospital. They showed up at the back door and she informed the physician and he stated he wanted to talk to them. They went outside and the patient had not been unloaded and when they opened the door to the rig the physician stated she needed to go to the other hospital where she needed to be monitored; but, he also said if she's unstable we'll take her but she probably needs to go to the other hospital and said to the medic it's your call. They took her to memorial. The RN stated they all took the EMTALA education and it's all important to them now. This re-education is very valuable. Took it within the past month. They have a crystal clear understanding of EMTALA.

3. Interview with the physician involved on 8/19/11 at 4:02 p.m., revealed he was told by the ER nurse that she received a call from EMS that a mother who was 6 months pregnant had fallen on her stomach and they were possible en route to Doctor's Hospital. She told the physician that they were going to be calling them back because she informed who she spoke to that they do not have the capability of fetal monitoring and it would probably be in the best interest of the patient to be taken straight to the other hospital. They had not heard anything back and then he was called out to the ambulance entrance where it was learned the mother was in the truck. He stated he told the medics he would treat the patient but he did not have the ability to do fetal monitoring; the best he could do would be an ultrasound and then would probably have to send her to the other hospital. He stated at no time did he refuse to take the patient; he felt it was in the best interest of the patient to be taken to the other hospital but never refused to take her. He walked back into the ER and the medics took her to the other hospital. He stated he has been addressed by the ED Medical Director, for this bad decision and has just recently taken another extensive course in EMTALA for which he has learned a valuable lesson.

Based on interviews, the facility failed to ensure that any patient presenting at the Emergency Department was appropriately transferred for 1 (Patient #21) of 1 patients reviewed for transfer.

The findings include:

1. During an interview with the Risk Manager (RM), on 8/19/11 at 3:35 p.m., she revealed she was informed the charge nurse was speaking to EMS on the phone and she told them if the patient was stable, they should take the patient to another hospital with obstetric capabilities because they did not have OB. The medic was not sure whether the patient was stable and they would call back. They did not get a call back and 10 minutes later showed up in the Bay. The physician went out to the ambulance bay and spoke to the medic before the patient was unloaded and the medic stated the BP was stable. The physician stated twice he would take the patient but would then have to transfer the patient to the other hospital for fetal monitoring. The medic then took the patient to the other hospital.

2. Interview with Registered Nurse (RN), on 8/19/11 at 3:51 p.m., who received the call revealed she received a phone call from Rescue 12, or 15, and they called to say that they were coming in with a 6 month pregnant female who had fallen on her belly. She asked if the patient was stable and they said she was and she explained to them they did not have a fetal monitor at the hospital and it would probably be in the patient's best interest to go to another hospital with OB capabilities. But, they would take the patient if they felt they needed to come to Doctor's Hospital. At no time did she refuse to take the pt. The guy that called was not the paramedic and he relayed the info to the paramedic who said they would call back. They never called back and just showed up at the hospital EMS bay. The physician was told about the call and they had not called back and she assumed they were going to the other hospital. They showed up at the back door and she informed the physician and he stated he wanted to talk to them. They went outside and the patient had not been unloaded and when they opened the door to the rig the physician stated she needed to go to the other hospital where she needed to be monitored; but, he also said if she's unstable we'll take her but she probably needs to go to the other hospital and said to the medic it's your call. They took her to memorial. The RN stated they all took the EMTALA education and it's all important to them now. This re-education is very valuable. Took it within the past month. They have a crystal clear understanding of EMTALA.

3. Interview with the physician involved on 8/19/11 at 4:02 p.m., revealed he was told by the ER nurse that she received a call from EMS that a mother who was 6 months pregnant had fallen on her stomach and they were possible en route to Doctor's Hospital. She told the physician that they were going to be calling them back because she informed who she spoke to that they do not have the capability of fetal monitoring and it would probably be in the best interest of the patient to be taken straight to the other hospital. They had not heard anything back and then he was called out to the ambulance entrance where it was learned the mother was in the truck. He stated he told the medics he would treat the patient but he did not have the ability to do fetal monitoring; the best he could do would be an ultrasound and then would probably have to send her to the other hospital. He stated at no time did he refuse to take the patient; he felt it was in the best interest of the patient to be taken to the other hospital but never refused to take her. He walked back into the ER and the medics took her to the other hospital. He stated he has been addressed by the ED Medical Director, for this bad decision and has just recently taken another extensive course in EMTALA for which he has learned a valuable lesson.

Based on record review, observation, interview and review of policies and procedures, it was determined the facility failed to ensure the governing body was responsible for the actions of the hospital as an institution and as it related to the Conditions of Participation at A- 0747. The governing body failed to ensure the hospital function was conducted in a proper manner and failed to provide proper oversight of an effective quality assessment and performance improvement program for dietary services as noted in Conditions of Participation at A-0263.

The cumulative effect of this lack of oversight and systemic issues resulted in the Governing Body's inability to ensure the facility maintained the provision of quality health care in a safe environment and assured that the patients' right to quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

The findings include:

Infection control and physical environment deficiencies are cited in this survey with the Conditions of Participation not being met for infection control based on extensive lack of cleanliness of food preparation equipment and surfaces, improper disinfectant concentration in cleaning solutions, ineffective hand washing and sanitary handling of food.

Refer to A-0 747.

A review of the governing board bylaws reveals that Article VII - Board Function states the board is responsible for the proper functioning of the facility and is responsible for an effective quality assessment and performance improvement program. A review of the board minutes and reports to the quality improvement committee reveals there were no reports on sanitation and cleanliness for dietary services. There is no mechanism found to monitor cleanliness and sanitation in the dietary department and no reporting nor oversight of infection control concerns in dietary.

Refer to A-0263

Based on record review, observation, interview and review of policies and procedures, it was determined the facility failed to ensure the Quality Assurance Performance Improvement program was maintained as an ongoing effective data-driven hospital-wide program (Refer to Condition of Participation A 0043 and A 0747 and Standards A 0395, A 0442, A 0505, and A 0724).

The findings include:

Based on observation, interview, and clinical record review, it was determined the facility failed to ensure:

1. The Hospital had an effective governing body that is responsible for the proper functioning of the facility and is responsible for an effective quality assessment and performance improvement program. A review of the board minutes and reports to the quality improvement committee reveals there were no reports on sanitation and cleanliness for dietary services. There is no mechanism found to monitor cleanliness and sanitation in the dietary department and no reporting nor oversight of infection control concerns in dietary (Refer to CoP A 0043).

2. Nursing properly supervised and evaluated the wound care in accordance with policies and procedures for wound care assessments (Refer to Standard A 0395). 3. The hospital ensured patient records were secured from access by unauthorized individuals (Refer to Standard A 0442). 4. Outdated and unusable drugs and biologicals were not available for patient use (Refer to Standard A 0505). 5. Equipment in the kitchen was maintained in a clean, safe operating condition (Refer to Standard A 0724). 6. It provides a sanitary environment to avoid sources and transmission of infections and communicable diseases. The dietetic department failed to ensure the kitchen was designed and equipped to facilitate the safe, sanitary, and timely provision of food service as it relates to the proper serving, preparing, and storing of food for patients, visitors and staff. The nursing department failed to use personal protective equipment (PPE) when treating dialysis patients. (Refer to CoP A 747).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and review of wound care policies and procedures, nursing failed to comprehensively assess 2 (Patients #25 and #24) of 3 patient's wounds at the wound care center and pain status of 1 (Patient #20) of 3 patient's reviewed for wound care.

The findings include:

1. Clinical record review on 2/08/11 for Patient #25 revealed the patient was admitted on [DATE] with several wounds to her right lower extremity. Review of the physician's wound care progress notes dated 1/19/11 revealed open wounds with severe cellulitis and ascending lymphangitis of the toes, all involving the right lower extremity.

Review of the form on which the nurses are to describe wound appearance lists the following areas for the nurses to assess: color of the extremity, peri wound appearance, fibrin amount, wound base color, tissue texture, whether bone/tendon/ligament was exposed, drainage amount, drainage description and odor.

Review of the wound care assessment dated [DATE] identifies 4 areas to the patient's right lower extremity: right lower leg, right 5th interspace, right 4th interspace and right first metatarsal.

The right lower leg wounds were comprehensively assessed by the nurse; however, there was no assessment of the wounds on the patient's right 4th and 5th interspace or first metatarsal of the right foot.

Interview on 2/08/11 at 12:30 p.m., with the wound care nurse while viewing the pictures of the wounds to the patient's right lower extremity revealed no identification as to which picture went with which wound. She confirmed there should be a number on the picture corresponding with the wound. She could not indicate why the other wounds were not assessed and stated, The doctor was concerned about admitting the patient to the hospital.

2. Clinical record review on 2/07/11 for Patient #20 revealed the patient was admitted on [DATE] with an infected medial right lower leg venous ulceration complicated by peripheral vascular disease.

Review of the form on which the nurses are to describe wound appearance lists the following areas for the nurses to assess: color of the extremity, peri wound appearance, fibrin amount, wound base color, tissue texture, whether bone/tendon/ligament was exposed, drainage amount, drainage description and odor.

In addition, nursing is required to complete a pain assessment on this form and whether there are any changes in the ability of the patient to care for self.

Review of the initial wound care assessment for Patient #20 dated 1/13/11 identifies 4 areas to be assessed including the right medial lower leg, left 4th toe callous/corn, left shin scab and right 4th toe gout. The nurse assessed the patient's right medial lower leg, however, failed to assess the other areas identified. In addition, the patient's pain was not assessed.

Review of the wound assessment dated [DATE] failed to assess the patient's pain status. In addition, the nurse documented the patient had a change in the ability to care for herself; however, did not document what the change was or the interventions offered to the patient regarding the change. This assessment revealed the area to the patient's left and right 4th toes were closed however, failed to complete the assessment for the scab on the patient's left shin.

Review of the 1/27/11 wound assessment revealed the right medial lower leg assessed; however, there was assessment related to the scab on the patient's left shin.

Review of the hospital's policy and procedure for assessment and reassessment as it relates to the wound care center, page 18 of 20, #1, reveals, The Registered Nurse will initiate a nursing assessment within one hour of the patient's arrival for the initial visit to the Wound Center to determine the need for care and treatment, to include: record relevant physical data, including pain assessment, assess wound, photograph, measure and document.

Interview with the CNO (Chief Nursing Officer) and Director of the Wound Care Center on 2/09/11 at 2:15 p.m., confirmed nursing should be completing a comprehensive assessment on all of the patients' wounds when presented to the wound care center as well as pain status and ability to care for self. They confirmed the missing assessments.

3. Clinical record review on 2/08/11 for Patient #24 revealed the patient was admitted on [DATE] for sacral and buttock sores.

Review of the wound care note by the physician dated 12/06/10 revealed the patient is an [AGE] year old female referred to the wound care center for evaluation of a nonhealing longstanding left buttock wound.

The patient resides in an assisted living facility.

A verbal order dated 12/06/10 from the physician was written by the nurse for zinc oxide to the patient's buttocks daily.

On 1/03/11, the wound care orders changed to Aquacel/DuoDerm every 3 days to the buttock wound; however, the order failed to instruct the patient as to how to clean the wound prior to the application of the dressing.

Review of the physician's wound care note dated 1/03/11 revealed the patient was referred back to the wound center for a nonhealing wound of the left buttock. The patient stated she had been using Bactroban on it.

On 2/07/11, the orders were changed to DuoDerm over buttock wound, change every 3 days, but, failed to instruct the patient as to how to clean the wound.

Interview with the wound care nurse on 2/08/11 at 12:30 p.m., revealed a home health agency was performing the wound care treatments to the patient's wound. There was no documentation that nursing alerted the assisted living facility or spoke to the patient about using the wrong product on her wound. The nurse confirmed the treatment orders were incomplete and needed to be clarified to reflect how the wound was to be cleaned prior to application of the dressings.

Based on observation and interview, the facility failed to ensure outdated and unusable drugs and biologicals were not available for patient use.

The findings include:

1. On 2/07/11, observation in the medication storage room of the emergency department revealed multiple expired IV (intravenous) fluids and other biologicals as listed below:

a. 3 bags of 0.9% Sodium Chloride 250 ml bag--expired March 1, 2010

b. 3 bags of 5% Dextrose in Lactated Ringers 1000 ml bag--one bag was in an open package, one bag expired November 1, 2010 and one bag expired September 1, 2010

c. 1 #16 French IV catheter--expired December 2006

d. 2 500 ml bottles labeled Evacuated Containers with preservatives--expired March 2010 and August 2010

e. 78 Gastroccult testing slides--expired July 2010

f. 21 bottles of Hemoccult Developer 15 ml bottles-- 9 bottles expired October 1, 2010, 1 bottle expired April 1, 2010 and 11 bottles expired February 1, 2011

g. 4 Micro-test Multi-media tubes expired 1/29/2010.

Interview with the emergency room Manager on 2/07/11 at 10:45 a.m., who was present during the tour revealed the supplies and the plain IV fluids are restocked by central supply. She further stated the medications and IV fluids containing additives were restocked by pharmacy and placed in the OmniCell medication distribution machine. She stated she was not aware if the person who restocks the supplies received from central supply rotates supplies when they are restock. She stated it appeared the most recent supplies received were placed in the front. All the expired items were in the back or on the bottom of the storage bins. She also stated it was the responsibility of the nurses to ensure the supplies they are using are not expired. She stated there is no routine time frame or check list to use or document on which the staff checks for expiration dates of supplies stored in the emergency department.

2. Observation during the tour of the wound care center on 2/07/11 at 1:20 p.m., revealed 10 Vaseline Petrolatum Gauze packages with an expiration date of 10/2010. The director of the unit who was present during the observation indicated she would have the items removed from stock.

Based on observation, interview, and review of Environmental Sanitation policies and procedures, the facility failed to ensure the equipment in the kitchen was maintained in a clean and safe condition.

The findings include:

Observation on 2/08/11 at 9:00 a.m., during the tour of the cafeteria in the presence of the Director of Nutrition Services (DNS), and Risk Manager (RM) revealed the following:

Build up of ice accumulating on the inside of the ice cream freezer. Large amount of sandy particles including dust and lint were on the inside seal of the freezer. In addition, black slimy residue was observed on the inside seal of the unit. There was no thermometer inside the freezer.

Observation of the reach-in deli refrigerator revealed a build up of crumbs on the bottom of the unit.

The tour continued to the inside of the kitchen and in the presence of the DNS, RM and Chief Operating Officer (COO), the following was observed:

The reach-in refrigerator that holds tube feeding formula had an accumulation of white hardened substance on the inside of the glass and bottom shelf of the unit.

The reach-in beverage cooler that holds milk and supplements contained a build-up of white chalky residue on the inside partition of the glass door.

The top of the ice cream chest had a large accumulation of dried, unidentifiable food substances on the lids of the chest and around the seal.

The inside of the Amana commercial microwave was coated with an accumulation of old, dried, hardened residue on the bottom and sides of the unit.

Hardened dried food particles were adhered to the top of the plate warmers.

A build-up of hardened brown residue was observed on the inside walls of the food warmer. The inside and outside of the door to the warmer was smeared with an unidentifiable substance.

The commercial blender had an accumulation of caked residue on the inside and outside of the control buttons as well as on the unit itself.

The robot coupe food processor was covered with hardened dried residue.

A build up of unidentifiable substances was observed on the inside of three food carts.

The bottom of the walk-in freezer had a large accumulation of food debris that had spilled out onto the floor and observed accumulating under the metal shelves and black substance was adhered to the plastic slats in the freezer.

Observation continued to the dry storage room and in the presence of the DNS, RM and COO, the following was revealed:

A build-up of dust and lint was observed adhered to the air conditioning vent as well as adhered to the lighting fixtures on the ceiling.

A build-up of brown sticky residue was observed on the outside of the carbon tank.

Observation of the drop ceiling above the 3 compartment sink revealed rusted slats holding the ceiling tile in place.

Observation of the salad cooler revealed the front door was rusted.

Observation of the cafeteria freezer revealed a large accumulation of frozen food particles lining the bottom of the unit.

The food warmer next to the cooler in the cafeteria had a loose seal at the bottom of the door and the temperature was set at 175 degrees F, however, the thermometer indicated it was at 98 degrees F. The DNS who was present during this observation confirmed the loose seal on the door.

Large accumulation of grease build up was observed on and around the heating lamp over the steam table in the cafeteria.

Black residue was observed on the AC (air conditioning) vent above the grill.

A large amount of caked on grease with lint was observed on the back of the grill in the cafeteria as well as on the metal slat on which the deep fry baskets were placed. Greasy residue was observed on the bottom of the table where the aluminum foil was placed as well as on the floor underneath and behind the grill.

Observation of the dish machine on 2/08/11 at 10:30 a.m., in the presence of the DNS revealed a high temperature dish machine in process of washing dishes. The wash cycle was recorded at 110 degrees, the rinse cycle was recorded at 130 degrees and the final rinse recorded at 195 degrees F. While in motion, the wash cycle needle and rinse cycle needle never moved.

As a result of surveyor intervention, the DNS phoned the company who services the dish machine. Review of the emergency service work order dated 2/09/11 revealed the thermostat to the dish machine needed to be reset on the wash tank to 160 degrees F from the 110 degrees it had been registered.

The top of the cart where the dessert plates were resting had an accumulation of dried food particles near the clean plates.

Observation revealed the power cord to the cooler by the tray line with a large accumulation of dust and lint adhered to the cord as well as the machine resting on top of the unit.

Review of the hospital's policy for Food Safety Measures reveals carts used for food transportation are cleaned three times a day, after each meal, with approved sanitizer...all kitchenware (pots, pans, etc.) used in preparation of food or serving food or drink, and all food storage containers shall be thoroughly cleaned and sanitized prior to each use...

Review of the Environmental Sanitation Program for the kitchen includes, garbage cans shall have tight fitting lids...and shall be cleaned and deodorized...for walk-in refrigerators and freezers, scraps and particles are to be picked up and the floor damp mopped...

The facility failed to ensure the garbage can lid was cleaned and the refrigerators, freezers, food warmer, grill and deep fryer, air conditioning vents and carbon tank free of food debris and in safe, clean and sanitary condition.

Based on observations, interviews, and record review, the hospital failed to ensure it provides a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. The dietetic department failed to ensure the kitchen was designed and equipped to facilitate the safe, sanitary, and timely provision of food service as it relates to the proper serving, preparing, and storing of food for patients, visitors and staff. The nursing department failed to use personal protective equipment (PPE) when treating dialysis patients.

The cumulative effect of this lack of oversight and systemic issues resulted in the facility's inability to ensure the facility maintained the provision of quality health care in a safe environment and assured that the patients' right to quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

The findings include:

1. Observation on 2/07/11 at 10:30 a.m., revealed two patients on the ICU (Intensive Care Unit) receiving dialysis treatments. Both patients had double lumen catheters as the port for receiving the treatment.

The Registered Nurse (RN) was wearing gloves and changed them as she went to one patient and the other. She sanitized her hands in between patients. When she was asked when she wears the personal protective equipment (PPE), she stated she puts a gown on when starting the treatment and when the treatment was finished.

A review of the Bloodborne Pathogen Exposure Control Plan revealed the following:

Dialysis -- wear gloves; mask= *, gown=*. The * = wear mask and gown if anticipation of body fluid splash.

A gown must be worn when the spurting or spattering of blood, body fluids, potentially-contaminated substances or chemicals might occur.

2. Observation on 2/08/11 at 9:00 a.m., during the tour of the cafeteria in the presence of the Director of Nutrition Services (DNS), and Risk Manager (RM) revealed the following:

Build-up of ice accumulating on the inside of the ice cream freezer. Large amount of sandy particles including dust and lint were on the inside seal of the freezer. In addition, black slimy residue was observed on the inside seal of the unit. There was no thermometer inside the freezer.

Observation of the reach-in deli refrigerator revealed a build up of crumbs on the bottom of the unit.

Temperature of the scrambled eggs on the cafeteria tray line temped at 130 degrees F. (Hot foods should be holding at 135 degrees F. or greater.)

Staff were observed going in and out of the kitchen and into the cafeteria holding food items with the front of their hair exposed and not contained in the hair net. A staff worker was observed wearing a baseball cap and her hair was in a ponytail and not contained.

The splash guard at the deli station was coated with a white slimy residue; various finger marks were observed on the guard itself. Dried unidentifiable food particles were observed on the plastic surrounding the outside and inside of the bin that holds the deli items.

The tour continued to the inside of the kitchen and in the presence of the DNS, RM, and Chief Operating Officer (COO), the following was observed:

A trash can was next to the hand wash sink. The lid did not fit securely and was covered with a dried, hardened, unidentifiable orange substance. This was also located next to the food warmer.

The reach-in refrigerator that holds tube feeding formula had an accumulation of white hardened substance on the inside of the glass and bottom shelf of the unit.

The reach-in beverage cooler that holds milk and supplements contained a build-up of white chalky residue on the inside partition of the glass door.

The top of the ice cream chest had a large accumulation of dried, unidentifiable food substances on the lids of the chest and around the seal.

The inside of the Amana commercial microwave was coated with an accumulation of old, dried, hardened residue on the bottom and sides of the unit.

Hardened dried food particles were adhered to the top of the plate warmers.

Orange slices and parsley for garnish were observed in an opened bag in refrigerator #8 that was neither labeled or dated.

A build-up of hardened brown residue was observed on the inside walls of the food warmer. The inside and outside of the door to the warmer was smeared with an unidentifiable substance.

Bottles of paprika, Italian seasoning, and a box of cornstarch were opened and not dated.

The commercial blender had an accumulation of caked residue on the inside and outside of the control buttons as well as on the unit itself.

The robot coupe food processor was covered with hardened dried residue.

A build up of unidentifiable substances was observed on the inside of three food carts.

The bottom of the walk-in freezer had a large accumulation of food debris that had spilled out onto the floor and observed accumulating under the metal shelves and black substance was adhered to the plastic slats in the freezer.

Various kitchen staff were observed with hair exposed from under their hair nets.

Observation continued to the dry storage room and in the presence of the DNS, the following was revealed:

Three bags of opened macaroni without dates or labels.

A bag of macaroni that was pierced and without a date or label.

A graham cracker bin with a large accumulation of crumbs and a marshmallow was observed resting on the bottom of the bin. Two other cracker bins were observed and all three bins had an unidentifiable residue on the sides and tops of the bins.

A bag of bread crumbs that was opened and not dated or labeled.

A plastic container with a slimy residue and flakes of coconut was observed on top of one of the shelves where several bags of nuts were opened and neither dated or labeled.

A build up of dust and lint was observed adhered to the air conditioning vent as well as adhered to the lighting fixtures on the ceiling. Boxes of cereal were observed directly underneath the dust and lint.

A build up of brown sticky residue was observed on the outside of the carbon tank.

Two tube feeding bottles of formula with a large accumulation of black dirt on the sides of the bottles were placed next to other bottles of formula for patient use.

Brown, dried, splattered material was observed on the wall behind the jelly packets.

A plastic container holding various condiments had an accumulation of a slimy substance on the inside of the container.

Observation during this tour of the three compartment sink in the presence of the DNS revealed a staff member wearing a mask. The DNS indicated the staff member was responsible for ensuring the proper amount of sanitizing solution was in the rinse water. When questioned about the mask, the DNS stated the staff member wasn't feeling too well.

After the first attempt, the test strip failed to reveal evidence of an adequate amount of sanitizing solution. The staff member refilled the sink with sanitizing solution and retested the water. The strips failed to reveal enough solution was present in the water. After the third attempt and with the assistance of the DNS, the staff member was able to successfully demonstrate enough sanitizing solution was in the water.

Observation of the drop ceiling above the 3 compartment sink revealed rusted slats holding the ceiling tile in place.

Observation of the salad cooler revealed the front door was rusted.

Observation of the food transport cart revealed hardened dried food particles coating the metal slats on the cart.

Observation of the cafeteria freezer revealed a large accumulation of frozen food particles lining the bottom of the unit.

The food warmer next to the cooler in the cafeteria had a loose seal at the bottom of the door and the temperature was set at 175 degrees F; however, the thermometer indicated it was at 98 degrees F. The DNS who was present during this observation confirmed the loose seal on the door.

Dried residue and dirt was adhered to the inside door and bottom shelf of the metal cupboard where cafeteria workers kept boxes of gloves.

Large accumulation of grease build up was observed on and around the heating lamp over the steam table in the cafeteria.

The plastic cutting board by the grill had numerous slits and cuts and inside of the slits and cuts was an accumulation of orange, gray, and black residue. Inside the microwave at the grill station was an accumulation of hardened, dried food splattered on the sides and shelf of the unit.

Black residue was observed on the AC (air conditioning) vent above the grill.

A large amount of caked on grease with lint was observed on the back of the grill in the cafeteria as well as on the metal slat on which the deep fry baskets were placed. Greasy residue was observed on the bottom of the table where the aluminum foil was placed as well as on the floor underneath and behind the grill.

Observation of the dish machine on 2/08/11 at 10:30 a.m., in the presence of the DNS revealed a high temperature dish machine in process of washing dishes. The wash cycle was recorded at 110 degrees, the rinse cycle was recorded at 130 degrees and the final rinse recorded at 195 degrees F. While in motion, the wash cycle needle and rinse cycle needle never moved. Trays and plates were coming out of the machine wet and a staff member was observed with gloved hands taking the trays and wiping the trays off with the same dish cloth. He dropped a plate, picked it up off the floor, walked it over to the sink and went back to wiping the trays with the same gloved hands. The cart on which he was placing the trays to dry off was coated with unidentifiable dried substances.

As a result of surveyor intervention, the DNS phoned the company who services the dish machine. Review of the emergency service work order dated 2/09/2011 revealed the thermostat to the dish machine needed to be reset on the wash tank to 160 degrees F from the 110 degrees it had been registered.

Observation of the tray line on 2/08/11 at 4:14 p.m., in the presence of the COO (Chief Operating Officer) and DSN revealed a staff worker with a mustache and beard assisting on the tray line. His facial hair was not covered. Two dietary staff who were also assisting on the line had hair exposed on the front of their foreheads and on the backs of their necks.

The top of the cart where the dessert plates were resting had an accumulation of dried food particles near the clean plates.

The staff member who had a mask around his face earlier in the day was wearing it around his neck. Interview with the DNS at this time stated, he feels better now.

Observation revealed the staff member responsible for placing the coffee on the patient's trays was observed folding his arms and his gloved hands were in his armpits. He was observed to unfold his arms, wipe his forehead with his right hand and began pouring coffee to place on the trays. He failed to remove his gloves when they were under his armpits or wash his hands before pouring and placing coffee on patient trays.

Observation of the cook revealed she was wearing gloved hands while plating food. She left the tray line to retrieve ground meat in the food warmer. She poured meat onto a plate, shut the door to the warmer, and returned to the tray line with the same gloved hands and was observed to thumb plates while plating food. She continued this practice until she ran out of carrots. While keeping the same gloves on during the entire plating of food, she was observed leaving the tray line to retrieve carrots, roast beef, and ground beef out of the food warmer. She never changed her gloves or washed her hands during the entire time the tray line was in operation. Observation revealed the cook gathered cooked carrots in her hand, dump them into an empty pan, and go back to the line and plate food. In addition, her badge was observed dangling over the gravy while reaching to plate the mashed potatoes.

Observation also revealed one of the staff on the tray line leave the tray line to retrieve a food cart while wearing gloves. She pulled her smock close in front of her, went over to the cart, pushed it over to the tray line and went back to placing the lids on the plates of food without changing her gloves or washing her hands. Dried food spillage was observed on the inside of the cart where she was placing patient trays.

Observation revealed a staff member leaving the tray line with gloved hands and go into different refrigerators then back over to the tray line to place condiments on patient trays without changing gloves or washing hands.

Observation revealed a staff member approach the sink, wash his hands less than 10 seconds, turn the water faucet off with his wet hands and dry his hands with a paper towel.

Observation revealed the power cord to the cooler by the tray line with a large accumulation of dust and lint adhered to the cord as well as the machine resting on top of the unit.

Observation revealed a second staff member approach the sink, wash her hands, turn off the water faucet off with the back of her wet hand and dry her hands with a paper towel.

The tray line ended at 5:07 p.m. The cook was asked to take the temperature of the fish and plain roast beef that was holding on the tray line. The temperature of the fish registered at 130 degrees F and the roast beef temped at 120 degrees F. (Hot foods must be held at 135 degrees F or greater). She confirmed they were not at the proper holding temperature. The DNS who was present after the end of the tray line confirmed temperatures are not taken of the food during the line or after the line to ensure proper holding temperatures are met.

Observation at 5:10 p.m., revealed 7 trays of plated food resting on the tray line after the line was finished. Interview with the DNS at this time revealed the trays are left on the line for 45 minutes as late trays. He stated they are left there for patients who may return late and request a tray. He confirmed he does not temp the foods while they are sitting on the line for that period of time or prior to sending them to the floor to be served to the patients.

Observation on 2/09/11 at 8:20 a.m., revealed five breakfast trays on the tray line containing scrambled eggs and pancakes. Staff was asked to temp the eggs and no one was able to take the temperatures until 8:37 a.m. According to the kitchen staff, the trays were left as late trays. A staff member was preparing to deliver the trays and prior to delivery, the temperature of the eggs registered at 128 degrees F and the pancakes registered at 122 degrees F. The temperatures of these foods were not at 135 degrees F. and there was no evidence of what the holding temperatures of the eggs and pancakes were after the completion of the tray line.

Observation on 2/09/11 at 8:45 a.m., in the presence of the DNS revealed the same staff member observed the day before with a mask on who was without the mask. The staff member was asked to check the sanitizing solution in the 3 compartment sink. It was not until 4 attempts later, at 8:55 a.m., and with the assistance of the DNS, that the staff member was able to achieve the proper amount of sanitizing solution in the sink. The staff member was observed sniffling and coughed into the back of his hand while checking the solution.

Interview with the DNS at this time could not confirm whether the staff member was sick or not. After surveyor intervention, the DNS requested the staff member to provide evidence that he was free of a transmittable disease.

Observation of the clean-up of the hospital cafeteria dining tables at 9:45 a.m., on 2/9/11 after breakfast service found a dietary employee wiping table tops with a cleaning solution. The employee stated she obtained the cleaning solution from the sanitizer tank in the three compartment 'pots sink' in the kitchen. An employee tested the sanitizer in the three compartment sink at 9:50 a.m., using a chemical test strip compared against a color chart on the test strip dispenser, reported the strip showed the concentration to be approximately 100 ppm. Testing by the employee of solution in the pail used to clean the tables found the concentration to be approximately 100 ppm. The label on the bottle of chemical sanitizer states the concentration should be between 200 ppm and 400 ppm.

Observation on 2/10/11 at 11:35 a.m., revealed 7 slices of cheese at the cafeteria deli bar with green mold. Visitors were observed attempting to get cheese out of the pan. The cafeteria employee who was present was asked to remove the moldy cheese from the deli bar. Observation during this time revealed the chicken salad was temped at 48 degrees F., egg salad at 45 degrees F. and tuna salad at 44 degrees F. A second cafeteria employee, who was responsible for temping the food on the deli bar stated, Well, it was 40 degrees yesterday when I temped the food. (According to the food code to which the hospital refers its policy, the danger zone of food temperatures are between 41 degrees F and 135 degrees F.)

The DNS promptly removed the egg, tuna, and chicken salad from the deli bar.

Review of the hospitals' policy and procedure for Food Safety Measures revealed:

a. Foods must be cooked to the appropriate temperature as established by the Food Code.

d. Foods must not stay in the temperature danger zone (41-135 degrees) for longer than 4 hours.

The hospital policy is in conflict with the 2009 FDA Food Code 2009. Review of the food code under 3-501.19 Time as a Public Health Control, section B indicates the following:

If time temperature control is used as the public health control up to a maximum of 4 hours, (1) the food shall have an initial temperature of 5 degrees celsius (41 degrees F) or less when removed from cold holding temperature control, or 57 degrees celsius (135 degrees F) or greater when removed from hot holding temperature control...(3) the food shall be cooked and served, served at any temperature if ready-to-eat, or discarded, within 4 hours from the point in time when the food is removed from temperature control.

The facility failed to ensure food on the tray line was within proper temperature during meal service in the cafeteria and for serving the late trays during dinner and breakfast while in the kitchen.

Further review of the hospital's policy reveals carts used for food transportation are cleaned three times a day, after each meal, with approved sanitizer...all kitchenware (pots, pans, etc.) used in preparation of food or serving food or drink, and all food storage containers shall be thoroughly cleaned and sanitized prior to each use...all foodstuffs in kitchen and storeroom shall be kept in container with tight-fitting lids and labels...cafeteria dining room tables are cleaned after each meal using approved sanitizer...

The facility failed to ensure equipment was in clean and sanitary condition and failed to ensure foods were in clean, properly labeled containers. In addition, the cafeteria employee failed to clean the tables with an appropriate sanitizing solution.

Review of the Cleaning and Sanitation of Cookware policy and procedure includes, remove cookware from sanitation sink and invert onto drain board. Allow cookware to air dry. DO NOT WIPE.

The facility failed to ensure cookware air dried and prevent staff from wiping the patient trays with the same towel.

Review of the Handwashing policy and procedure includes, apply hand soap, preferably a liquid, antiseptic soap; work up a lather by rubbing hands together vigorously for a minimum of 20 seconds...turn faucets off with a dry paper towel, discard towel appropriately.

Kitchen staff failed to utilize proper hand hygiene techniques while washing their hands after food contact.

Review of the Personal Hygiene and Health of Food Service Employees includes, hair restraints that cover all of the hair must be worn at all times when on duty in the preparation/serving areas. Men must also wear a beard restraint when indicated...if any employee is known to be infected with a disease in which there is a likelihood of such person contaminating food or food contact surfaces or transmitting disease to other employees, the employee may be excused from work and asked to report back with written medical permission to return to work.

The kitchen staff failed to ensure they were wearing proper hair restraints while in the kitchen. Furthermore, the DNS knew the kitchen employee was not feeling well and was wearing a mask. While attempting to check for proper sanitizing solution, the employee was observed sniffling and cough into the back of his hand. It wasn't until after surveyor intervention that the DNS dismissed the employee from the kitchen to determine whether he was infectious.

Review of the Environmental Sanitation Program for the kitchen includes, garbage cans shall have tight fitting lids...and shall be cleaned and deodorized...for walk-in refrigerators and freezers, scraps and particles are to be picked up and the floor damp mopped...

The facility failed to ensure the garbage can lid was cleaned and the refrigerators and freezers were free of food debris lining the bottom of the units.