Healthcare Inspection – Nutrition and Food Service Environment of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a request in May 2016 from the then-Senator Mark Kirk and the then-Congresswoman Tammy Duckworth to assess Nutrition and Food Service (NFS) environment of care concerns at the Edward Hines, Jr. VA Hospital (facility), Hines, IL. We substantiated the persistent presence of cockroaches in and around NFS areas. During our unannounced site visit on May 10, 2016, we found dead cockroaches on glue traps dispersed throughout the facility’s main kitchen. We observed conditions favorable to pest infestation. We substantiated that several patients received food trays with cockroaches on them. We reviewed email correspondence between mental health staff to NFS managers from March 11, 2011, through December 28, 2015, and a mental health report dated March 13, 2014, that reported six complaints from patients that cockroaches were present on food trays delivered from the facility’s main kitchen to the MH unit via a transportation cart. We substantiated that leadership had knowledge of unsanitary food service conditions (cockroaches) in the NFS kitchen but had not successfully resolved the problem. The facility leadership relied on its pest control program and did not take additional action to control the problem. We determined that between March 2011 and September 2016, ten different individuals have been assigned to the Director’s position. The facility did not have a permanent Director which may have contributed to the failure to readily resolve a persistent pest issues. Additionally, Environment of Care inspection reports for at least the previous 2 years did not document the presence of cockroaches and facility leadership may have considered the cockroaches on patient trays intermittent. NFS staff informed us that understaffing contributed to the presence of cockroaches in the facility’s main kitchen.