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Based on the onsite validation survey, completed December 8 through December 11, 2014, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tags (for building A1) K0011, K0018, K0025, K0027, K0029, K0038, K0050, K0052, K0062, K0074, K0078, K00147, K0020 (builidng A5), and K0038 (Building A5). See survey event ID #1f5W21 for full details of the cited deficiencies.

Based on observations, interviews and document review, the facility failed to ensure that equipment was maintained and calibrated at an acceptable level to ensure patient safety. Five of ten refrigerators, used to store patient food in patient care units, were found to have temperatures out of range for safe food storage and lack of documentation that the temperatures were adjusted by staff.

This failure created the potential for negative outcomes to patients, including illness, if consuming food not stored at an acceptable temperature.

FINDINGS:

According to facility policy, Patient Refrigerators/Freezers, all refrigerator/freezer temperature checks will be completed and maintained by the departments in which they are located. Food refrigerators will be maintained at a temperature of 33-40 degrees F. Any refrigerator/freezer noted out of temperature range or to be malfunctioning shall be reported immediately to Plant Operations and noted on the log.

According to facility log titled, Patient Food, Medication, Breast Milk Refrigerator/Freezer Log, the acceptable temperature range for refrigerators in which patient food is stored is 33-40 degrees Fahrenheit. Per the log, the temperatures will be recorded for the refrigerators each day and if temperatures are out of range, actions by staff will be documented on the log including checking the temperature again after two hours and notifying Plant Operations if necessary.

1. Five of ten temperature logs reviewed for refrigerators in which patient food was stored, revealed temperature logs were not completed each day and actions by staff were not documented on the logs when temperatures were out of range.

a) On 11/18/14, observations were made on 10 patient care areas that had refrigerators containing patients' food. The following patient care units had incomplete refrigerator logs for the month of November, 2014: ICU-A, 4 North, 4 Central, 3 Central, and P2.

b) The log for ICU-A revealed 4 days from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperatures were checked and recorded by staff. For the 14 days temperatures were recorded, 10 were out of range at 41 or 42 degrees F, meaning the refrigerator temperature was higher than the acceptable high temperature of 40 degrees. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food.

c) The log for 4 North revealed 7 days from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperatures were checked and recorded by staff. For the 11 days temperatures were recorded, 1 was out of range at 41 degrees. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food.

d) The log for 4 Central revealed 8 days from 11/01/14 - 11/18/14 in which temperatures were recorded as out of range at 41 or 42 degrees F. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food.

e) The log for 3 Central revealed 3 days in which temperatures were recorded as out of range at 32 degrees. The log revealed on one of these days, 11/08/14, the temperature control was adjusted to raise the temperature but a second check of the temperature after 2 hours, or at any time afterward was not documented.

f) The log for P2 revealed 1 day from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperature was checked and recorded by staff.

g) On 11/18/14 at 9:30 a.m., an interview was conducted with Registered Nurse (RN) #12, the ICU-A unit manager, who stated the expectation of staff was that the refrigerator logs would be completed by nursing staff each day and would contain documentation of the refrigerator temperature, what adjustments were made of the temperature control, if needed, and a recheck of the temperature in 2 hours. RN #12 confirmed the logs for the unit were missing documentation and the facility's policy was not being adhered to by staff.

h) On 11/20/14 at 10:45 a.m., the Assistant Vice President of Quality confirmed the refrigerator logs in which patient food was stored were not being completed by staff per the facility's policy.

Based on observation, interview and document review, the facility failed to have a process in place which ensured opened food items were labeled and disposed of by the expiration date.

This failure created the potential for patients to contract illnesses due to exposure to food borne pathogens if expired and unsafe food was served to patients.

FINDINGS:

FACILITY POLICY

According to the policy, Food Safety Standards and Requirements, upon receiving the facility should "date all products to ensure first in-first out procedure." Manufacturer's expiration, "use by" or "sell by" dates must be adhered to. All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers. Date mark ready-to-eat foods that are clearly identifiable do not need to be labeled with the name of the product but must be dated.

1. A tour of the kitchen was conducted on 11/18/14 beginning at 9:50 a.m., with the Food/Dietetic Director (Employee #1). The Food/Dietetic Director was asked what document the facility used for guidance for determining the shelf life of food items. S/he provided a document titled "What is the expiration date", which showed the following guidelines for labeling and determining shelf life.

- Individual cans/bottles should have the opened date in permanent ink or sticker.
- Food prepared for later use = use within 5 days, marked in permanent ink or with sticker.
- Food leftover after meals = use within 2 days, marked in permanent ink or with sticker.

During the tour numerous food items were observed with no labels to identify when the item was open or prepared and when the item expired and should be discarded. As example,

Observation of the tray line cooler revealed an open bag of blue cheese, an open bag of chopped onions and an open bag of hashbrowns with no dates when the items were opened and when they should be discarded. Additionally containers of cut strawberries and oranges were noted with no date identifying when the items were prepared and when they expired.

An interview was conducted with Employee #2 (Kitchen Line Staff employee) on the process for labeling and dating food items in the tray line cooler. Employee #2 stated s/he usually dated items before putting them in the cooler but s/he was busy today and didn't do it. The employee acknowledged food items were suppose to be labeled and dated prior to being placed in the cooler.

Observation of the tray line bread rack, on 11/18/14, revealed croissants and ciabatta roles in open unlabeled bags with no date of when the items were opened and when they expired. Additionally three loaves of bread had expiration dates of 11/16.

Observation of a second bread rack showed seven loaves of bread which had expired 11/13. According to the Food/Dietetic Director the person who delivered the bread was to ensure expired loaves were removed.

Observation of the meat cooler revealed a bag of unlabeled meat with no date of when it was received and when it expired. The Food/Dietetic Director stated it looked like a filet but acknowledged it "shouldn't be in here." S/he stated "all staff" would monitor and discard expired items and s/he would "do spot checks to see if it was done."

2. Further observations during a subsequent tour of the kitchen on 11/19/14 beginning at 9:40, with the Food/Dietetic Director showed the facility continued to store unlabeled and undated food items. Specifically,

The cooler contained an open bag of lettuce, a plastic container of cut pineapple and plastic containers of blueberries and blackberries with no date of when the items were received, prepared and expired. Additionally a plastic container of green melon had an expiration date of 11/17 (two days prior).

An opened container of coleslaw dressing had no open date or expiration date noted.

The meat cooler contained a bag of chicken with no received or expiration date. According to the Food/Dietetic Director, the kitchen staff probably took the bag out of the box and discarded the box. S/he acknowledged the bag of chicken should have been dated with a received and expiration date.

Based on the onsite validation survey, completed December 8 through December 11, 2014, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tags (for building A1) K0011, K0018, K0025, K0027, K0029, K0038, K0050, K0052, K0062, K0074, K0078, K00147, K0020 (builidng A5), and K0038 (Building A5). See survey event ID #1f5W21 for full details of the cited deficiencies.

Based on observations, interviews and document review, the facility failed to ensure that equipment was maintained and calibrated at an acceptable level to ensure patient safety. Five of ten refrigerators, used to store patient food in patient care units, were found to have temperatures out of range for safe food storage and lack of documentation that the temperatures were adjusted by staff.

This failure created the potential for negative outcomes to patients, including illness, if consuming food not stored at an acceptable temperature.

FINDINGS:

According to facility policy, Patient Refrigerators/Freezers, all refrigerator/freezer temperature checks will be completed and maintained by the departments in which they are located. Food refrigerators will be maintained at a temperature of 33-40 degrees F. Any refrigerator/freezer noted out of temperature range or to be malfunctioning shall be reported immediately to Plant Operations and noted on the log.

According to facility log titled, Patient Food, Medication, Breast Milk Refrigerator/Freezer Log, the acceptable temperature range for refrigerators in which patient food is stored is 33-40 degrees Fahrenheit. Per the log, the temperatures will be recorded for the refrigerators each day and if temperatures are out of range, actions by staff will be documented on the log including checking the temperature again after two hours and notifying Plant Operations if necessary.

1. Five of ten temperature logs reviewed for refrigerators in which patient food was stored, revealed temperature logs were not completed each day and actions by staff were not documented on the logs when temperatures were out of range.

a) On 11/18/14, observations were made on 10 patient care areas that had refrigerators containing patients' food. The following patient care units had incomplete refrigerator logs for the month of November, 2014: ICU-A, 4 North, 4 Central, 3 Central, and P2.

b) The log for ICU-A revealed 4 days from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperatures were checked and recorded by staff. For the 14 days temperatures were recorded, 10 were out of range at 41 or 42 degrees F, meaning the refrigerator temperature was higher than the acceptable high temperature of 40 degrees. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food.

c) The log for 4 North revealed 7 days from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperatures were checked and recorded by staff. For the 11 days temperatures were recorded, 1 was out of range at 41 degrees. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food.

d) The log for 4 Central revealed 8 days from 11/01/14 - 11/18/14 in which temperatures were recorded as out of range at 41 or 42 degrees F. There was no documentation by staff that the temperature control on the refrigerator was adjusted to bring the temperature back into the acceptable range and that the temperature was rechecked by staff to ensure safety of patient food.

e) The log for 3 Central revealed 3 days in which temperatures were recorded as out of range at 32 degrees. The log revealed on one of these days, 11/08/14, the temperature control was adjusted to raise the temperature but a second check of the temperature after 2 hours, or at any time afterward was not documented.

f) The log for P2 revealed 1 day from 11/01/14 - 11/18/14 in which there was no documentation that the refrigerator temperature was checked and recorded by staff.

g) On 11/18/14 at 9:30 a.m., an interview was conducted with Registered Nurse (RN) #12, the ICU-A unit manager, who stated the expectation of staff was that the refrigerator logs would be completed by nursing staff each day and would contain documentation of the refrigerator temperature, what adjustments were made of the temperature control, if needed, and a recheck of the temperature in 2 hours. RN #12 confirmed the logs for the unit were missing documentation and the facility's policy was not being adhered to by staff.

h) On 11/20/14 at 10:45 a.m., the Assistant Vice President of Quality confirmed the refrigerator logs in which patient food was stored were not being completed by staff per the facility's policy.

Based on observation, interview and document review, the facility failed to have a process in place which ensured opened food items were labeled and disposed of by the expiration date.

This failure created the potential for patients to contract illnesses due to exposure to food borne pathogens if expired and unsafe food was served to patients.

FINDINGS:

FACILITY POLICY

According to the policy, Food Safety Standards and Requirements, upon receiving the facility should "date all products to ensure first in-first out procedure." Manufacturer's expiration, "use by" or "sell by" dates must be adhered to. All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers. Date mark ready-to-eat foods that are clearly identifiable do not need to be labeled with the name of the product but must be dated.

1. A tour of the kitchen was conducted on 11/18/14 beginning at 9:50 a.m., with the Food/Dietetic Director (Employee #1). The Food/Dietetic Director was asked what document the facility used for guidance for determining the shelf life of food items. S/he provided a document titled "What is the expiration date", which showed the following guidelines for labeling and determining shelf life.

- Individual cans/bottles should have the opened date in permanent ink or sticker.
- Food prepared for later use = use within 5 days, marked in permanent ink or with sticker.
- Food leftover after meals = use within 2 days, marked in permanent ink or with sticker.

During the tour numerous food items were observed with no labels to identify when the item was open or prepared and when the item expired and should be discarded. As example,

Observation of the tray line cooler revealed an open bag of blue cheese, an open bag of chopped onions and an open bag of hashbrowns with no dates when the items were opened and when they should be discarded. Additionally containers of cut strawberries and oranges were noted with no date identifying when the items were prepared and when they expired.

An interview was conducted with Employee #2 (Kitchen Line Staff employee) on the process for labeling and dating food items in the tray line cooler. Employee #2 stated s/he usually dated items before putting them in the cooler but s/he was busy today and didn't do it. The employee acknowledged food items were suppose to be labeled and dated prior to being placed in the cooler.

Observation of the tray line bread rack, on 11/18/14, revealed croissants and ciabatta roles in open unlabeled bags with no date of when the items were opened and when they expired. Additionally three loaves of bread had expiration dates of 11/16.

Observation of a second bread rack showed seven loaves of bread which had expired 11/13. According to the Food/Dietetic Director the person who delivered the bread was to ensure expired loaves were removed.

Observation of the meat cooler revealed a bag of unlabeled meat with no date of when it was received and when it expired. The Food/Dietetic Director stated it looked like a filet but acknowledged it "shouldn't be in here." S/he stated "all staff" would monitor and discard expired items and s/he would "do spot checks to see if it was done."

2. Further observations during a subsequent tour of the kitchen on 11/19/14 beginning at 9:40, with the Food/Dietetic Director showed the facility continued to store unlabeled and undated food items. Specifically,

The cooler contained an open bag of lettuce, a plastic container of cut pineapple and plastic containers of blueberries and blackberries with no date of when the items were received, prepared and expired. Additionally a plastic container of green melon had an expiration date of 11/17 (two days prior).

An opened container of coleslaw dressing had no open date or expiration date noted.

The meat cooler contained a bag of chicken with no received or expiration date. According to the Food/Dietetic Director, the kitchen staff probably took the bag out of the box and discarded the box. S/he acknowledged the bag of chicken should have been dated with a received and expiration date.