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Based on food service observation, dietary staff interview and dietary document review, the hospital failed to ensure the Nutrition Services Manager provided effective oversight into the day to day operations of the department as evidenced by 1) lack of an effective temperature monitoring of potentially hazardous foods in the cafeteria; 2) ensure foods were stored in a manner that maintained food safety and/or palatability and 3) retention of tube feedings that were returned to dietary services after being delivered to inpatient medical units. Failure to ensure comprehensive daily management of foodservice operations may put patients at risk for developing foodborne illness further compromising clinical status.

Findings:

1. During review of food storage practices in the cafeteria on 1/5/11 beginning at 3 p.m., it was noted that the thermometer in the glass front cafe refrigerator read 42?F. It was also noted that there were greater than 6 individual containers of tuna salad. The temperature of one container was noted to be 47?F. It was also noted there was a ham sandwich with a temperature of 43?F. Protein based items are considered potentially hazardous foods (PHF). PHF's are foods capable of supporting bacterial growth associated with foodborne illness. Safe food handling practices would ensure that PHF's are maintained under safe food preparation/storage temperatures, defined as 41-135?F. Food handling practices would also ensure that if PHF's are held outside of this temperature range, it would not be for greater than 4 hours cumulatively, prior to cooking/consumption (Food Code, 2009)

In a concurrent interview with DS C he stated that the individual portions were dished up each day and left in the refrigerated unit. He also stated that they would stay there until they were either sold or expired. In an interview on 1/5/12 with DMS A she was asked how she ensured food temperatures were maintained within safe food handling parameters. She stated that refrigerator and food temperatures were monitored several times during the day by either dietary staff or dietary supervisory staff. She also stated that food temperatures would be recorded each time temperatures were taken. Review of hospital document titled "Supervisors Daily Food Protection Check Sheet" dated 6/11 revealed that the review was limited to checking that refrigerator temperatures were recorded. There was no indication that staff was taking food temperatures.

The surveyor also asked DMS A to describe the items that would be offered on the salad bar. She proceeded to list the items, one of which was cut tomatoes. Tomatoes once they are cut are also considered to be a PHF (Food Code, 2009).

In an interview with DS D who was responsible for checking salad bar temperatures confirmed that cut tomatoes were a regular item on the salad bar and also stated that since all the protein based items were discontinued in October there was no temperature monitoring of the salad bar, in particular the cut tomatoes. DMS A acknowledged that this item should have been monitored.

In an interview on 1/4/12 at 11 a.m., DMS A staff was asked to describe her position responsibilities in relationship to food services. She stated that she was responsible for the day to day evaluation of the processes. She also stated that when supervisory staff identified problems they would be responsible to make her aware of any issues. While DMS A was identified as the position responsible for the day to day operations, it was noted that the developed systems within the department relied primarily on daily supervisors to identify issues surrounding safe food handling practices.

2. During initial tour on 1/4/12 beginning at 9 a.m., the following was noted:
a. In the walk-in refrigerator it was noted that there were thawed, 5 pound sealed bags of chili with beans in a box. It was also noted that on the exterior of the box was printed "Keep Frozen." It was noted that they were dated 12/29/11 with an expiration date of 1/3/12 (a total of 5 days). In a concurrent interview with DMS A the surveyor asked her how the expiration date of the product was determined. She stated that staff was guided to use the food storage guidelines. Concurrent review of the food storage guidelines dated 12/17/11 revealed that the only items listed with a 5-day hold time was sour cream, pound cake and bran muffins. It was also noted that the chili was not listed on the guidance. The surveyors also asked DMS A to describe the system for ensuring items were stored per manufacturers' guidance. She acknowledged she had not reviewed this particular product for shelf life.

Review of the undated product specifications for the chili guided staff to "Keep Frozen ...Let the chili thaw under refrigeration approximately 36 to 48 hours. Then place the chili in a warming unit ..."

b. In the walk-in refrigerator there was a case of sour dough bread loafs. It was noted that on the exterior of the box it was printed to "Keep Frozen." Review of manufacturers' guidance dated 1/5/12 for bread storage revealed that bread should never be stored in the refrigerator. The guidance bread should be stored either in a freezer or at room temperature.

3. When touring the dry storage area on 1/5/12 beginning at 1:30 p.m., in the basement of the hospital, three tube feeding bottles were found on the shelving where tube feed products were stored. The three bottles had a hospital patient label adhered that identified a patients' name and room number. Dietary Staff E explained that the tube feeding products were delivered to the floor and placed in the nursing unit. The labeling indicated that the product was previously delivered to the nursing unit. Dietary Staff E indicated it was not hospital policy to return products's to the food storage area and that the items should have been discarded upon receipt in dietary services.
Further interview with the DMS A on 1/5/12 at 2 p.m., confirmed the previous information. The Manager stated the facility policy was to discard any food items including tube feeding if they were returned to dietary services. Unopened products were not to be restocked for later use.

Based on dietary document review and dietary staff interview the hospital failed to ensure the nutritional needs and/or physician ordered diets of inpatients were met as evidenced by 1) the lack of a comprehensive nutritional analysis of patient menus. Failure to complete a nutritional analysis of the menu may result in unmet nutritional needs further compromising the clinical and nutritional status of patients.

Findings:

The Dietary Reference Index (DRI) published by the National Academy of Sciences, Institute of Medicine (NAC/IOM) is intended as a reference guide to health professionals in the daily planning of nutritional needs of individuals and groups. The DRI is comprised of macronutrients such as calories, protein, fat, carbohydrate, cholesterol and fiber as well as greater than 30 vitamins and minerals (NAC/IOM, 2005).

On 1/5/12 beginning at 1:30 p.m., hospitals' menu and the accompanying nutritional analyses were reviewed with DMS A and B. It was noted that while the hospital developed an analysis that incorporated the menus' macronutrients the analysis consisted of only sodium, potassium and phosphorus as representation of the vitamins/minerals. In a concurrent interview with DMS B the surveyor asked her to describe the rationale for limiting the analysis for the vitamin/minerals. She explained that she thought that the sodium, potassium and phosphorus were the primary ones a dietitian would be concerned about. DMS B also acknowledged that limited analysis would not ensure that the comprehensive nutritional needs of inpatients would be met.

Additional review of the hospitals' regular diet revealed that fiber content did not meet the recommended DRI. It was noted that the total daily fiber content ranged from 17-22 grams of daily fiber. The DRI for fiber is age and gender specific and the recommended intake ranged from 19-38 grams/day (NAC/IOM, 2005). In a concurrent interview DMS B also explained that while completing the nutritional analysis it was recognized that not all diets met the physician ordered parameters; however the menus were not yet adapted.

Based on trayline observations, dietary staff interview and dietary document review the hospital failed to ensure 1) physician ordered therapeutic diets were implemented as evidenced by patient menus that were not consistent with the physician approved parameters of the hospitals' diet manual; 2) obtain clarification of diet orders that were consistent with the facility's approved Diet Manual in a timely manner and 3) failed to assure that 1 patient (Patient 4) received a diet as ordered by the physician. Failure to ensure physician ordered diets were followed may compromise the clinical status of patients.

Findings:

1. During trayline observations on 1/4/12 beginning at 11:45 a.m., it was noted that there were greater than 10 patients with physician ordered standard carbohydrate consistent diets. Consistent-carbohydrate diets utilize meal plans without a specific calorie level; instead, it incorporates consistent carbohydrate content from day to day at breakfast, lunch, and dinner (American Diabetes Association, 1997). It was also noted that while some individual patients self-selected their own menu others were given the standard selection that consisted of braised beef tips, rice, vegetables, bread, and fruit.

On 1/5/12 beginning at 11:30 a.m., the physician approved hospitals' diet manual, dated 12/11 was reviewed with DMS A and B. It was noted that the standard consistent carbohydrate diet should contain between 60-75 grams of carbohydrate per meal. Review of the hospitals' undated menu analysis for the consistent carbohydrate revealed that for 4 of 7 days the breakfast meal did not meet expected parameters. It was noted that the amount of carbohydrate offered ranged from 45-57 grams/day. DMS B also explained that while completing the nutritional analysis it was recognized that not all therapeutic diets met the physician ordered parameters; however menus were not yet adapted.

2. On Jan 6, 2012 review of Patient 4's medical record, showed an admitting diagnosis of lower leg cellulitis and history of diabetes. The physician ordered diets were as follows: 12/25/11 noted a telephone order for a Regular ADA which later that day was changed to a Diabetic Diet; 12/28/11 - Consistent Carbohydrate diet; 1/3/12 - a High Carbohydrate Consistant Diabetic diet; and 1/5/12 - Consistant Carbohydrate High Calorie with snacks. The patient consumed 100% of all meals beginning at dinner on 12/31/2010 through 1/5/2012.

The facility Diet Manual was reviewed on 1/6/12 at 1:30 p.m.. It was noted there were three levels of a Consistanent Carbohydrate Diet - low, regular and high. In a concurrent interview with DMS B she stated that if the physician ordered a diabetic or ADA diabetic diet the hospital provided a regular Consistant Carbohydrate Diet. The Diet Manual did not include orders for a Regular ADA diet or Diabetic Diet. Further, the Manager explained that when a Diabetic Diet was ordered the patient received a Regular Carbohydrate Consistant Diet. This was done by the dietary services diet aide who sometimes conferred with the registered dietitian. There was no contact made by facility nursing staff or the dietitian to clarify the order with with the physician to ensure that the ordered diet was appropriate for the patients' medical status and was consistent with the hospitals' diet order as identified in the approved Diet Manual.

The facility did not have a policy that reflected a process for clarification of diet orders that were inconsistent with the approved Diet Manual.

The hospital's Nutritional Screen and Assessment Policy dated 7/11, identified parameters for invention by a dietitian. The policy guided staff that the dietitian could be contacted by nursing staff, physician referral or determination by the registered dietitian's review of information in the medical chart.