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Based on observation, interview and policy review the hospital failed to provide adequate oversight of daily operations, staff, and policy enforcement for food preparation and storage. (Refer to A-620)

These failures had the potential to expose all patients, staff and visitors to food borne illness and/or cross contamination that could result in illness. The hospital census was seven.

The cumulative results of these findings resulted in the overall non-compliance with CFR 482.28, Condition of Participation: Food and Dietetic Services.

Based on observation, interview and policy review the hospital failed to ensure that the Dietary Services Department followed hospital and dietary policies when:
- Staff failed to properly date food items located in the kitchen dry storage area, freezers and refrigerators.
- Staff failed to remove expired food items from stock in the kitchen dry storage area, freezers and refrigerators.
- Staff failed to seal zippered storage bags with open food products.
- Staff failed to taste and assess the appearance of each meal served from the tray line.
- Staff failed to assess and document food temperatures at the beginning and end of each tray line.
- Staff failed to check and record temperatures of refrigerator and freezer units daily.
- Staff failed to wear hair coverings in the kitchen.
- Daily kitchen operations, staff oversight, and policy enforcement were not provided by a qualified Dietary Manager.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection and illness. The hospital census was seven.

Findings included:

1. Review of the hospital's policy, "Dietary," dated 09/2022, showed:
- Expiration dates on food products would be checked closely.
- All food would be thoroughly cooked or heated to the proper temperature to prevent contamination.
- Refrigerator and freezer units would be checked daily to ensure proper temperature control.
- All employees would wear hair coverings when in the kitchen area.

Review of the hospital's policy, "Food Storage," dated 08/2019, showed that all food products would be dated upon receipt or when they were prepared. A use by date would be marked on all food containers according to the timetable in the dry, refrigerated and freezer storage chart. Any open products would be placed in seamless plastic or glass containers with tight-fitting lids or zipper storage bags.

Observation on 06/20/23 at 2:00 PM, showed 20 expired single serve cereal boxes prepared for morning breakfast distribution on the kitchen tray line.

Observation on 06/20/23 at 1:50 PM, in the cooler number three, showed one bottle of chocolate sauce with a receive date of 03/07/23 and an expired date of 04/07/23, one eight ounce carton of expired white milk, and four slices of bread in two single serve plastic wraps without open or use by dates.

Observation on 06/20/23 at 1:45 PM, in the vegetable freezer number five, showed 13 packages of chopped spinach, three packages of frozen turnip greens, one large bag of frozen garlic bread and two loaves of white bread without receipt or use by dates. One bag of hoagie buns had expired 03/24/23.

Observation on 06/20/23 at 1:30 PM, in the dry food storage, showed one bottle of cherries, one bottle of molasses, one bottle of ranch dressing, one bin of single serve cereal boxes, one bin of 1.5 ounces of ranch dressing packets and one bin of crackers without receipt or use by dates.

Observation on 06/20/23 at 1:35 PM, showed one open zipper storage bag of peanuts without receipt or use by date in the same bin as marshmallows.

Observation on 06/20/23 at 1:40 PM, in the meat freezer number four, showed two packages of hotdogs without receipt or use by dates.

Observation on 06/20/23 at 1:55 PM, in the cooler number two, showed five bags of mixed lettuce without receipt or use by dates.

Observation on 06/20/23 at 2:00 PM, in the cooler number one, showed ¼ bag of shredded yellow cheese in an open zipper storage bag without an open or use by date.

Observation on 06/20/23 at 2:05 PM, showed six containers of expired spices and seven containers of spices without receive, open or use by dates on the kitchen spice rack.

Observation on 06/20/23 at 2:30 PM, in the nourishment room refrigerator on unit 2A, showed a zipper storage bag with six 1.5 ounces packets of syrup without receive or used by date and one container of leftover food without a patient name or date.

Observation on 06/20/23 at 2:35 PM, in the nourishment room freezer on unit two A, showed a zipper storage bag with 14 orange sherbet containers without receive or use by dates and two re-usable freezer packs belonging to staff.

During an interview on 06/20/23 at 1:15 PM, Staff C, Cook, stated that when the food delivery arrived, the items were placed in the appropriate storage area (dry goods, refrigerator, or freezer). When each item was placed in their bin or the shelf a sticker would be applied with the arrival date documented. When food supplies were opened, they should be placed in zipper storage bags with the arrival date, date opened, and use by date.

During an interview on 06/20/23 at 3:20 PM, Staff I, Dietary Aide, stated that all food items stored in the medical unit's nutrition room should be dated with the date stocked and a use by date to ensure that any expired items were appropriately discarded.

2. Review of the hospital's policy, "Food Tasting," dated 08/2019, showed that the Cook and/or Dietary Manager would taste all foods prepared before serving.

Review of the hospital's policy, "Food Temperature," dated 08/2019, showed foods would be served at proper temperature to ensure food safety. Thermometers should be inserted into center of the food product to obtain an accurate reading. Temperatures would then be recorded on the "Food Temperature Chart" form at beginning of tray line and at the end of tray line, for each food item before serving them.

Review of "Tray line Temperature Monitoring Form," showed five missed start and midpoint food temperatures for the dinner meal out of 20 dinners and 27 missed food taste and appearance assessments out of 60 meals.

During an interview on 06/21/23 at 12:55 PM, Staff F, Kitchen Supervisor, stated that the food was tasted and assessed for appearance by the cook. Food temperatures were checked twice and the information was recorded onto the temperature log for every meal, every day.

Review of dietary refrigerator/freezer temperature logs showed that on 05/2023 there were three missing daily temperature checks for freezer number four. On 06/2023 there were five missing daily temperature checks for the refrigerator number three. On 04/2023 and 06/2023 there were 22 missing daily temperature checks for the retail refrigerator.

During an observation and concurrent interview on 06/20/23 at 1:45 PM, Staff C, Cook, stated that refrigerator and freezer temperatures should be checked daily.

3. Observation on 06/20/23 at 1:10 PM, showed staff D, Chief Operating Officer (COO), failed to don hair covering prior to entering kitchen.

During an interview on 06/20/23 at 1:10 PM, Staff C, Cook, stated anyone entering the kitchen should have a hair covering in place.

4. Review of the hospital's policy titled, "Organizational Chart," dated 08/2019, showed that the Dietary Manager had the responsibility for the overall operation of the Dietary Department.

During an interview on 06/20/23 at 12:30 PM, Staff B, Interim CEO, stated that the hospital did not have a Dietary Manager. There were upcoming interviews scheduled to hire one. Staff D, COO, was the only administrator with previous food service experience and she was responsible for the Dietary Department.

During an interview on 06/20/23 at 12:40 PM, Staff D, COO, stated that she did not have any formal certification for food service. Her family had owned and operated a convenience store with minor food service for 14 years, which gave her a working knowledge related to ordering and cleaning. She had upcoming interviews scheduled to hire a Dietary Manager.

During an interview on 06/20/23 at 2:05 PM, Staff E, Registered Dietician, stated that the hospital kitchen did not currently have a Dietary Manager to oversee daily kitchen operations. She provided contracted services to the hospital to ensure the dietary needs of all patients admitted to the hospital were met. She had provided her contact information to the Kitchen Supervisors in order to assist them with appropriate substitutions for menu items when necessary. She had provided education to the kitchen and nursing staff regarding alternative meal options and appropriate nutritional substitutes. A detailed Diet Manual was readily available to the dietary staff.