HospitalInspections.org

Based on observation, policy and procedure manual review and interview, it was determined the Facility failed to ensure outdated food items were not available for patient use and failed to ensure established policies and procedures were specific to the Facility. Failure to ensure outdated food items were not available for patient use created the potential that a patient would receive expired food items, and failure to fully develop policies, procedures or other mechanisms for employees to reference did not allow the Facility employees to be knowledgeable regarding correct policies and procedures. The failed practices had the potential to affect any patient admitted to the Facility. Findings follow.

A. During a tour of the kitchen on 12/11/14 from 1000-1030, the following was observed:

1) Walk in refrigerator:
a) Mushrooms - one of one container, expired 12/08/14
b) Beets - one of one container, expired 12/06/14
c) Olives - one of one container, expired 12/06/14
d) Diced peaches - one of one container, expired 12/04/14
e) Mixed fruit - one of one container, expired 11/30/14
f) Pears - one of one container, expired 12/09/14

2) Upright refrigerator:
a) Cheese - one of one package, expired 11/29/14
b) Chicken - one of one container, expired 11/08/14

3) Spice storage rack - two of two gallons of soy sauce, opened, not refrigerated. Review of Manufacturer's label stated, "refrigerate after opening".

B. Review of the Dietary Department Policy and Procedure Manual (with a review date of 10/07/14) revealed Dietary policies were incomplete and not made specific to the Facility. Examples include:
1) Policy titled " Annual Review of Manual By Foodservice " stated, " In order to meet the objectives of the Food and Nutrition Services Department of ____. "
2) The following policies all included a statement with instructions to revise the policy to make it " facility specific: " Initial Nutrition Screening and Prioritization; RD Coverage; Diet Manual; Relationships with Other Departments and; Department Meetings.
3) Policy titled "General Information" stated:
Breakfast 00:00 to 00:00
Lunch 00:00 to 00:00
Dinner 00:00 to 00:00
The cafeteria is located on the ____ floor of the hospital.
4) Policy titled " Medical Record Documentation" stated, "The appropriate nutrition information will be documented in the medical record by completing_____. Documentation completed in the medical record will be filed under the ____ section of the paper chart ....If a computerized charting system is used: In the case of the computer system being down, a ____ will be used and will be filed in the ____ section of the chart."
5) Policy "Registered and Licensed Dietitians" stated, "The Clinical Staff will be licensed by the State of ____ (if required) ...Prior to employment, the Clinical Dietitian will be licensed by the State of ____ and registered by the Commission of Dietetics Registration."
6) Policy titled "Intake Analysis and Documentation" stated, "The Food and Nutrition Services Department conducts Nutrient Intake Analysis for ____ day(s), unless otherwise specified."
7) Policy titled "Committee Concerned with Nutrition Care" stated, "The __________ committee is designated as the facility approved committee concerned with nutritional care."

C. During an interview on 12/12/14 at 0910, the Foodservice Director confirmed the policies were not completed and specific to the Facility. The Foodservice Director confirmed the expired foods at the time of the tour.