HospitalInspections.org

Based on observation, record review, and interview with key personnel on April 29, 2014, it was determined that the Critical Access Hospital failed to appropriately store patient nutritional products in accordance with accepted standards of practice and hospital policy.

Findings include:

1. The Policy titled 'Refrigeration and Freezer Temperatures' stated: "All refrigeration and freezer temperatures will be monitored to ensure safe, adequate refrigeration/freezing of food items. All deviation from acceptable refrigeration/freezer temperatures will be recorded with appropriate action taken." This policy continued: "In response to the discovery of deviant cooler temperature readings, the following action will be taken: i. Check the reason for the deviant temperature readings and determine if problem can be easily corrected... ii. Take internal temperatures of potentially hazardous foods, to determine if food has exceeded 41 [degrees] F [Farenheit]. iii. If there is a reason to suspect that potentially hazardous food has exceeded 41 [degrees] F for 4 hours, discard the food." Finally, the policy stated: "Immediately report any deviant cold storage temperatures."

2. During observations in the ASU on April 29, 2014 at approximately 1:40 PM, the surveyor noted the 'Refrigerator Temperature Log' for the patient food refrigerator documented a temperature of 43 degrees for this day. Note: This is outside the acceptable range of 33-40 degrees. The log also documented that the thermostat had been adjusted.

3. On April 29, 2014 at approximately 1:40 PM, the surveyor observed that the thermometer in the refrigerator read 42 degrees (still outside the accepted range). The surveyor observed dairy products in this patient refrigerator.

4. During an interview on April 29, 2014 at approximately 1:40 PM, the Director of Surgical Services stated that the temperatures were logged in the morning at approximately 8:00 AM. She stated that the ASU staff would check the temperature again the next morning. She stated that nothing further had been done regarding this deviant temperature.

5. The same log also noted two other days the temperature was deviant for the month of April.