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Based on observation, interview and record review, the dietary services supervisor (DSS) at Hospital B failed to ensure a system to determine competency for five cooks as it related to correct cool down procedures for potentially hazardous foods.

Findings:

On 5/7/13 at 1:40 P.M., at Hospital B, inside the kitchen was a walk-in refrigerator that contained a 2-3 gallon pot of "Beef Chili, dated 5/7/13." Cook 47 was asked to check the internal temperature of the beef chili which was 200 degrees Fahrenheit (F). The FSD asked the Retail Services Manager (RSM) for the cool down log for the beef chili, and the RSM said that there was no cool down log for that. The RSM went inside the walk-in refrigerator and observed the cooked beef chili, dated 5/7/13. The RSM verified that the beef chili was for the cafe but that "it shouldn't be in the refrigerator. It should've been cooked and remained hot."
The RSM stated the cook that had prepared the beef chili had gone home for the day, and could not state why the beef chili was in the walk-in refrigerator. The RSM verified that she was unaware that the cooked beef chili was in the walk-in refrigerator as it was not planned to be that way. The RSM further verified that there was not a dietary employee who would have known that there was a need to cool that down, as no one knew it was there except for the cook that had gone home for the day.
At that time, Hospital B's cool down log was requested. The log was entitled Hazard Analysis of Critical Control Points (HACCP) [hospital name] HACCP Log Cooling of Potentially Hazardous Food. The log that the facility chose to utilize had not provided complete guidance and proper instruction on safe cool down of potentially hazardous foods. The log indicated, "All potentially hazardous foods must be monitored by recording the internal temperatures as the item cools. Potentially hazardous foods include but are not limited to large cuts of meat, meatloaf, and stews. Cooked foods must be cooled from 140 degrees F. to 45 degrees F. within 4 hours or discarded."
Time/temperature control for food safety would include cool down monitoring of potentially hazardous foods (PHF). PHF's are those foods capable of supporting bacterial growth associated with foodborne illness (Food Code, 2009). Cool down monitoring would ensure that cooked potentially hazardous foods shall be cooled: 1) within 2 hours from 135?F to 70?F; and within an additional 4 hours from 70?F to 41?F) or less (Food Code, 2009).
The cool down logs were reviewed from 4/25/13 through 5/4/13 in which there were a total of 19 logged entries of PHFs that were cooled down, and 17 of 19 times were done incorrectly. The FSD identified that five different cooks were involved with the cool down log for the same time period in which it had not been done in accordance with safe food handling practices.
The DSS said, "I have not reviewed the logs since they have been implemented." Further, the DSS and the RSM verified that they have never observed the cooks checking time and temperature monitoring to ensure safe cool down of PHFs were done correctly for the health and safety of the patients.
According to the job description provided for the Patient Service Manager [DSS], "...develop and adhere to policies covering sanitary regulations and HACCP compliance. Responsible for overseeing the selection, training, and supervision of food service personnel. Evaluate performance of all employees supervised."

Based on interview and record review, the hospital failed to ensure that a therapeutic protein supplement was ordered for 2 of 43 sampled patients (Patient 48 and 49), by the practitioner responsible for their care.
Findings:

1. On 5/8/13 at 1:21 P.M., Patient 48's medical record was reviewed. Patient 48 was admitted to Hospital B on 5/2/13, according to the Facesheet. On 5/2/13, the physician ordered a "carb limited std" diet [carbohydrate limited standard diet], according to physician orders.
On 5/3/13 an initial nutrition assessment was completed for Patient 48 by a Registered Dietitian (RD 50). RD 50's plan included, "Add ... Beneprotein [a powdered protein supplement] BID [two times a day]."
The Clinical Nutrition Manager (CNM) reviewed the electronic order for beneprotein and confirmed that RD 50 ordered the Beneprotein without a physician's order. During the same record review, the CNM acknowledged that Beneprotein was not incorporated into the physician's diet order for a carbohydrate limited diet.
The CNM verified that the registered dietitians were not independent practitioners and were not allowed to order therapeutic treatment interventions for patient care. The CNM stated that she was unaware that an RD at the hospital was prescribing Beneprotein for patients without a physician's order.
2. On 5/8/13 at 3:00 P.M., Patient 49's medical record was reviewed. Patient 49 was admitted to Hospital A on 4/29/13. On 4/29/13, the practitioner responsible for the care of the patient ordered Patient 49 a carbohydrate limited diet.
On 4/30/13, Registered Dietitian (RD 51) completed a nutrition assessment for Patient 49. RD 51's nutrition plan included to provide beneprotein packets three times a day. RD 51 ordered the beneprotein three times a day on 4/30/13, without a physician's order.
On 5/8/13 at 3:36 P.M., RD 51 verified that she had ordered the beneprotein three times a day for Patient 49 without speaking with a physician to obtain an order. During the same record review, the Clinical Nutrition Manager (CNM) acknowledged that Beneprotein was not incorporated into the physician's diet order of carbohydrate limited diet.
The CNM verified that registered dietitians were not independent practitioners and were not allowed to order therapeutic treatment interventions for patient care, without a physician's order. The CNM stated that she was unaware that RD's at the hospital were prescribing Beneprotein for patients' without a physician's order.
On 5/9/13 at 11:00 A.M., the CNM stated that she spoke with all nine of the clinical dietitians that worked at the hospital yesterday evening to determine how many RD's were writing orders, and she had determined that it was limited to two RDs, in which she informed them that they do not have hospital privileges to write orders.