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Based on observation, record review and interview, Central Louisiana State Hospital (CLSH) failed to meet the condition of participation relative to food and dietetic services as evidenced by:

1. the hospital's dietitian failing to ensure that the dietary department had developed and/or implemented policies and procedures to address all aspects of food preparation and safe practices for the dietary department; (Findings in Tag A620)

2. failing to ensure there were adequate numbers of dietary staff to allow for food preparation to be provided under requirements stipulated in the hospital's dietary policies and procedures and ensure that there was supervisory dietary staff available to oversee all aspects of the dietary staff practices relative to the preparation, cooking, handling, and serving of food; (Findings in Tag A620)

3. failing to provide routine training to all dietary staff to ensure that food was prepared according to the dietary policies and procedures and acceptable dietary standards of practice. (Findings in Tag A622)

These failures placed all patients and staff who consumed food prepared in the dietary kitchen of the hospital at risk. According to written reports provided by CLSH's Quality Management Department, on the morning of 5/7/10, 36 patients and 4 staff members at CLSH began experiencing varying degrees of nausea, vomiting, diarrhea and abdominal pain. A total of 11 patients were transferred to the hospital on 5/7/10 for emergency treatment, 5 of the 11 patients were admitted to the hospital of which 2 of these expired., and the remaining 6 patients were evaluated in the emergency room, treated, and discharged back to CLSH from the emergency department of Hospital A. 4 staff employees also became ill and were evaluated in the emergency room of Hospital A. All of the patients and staff employees, who became ill with gastrointestional symptoms and all of the patients and staff, who were sent to Hospital A for emergency treatment secondary to gastrointestional symptoms, had consumed food prepared in CLSH's kitchen which was eaten on the evening of Thursday, 5/6/10.

Based on observation, record review and interview the hospital dietitian failed to ensure that
the dietary department had developed and/or implemented policies and procedures to address all aspects of food preparation and safe practices for the dietary department, to ensure there were adequate numbers of dietary staff to allow for food preparation to be provided under requirements stipulated in the hospital's dietary policies and procedures and to ensure that there was supervisory dietary staff available to oversee all aspects of the dietary staff practices relative to the preparation, cooking, handling, and serving of food. Findings:

A briefing was held at CLSH on 5/8/10 at approximately 4:15 p.m. with the State Secretary, State Epidemiology, State Office of Public Health, State/Local Police, State Health Standards Section and CLSH Administrative staff and Medical Director. During the briefing, S19, CLSH's Medical Director, stated to all in attendance, that on Friday (5/7/10) around 6:30 a.m. there were 30-31 patients that began to have diarrhea, nausea and vomiting, and it was believed that the supper night (5/6/10) meal may have caused the illnesses. On 5/8/10 CLSH's main kitchen was closed prior to breakfast.

Review of documentation provided by and interview with S5 RN, Program Coordinator, Quality Management on 5/12/10 at approximately 10:00 a.m. revealed that on Friday, 5/7/10, 36 patients at CLSH began having various degrees of nausea, vomiting, diarrhea and abdominal pain. S5 RN revealed that a total 11 patients were transferred to the hospital, 5 of the 11 were hospitalized (2 expired), and 6 of the 11 were evaluated in the emergency room and returned to CLSH. S5 RN revealed 4 employees also became ill and were evaluated in the emergency room. S5 RN confirmed all of the above patients and employees consumed chicken which was prepared in the hospital's kitchen and served for the evening meal on Thursday, 5/6/10.

Review of the CLSH Dietary Office Work Schedule for the month of May, 2010 revealed S3 was the full-time Registered Dietitian/Nutrition Services Administrator (Chief Dietitian) and S4, was the full-time Registered Dietitian, Hospital Nutrition Services Assistant Director (Clinical Dietitian). The schedule reflected S3, Chief Dietitian, worked on 5/5/10 form 7:30 a.m. to 6:00 p.m. and on 5/6/10 from 7:30 a.m. to 12:00 p.m. The schedule also reflected that S4, Clinical Dietitian, was off on 5/5/10 but worked on 5/6/10 from 5:30 a.m. to 3:00 p.m.
Review of CLSH Week 7 Spring Dietary Menu dated 5/2/10 to 5/8/10 revealed that on Thursday 5/6/10 the Supper meal consisted of Mandarin Orange with Chicken on Salad with Honey Mustard Dressing; Mechanical Soft Chicken Salad Sandwich on Croissant; Broccoli Cheese Potato and Fruit Salad.
During an interview on 5/10/10 at approximately 9:10 a.m., with S3, Chief Dietitian, she confirmed the evening meal for 5/6/10 was served as listed.

Preparation of Chicken 5/5/10
Interview with S9, FSS 3 Main Cook, on 5/10/10 at 9:20 a.m. and 11:30 a.m. revealed she worked on Wednesday 5/5/10 and on Thursday 5/6/10 from 8:00 a.m. to 4:30 p.m. S9, stated the chicken for Thursday's (5/6/10) evening meal was delivered on Tuesday (5/4/10) and was placed in the thawing cooler. S9 stated that when the meat was taken out of the thawing cooler on Wednesday (5/5/10) the chicken was still frozen. S9, FSS Main Cook stated that 50 pounds of chicken was cooked on Wednesday afternoon (5/5/10) by S10, Main Cook for the Thursday (5/6/10) evening meal. S9, FSS 3 Main Cook stated that when the chicken was placed in the pot to boil on (5/5/10), the chicken was still frozen. S9 FSS 3 Main Cook stated that chicken was not usually cooked that far in advance, it was usually cooked the same day of service.
Interview with S10 FSS 3 Main Cook on 5/10/10 at 10:00 a.m. revealed she worked on Wednesday 5/5/10 from 8:00 a.m. to 4:30 p.m., and she cooked the chicken pieces on Wednesday afternoon for Thursday evening meal. CLSH's Policy and Procedure for the Dietary Department reflected "Foods are to be prepared as near to serving time as possible".
S10, Main Cook stated that on Wednesday afternoon the chicken was still frozen, and she began to cook it slowly. Review of CLSH's Policy and Procedure for HACCP Food Safety System Plan B for the production of meats, poultry, fish and seafood reflected the criteria for thawing was to use approved methods for thawing and continue to thaw if still frozen. Review of CLSH's Policy and Procedure for the Dietary Department did not reflect methods for thawing.
S10, Main Cook stated that she had to break the frozen chicken apart while it was cooking. S10, Main Cook stated that she checked the temperature of the chicken while cooking it, and when she finished cooking the chicken, she put the chicken in 2 six inch pans and placed the pans on a rolling cart (to cool) outside the cooler. S10, stated that when she left work on Wednesday at 4:30 p.m. the chicken was not cool enough to be placed in the cooler, and she (S10) told the evening staff to place the chicken in the cooler. S10, Main Cook stated that she did not recall who she told to place the chicken in the cooler.
Interview with S3, Chief Dietitian on 5/12/10 at 9:45 a.m. revealed after surveyors asked questions concerning how the chicken was cooked, she (S3) followed up with S10, Main Cook, and S10 stated that she boiled the chicken at a full boil for 1 hour and did not check the endpoint temperature because she knew it had reached the boiling point. Review of CLSH's Policy and Procedure for HACCP Food Safety System Plan B for cooking of meats, poultry, fish and seafood reflected cooking poultry at equal to or greater than 165 degrees F and check the product temperature at geometric center. Further review of the hospital's policy reflected the preparation temperature at completion of the cooking process (endpoint temperature) for poultry should be 165 degrees F for 15 seconds.
Further interview on 5/10/10 at 10:38 a.m. with S12, FSS 3, Cook concerning placement of the chicken after it was cooked revealed she worked on Wednesday (5/5/10) and Thursday (5/6/10) from 10:00 a.m. until 6:30 p.m. S12 stated that she did not put the chicken in the cooler on Wednesday (5/5/10) after S10, Main Cook left work S12, Cook, stated she did not know who put the chicken in the cooler on Wednesday evening (5/5/10).
Interview on 5/10/10 at 10:20 a.m. with S11, FSS 3 Cook, revealed she worked from 10:00 a.m. to 6:30 p.m. on Wednesday (5/5/10) and Thursday (5/6/10). S11 Cook stated that she did not place the chicken in the cooler on the evening of Wednesday 5/5/10.
During an interview on 5/10/10 at 11:06 a.m. with both S11 Cook and S12 Cook, S11 stated to S12 "You should have put the chicken in the cooler". S12 stated "Oh, I remember. I did put the chicken in the cooler. It was about 5:00 or 5:30." S12 stated that she touched the pans with her hand and "it felt okay". S12 stated she did not use the thermometer to check the temperature of the chicken prior to placing the chicken in the cooler.
Review of the hospital's policies and procedures for "cooling" of meat, poultry, fish and seafood reflected "Cool under refrigeration...Cool from 140 degrees to 40 degrees F in 4 hours...Check the product temperature at geometric center at 4 hours...Discard if not cooled from 140 degrees F to 40 degrees in 4 hours".
Review of CLSH's dietary logs for temperature monitoring dated 5/5/10 did not reflect documented temperatures of the chicken which was cooked and placed to cool by S10 Main Cook on 5/5/10; nor were there temperatures of the chicken documented by S12 Cook prior to the chicken being placed in the cooler on 5/5/10 according to the hospital's policy and procedure.
Interview on 5/11/10 at 1:30 p.m. and on 5/12/10 at approximately 9:00 a.m. with S3, Chief Dietitian and S4, Clinical Dietitian confirmed there was no policy in place for approved methods of thawing.

S3, Chief Dietitian, stated, at that time, that meats were usually cooked on the day of service and not in advance; however; due to dietary staff shortage for approximately the last 2 months, some meats were being cooked the day before the food was served. S3 stated that some dietary positions had been lost due to budget cuts and one of the supervisors were out on extensive sick leave.

Further interview, at that time, with S3, Chief Dietitian and S4, Clinical Dietitian revealed the hospitals's HACCP Food Safety System Plan for cooking and cooling meats was being utilized during daily routine cooking of meals. They confirmed that were aware that meats were being cooked 24 hours or greater in advance, but they were not following the HACCP Plan for foods cooked in advance of the day of service.

S3, Chief Dietitian confirmed, at that time, that dietary staff had not been instructed to document temperature checks of food into a temperature log even though the dietitian was aware that chicken and other foods were being cooked in advance of the date being served, and the dietitian had not provided any inservices or instruction to the cooks to start using the the HACCP Plan B for meats cooked and cooled 24 hours or greater in advance of the day of service. S3, Chief Dietitian and S4, Clinical Dietitian stated they did not know why the HACCP Plan had not been followed for meats cooked in advance. S3, further stated that during the cooling process for meats cooked in advance, staff should check the temperature to assure the meat cooled to 70 degrees F in 2 hours before placing the meat in the cooler. This statement by S3 was in conflict with the hospital's policy which required food to be cooled under refrigeration from 140 degrees to 40 degrees F in 4 hours and discard if not cooled from 140 degrees F to 40 degrees in 4 hours.

Preparation of Chicken 5/6/10

Interview with S10, Main Cook on 5/10/10 at approximately 10:00 a.m., revealed that on Thursday morning (5/6/10) when she returned to work at approximately 7:30 a.m., the chicken was in the cooler. S10, Main Cook stated she chopped and divided the 50 pounds of chicken in approximately 15 minutes. S10 stated that she divided the chicken into separate pans for the chicken salad croissants and the mandarin chicken salad. S10 further stated she replaced the divided chicken into the cooler. S10 stated that she also prepared the honey mustard dressing on the morning of 5/6/10 using mayonnaise, mustard and Splenda.
Interview on 5/10/10 at 9:20 a.m. with S9 FSS 3, Main Cook, revealed on Thursday (5/6/10) at approximately 2:30 p.m. she removed the chicken, which was divided for the chicken croissant sandwiches, from the cooler and mixed the chicken to be used of the chicken salad with mayonnaise and chopped celery. S9 stated she fixed the sandwiches and placed them back into the cooler between 3:15 p.m. and 3:30 p.m.
Interviews with the 3 male FSS 3 Cooks, S14, Cook, S17 Cook and S18 Cook on 5/10/10 at 12:44 p.m., 1:24 p.m. and 1:38 p.m. respectively, revealed they worked on Thursday 5/6/10. However, the male cooks denied preparing the lettuce for the mandarin chicken salad on Thursday afternoon. Interviews with S11 FSS 3, Cook and S12 FSS 3 Cook on 5/10/10 at 10:20 a.m. and 10:38 a.m. respectively, revealed they also worked on Thursday (5/6/10) however, they denied preparing the lettuce for the mandarin chicken salad.

Service of Chicken 5/6/10

Interview on 5/10/10 at approximately 1:38 p.m. with S18 FSS 3 Cook revealed he worked on Thursday 5/6/10 from 10:00 a.m. to 6:30 p.m. with S11 Cook, and he was assigned as the main cook. S18 stated he served the evening meal on Thursday 5/6/10 for Units 9B, 9C in mobile Styrofoam plates and Unit 8 in bulk insulated containers. S18 Cook stated that some patients may come to the cafeteria to eat, but no patients ate supper in the main cafeteria that day. S18 stated the plating of the evening meal service started at approximately 4:45 p.m., and at that time chicken salad croissant sandwiches, chicken for the main dish, lettuce, mandarin orange, honey mustard dressing, broccoli cheese potato and fruit salad were already on the serving line. S18 stated that he did not place the food items on the serving line, and he did not know who placed them there.
S18 Cook stated at that time there was no ice on the serving line, the serving line warmer was on, there were flat metal covers over the steaming sections, and the food items listed above was sitting on top of the metal covers. S18 stated he was not aware that the chicken and other food items were to be served as a cold food item, and he had not received training concerning the service of hot and cold food items. S18 stated he did not check the temperature of the food items on the serving line. S18 stated the mobile Styrofoam plates were packed into cardboard boxes and delivered to the Units 9B and 9C at approximately 5:00 p.m. by S11 Cook.
Interview on 5/10/10 at 10:20 a.m. and 4:29 p.m., with S11 FSS 3 Cook, revealed she worked from 10:00 a.m. to 6:30 p.m. on Thursday (5/6/10) with S18 Cook. S11 Cook stated that S18 Cook was assigned cook #1 and was responsible for setting up the serving line, and she was assigned cook #2. S11 stated the evening meal service started at approximately 4:45 p.m. for Units 9B and 9C, and at that time chicken salad croissant sandwiches, chicken for the main dish, lettuce, mandarin orange, honey mustard dressing, broccoli cheese potato and fruit salad were already on the serving line. S11 stated there was no ice on the serving line, the serving line warmer was on, there were flat metal covers over the steaming sections, and the food items listed above was sitting on top of the metal covers. S11 stated she did not place the food items on the serving line or check temperatures for Units 9B and 9C, and since S18 was cook #1, she assumed he had set up the serving line. S11 stated that she assisted S18 Cook with serving the Styrofoam mobile plates for Units 9B and 9C and delivered the plates in cardboard boxes to the units at approximately 5:05 p.m. S11 stated that she then returned to the main cafeteria, picked up the bulk containers for Unit 8 and went to Unit 8 and served the meal.
Interview on 5/10/10 at 12:44 p.m. with S14 FSS 3 Cook revealed he worked on Thursday 5/6/10 from 10:00 a.m. to 6:30 p.m. with S12 FSS 3, Cook, and they served Units 7F and 7M. S14 stated he removed chicken salad sandwiches from the cooler on Thursday 5/6/10 for the evening meal on Unit 7F and 7M, but he did not know what time. S14 Cook did not offer any information concerning the removal of other food items from the cooler for Unit 7F and 7M. S14 stated the plating of food into Styrofoam mobiles begin at approximately 4:40 p.m. in the main cafeteria for transport of the food to the units. The plates were packed in boxes and delivered to the units at approximately 5:15 or 5:20 p.m. S14 stated the meal was not iced during serving or during delivery because he was not aware if the food was to be served as a cold or hot food item. S14 stated that he and S12 Cook did not check temperatures of the food because the food was delivered in Styrofoam mobile plates.
Interview on 5/10/10 at 10:38 a.m. and 6:08 p.m. with S12 FSS 3 Cook revealed she worked on Thursday (5/6/10) from 10:00 a.m. until 6:30 p.m. with S14 Cook, and they served Units 7M and 7F. S12 stated they did not serve the Thursday (5/6/10) evening meal for Unit 7F and 7M in mobile Styrofoam plates. S12 stated on Thursday (5/6/10) she pulled pans of chicken salad sandwiches, plain chicken, lettuce, oranges and fruit salad from the cooler, placed ice inside of large insulated containers then placed the pans of food inside the containers and covered with the insulated tops. S12 stated that she and S14 left the main cafeteria with containers of food for Units 7F and 7M at approximately 4:50 p.m. S12 stated that when she got to Units 7F and 7M she set up the containers on the serving line, checked the temperatures and served the patients from the containers. S12 Cook stated that she also delivered pans of food for the evening meal to Unit 31 at approximately 4:00 p.m. on 5/6/10.
Review of CLSH's Policy and Procedure for HACCP Food Safety System Plan I criteria for control reflected "Hold" less than or equal to 40 degrees F for cold food items, and discard cold foods if greater than 40 degrees F for greater than one hour.
Review of CLSH's HACCP daily time and temperature log dated 5/6/10 did not reflect documented temperatures of the cold food items held and served for the evening meal to Units 7F, 7M, 9B, 9C and Unit 8 per the hospital's policy and procedure. Further review of the log reflected the temperature of the baked potato was 195 degrees F at 4:30 p.m. and "Trays on Units".
Interview on 5/10/10 at 5:29 p.m. with S8, FSS 5 Dietary Supervisor revealed she was present in the main cafeteria during the preparing of food to bring to patients for the evening meal on 5/6/10. S8 stated that she stood at the end of the serving line, but she did not notice that the dietary staff had not placed ice on the line for the cold food items. S8 Dietary Supervisor confirmed that the procedure for service of cold food items was to ice on the serving line, and to check temperatures.
Interview on 5/11/10 at 1:31 p.m. with S4, Clinical Dietitian, stated she was scheduled to work on Monday, Tuesday, Thursday and Friday from 5:00 a.m. to 3:30 p.m. S4 stated that she occasionally observed dietary staff performing their duties in the kitchen on the evening shift. S4 stated that she had a good staff, and if S8, FSS 5 Dietary Supervisor was present observing dietary staff performing their duties, then she (S4) assumed it was taken care of. Therefore, S4 stated that she had no specific routine for monitoring of dietary staff.

Observation of the Kitchen
Observation and tour of the Kitchen and Round Cafeteria on 5/11/10 at approximately 11:00 a.m. in the presence of S3, Chief Dietitian and S4 Clinical Dietitian, S5 RN, Program Coordinator, QM and S6, RN 3, QM revealed the following:
The Thawing Cooler contained 2 rolls of meat, 1 bag of meat pieces and 2 sandwiches which were not labeled or dated.
The Meat Freezer contained opened bags of meat balls, fish cod squares, meat pies, bread rolls and/or tortillas which were not labeled or dated, and an opened bag of yellow rolls which were not labeled.
The Vegetable Freezer contained the following boxes or bags of food items which were not dated or labeled with the date received or the date opened: 6 bags of okra, 2 bags of steak fries, 1 bag of broccoli, 3 bag of carrots, 16 bags o crinkle fires, 4 bags of onion rings, 2 boxes of sweet potato patties, one box of corn on the cob, one box of carrots and 12 boxes of frozen egg substitutes. The freezer also contained the following unopened boxes which were not dated as to the date the items were received: one box of cut okra, one box of mixed vegetables, 2 boxes of chopped spinach, 2 boxes of baby carrots and one box of corn on the cob.
The Refrigerator in the Employee's Lounge (which was a refrigerator for general dietary use) was located behind the serving line and contained the following opened food items with the date written in black marker: 2 large jars of mayonnaise dated "5/7/10"; 1 jar of sweet pickle relish dated "4/17/10"; 1 large jar of mustard dated "11/13"; 1 large jar of mustard dated "8/7"; 1 jar of dill pickles dated "4/16"; and 1 container of ketchup dated "2/15". The refrigerator contained the following food items which were not dated with the date received: 2 boxes of shredded cheese (1 opened and 1 unopened); 4 cans of parmesan cheese; 1 can of seafood; 3 boxes of pastry shells; 1 large box of fresh apples; 6 cans of parmesan cheese with a manufacture's expiration date of 1/29/10; and 5 cans of parmesan cheese with a manufacture's expiration date of 2/16/10.
Review of the CLSH Dietary Policy and Procedure Manual revealed there was no policy to reflect shelf life times. Further review of the policy for food preparation and food storage reflected that all food items should be clearly labeled and dated. Interview with S4 Clinical Dietitian on 5/11/10 at approximately 11:15 a.m. confirmed the above findings. S4 Clinical Dietitian confirmed all items in the freezer and/or refrigerator should be labeled or dated.
Interview with S4 Clinical Dietitian on 5/11/10 at approximately 1:30 p.m. revealed the Dietary Supervisors (FSS 5) were responsible for daily checks of the refrigerators and freezers to assure everything is dated and labeled. S4 revealed that there were 2 FSS 5 supervisors, however one of the supervisors had been off work for several months. S4 Clinical Dietitian revealed that S8 was the only FSS 5 Supervisor on duty for the last several months.
Further interview with S4 Clinical Dietitian at that time revealed she performed random checks of the refrigerators and freezers on Fridays. However, due to other circumstances she stated she had not checked the refrigerators or freezers in approximately 3 weeks. S4 confirmed that she completed a quick check in April, 2010, and she (S4) did not check the refrigerators and freezers as good as she would normally check it. S4 Clinical Dietitian revealed she did not document her random checks.
Interview on 5/11/10 at 1:30 p.m. with S3, Chief Dietitian, confirmed she had no involvement with the clinical supervision of the dietary staff, the clinical supervisory duties were the responsibility of S4, Clinical Dietitian, and S4 was responsible for submitting monthly reports to S3 Chief Dietitian. S3, Chief Dietitian, confirmed the hospital had not identified the findings above as a problem.

Based on observation, record review and interview the hospital's Dietitian failed to ensure that dietary staff were determined competent in their respective duties by failing to provide routine inservices to all dietary staff to ensure that food was prepared according to the dietary policies and procedures and acceptable standards of practice. The Dietitian failed to supervise and inservice staff concerning proper storage of food items, proper thawing techniques and cooking/cooling and serving of foods at the proper temperature. The Dietitian failed to supervise and inservice staff on policies and procedures when a new practice of cooking foods in advance of the date to be served was implemented in the kitchen. Findings:

During a briefing at CLSH on 5/8/10 at approximately 4:15 p.m. with the State Secretary, State Epidemiology, Office of Public Health, State/Local Police and CLSH staff and State Health Standards Section, S19 Medical Director revealed that on Friday (5/7/10) around 6:30 a.m. there were 30-31 patients that began to have diarrhea, nausea and vomiting, and it was believed that the supper night (5/6/10) meal may have caused the illnesses. On 5/8/10 CLSH's main kitchen was closed prior to breakfast.

Review of documentation provided by and interview with S5 RN, Program Coordinator, Quality Management on 5/12/10 at approximately 10:00 a.m. revealed that on Friday, 5/7/10, 36 patients at CLSH began having various degrees of nausea, vomiting, diarrhea and abdominal pain. S5 RN revealed that a total 11 patients were transferred to the hospital, 5 were hospitalized (2 expired), and 6 were evaluated in the emergency room and returned to CLSH. S5 RN revealed 4 employees also became ill and were evaluated in the emergency room. S5 RN confirmed all of the above patients and employees consumed chicken which was served for the evening meal on Thursday, 5/6/10.

Review of the CLSH Dietary Office Work Schedule for the month of May, 2010 revealed S3 was the full-time Registered Dietitian/Nutrition Services Administrator (Chief Dietitian) and S4, was the full-time Registered Dietitian, Hospital Nutrition Services Assistant Director (Clinical Dietitian). The schedule reflected S3, Chief Dietitian, worked daily Monday through Thursday, and S4, Clinical Dietitian, worked on Monday, Tuesday, Thursday and Friday.
Review of the hospital's policies and procedures for a safe food system revealed policies for dating and labeling of stored foods, but the policy did not address what date should be labeled on the items or the length of time mayonnaise and mustard could remain on the shelf. The policy did not reflected a specific method for proper thawing of foods. The policy reflected specific instruction for proper cooking, cooling and serving of all food items. The policy reflected foods should be prepared as close to serving time as possible, but it did not reflect what staff should do if foods were cooked in advance of the date of service.
Interviews were conducted with dietary cooks who prepared and served chicken on 5/5/10 and 5/6/10 which revealed the staff did not follow the dietary policies and procedure or lacked the knowledge of. S10 Main Cook stated on 5/10/10 at 10:00 a.m. that she cooked chicken pieces in advance on the afternoon of Wednesday, 5/5/10 for Thursday, 5/6/10 evening meal, and the chicken was still frozen when she started the cooking process. S10 stated that she did not place the chicken in the refrigerator to cool before she left work at 4:30 p.m. but instructed evening staff to do it. S12 was the evening Cook, and on 5/10/10 at 11:06 a.m. she stated that she placed the cooked chicken in the cooler at approximately 5:00 or 5:30 p.m. on 5/5/10, but she did not check the temperature of the chicken.
S18 was the Cook who served the evening meal of chicken on 5/6/10, and on 5/10/10 at 1:38 p.m. S18 stated that there was no ice on the serving line, and he (S18) did not check temperatures of the food prior to serving it. S18 stated he was not aware that the chicken and other food items were to be served as a cold food item, and he had not received training concerning the service of hot and cold food items. S14 was also the Cook who served the evening meal of chicken on 5/6/10, and on 5/10/10 at 12:44 p.m., S14 stated that there was no ice on the serving line. S14 stated that he was not aware if the food was to be served as a cold or hot food item, and he (S12) did not check temperatures of the food prior to serving.
Observation and tour of the Kitchen and Round Cafeteria on 5/11/10 at approximately 11:00 revealed multiple freezers and/or refrigerators contained numerous packages of opened and/or closed food items which were not labelled, dated and/or with dates that had expired.
Review of 17 CLSH Employee Training Records for dietary staff reflected in-service training was provided monthly. The record reflected for the last 3 months topics included: (February) Cellular Phones and National Patient Safety Goals; (March) Landscaper Safety; and (April) First Aid/Personal Safety Class and/or "MSDS" Policy and Recommended Protective Equipment Housekeeping Supplies.
Interview on 5/11/10 at 1:30 p.m. and on 5/12/10 at approximately 9:00 a.m. with S3, Chief Dietitian and S4, Clinical Dietitian confirmed there was no specific policy in place for the date that should be labeled on stored foods, the length of time mayonnaise and mustard could remain on the shelf or a specific method for proper thawing of foods. S3, Chief Dietitian, stated that meats were usually cooked on the day of service and not in advance; however; due to dietary staff shortage for approximately the last 2 months, some meats were being cooked the day before the food was served.

Further interview, at that time, with S3, Chief Dietitian and S4, Clinical Dietitian revealed the hospitals's HACCP Food Safety System Plan for cooking and cooling meats was being utilized during daily routine cooking of meals. They confirmed that were aware that meats were being cooked 24 hours or greater in advance, but they were not following the HACCP Plan for foods cooked in advance of the day of service.

S3, Chief Dietitian confirmed, at that time, that dietary staff had not been instructed to document temperature checks of food into a temperature log even though the dietitian was aware that chicken and other foods were being cooked in advance of the date being served, and the dietitian had not provided any inservices or instruction to the cooks to start using the the HACCP Plan B for meats cooked and cooled 24 hours or greater in advance of the day of service. S3, Chief Dietitian and S4, Clinical Dietitian stated they did not know why the HACCP Plan had not been followed for meats cooked in advance.

S3, further stated, at that time, that during the cooling process for meats cooked in advance, staff should check the temperature to assure the meat cooled to 70 degrees F in 2 hours before placing the meat in the cooler. This statement by S3 was in conflict with the hospital's policy which required food to be cooled under refrigeration from 140 degrees to 40 degrees F in 4 hours and discard if not cooled from 140 degrees F to 40 degrees in 4 hours.

Interview on 5/11/10 at 1:31 p.m. with S4, Clinical Dietitian, stated she was scheduled to work on Monday, Tuesday, Thursday and Friday from 5:00 a.m. to 3:30 p.m. S4 stated that she occasionally observed dietary staff performing their duties in the kitchen on the evening shift. S4 stated that she had a good staff, and if S8, FSS 5 Dietary Supervisor was present observing dietary staff performing their duties, then she (S4) assumed it was taken care of. Therefore, S4 stated that she had no specific routine for monitoring of dietary staff.
Interview with S4 Clinical Dietitian on 5/11/10 at approximately 1:30 p.m. revealed she performed random checks of the refrigerators and freezers on Fridays. However, due to other circumstances she stated she had not checked the refrigerators or freezers in approximately 3 weeks. S4 confirmed that she completed a quick check in April, 2010, and she (S4) did not check the refrigerators and freezers as good as she would normally check it. S4 Clinical Dietitian revealed she did not document her random checks.
Interview on 5/11/10 at 1:30 p.m. with S3, Chief Dietitian, confirmed she had no involvement with the clinical supervision of the dietary staff, the clinical supervisory duties were the responsibility of S4, Clinical Dietitian, and S4 was responsible for submitting monthly reports to S3 Chief Dietitian. S3, Chief Dietitian, stated that dietary in-services were conducted once monthly on identified problems and/or safety topics, and if no problems were identified monthly in-services were still held. S3, Chief Dietitian, confirmed the hospital had not identified the findings above as a problem.
During a telephone interview with S4, Clinical Dietitian, on 5/27/10 at 10:00 a.m. (after the date of exit), S4 revealed that she kept S3, Chief Dietitian, informed verbally of things that was going on in the dietary department, and she did not necessarily submit written report unless there were identified problems. S4 stated that she conducted the in-service training for the dietary staff, and the inservice topics listed on the Employee Training Records were handouts for the employees to read.