HospitalInspections.org

Based on a review of facility documentation, interviews with staff, and policy review, the Governing Body failed to have a system in place to monitor the contracted service for Food and Dietetic Services to ensure that appropriate actions were taken and documented when kitchen refrigerator temperatures were out of range and/or failed to have a mechanism in place to ensure that food remained safe to consume when refrigerator temperatures were out of range. The findings include the following:

The hospital's dietary department utilized a Temp Trak system to monitor the temperatures for all refrigerators and freezers 24 hours a day. Review of the Temp Trak system data identified multiple occasions when the refrigerator temperatures were not within the acceptable range of 32-45 degrees Fahrenheit (°F).

a. Review of the Temp Trak system during the period of 4/12/19 and 4/16/19 identified that temperatures were not within the acceptable range for one or more refrigerators on 31 occasions, as indicated by the system's recently cleared (acknowledged) alert conditions.

On 28 of the 31 occasions (between 4/12/19 and 4/16/19), documentation failed to identify that staff identified the cause and/or provided remediation.

Review of maintenance work orders between 4/4/19 and 4/16/19 indicated that a work order dated 4/15/19 noted ice was forming on the fan in the dairy walk-in refrigerator. There was no documentation that identified the cause and/or remediation for 30 of the 31 alerts.

Interview with IT #1 on 5/1/19 at 11:00 AM identified that the Temp Trak system would alarm if the temperature did not meet the identified parameters (32-45°F) for one hour, and would reset automatically once the identified parameters are met for one hour. IT #1 stated that there were times when the Temp Trak system alarmed and it could be hours to days later when the alarm was acknowledged or cleared. For example, on 4/12/19 at 2:00 PM the cold prep refrigerator (vegetables/condiments) alarmed for a temperature of 47.5°F. The Temp Trak log indicated that the alarm reset itself at 5:00 PM (3 hours later), however the alarm was not acknowledged or cleared until 4/13/19 at 3:18 PM (25 hours later).

Interview with Dietary Worker (DW) #1 on 5/1/19 at 1:30 PM indicated that she checks the alarm notifications on her arrival at 5:30 AM, at 11:30 AM, 1:30 PM and the evening shift staff check prior to leaving at 7:30 PM. DW #1 indicated that if the temperatures are high (50°F or higher) she reports this to a supervisor, however, was unable to provide associated documentation for the out of range readings. DW #1 further stated that when the alarm codes are reviewed she clears them and from a prepopulated list chooses the statement "monitoring status" which means she will continue to monitor. DW #1 further indicated that prior to the Dietary Supervisor leaving about a month ago, she used to keep her computer on at all times so if a temperature alarmed staff would know in real time while the department was open (5:00 AM -8:00 PM) and could check the alarm. However, since her departure there was no "real time" system in place. DW #1 stated she uses the computer for other tasks and cannot leave it on the temperature tracking system. In addition, there is no monitoring of the alarm system when the dietary department is closed.

Interview with the Dietary Director on 5/1/19 at 9:15 AM identified that the Temp Trak system is manually monitored 3 times a day. If there is a system alert staff are expected to check the temperature, clear the alert and notify maintenance staff or the supervisor of any issues.

Interview with the Executive Chef on 5/1/19 at 9:30 AM indicated that four times a day the Temp Trak system is checked by dietary office staff and if there is an alert, staff should manually check the temperature, clear the alert, and fill out a work order if there is an issue.

Review of the policy for Refrigerator/ Freezer Temperature Monitoring Maintenance indicated that food refrigeration will be between 36-40°F.

c. Review of Temp Trak reports between 4/11/19 and 4/17/19 indicated that the sensor #222-248 (cook prep refrigerator) registered temperatures of 68 to 70°F. Review of maintenance logs and interview with the Dietary Director and the Executive Chef on 5/1/19 at 1:50 PM stated this refrigerator had been taken out of service on 2/28/19 and replaced with a new refrigerator. The Director of Dietary indicated that a Temp Trak sensor had not been placed on the new cook prep refrigerator and that refrigerator temperatures had not been monitored from 2/28/19 to 4/16/19.


d. "Recently Cleared Alert Conditions" documentation was reviewed with the Information Technologist (IT) responsible for the Temp Trak system on 5/1/19 at 11:00 AM. Between 4/12/19 and 4/16/19, sensor 76-137E alarmed and was cleared 11 times. Review of the facility documentation indicated that the alarm was being triggered due to high temperatures and a low battery in the sensor. The documentation failed to reflect that the low battery issue was addressed.

Interview with the Regional Director of Quality on 5/2/19 at 11:50 AM identified that the contracted service of food and dietetics is reviewed annually by the Medical Executive Committee. The System Director of Food and Nutrition meetings dated 2/1/19 and 4/5/19 identified agenda items of financial review, patient experience and operations update. The issue of kitchen refrigerator temperatures being out of range over time was not addressed.

The hospital discontinued the use of the Temp Trak system on 4/16/19. Facility staff began obtaining refrigerator and freezer temperatures every four hours as well as monitoring food temperatures. Repairs were made to refrigerators and freezers and staff throughout the dietary department were reeducated on food safety practices.

Based on a review of facility documentation, interviews and policy review, the facilty failed to ensure that a comprehensive QAPI program was established for the Food and Dietetics Services department to monitor the effectiveness and safety of services with monitoring and/or responding to refrigerator temperatures that were out of range to ensure that food remained safe to consume. The findings include the following:


a. Review of the hospital's Local Health Department report dated 8/22/18 indicated that the hospital's walk-in cooler temperatures were above the 41 degree Fahrenheit (°F) threshold, with deli meat being 43°F. The report indicated that the items were discarded. A Local Health Department survey was conducted on 3/8/19 that identified the facility failed to ensure that cold storage met the identified parameters (below 41°F), and that the items were voluntarily discarded. A Local Health Department survey was conducted on 3/22/19 and indicated that the facility failed to ensure that cold storage met the identified parameters (below 41°F), and that numerous items were voluntarily discarded. The report indicated that a meeting with the local health department and the facilty would be scheduled due to repeated critical violations. A Local Health Department survey was conducted on 4/16/19 that identified that the facility failed to ensure that cold storage met the identified parameters (below 41°F), requiring items to be discarded.

Review of the Food and Nutrition quality assurance (QA) data for 2016, 2017 and 2018 indicated that the indicators reviewed were three categories from the Press Ganey patient evaluation. The items reviewed were the quality of food, temperature of food, and courtesy of the server. Although the department had ongoing issues with maintaining appropriate food temperatures, the department's QA focused on the outcome of meals, not on the storage and preparation of the food.


b. The hospital's dietary department utilized a Temp Trak system to monitor the temperatures for all refrigerators and freezers 24 hours a day. Review of the Temp Trak system data during the period of 4/11/19-4/17/19 identified multiple occasions when the refrigerator temperatures were not within the acceptable range of 32-45°F. Facility documentation failed to indicate steps taken to remediate the issue.

Interview with IT #1 on 5/1/19 at 11:00 AM indicated that there were times when the Temp Trak system alarmed and it could be hours to days later when the alarm was acknowledged or cleared. For example, on 4/12/19 at 2:00 PM the cold prep refrigerator (vegetables/condiments) alarmed for a temperature of 47.5°F. The Temp Trak log indicated that the alarm reset itself at 5:00 PM (3 hours later), however the alarm was not acknowledged or cleared until 4/13/19 at 3:18 PM (25 hours later).

Interview with the Executive Chef on 5/1/19 at 9:30 AM indicated that three times a day the Temp Trak system is checked by dietary office staff and if there is an alert, staff are supposed to manually check the temperature, clear the alert, and fill out a work order if there is an issue.

Interview with Dietary Worker (DW) #1 on 5/1/19 at 1:30 PM indicated that she checks the alarm notifications on her arrival at 5:30 AM, at 11:30 AM, 1:30 PM and the evening shift staff check prior to leaving at 7:30 PM. DW #1 indicated that if the temperatures are high (50 degrees or higher) she reports this to a supervisor, however there is no associated documentation. DW #1 indicated that when the alarm codes are reviewed she clears them and from a prepopulated list chooses the statement "monitoring status" which means she will continue to monitor. DW #1 indicated that prior to the Dietary Supervisor leaving about a month ago she used to keep her computer on at all times so if a temperature alarmed staff would know in real time while the department was open (5:00 AM -8:00 PM) and could check the alarm. However, since her departure there is no real time system in place. DW #1 indicated that she uses the computer for other tasks and cannot leave it on the temperature tracking system. In addition, there is no monitoring of the alarm system when the dietary department is closed.

Interview with the Regional Director of Quality on 5/2/19 at 11:50 AM identified that the contracted service of food and dietetics is not incorporated in the hospital's quality improvement council.

The facility failed to have an effective QAPI program for the Food and Dietetics Services department to ensure that food remained safe to consume when refrigerator temperatures were out of range.

The Condition of Food and Dietetic Services has not been met.

Based on a review of facility documentation, interviews with staff, and policy review, the Director of Food and Dietetic Services failed to effectively supervise the day to day operations of the dietary department including failure to respond to out of range refrigerator temperatures to ensure the safety of patients, staff, and the general public.


Please see A620

Based on a review of facility documentation, interviews with staff, and policy review, the Director of Food and Dietetic Services failed to effectively supervise the day to day operations of the dietary department including failure to respond to out of range refrigerator temperatures to ensure the safety of patients, staff, and the general public. The findings include the following:


The hospital's dietary department utilized a Temp Trak system to monitor the temperatures for all refrigerators and freezers 24 hours a day. Review of the Temp Trak system data identified multiple occasions when the refrigerator temperatures were not within the acceptable range of 32-45 degrees Fahrenheit (°F).

a. Review of the Temp Trak system during the period of 4/12/19 and 4/16/19 identified that temperatures were not within the acceptable range for one or more refrigerators on 31 occasions, as indicated by the system's recently cleared (acknowledged) alert conditions.

On 28 of the 31 occasions (between 4/12/19 and 4/16/19), documentation failed to identify that staff identified the cause and/or provided remediation.

Review of maintenance work orders between 4/4/19 and 4/16/19 indicated that a work order dated 4/15/19 noted ice was forming on the fan in the dairy walk-in refrigerator. There was no documentation that identified the cause and/or remediation for 30 of the 31 alerts.

Interview with IT #1 on 5/1/19 at 11:00 AM identified that the Temp Trak system would alarm if the temperature did not meet the identified parameters (32-45°F) for one hour, and would reset automatically once the identified parameters are met for one hour. IT #1 stated that there were times when the Temp Trak system alarmed and it could be hours to days later when the alarm was acknowledged or cleared. For example, on 4/12/19 at 2:00 PM the cold prep refrigerator (vegetables/condiments) alarmed for a temperature of 47.5°F. The Temp Trak log indicated that the alarm reset itself at 5:00 PM (3 hours later), however the alarm was not acknowledged or cleared until 4/13/19 at 3:18 PM (25 hours later).

Interview with Dietary Worker (DW) #1 on 5/1/19 at 1:30 PM indicated that she checks the alarm notifications on her arrival at 5:30 AM, at 11:30 AM, 1:30 PM and the evening shift staff check prior to leaving at 7:30 PM. DW #1 indicated that if the temperatures are high (50°F or higher) she reports this to a supervisor, however, was unable to provide associated documentation for the out of range readings. DW #1 further stated that when the alarm codes are reviewed she clears them and from a prepopulated list chooses the statement "monitoring status" which means she will continue to monitor. DW #1 further indicated that prior to the Dietary Supervisor leaving about a month ago, she used to keep her computer on at all times so if a temperature alarmed staff would know in real time while the department was open (5:00 AM -8:00 PM) and could check the alarm. However, since her departure there was no "real time" system in place. DW #1 stated she uses the computer for other tasks and cannot leave it on the temperature tracking system. In addition, there is no monitoring of the alarm system when the dietary department is closed.

Interview with the Dietary Director on 5/1/19 at 9:15 AM identified that the Temp Trak system is manually monitored 3 times a day. If there is a system alert staff are expected to check the temperature, clear the alert and notify maintenance staff or the supervisor of any issues.

Interview with the Executive Chef on 5/1/19 at 9:30 AM indicated that four times a day the Temp Trak system is checked by dietary office staff and if there is an alert, staff should manually check the temperature, clear the alert, and fill out a work order if there is an issue.

Review of the policy for Refrigerator/ Freezer Temperature Monitoring Maintenance indicated that food refrigeration will be between 36-40°F.

The facility failed to ensure the mechanism in place was effective and/or that the Director adequately supervised the day to day operations to address the out of range temperatures which had the potential to affect food safety.


c. Review of Temp Trak reports between 4/11/19 and 4/17/19 indicated that the sensor #222-248 (cook prep refrigerator) registered temperatures of 68 to 70°F. Review of maintenance logs and interview with the Dietary Director and the Executive Chef on 5/1/19 at 1:50 PM stated this refrigerator had been taken out of service on 2/28/19 and replaced with a new refrigerator. The Director of Dietary indicated that a Temp Trak sensor had not been placed on the new cook prep refrigerator and that refrigerator temperatures had not been monitored from 2/28/19 to 4/16/19.


d. "Recently Cleared Alert Conditions" documentation was reviewed with the Information Technologist (IT) responsible for the Temp Trak system on 5/1/19 at 11:00 AM. Between 4/12/19 and 4/16/19, sensor 76-137E alarmed and was cleared 11 times. Review of the facility documentation indicated that the alarm was being triggered due to high temperatures and a low battery in the sensor. The documentation failed to reflect that the low battery issue was addressed.


The hospital discontinued the use of the Temp Trak system on 4/16/19. Facility staff began obtaining refrigerator and freezer temperatures every four hours as well as monitoring food temperatures. Repairs were made to refrigerators and freezers and staff throughout the dietary department were reeducated on food safety practices.