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Based upon record review and interviews, the hospital failed to ensure the Dietary Manager was qualified through education, experience or training in order to manage the food service operations. Findings:

Interview with Staff A on 01/23/23 at 1:00 p.m. revealed the Dietary Services and dietary employees were provided by Contract A. Staff E was identified as the Dietary Manager.

On 01/24/23 at 9:30 a.m. a tour of the Dietary Department was conducted. Interview with Staff E during the tour revealed she had completed the dietary manager training but had not taken the certification test.

Review of the personnel file for Staff E revealed there failed to be documented evidence the designated manager had previous dietary experience, training, or competencies.

Interview on 01/26/23 at 9:10 a.m. with Staff H revealed she was the supervisor of the contracted food service management company (Contract A). When asked about the education and training that was conducted with Staff E, she replied the Dietary Manager was trained approximately two years ago by the former Dietary Manager. On 01/26/23 at 9:40 a.m. Staff E provided for review "Competencies for Food and Nutrition Services Employees" which was developed by the Association of Nutrition and Foodservice Professionals. The directions stated "The following checklists are intended to verify that individual employees have met the competencies and skill sets listed to carry out the functions of the facility's Food and Nutrition specific protocols and operational procedures are addressed. Each line item should be verified by a staff member knowledgeable and or responsible for the competency information and must be reflective of the facility's resident population as appropriate." Further review of the competency tool revealed Staff E initialed each skill and signed the form as the employee and supervisor. There failed to be documented evidence a knowledgeable staff member verified Staff E competencies.

Based upon record review and interview, the hospital failed to ensure the therapeutic diet manual was current and approved by the dietician. Findings:

On 01/24/23 at 9:30 a.m. a tour was conducted of the Dietary Department and staff E provided the Dietary Manual for review.

Review of the Dietary Manual revealed a signature page which identified "Please sign below to show delivery of the 2006 Oklahoma Diet Manual. September 2009." The staff who signed this page were from the medical/surgical unit, Intensive Care Unit, Mental Health Unit, Emergency Room and Senior Outpatient. There failed to be documented evidence the manual was current and approved by the Dietician or Medical Staff.