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Based on interview and departmental documentation review, the hospital did not assess the regular and therapeutic diet menus to ensure each diet met the daily nutritional needs of patients. This failure had potential to allow the facility to serve patients diets that did not meet their nutritional needs during hospitalization.

Findings:

Dietary Reference Intake (DRI) is a system of nutrition recommendations from the Food and Nutrition Board of the Institute of Medicine. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. The averages vary by age and sex. DRIs include the Recommended Dietary Allowance (RDA) which is an average daily level of intake to meet the nutrient requirements of 97 to 98 percent of healthy people.

Review of the undated nutrient analysis titled "[Company name] Nutrition Analysis Report" for 4 diets including Regular, Renal (a diet generally for patients with kidney disease), 75 Gram Carbohydrate (a diet generally ordered for patients with diabetes), and Puree (generally regular food that has been modified into a smooth, mashed potato consistency for patients with chewing and/or swallowing difficulty) showed the analysis of the weekly average of RDAs the demographic Females, 51-70 years.

In an interview on 4/20/22 at 3:25 p.m., with the Area Director of Food and Nutrition (ADFN) and Registered Dietitian 1 (RD 1), ADFN and RD 1 stated they both reviewed the nutrient analysis for the menu and RD 1 confirmed the analysis was limited to weekly nutrient averages, not daily. ADFN stated she signed off on the 7-day cycle menu using the weekly nutrient analysis percentages as the assessment tool to assess the menu for meeting patient nutrient needs. ADFN stated the average stay for a patient in the hospital was 3 days, not the entire week. RD 1 stated the weekly nutrient average showed the menu was low in nutrients for some diets for specific diets and were documented in the diet manual.

Review of the undated section of the diet manual titled "IDDSI [International Dysphagia Diet Standardization Initiative] Dysphagia [difficulty swallowing], Pureed (PU4)", showed the Pureed diet was low in the following nutrients in comparison to the DRI's: Vitamin K 79.6 %, Magnesium 79.4 %, and Folate 72.9 %.

Review of the undated section of the diet manual titled "Renal Diet" showed the diet did not meet the DRI's for the following nutrients: Vitamin D 78.8%, Vitamin E 74.5%, Magnesium 52.8%, Zinc 86.6%, Calcium 76.2%.

Based on dietetic services observations, dietary management and dietary staff interview, and departmental document review, the hospital failed to ensure a reach-in freezer holding frozen food was maintained to prevent significant amounts of ice build-up. This failure did not ensure the effectiveness of equipment used for frozen storage, potentially resulting in food contamination during storage.

Findings:

According to USDA Food Code (2017), equipment is to be maintained in a state of repair and condition that retains the equipment characteristic qualities under normal use conditions.

According to USDA Food Code annex (2017), failure to properly maintain equipment can lead to placing the consumer at risk. Refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature for safety foods at safe temperatures.

An observation on 4/20/22 at 11:30 a.m., showed a 3-door reach-in freezer located in the cafeteria kitchen, with 3 cantaloupe sized mounds of ice build-up, on the shelving inside the freezer. Icicles hung from the underside of the ice mounds. Additionally, there was a sheet of ice on the bottom, inside surface of the freezer.

In a concurrent interview on 4/20/22 at 11:30 a.m., the Area Director of Food and Nutrition (ADFN) stated she was not aware of the ice build-up inside the freezer. She said she did not always look inside the freezer, but she did look at the freezer temperatures by looking at the freezer temperature log filled out by staff and located on the outside of the freezer. When asked how she knew the temperatures recorded by staff were accurate, she stated she did open the freezer almost daily to look at the internal thermometer. She stated she was not aware if a maintenance work order was put in for the ice build-up in the freezer.

In an interview on 4/20/22 at 1:59 p.m., the Executive Chef (EC) stated he reported the freezer ice build-up twice this month by placing a work order, but did not get a response. He said the first work-order, which he marked "urgent" was placed on 4/1/22. He said it was for 3 pieces of cooling equipment, but he did not specify there was ice build-up in the freezer. He stated the second work order was placed on 4/5/22 and specified the freezer had ice build-up.

Review of the Service Request dated 4/1/22, showed EC placed a work order which read, "multiple refrigerators down in retail kitchen." The number on the work order showed 1-273288.

Review of the Service Request dated 4/5/22, showed EC placed a work order which read "triple door freezer is leaking on inside and creating frozen ice on inside ..." The number on the work order showed 1-273394.

Review of the 2-page document titled "Work Order Form Plant Operations" showed work order 1-273288, placed by EC was received by the engineering department on 4/1/22 and assigned to Engineering Worker 1 (EW1). The document showed the work order was completed on 4/14/22. A comment on the document showed "checked all units and were working ok, asked around and no one knew about issues."

Review of the 2-page document titled "Work Order Form Plant Operations" showed work order 1-273394 was received by the engineering department on 4/5/22 and was assigned to Engineering Worker 2 (EW2). The document noted EW2 requested staff to stop using/empty freezer and let him know when so he could defrost and clear drain. A handwritten note on the document read "Look at on 4/6/22. Worked on it. Check on Saturday - still issue. Day shift Saturday 7 am - 8 am 4/9/22 ..." There was no documentation indicating additional follow-up or closure for this work order.