HospitalInspections.org

Based on observation, interview with facility staff and a review of the facility's temperature log and policy and procedures, the facility failed to ensure the system to maintain the freezer in safe operating condition was implemented. The documented temperatures of the freezer ranged from 15 to 30 degrees.

Findings include:

On 11/17/20 at 10:56 AM during the initial tour of the kitchen with the Food Service Manager (FSM) observed the reach-in freezer was displaying a temperature of 8 degrees. FSM reported the goal is to keep the freezer temperature below 10 degrees. A review of the temperature log on the freezer door for the month of November 2020 noted the temperatures ranged from 15 to 30 degrees. The FSM stated that when the temperature is out of range, the temperature is checked a half hour later. Review of the log found no entries for the "Recheck Temp". There was documentation that maintenance was notified on 11/02/20 and 11/03/20. A request was made for documentation that maintenance addressed the issue. No documentation was provided. Also noted there are missing entries for temperature log. The AM check was missing documentation on 11/01, 11/02, 11/06, 11/07, 11/08 and 11/13. The PM check was missing documentation on 11/06, 11/11 and 11/14.

Further review of the "Freezer Temperature Record" for November 2020 noted temperature maintained at 0 (zero) degrees and below for freezer. Also noted the following: "If the temperature exceeds the standard, recheck temperature after 30 min. If still above standard, must notify D. Manager or Dietitian (in their absence) or Maintenance so that corrective action may be taken". A review of the policy and procedure "Food & Nutrition Services" notes temperatures must be maintained at the following Fahrenheit settings, frozen foods at 0 (zero)degrees or below.

On 11/18/20 at 10:20 AM the FSM reported the freezer had been shut down.