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Based on food storage observations, dietary staff interview, and dietary document review, the hospital failed to ensure the maintenance of all essential equipment as evidenced by elevated food temperatures for 2 refrigeration units with potentially hazardous foods held in them. Failure to ensure effective functioning of essential equipment may put patients at risk of foodborne illness.

Findings:

*1. At 11:30 a.m. on 3/15/11 meal preparation activities were observed in the "Blue Room," (pediatric room service).

The single-door reach in refrigerator (R6) was observed to have temperature 45 ? F (Fahrenheit) and contained assorted sandwiches, desserts, puddings and cottage cheese and fruit plates. Dietary Staff U took the temperature of a random turkey sandwich dated 3/15 and it was 49.5?F and a pudding also dated 3/15 was 41.3?F. DS U returned the foods to the refrigerator for service.

At 3:20 p.m. on 3/15/11 the same refrigerator temperature was observed to be 46?F.

On 3/16/11 at 4:15 p.m. refrigerator R6 was observed to have a sign on it "Do Not Use". During an interview at 4:30 p.m. DS FF stated he had observed the refrigerator to be 45?F at noon this day and stopped the staff from using it.

*2. On 3/15/11 at 10:37 a.m., the freezer temperature of the ice cream freezer in the dry goods storeroom was observed to have three different thermometers, variously reading 9?, 16? and -4?F. The ice cream inside was not firm to touch. During an interview at 10:44 a.m., Dietary Staff D stated he was responsible for monitoring temperatures of the freezer but did not monitor that one because it wasn't on his list. During a concurrent interview, DMS A stated not all refrigerators/freezers were monitored by hand, and that the freezer in question was monitored by an electronic system.

On 3/17/11 at 10:45 a.m. the hospital provided electronic monitoring reports that revealed the freezer was not on an electronic system and the temperature was not monitored.

Review of Food and Nutrition Policy 05.510.08 directed "All active cold temperature units ( ...freezers ...) will be designated to be monitored by the automated temperature monitoring system or manually in the Nutrition and Food Services Master Active Temperature List." On 3/17/11 at 10:46 a.m., DS FF stated the freezer with the ice cream had just been added to his list to monitor since the survey observations on 3/15/11 at 10:37 a.m. that the ice cream was soft and the temperature not monitored.

*3. During the initial tour on 3/15/11 at 10:25 am, in the cold production refrigeration (R-22) there were several potentially hazardous foods with temperatures above 41?F (Cross Reference A749). Concurrent observation also noted that the thermometer in the refrigerator, which was placed along the back wall of the unit, was 34?F. It was also noted that there was an additional temperature probe mounted to the interior right hand side of the unit.

In an interview on 3/13/11 at 10:30 a.m. with DMS B, she stated refrigerator temperatures were monitored by supervisory staff at the beginning of each day. On 3/16/11 at 4 pm, in an interview with DMS A he stated that the temperature of the unit was monitored via a remote system. In a follow up interview on 3/17/11 at 1 pm, DMS A stated that while the refrigerator was monitored on a remote system the department did not utilize the system because it was inaccurate. He further stated that in place of the automated monitoring he instructed supervisory staff to check refrigerator temperatures every morning.

Review on 3/17/11 at 2 pm, of dietary documents titled "HACCP Refrigerator Freezer Temperature Log" from 3/11-3/16/11 revealed that staff was taking temperatures once daily, between the hours of 8 and 9:45 a.m. and consistently recorded refrigerator temperatures of 38?F or below. Concurrent review of remote temperature recording print-out noted that the remote system recorded a minimum of 84 temperatures during a 24-hour timeframe. It was also noted that for the timeframe of 3/14/11 at 11 pm through 3/16/ 11 am, many of refrigerator temperatures, including those that were recorded after 7 pm, were consistently above 41?F. On 3/15/11 at 10:30 am, the remote system recorded a temperature that was between 44.5 and 51.9?F.

Dietary policy 05.510.08, revised 2/10, for temperature monitoring of refrigerators/freezers outlined a procedure that all active refrigerators would be monitored by the automated temperature monitoring system. The policy also noted that when units were out of compliance for 30 consecutive minutes the system would send a phone or text notification to the designated food service supervisor. There was no documentation of implementation of an effective system of equipment monitoring to ensure food safety.