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Based on observation, record review, and interview, the facility staff failed to ensure practices and processes were in place to prevent expired prepared sandwiches from being available for patient consumption.

Findings include:

During a tour of the emergency department medication room on 1/8/2024 observed in the nutrition refrigerator were sandwiches not dated or expired date.

4 -sandwiches were not dated as to when prepared
4- sandwiches were dated 1/3/2024
4- sandwiches were dated 1/4/2024

An interview with Staff #12 (dietary) on 1/8/2024 at 11:00 AM was asked how long the prepared sandwiches are available to patients once prepared. Staff #12 stated, "The sandwiches are good for 72 hours from the prepared day." Staff #12 acknowledged that all the sandwiches were expired and should have been pulled and not available for patient consumption.

A review of the dietary guidelines titled, "DATING & LABELING OF FOOD IN PRODUCTION" revealed the following:

"All foods opened, prepared, and used in the unit must be dated and labeled. Date marks are important for all TCS foods because while the growth of bacteria in refrigerated foods is largely controlled by temperature, it is not stopped altogether.

* TCS foods requiring a date mark shall be labeled with the common name, preparation date, discard date, and associate initials.

* RTE, TCS food that is prepared onsite and held refrigerated for more than 24 hours must be used within 4 days including the day of production."

An interview with Staff #8 on 1/8/2024 at 11:30 AM acknowledged that the sandwiches were not dated and beyond the consumption date for patients. Staff #8 confirmed there was no process for staff members to check the sandwich dates and destroy if beyond the 4 days including the day of production."