The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

UNIVERSITY OF COLORADO HOSPITAL AUTHORITY 12605 EAST 16TH AVENUE AURORA, CO 80045 Sept. 10, 2018
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations and interviews, the facility failed to maintain appropriate processes in the area of food storage to ensure expired food and unlabeled food was not readily available for delivery to patients.

Findings include:

Facility policy:

Food and Nutrition Service policy and procedure process labeling of food deliveries read, all incoming food products and freshly prepared products are to be labeled with the date of receipt, defrost date, and /or preparation date to ensure proper use and rotation of product.
Labels are to be placed on all products with date of expiry of re-packaged/produced item (3 days from preparation), date received, and /or date defrosted. All loose items that are not packed in a box will also be labeled with the date of original date of receipt.

1. The facility failed to ensure all food was labeled appropriately and dated with a use by date. The facility further failed to ensure food was discarded after the expiration date or use by date.

a. A tour of the kitchen was conducted on 9/4/18 at 2:05 p.m. with the Director of Food Services, Purchasing / Materials Technician, and Manager of Quality. Observations of the kitchen revealed multiple unlabeled food items and multiple food items which had expired.

A sample of expired food included:

1 - pan of spaghetti four days past the expiration date
1 - pan of penne pasta four days past the

expiration date

A sample of opened food containers with no labels or use by date included:

25 - Balsamic Vinaigrette containers with no date label
5 - grab and go chicken salad sandwiches with no date label
1 - tray with cut up vegetables, 15 different vegetables with no date label
1 - frozen package of chicken tenders with no date label
1 - bag of parmesan grated cheese with no date label
1 - bag of radishes with no date label
1 - quart container of cut up jalapeno peppers with no date label


b. During the tour an interview was conducted with Purchasing /Materials Technician (Technician) #2 who reported all opened items in the freezer were required to be left in the original box which would have a use by date or needed to be wrapped in plastic and labeled. He said the date would indicate when the food item had been opened and how long it was good for. Technician #2 reported the unlabeled items were not labeled according to the kitchens process.

c. During the tour an interview was conducted with the Director of Food Services (Director) #1. Director #1 stated she was in charge of patient food service at the facility. Director #1 stated the unlabeled and undated food items was a training and education issue. There had been multiple people filling in for regular staff who were out on paid time off. Director #1 reported there was a chance the outdated and unlabeled food could have been used for patients. Director #1 reported the food would need to be monitored more closely for labels and dates on all foods.

d. During the tour an interview was conducted with Manager of Quality (Manager) #3 who reported she was over the Food services area. Manager #3 said she had not been touring the kitchen. Manager #3 said she had not been checking the food service area for undated or outdated food. Manager #3 reported she would start touring the food services area because it was important to monitor the food service area for outdated or undated food items.