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MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE 509 BILTMORE AVE ASHEVILLE, NC 28801 Feb. 21, 2020
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on review of hospital policy, food temperature logs, and interviews with staff, the hospital's dietary staff failed to monitor and record food temperatures according to policy for 2 of 2 hospital campuses (Campus A and Campus B).

The findings include:

Review of policy titled, "PATIENT FOOD SERVICES: TRAYLINE/TASTE/TEMPERATURE RECORD," with revision date of 01/20, revealed "POLICIES: All items intended for patient food service are listed on the Taste/Temperature Record. Completed forms are kept on file for one year .... Daily Preparation of Forms: Supervisor or Office: Run the Taste and Temperature Report form Webtrition (Electronic form) for each meal. Supervisor: ...TEMPERATURES: logs temperatures at all points indicated on the form in conjunction with appropriate maintenance ... Two temperatures must be noted on the form, a beginning and either a midpoint or an ending temperature. Takes immediate action if temperatures indicate a violation ..."

1. Review of food temperature logs from Hospital Campus B revealed incomplete January 2020 food temperature logs. Review revealed no documentation of food temperatures on 01/08/2020, 01/09/2020, 01/11/2020, 01/12/2020, 01/13/2020, 01/18/2020, 01/21/2020, 01/22/2020, 01/24/2020, 01/25/2020, 01/28/2020, 01/29/2020 or 01/30/2020 (missing 13 of 31 days).

2. Review of food temperature logs from Hospital Campus A revealed incomplete December 2019 food temperature logs. Review revealed no food temperatures were found for 12/15/2019, 12/25/2019, 12/28/2019, 12/29/2019, 12/30/2019, or 12/31/2019 (missing 6 of 31 days). Review of February 2020 food temperatures between February 1, 2020 and February 21, 2020 revealed incomplete temperature logs. Review revealed no temperature logs were found for 02/01/2020, 02/05/2020, 02/10/2020, or 02/12/2020 (missing 4 of 21 days).

Interview on 02/20/2020 at 1455 with AS #1 (Director of Food and Nutrition) revealed the staff member could not locate the missing food temperatures for December 2019, and January and February 2020. Interview revealed the policy to obtain and document food temperatures for each meal was not followed.

NC 479; NC 887; NC 272; NC 736; NC 784; NC 050; NC 025; NC 019; NC 069; NC 066; and NC 120