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WELCH COMMUNITY HOSPITAL 454 MCDOWELL STREET WELCH, WV 24801 May 29, 2019
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, document review and interviews it was revealed the Dietary Manager Supervisor II failed to ensure that staff checked and documented freezer and cooler temperatures on the daily log sheets and labeled open food products according to facility policy and procedures. Staff failed to record daily temperatures on three (3) out of four (4) freezers and coolers and failed to label eighteen (18) opened food containers. This failure has the potential to adversely place all patients, staff and visitors at risk for food borne illnesses.

Findings include:

1. An observation was conducted in the Dietary Department's small storage room on 5/28/19 at 3:27 p.m. The dietary freezer's temperature log in the small storage room did not have temperatures documented on 5/5/19, 5/6/19, 5/13/19 and 5/14/19. Inside the freezer a bag of chicken breast filets was left torn open and unlabeled with an open date and a freezer bag of labeled beef stew meat was not dated when the product was repackaged. The dietary cooler's temperature log in the small storage room did not have a temperature documented on 5/5/19.

2. An observation was conducted in the Dietary Department's large storage room on 5/29/19 at approximately 11:37 a.m. The dietary freezer's temperature log in the large storage room did not have temperatures documented on 5/13/19, 5/14/19, 5/15/19, 5/16/19, 5/17/19, 5/18/19, 5/19/19, 5/21/19, 5/22/19, 5/23/19, 5/24/19, 5/26/19, 5/27/19 and 5/28/19.

3. An observation was conducted in the dietary kitchen at approximately 11:45 a.m. On the preparation counters thirteen opened seasoning containers were unlabeled with opened dates. A cart located under a preparation counter containing three (3) large covered containers of flour, sugar and cornmeal was unlabeled with date the dry product was placed in the containers.

4. A document review was conducted on 5/29/19. Welch Community Hospital policy titled Cooler and Freezer Temperatures, effective date 3/3/09, reviewed 3/3/11, in section Policy states in part: "Each cooler and freezer will have a temperature chart hung on the door for daily recording of temperatures" and in section Procedure states in part: "A. A monthly chart will be hung on each door for proper recording. B. At the beginning of each morning, dietary staff will record temperatures of all coolers and freezers."

5. A document review was conducted on 5/29/19. Welch Community Hospital policy titled Dating and Labeling Food, effective date 3/26/12, in section Policy states in part: "Any and all food that is opened will be immediately labeled and dated for the day it is opened and seven (7) days thereafter."

6. An interview with the Dietary Manager Supervisor II was conducted on 5/29/19 at approximately 11:37 a.m. When asked whose responsibility it is to check and document daily temperatures on the freezer and cooler temperature logs, the Dietary Manager Supervisor II stated, "It is everyone's responsibility including mine." On 5/29/19 at approximately 11:45 a.m. a discussion in the kitchen with the Dietary Manager Supervisor II was conducted. When asked about the labeling of food items in the freezer, cooler, dry seasonings and storage of dry food products, the Dietary Manager Supervisor II concurred all opened containers should be labeled with the opened dates.