HospitalInspections.org

Based on observation, document review, and staff interviews, the critical access hospital (CAH) staff failed to ensure that hospital staff properly stored and labeled prepared food products in the freezer and refrigerator area. The Critical Access Hospital (CAH) reported a census of two patients when entrance was made.

Failure to properly label and store prepared food created a risk to patient safety by an increased likelihood of foodborne illness due to potential bacterial contamination from unknown storage times and improper temperatures. It also introduced an increased risk of nutritional errors for patients on therapeutic or specific diets and a lack of traceability in the event of a foodborne outbreak. The absence of proper labeling and documentation hinders the hospital's ability to identify, isolate, and respond to potential sources of contamination, which could result in poor patient outcomes.

Findings include:

1. Review of policy Dietary Infection Prevention, date of last review 10/20/24 revealed: a. Purpose: "... to reduce the risk of transmission of infection among staff, and patients ..." b. Purpose: Equipment and supplies cleaning: "... food and supplies are stored according to food service, safety, and sanitation policies and procedures as outlined in food code 2017 ..."

2. Review of the ServSafe Food Protection Managers certification, 7th additional training, date of last revision 07/01/2023 revealed: a. ... "Labeling food for use on-site:... items not in their original containers must be labeled; food labels should include the common name of the food or a statement that clearly and accurately identifies it...if the item contains two or more ingredients, list the ingredients in descending order by weight; list the artificial colors and flavors in the food including chemical preservatives; list name and place of business of the manufacturer, packer, or distributor; and list source of each major food allergen contained in the food ..." b. ..."Date marking:... if it is held at 41°F (5°C) or lower: the count begins on the day that the food was prepared or a commercial container was opened ..."

3. On 04/30/2025 at 9:00 AM, accompanied by the Food Service Manager and the Chief Nursing Officer (CNO) observation of the kitchen area was conducted, which revealed eight plastic bags of ham balls in the refrigerator/ freezer without proper labeling.

4. On 04/30/2025 at 9:00 AM, during observation, the Food Service manager confirmed the ham balls should have been labeled correctly with the date prepared to ensure proper storage and handling. The Food Service Manager was observed disposing of the unlabeled ham ball containers.

5. On 05/01/2025 at 8:00 AM, during an interview with the hospital Dietician/Food Service Director, it was reported that staff completed a food labeling training on February 27th, 2025. The hospital Dietitian recalled that all kitchen staff have been trained to label prepared items with the name of the item and the date prepared in accordance with the policy for Dietary Infection Prevention. The hospital Dietitian revealed the Sous Chef and the Food Service manager completed the ServSafe Program, which provided staff direction on food safety, labeling and dating to prevent foodborne illnesses.