Improper Storage of Resident's Personal Food Item
Penalty
Summary
The facility failed to ensure safe and sanitary storage practices for foods brought to residents by family and other visitors, specifically for one resident. The deficiency was identified when a bottle of creamy horseradish, which required refrigeration after opening, was found on the bedside table of a resident. The bottle was not labeled with the resident's name, nor was it stored according to the manufacturer's directions. The facility's policy required perishable food items to be labeled, dated, and discarded after 48 hours if refrigerated, and discarded after 2 hours if left at the bedside. The resident involved was cognitively intact and had a medical history that included Vitamin D deficiency, hyperlipidemia, and gastro-esophageal reflux disease. During interviews, the resident confirmed that the horseradish was brought by her sister, and a Licensed Vocational Nurse acknowledged the failure to label and refrigerate the item. The Dietary Service Supervisor reiterated the policy that perishable items should not be left out for more than 2 hours and should be stored in the refrigerator if not consumed immediately. This oversight had the potential to cause foodborne illness to the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, the Infection Control Preventionist removed the items from Resident 42 bedside. The Infection Control Preventionist explained the risk versus benefits of having items unrefrigerated to Resident 42. Resident 42 verbalized understanding and agreed for items to be discarded. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, the Infection Control Preventionist conducted visual rounds in residents' rooms to ensure that perishable items left at the bedside had the resident's name and date on the item, and if the item required refrigeration, that it was not left at the bedside for more than two hours. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Staff Development and Administrator in-serviced facility staff, including but not limited to Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), Dietary Staff, and Activities Department, on the facility's policy and procedure titled, "Food Brought in by Visitors," with emphasis on perishable food requiring refrigeration being discarded after 2 hours at bedside, and if refrigerated, it will be labeled, dated, and discarded after 48 hours. The in-service also included that if the resident desires to have food brought in, the Dietary Staff would provide education regarding safe food handling practices and need to have the resident's name and date it was brought to the facility. Department managers, including but not limited to the Director of Staff Development, Social Services Director and Social Service Assistant, Activities Director, Case Manager Admissions Coordinator, Infection Preventionist, Minimum Data Set Nurse (MDSN) and MDSN Assistant, and Quality Assurance Nurse, will conduct room rounds daily for five days weekly for two weeks, and then monthly thereafter, to ensure food brought into the facility is properly stored and labeled. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assurance and Performance Improvement (QAPI) Committee during its monthly meeting the status of the compliance for food brought into the facility by visitors, including whether it is stored properly, labeled, for three months or until compliance is met.