Long-Term Care Survey Alert

Infection control generally conjures images of nursing staff taking a patient's temperature not the temperature of food being served at mealtimes. "Yet the temperature of food is a hot new item leading to citations for F371 at the immediate jeopardy level," cautions Annaliese Impink, a health care attorney with The Law Offices of Bianculli & Impink in Arlington, VA.

"Surveyors' big focus is on infection control issues in the kitchen," agrees James Marx, an infection control specialist with Broadstreet Solutions in San Diego, CA. That's because food-borne illness is a serious problem in nursing facilities, adds Annette Kobriger, a nutritional consultant in Chilton, WI.

Salmonella, E. coli or other gastrointestinal infection transmitted by contaminated food can cause major health consequences for frail elderly residents, including severe fluid and electrolyte imbalances and even renal or cardiac failure. In addition, elderly people may be more prone to food poisoning, due to weaker stomach acidity and impaired immunity.

A facility doesn't have to have an outbreak of food-borne illness to end up with an IJ citation, however. Impink recalls a recent case involving undercooked chicken where a facility was tagged with IJ even though they recognized the problem as soon as the trays were served and pulled the food immediately so no one got sick. The facility's corrective plan involved checking the temperature of meat in the kitchen in assembly line fashion before it was served.

Temperature control is the primary way to prevent bacteria-laced food. "That involves cooking food to proper temperature to kill bacteria and holding food at temperatures to prevent bacterial growth," Marx explains. For example, ground beef should be cooked to at least 160 degrees Fahrenheit and chicken to 180 degrees, according to the United States Department of Agriculture. Casseroles should be cooked to 160 degrees.

Facilities should watch out for the "danger zone" which includes a range of temperature between 40 and 140 degrees Fahrenheit where bacteria in food multiply rapidly. While the Food and Drug Administration Food Code allows food to be in this temperature zone for up to four hours, other sources say food is best discarded after two hours at room temperature. "That means that facilities that bring food up to the floors to allow residents to eat on their own schedules have to be very careful to maintain food at the right temperature hot or cold enough," says Marx.

Certain foods pose more risk of food poisoning than others. Baked potatoes can serve up a potentially deadly dose of botulism if they are kept hot but not hot enough for several hours. Corned beef can also provide a hazard if it's cooked and then put in the refrigerator to cool.

"If it doesn't cool fast enough, it becomes a breeding ground for bacteria," Marx says. According to the FDA Food Code, which is included in the surveyor guidance, food should be cooled from 140 degrees F. to 70 degrees F. in two hours and from 70 degrees to 41 degrees in an additional four hours.

Nursing staff should also check the temperature of food kept on warming trays on the unit that may have entered the "danger zone" prior to being served to residents. Stir the food with a clean utensil first and then check the temperature near the surface.

As far as surveyors are concerned, however, the proof that you followed the food safety rules lies in the documentation. Even so, "this is a tricky issue," says Impink, "because facilities that add additional documentation requirements run the risk that an overzealous surveyor will discover that someone forgot to complete the log or put a date on a food label," Impink notes.

"The surveyor can then cite you for failing to follow your own policies and procedures, failing to complete documentation, or failing to institute effective systems to assure the proper handling and storage of food items," she says.

On the flip side, however, facilities can protect or defend themselves against survey citations by implementing the appropriate documentation systems.

If facilities take this precautionary route, they should use a limited checklist of high priority documentation tasks and assign only one or two people for making sure they get done, in Impink's view. "The responsibility for the checklist, for example, could be incorporated into the dietary supervisor's daily routine," she adds.

While surveyors may cite lukewarm food as a palatability issue, it's not a safety problem if the food hasn't been in the danger zone for more than four hours.

For example, Impink has seen a facility get a citation for F362 at a scope and severity level of "F" for failure to have sufficient staff to ensure that meal trays were delivered within an hour of arriving on the unit.

If a facility were handed an IJ citation in such a situation, however, Impink believes it could argue that there is no potential for serious harm to residents. "As long as the issue does not involve the potential for bacteria growth or spoilage, I think a judge would be hard pressed to uphold a dietary tag at the 'IJ' level simply because the residents [or surveyors] felt the food wasn't hot or cold enough," she argues.