Differentiating between Deficiencies

Differentiating between deficiencies or violations that represent a breakdown in a system and those that represent a discrete problem is not always easy.

However, a facility probably will not succeed in correcting the failure if it does not identify the source of the failure.  

 

Example

W473 §483.480(b)(2)(ii), Food must be served - at appropriate temperature.

Based on observations and interviews, the surveyor learned that the facility failed to ensure hot food was served at an appropriate temperature for 6 of 6 individuals (Individuals # 1 - 6).

A summary of the findings includes:

How would you determine whether this is a system failure or a discrete failure?