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, but if the facility does not identify the source of the failure, it probably will not succeed in correcting it.
Here is an example of a deficiency. How would you determine whether this is a system failure or a discrete failure?
W473 483.480(b)(2)(ii), Food must be served – at appropriate temperature.
Based on observations and interviews, the facility failed to ensure that hot food was served at an appropriate temperature for 6 of 6 individuals (Individuals #'s 1 – 6).
A summary of the findings includes:
- At 5:02 p.m. Individuals #'s 1-6 and DCS #1 went to a fast food place and purchased boxes of chicken for dinner. They returned at 5:27 p.m.
- Upon their return, DCS #2 removed 2 pizzas from the oven.
- Dinner was served at 5:51 p.m. (24 minutes after the pizzas were taken from the oven and the chicken had arrived).
- Temperature readings of the food at the time it was served were 78 degrees for the pizza and 72 degrees for the chicken.
- Individuals #'s 1, 2, and 4 ate chicken, and Individuals #'s 3, 5, and 6 ate pizza.
- Individual #3 said, "Yuck, this food is cold!"
- DCS #2 stated she was trained that hot food should be served right away.
- The QIDP stated she trains staff on an annual basis to serve hot food immediately after it is done.