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.



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:

  • At 5:02 p.m. Individual #s 1-6 and DCS A went to a fast food restaurant and purchased boxes of chicken for dinner. They returned at 5:27 p.m.
  • Upon their return, DCS B 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.
  • Individual #s 1, 3, and 4 ate chicken. Individual #s 2, 5, and 6 ate pizza.
  • Individual #3 said, "Yuck, this chicken is cold!"
  • DCS B 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 prepared


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