Standards FAQ Details | Joint Commission

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Friday 9:54 CST, May 25, 2018

Standards FAQ Details


Environment of Care (EC) (Hospital and Hospital Clinics / Hospitals)

Refrigerator Temperature - Refrigerators Provided in Patient Rooms
Modify | April 11, 2017
When organizations provide refrigerators in patient rooms for personal use, is temperature monitoring and log maintenance required for these refrigerators?

There are no standards that prescriptively require temperature monitoring or maintaining a temperature log for refrigerators provided for personal patient use.  However, a process is required to ensure the refrigerator functions properly to ensure safe storage of its food contents. Use of a temperature monitoring is but one approach the organization may choose to ensure the unit is functioning properly. 

The Joint Commissions standards require that organizations store food and nutrition products, including those brought in by patients or their families, using proper sanitation, temperature, light, moisture, ventilation, and security (see PC.02.02.03).  When nutritional products, such as breast milk or baby formula are stored in these units, evidence-based guidelines from sources, such as the CDC, the formula manufacturer, etc., are to be followed to ensure safe storage. Organizations should also have processes that address cleaning between patients and maintenance responsibilities. Consulting with local/state board of health agencies is recommended as there may be additional requirements to consider.

A risk assessment should be conducted to identify any risk points associated with this practice.  Conducting a risk assessment is a helpful way of identifying risks associated with various options being considered by the organization.   A proactive risk assessment examines a process in detail including sequencing of events, actual and potential risks, and failure or points of vulnerability and that prioritizes, through a logical process, areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services provided.

The introductory section of the Leadership (LD) chapter provides an example of a pro-active risk assessment model that an organization may use.  However, this specific approach is not mandated as there are other risk assessment tools available that may better meet the needs of the organization.  Leadership responsible for patient care practices, infection prevention and control, safe management of food and facilities maintenance should be encouraged to participate in the risk assessment process.

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