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Based on observation, interview, and record review, the facility failed to ensure a Crash Cart (emergency cart containing equipment, supplies and medication used during a medical emergency or cardiac arrest) was checked and ready to use.

This failure had the potential to cause a delay in the delivery of emergency care, which could lead to further illness, injury and/or death in a universe of 133 patients.

Findings:

During an observation on May 14, 2019, at 9:30 AM, in the Surgery Department, a Crash Cart/Defibrillator checklist was missing the weekly (every Monday) Defibrillator/Pacer check, for entry date May 6, 2019.

During an interview on May 14, 2019, at 9:32 AM, the Director of Perioperative Services (Surgery) stated, "The nurses are responsible and yes it looks like they (nurses) missed it, it (checklist) should have been checked."

Review of facility policy dated January 11, 2018, titled "Emergency Crash Cart Availability and Readiness", indicated: "Purpose: To provide guidelines to ensure readiness of crash carts for use during patient care emergencies. Procedure 1. Routine checks process ... Items to be checked every Monday, during operating hours, will include: a. Defibrillator test (unplugged unless otherwise specified by manufacturer)."

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff documented and evaluated the effectiveness of nutrition care interventions for 5 of 10 patients (Patients 1, 11, 12, 13 and 14) in a universe of 133 patients.

This failure occurred when the nursing staff did not document the intake amount of the nutritional supplement ordered by the physician. This lack of documentation resulted in the inability to evaluate the effectiveness of nutrition interventions for these patients.

Findings:

A review of the medical records for Patient 1 indicated she was admitted to the hospital on May 6, 2019, with diagnoses that includes nausea, vomiting and diarrhea for one and a half months, multiple pressure ulcers and protein-calorie malnutrition.

A nutrition assessment dated May 6, 2019, indicated Patient 1 was a high nutrition risk. According to the assessment, Patient 1 was eating only 25 percent of her clear liquid diet (a diet containing fluids that can be seen through - sometimes order for stomach problems and has very limited nutritional value). A nutrition reassessment note dated May 9, 2019, indicated Patient 1 was now on a soft diet, but continued with poor meal intake, eating zero to 25 percent of her meals. The assessment recommended adding a liquid nutritional supplement three times a day. The nutrition reassessment plan included a goal for Patient 1 to meet greater than 75 percent of her estimated nutrition needs.

A physician's order for the recommended nutritional supplement was noted on May 12, 2019. A review of the nursing documentation, dated May 14, 2019, at 3:30 PM, showed there was no documented evidence to indicate Patient 1 consumed the nutritional supplement.

During an interview with the Registered Nurse (RN 1), caring for Patient 1 on May 14, 2019, at 3:30 PM, RN 1 indicated he did not know how much of the supplement Patient 1 had been consuming. During a concurrent interview with Patient 1's Certified Nurses Aid (CNA 1), she stated Patient 1 had three unopened nutritional supplements at her bedside and she had not been consuming the nutritional supplement. During a concurrent interview with the Director of Quality (DOQ) she verified the medical record did not contain documentation of how much Patient 1 consumed of the nutritional supplement to determine the effectiveness of the nutrition intervention.

A review of the medical record for Patient 11 indicated he was admitted to the hospital on May 5, 2019, with diagnoses that included sickle cell anemia (a group of disorders of the blood that causes red blood cells to become misshapen, breakdown and die causing pain).

A nutrition assessment dated May 10, 2019, indicated Patient 11 was 6 foot 4 inches tall and weighed 140 pounds. His Body Mass Index (BMI uses height and weight to calculate an index in order to categorize a person as underweight, normal weight, overweight or obese) was 17. A BMI under 18.5 is considered underweight. The nutrition assessment indicated Patient 11 was eating zero to 25% of his meals. The assessment Patient 11 was a high nutritional risk and recommended to start a liquid nutritional supplement three times a day. A review of the physician's order, dated May 10, 2019, showed to start the liquid nutritional supplement three times a day. Follow-up nutrition assessments were dated May 10 and May 13, 2019. These assessments indicated Patient 11 had an order for the nutrition assessments but did not have an assessment of the amount of the supplement he consumed.

A review of Patient 11's medical record on May 15, 2019, at 9:40 AM, showed there was no documentation to indicate if Patient 11 was consuming the nutritional supplements. During a concurrent interview with the DOQ, she verified there was no documented evidence in the medical record of Patient 11 consuming the nutritional supplement and there was no documentation of the effectiveness of this intervention.

During an interview with CNA 2, on May 15, 2019, at 9:45 AM, she stated the amount of nutritional supplement consumed by the patients should have been documented in the medical record.

An observation and concurrent interview conducted with Patient 11, on May 15, 2019, at 9:50 AM, at the bedside of Patient 11, three unopened nutritional supplements were seen. Patient 11 stated he did not drink the supplements that had been ordered.

A review of the medical record for Patient 12 indicated he was admitted to the hospital on April 28, 2019, with diagnoses to include a wound dehiscence (the separation of a wound along a surgical incision) over the spine area.

A review of a nutrition assessment dated April 30, 2019, indicated Patient 12 was 6-foot 1 inch tall, weighed 140 pounds and his BMI was 18.4 (underweight). The assessment indicated he was at a high nutrition risk and recommended a nutritional supplement. A review of the physician orders dated May 10, 2019, indicated an order for a nutritional supplement three times a day.

A review of the medical record on May 15, 2019, at 10:15 AM, indicated of the 12 opportunities in which Patient 12 should have received the nutritional supplement, the amount of the supplement consumed was documented three times. During a concurrent interview with the DOQ, she verified there was a lack of evaluation for the effectiveness of the intervention of nutritional supplement for Patient 12.

A review of the medical record for Patient 13 indicated the patient was admitted to the hospital on April 15, 2019, with diagnoses to include headache for 2 weeks. A nursing assessment dated the same day indicated Patient 13 had a poor appetite. Nutrition assessments dated April 19 and 22, 2019, indicated Patient 13 was at a high nutrition risk. A physician's order for a nutritional supplement three times a day was dated April 24, 2019. Further review of the medical record showed out of 60 opportunities in which Patient 13 should have received the nutritional supplement between April 21 and May 14, 2019, the amount of supplement consumed was documented six times. This was verified through an interview with the DOQ on May 15, 2019, at 10:35 AM.

A review of the medical record for Patient 14 indicated Patient 14 is a 97-year-old, admitted to the hospital on May 8, 2019, with diagnoses to include hip fracture and major depression. A physician's order dated May 11, 2019, indicated Patient 14 was to receive a liquid nutritional supplement. A nutrition assessment dated May 13, 2019, indicated Patient 14 was eating zero to 10 percent of meals served. There was no documented evidence in the nutrition assessment of how much of the nutritional supplement Patient 14 consumed. The assessment plan showed the goal was to meet greater than 75 percent of the patient's estimated nutrition needs. Further review of the medical record conducted on May 15, 2019, at 10:50 AM, with the DOQ, revealed there was no documented evidence of
the amount of the nutritional supplement Patient 14 consumed or an evaluation of the effectiveness of this intervention.

Based on observations, interviews, and record reviews, the hospital failed to ensure an effective infection control surveillance program to prevent the following lapses in sanitary conditions in the Food and Nutrition Services department and a nursing unit pantry:

1. A liquid egg white product was not stored at a safe temperature,

2. Two frozen meat items stored in the walk-in freezer were not sealed to prevent cross contamination and freezer burn,

3. A bag of cooked, thawed chicken breasts were labeled with a thaw dated of May 10, 2019 and a use-by date of June 10, 2019. According to the hospital's policy the maximum storage time was four days,

4. The walk-in refrigerator (#3) condenser fan covers were dusty, a blender cup was stored with food residual on the blade and three drawers that contained food preparation equipment were dirty with a dried liquid food residual,

5. A dirty, used food container was stored with patient food supplies in the 2100 West nursing unit nourishment pantry.

These failures had the potential to result in cross contamination of patient food, potential compromised quality of the food and ultimately a potential for food borne illness in a universe of 133 patients receiving nutritional services.


Findings:


1. During an observation in the cafeteria on May 13, 2019, at 10 AM, an unopened quart of liquid egg whites was noted in a reach-in refrigerator. The carton did not feel very cold. The package was opened, and the temperature of the contents was measured. Both the surveyor's and the hospital's thermometers registered 59.5 degrees Fahrenheit (F).

According to the 2017 US Food and Drug Administration (FDA) Food Code, Time and Temperature Controlled for Safety (TCS) foods (food that requires safe storage temperature to prevent harmful bacterial growth), except during preparation, cooking, or cooling, or when time is used as the public health control, TCS food shall be maintained at 135 F or above ...or at 41 F or less.

During a concurrent interview with the dietary staff responsible for storage of the liquid egg product, Dietary Staff 1 (DS 1), stated the liquid egg product had been in the refrigerator at 5 AM when she arrived at work. DS 1 was not sure when the carton had been removed from the refrigerator. Concurrently, DS 1 stated when the cartons were removed from the refrigerator and placed by the stove, they were placed in a pan containing ice and the temperature of the egg product was not monitored during this time. DS 1 was not able to state why the contents of the carton was almost 60 F or how long the product was greater than the required storage temperature of 41 F or less.

The unopened carton had been placed back in the refrigerator without checking the temperature of the contents or monitoring the time it was held in the "Danger Zone". According to the FDA Food Code, bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature "Danger Zone" of 41 F to 135 F too long.

2. During an observation in the kitchen's walk-in freezer, on May 13, 2019, at 9:25 AM, a box containing frozen sausage patties and a box containing frozen pork topping crumbles were noted to be open to air with the plastic bag inside the boxes not sealed.

During a concurrent interview with the Director of Food and Nutrition Service (DFNS), she verified that the contents of the boxes were not sealed and stated the plastic bags inside the boxes should have been closed.

According to the 2017 FDA Food Code, food shall be protected from contamination by storing the food so that it is not exposed to ...contaminants.

In addition, according to the Library of Congress Research Centers Science Reference Services, freezer burn occurs when meat is not wrapped tightly and moisture is allowed to escape, leaving the meat dehydrated. Freezer burn may cause the texture and taste of meats to deteriorate.

A review of the hospital's policy titled, "Food Storage" (reviewed March, 2016) stated "All food items that have been opened or prepared will be covered, labeled and dated ..."

3. During an observation in the kitchen, on May 13, 2019, at 9:50 AM, a bag of thawed cooked chicken breasts was observed in the reach-in refrigerator for the cafeteria. The bag was labeled with an opened date of May 10, 2019 and a use by date of June 10, 2019.

During a concurrent interview with the DFNS, she stated the use by date should be 3 to 4 days after the open date, not 31 days. The DFNS could not explain why the use by date was June 10, 2019.

A review of the hospital's policy titled "Food Product Shelf Life Guidelines" (reviewed January 21, 2017) indicated for cooked poultry stored in the refrigerator, the shelf life was 3 to 4 days.

4. During a tour of the kitchen walk-in refrigerator number 3, on May 13, 2019, at 9:35 AM, the plastic covers over the condenser fans were noted to have an accumulation of dust. The refrigerator was used for the storage of meat. The fans blew air directly on the food which had the potential for cross contamination of the meat.

During a concurrent interview with the DFNS, she stated the Engineering staff cleaned the fan covers when a work order is submitted. The DFNS noted a work order should have been submitted for the accumulation of dust, but stated there had not been one submitted.

Continuing the kitchen tour at 10:40 AM, a blender cup was noted with food residual on one of the blades. Also noted were three stainless steel drawers with a dried liquid food residual that had spilled into the drawers. One of the drawers contained an immersion blender.

During a concurrent interview with the DFNS, she stated the blender cup was stored and ready for use, and should have been clean. The DFNS also verified the dried liquid food residual in the drawers where the immersion blender was stored should have been clean.

A review of the hospital's policy titled, "Sanitation Procedures for Stainless Steel Sinks and Prep Tables" (reviewed March, 2016) indicated the procedure was to wipe up food spills daily as needed with a sanitizer solution and a clean cloth.

According to the 2017 FDA Food Code, equipment food-contact surfaces and utensils shall be clean to sight and touch and nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

5. During a tour of the 2100 West nursing unit nourishment room, on May 13, 2019, at 2:50 PM, a soiled plastic food container was noted in a cupboard stored with patient food service supplies.

During a concurrent interview with Nurse Manager 1, she verified the finding and stated staff were not supposed to store personal food and soiled food containers in the nourishment pantries.

A review of the hospital's policy titled, "Food Storage" (reviewed March, 2016) indicated that food storage areas shall be kept clean at all times.

During an interview with the Infection Control Manager (ICM) on May 15, 2019, at 12:00 PM, she stated that surveillance in the kitchen for sanitary conditions was conducted quarterly. She also stated that Environment of Care rounds, which included the kitchen area, were conducted three times a year. The ICM stated that when deficient practices were identified during these rounds, the expectation was that they were resolved immediately. She stated that she had not observed the above deficient practices in the kitchen or the nursing unit pantries. She verified that staff food containers were not supposed to be stored in the nourishment rooms pantries.