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Based on interview and record review the facility failed to be in compliance with State regulations by not evaluating the competency of the facility staff.

The facility failed to ensure that all employee files reviewed were maintained to include the training/education and unit specific competencies required for specific departments such as the ED (Emergency Department), OB and L&D (Obstetric Department and Labor and Delivery), Respiratory Therapy (RT) and Medical Surgical & Telemetry Departments. The facility also failed to ensure that a Registered Nurse who worked in OB and Labor and Delivery, had an active training certificate for Pediatric Advanced Life Support (PALS). These failures had the potential for staff to be involved in the delivery of patient care without the necessary training and education required thereby increasing the risk of harm to the patients.

PALS: Gives healthcare professionals the knowledge and skill to better recognize and treat critically ill infants and children. This certification is for healthcare providers who initiate and direct advanced life support in pediatric emergencies. AHA (American Heart Association), 2010.

Findings:

1. A record review of the employee file for Registered Nurse (RN) 4 revealed that her date of hire was 8/11/08. She was to work in the OB & L & D Units. RN 4's employee file revealed no documented evidence that she received unit specific competencies and there were no annual evaluations in RN 4's employee file.
During an interview, with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RN 4 did not receive a unit specific competency.

2. A record review of the employee file for Respiratory Therapist (RT) 1 revealed that her date of hire was 12/20/07. She was to work in the Respiratory Department. RT 1's employee file revealed no documented evidence that she received unit specific competencies, there was no annual evaluation of RT 1 and her PALS certificate expired on January 2012.

During a concurrent interview with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RT 1 did not receive a unit specific competency. He confirmed that RT 1's PALS certificate expired on January 2012.

3. A record review of the employee file for RT 2 revealed that her date of hire was November 2011. She was hired to work in the Respiratory Department. RT 2's employee file revealed no documented evidence that she received unit specific competencies.

During a concurrent interview with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RT 2 did not receive a unit specific competency. He stated that none of the facility employees received unit specific competencies and that they received a general competency that the facility provided upon the hire of all staff members.

4. During a review of Pharmacist (Pharm) 1's employee file with Human Resources Staff (HR) 2 on 4/19/12 it was noted that there was no competency evaluation for Pharm 1. There was no unit specific orientation documentation for Pharm 1.

In a concurrent interview with HR 2, she acknowledged that Pharm 1 did not have a competency evaluation or a unit specific orientation.

5. During a review of ICRN's employee file with HR 2 on 4/19/12 it was noted that there was no annual competency evaluation for ICRN.

In a concurrent interview with HR 2, she acknowledged that ICRN did not have an annual competency evaluation.

In an interview on 4/19/12 at 9:50 AM with the Director of HR, he stated that there was no policy for doing employee competencies. He stated that he doesn't "have a feel for who is competent or who is not." (Refer to A-0152)


The California Code of Regulations Title 22 at subsection 70213(c) states:

Policies and procedures which contain competency standards for staff performance in the delivery of patient care shall be established, implemented, and updated as needed for each nursing unit, including standards for the application of restraints. Standards shall include the elements of competency validation for patient care personnel other than registered nurses as set forth in Section 70016, and the elements of competency validation for registered nurses as set forth in Section 70016.1. At least annually, patient care personnel shall receive a written performance evaluation. The evaluation shall include, but is not limited to, measuring individual performance against established competency standards.


On 4/19/12 at 1:10 PM Immediate Jeopardy was called in the presence of hospital administrative staff due to the hospital's employees not having unit specific orientation or competencies. There was no way to know whether or not the hospital staff was able to perform the tasks needed to give patient care safely in their assigned departments.

The Immediate Jeopardy was abated on 4/19/12 at 7:20 PM upon receipt of an acceptable plan of correction. The plan of correction included an assessment of the competency for all employees reporting for work beginning the evening of 4/19/12. The assessment would be performed by managers, educators, or other staff who are qualified to assess the competencies under review. Going forward, all employees would have a competency assessment before they reported for their next shift until all employees are evaluated.

Copies of completed competency assessments would be forwarded as soon as possible to the Director of Quality for review and tracking.

The cumulative effect of this deficient practice had the potential to place any patient in the facility at risk of receiving unsafe care.

Based on interview and record review, the facility failed to ensure that all employee files reviewed were maintained to include the training/education and unit specific competencies required for specific departments such as the ED (Emergency Department), OB and L&D (Obstetric Department and Labor and Delivery), Respiratory Therapy (RT) and Medical Surgical & Telemetry Departments. The facility also failed to ensure that a Registered Nurse who worked in OB and Labor and Delivery, had an active training certificate for Pediatric Advanced Life Support (PALS). These failures had the potential for staff to be involved in the delivery of patient care without the necessary training and education required thereby increasing the risk of harm to the patients.

PALS: Gives healthcare professionals the knowledge and skill to better recognize and treat critically ill infants and children. This certification is for healthcare providers who initiate and direct advanced life support in pediatric emergencies. AHA (American Heart Association), 2010.

Findings:
1. A record review of the employee file for Registered Nurse (RN) 4 revealed that her date of hire was 8/11/08. She was to work in the OB & L & D Units. RN 4's employee file revealed no documented evidence that she received unit specific competencies and there were no annual evaluations in RN 4's employee file.

During an interview, with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RN 4 did not receive a unit specific competency.

2. A record review of the employee file for Respiratory Therapist (RT) 1 revealed that her date of hire was 12/20/07. She was to work in the Respiratory Department. RT 1's employee file revealed no documented evidence that she received unit specific competencies, there was no annual evaluation of RT 1 and her PALS certificate expired on January 2012.

During a concurrent interview with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RT 1 did not receive a unit specific competency. He confirmed that RT 1's PALS certificate expired on January 2012.

3. A record review of the employee file for RT 2 revealed that her date of hire was November 2011. She was hired to work in the Respiratory Department. RT 2's employee file revealed no documented evidence that she received unit specific competencies.

During a concurrent interview with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RT 2 did not receive a unit specific competency. He stated that none of the facility employees received unit specific competencies and that they received a general competency that the facility provided upon the hire of all staff members.

4. During a review of Pharmacist (Pharm) 1's employee file with Human Resources Staff (HR) 2 on 4/19/12 it was noted that there was no competency evaluation for Pharm 1. There was no unit specific orientation documentation for Pharm 1.

In a concurrent interview with HR 2, she acknowledged that Pharm 1 did not have a competency evaluation or a unit specific orientation.

5. During a review of ICRN's (Infection Control Registered Nurse) employee file with HR 2 on 4/19/12 it was noted that there was no annual competency evaluation for ICRN.

In a concurrent interview with HR 2, she acknowledged that ICRN did not have an annual competency evaluation.

In an interview on 4/19/12 at 9:50 AM with the Director of HR, he stated that there was no policy for doing employee competencies. He stated that he doesn't "have a feel for who is competent or who is not."

On 4/19/12 at 1:10 PM Immediate Jeopardy was called in the presence of hospital administrative staff due to the hospital's employees not having unit specific orientation or competencies. There was no way to know whether the hospital staff was able to perform the tasks needed to give patient care safely in their assigned departments.

The Immediate Jeopardy was abated on 4/19/12 at 7:20 PM upon receipt of an acceptable plan of correction. The plan of correction included an assessment of the competency for all employees reporting for work beginning the evening of 4/19/12. The assessment would be performed by managers, educators, or other staff who are qualified to assess the competencies under review. Going forward, all employees would have a competency assessment before they report for their next shift until all employees are evaluated.

Copies of completed competency assessments would be forwarded as soon as possible to the Director of Quality for review and tracking.

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Provision of Services by failing to:

1. Ensure that outdated medications were not available for patient use. This failure had the potential for expired medications to be administered to patients. The facility also failed to ensure that only pharmacy compounds or admixes all sterile medications except in emergencies. This failure had the potential for medications to not be prepared safely for patient use. The facility failed to ensure that the medication room in the Medical Surgical Unit was locked at all times. This failure had the potential for unauthorized personnel to access patient medications. (Refer to C-0276)

2. Ensure that its infection control program included a system for monitoring and evaluating the facility staff's aseptic practices, such as: techniques for handwashing, sterilization, disinfection, food sanitation and housekeeping. The facility failed to ensure that 1 of 7 employee health files reviewed included a chest X-ray for tuberculosis (TB) screening upon hire when the employee informed the facility that she had a previously positive TB skin test. These failures had the potential to result in an ineffective infection control program, placing patients and employees at risk of contracting an infection. The facility failed to ensure that for 1 of 20 sampled patients, (Patient 1), the intravenous site, tubing, oxygen tubing and sterile water, used for humidifying Patient 1's oxygen, were dated, timed and initialed to indicate the length of time they were in use for Patient 1. This failure had the potential to result in an ineffective infection control program, placing Patient 1 at risk of contracting an infection. The hospital failed to ensure that there were infection control measures in place to prevent the development of food borne illness and cross contamination in the food service departments. The hospital failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietetics services staff. By not having these measures and a thorough surveillance system, potentially hazardous foods had been stored, prepared and distributed under unsafe and unsanitary conditions and there was potential for such continuation in the absence of identification and remediation. (Refer to C-0278)

3. Ensure the that the nutrition needs of the patients were met in accordance with recognized dietary practices and orders of the practitioner responsible for the care of the patients when:

a. The dietary services failed to ensure safe and sanitary practices were utilized in the storage, preparation and distribution of food to patients, staff and visitors;

b. The quality of the food served was maintained when commercially dried spices were not monitored for freshness;

c. The dietary management and staff had routine competency evaluations and job specific orientations to ensure knowledge of safe dietary practices;

d. The hospital failed to developed and maintained a disaster food plan and supplies to meet the needs of the patients and staff during a disaster;

e. The hospital failed to utilize a diet manual that provided the medical, nursing and dietary staff guidance on the specific diets the hospital provided. It failed to ensure the menus met the current national standards for recommended dietary allowance when the menus had not been analyzed for all nutrients including (but not limited to) vitamins, minerals, trace elements and fiber;

f. The hospital failed to obtain required approval for many dietary policies and procedures;

g. The nutrition needs of 2 of 6 patients reviewed for nutrition care (Patients #16 and 18) were not met;

h. The physician orders for diets for Patient #17 were not specific and allowed nursing to determine the diet order instead of the practitioner who was lawfully responsible for the care of the patient;

i. The dietary services failed to participate in the hospital's Performance Improvement Plan by failing to collect data to measure, track and analyze quality indicators for any of the deficient practices observed during the survey.

These failures had the potential to result in: food borne illness in the patients, staff and visitors; the quality of the food provided to the patients affected; malnutrition in patients and staff in the event of a disaster; the nutrition needs of the patients not met; a lack of guidance for the medical, nursing and dietary staff with regards to the diets provided at the hospital; the medical staff and governing body not having oversight regarding the policies and procedures in the dietary department. The deficient practices in the dietary department were allowed to continue and jeopardized the health and safety of the patients, staff and visitors who ate at the hospital. (Refer to C-0279)

4. Ensure that 3 of 9 sampled physician credential files had proper documentation to indicate that the physicians (Physicians 1, 2 and 3) were re-appointed (evaluated) to indicate that the physicians were qualified to carry out all responsibilities specified by the facility's "Bylaws and Rules," and to provide patient care. This failure had the potential to affect the quality of care provided to patients by Physicians 1, 2 and 3. (Refer to C-0287)

5. Ensure that the Registered Nurse administered a medication ordered by a physician for 1 of 20 sampled patients (Patient 10). This failure contributed in Patient 10 not receiving a medication that the physician ordered to help minimize the development of blood clots. (Refer to C-0297)

6. Ensure that a care plan for 4 of 20 sampled patients (Patients 1, 13, 14 and 19) were kept current and revised to reflect the care needs of the patient. This failure resulted in the potential for Patients' 1, 13, 14 and 19 to not have their needs met. (Refer to C-0298)

The cumulative effect of these systemic problems resulted in the facility being unable to provide safe and effective patient care.

Based on observation, interview and record review, the facility failed to ensure that outdated medications were not available for patient use. This failure had the potential for expired medications to be administered to patients. The facility failed to ensure that only pharmacy compounds or admixes all sterile medications except in emergencies. This failure had the potential for medications to not be prepared safely for patient use. The facility failed to ensure that the medication room in the Medical Surgical Unit was kept locked. This failure had the potential for unauthorized personnel to access patient medications.

Findings:

On 4/17/12, at 8:45 AM, a tour of the Medical Surgical medication room was conducted with the facility's Medical Surgical Manager. The following were observed:

1. A laminar flow hood (An area used to prepare intravenous {IV} admixtures in the pharmacy) was located in the medication room. The Medical Surgical Manager stated that the nurses use the laminar flow hood to prepare medications such as antibiotics, IV push medications and aseptically mixed medications. According to the Medical Surgical Manager, the nurses prepare the medications because the facility does not have a pharmacy.

2. A "Sterile Bacteriostatic Surgical Lubricant," tube was opened, not labeled and had an expiration date of October, 2011.

An interview, on 4/17/12, at 8:45 AM, with the Medical Surgical Manager was conducted. When asked what the expiration date was on the tube, she stated, "It states, an expired date of October 2011 but not sure. I assume it's the expiration date but it's a little confusing the way it is written."

3. Five Prochlorperazine 25 milligram suppositories (a medication, used rectally, to treat nausea and vomiting) had an expiration date of November 2008. During an interview with RN 2, she confirmed the findings and stated, "Wow, that's not good." Six additional Prochlorperazine suppositories had an expiration date of March 2010.

4. A box of "Meningococcal Polysaccharide Vaccine," with an expiration date of January 14, 2010, contained 1 vial with an expiration date of January 14, 2010 and a second vial with the expiration date of June 20, 2011. RN 2 confirmed the findings and verified the dates and stated, "That's confusing."

5. The Medical Surgical Unit Medication Room was unlocked. When RN 2 was asked if the medication room is supposed to be kept locked, she stated, "It is supposed to be. It's a work in progress."

A record review, on 4/18/12, at 1:30 PM, of the facility policy titled, "Drug Storage, revised on March 2009," documented the following, "...Outdated or otherwise unusable drugs shall be stored in an area authorized by the Pharmacist and approved by the administrator. The specified area shall be clearly marked, "OUT-DATED DRUGS - DO NOT USE ...All drug storage areas shall be lockable and accessible only to authorized personnel ...No outdated, improperly labeled, or otherwise unsafe medications are stocked anywhere in the hospital or clinic medication areas."

Based on interview and record review the facility failed to ensure that its infection control program included a system for monitoring and evaluating the facility staff's aseptic practices, such as: techniques for handwashing, sterilization, disinfection, food sanitation and housekeeping. The facility failed to ensure that 1 of 7 employee health files reviewed included a chest X-ray for tuberculosis (TB) screening upon employee hire when an employee informed the facility that she had a previously positive TB skin test. These failures had the potential to contribute in an ineffective infection control program, placing patients and employees at risk of contracting an infection. The facility failed to ensure that for 1 of 20 sampled patients, (Patient 1), the intravenous site, tubing, oxygen tubing and sterile water used for humidifying Patient 1's oxygen were dated, timed and initialed to indicate the length of time they were in use for on Patient 1. This failure had the potential to result in an ineffective infection control program, placing Patient 1 at risk of contracting an infection. The hospital failed to ensure that there were infection control measures in place to prevent the development of food borne illness and cross contamination in the food service departments. The hospital failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietetics services staff. By not having these measures and a thorough surveillance system, potentially hazardous foods had been stored, prepared and distributed under unsafe and unsanitary conditions and there was potential for such continuation in the absence of identification and remediation.

Findings:

1. An interview was conducted on 4/18/12 at 2:00 PM with the ICRN (Infection Control Registered Nurse) regarding the facility infection control program. The ICRN stated that she started in the infection control position in the middle of December 2011. She stated that she was a member of APIC (Association for Professionals in Infection Control, an organization for infection control practitioners) and had attended a California Department of Public Health Infection Control Preventionist course in February of 2012. She stated that there were not a lot of proactive infection prevention programs at the facility prior to her being in the infection control position. She was unaware of any prior inservice training for the staff on identified infection control issues in the facility.

In an interview with the Chief Nursing Officer (CNO) on 4/19/12 at 6:00 PM, she stated that the facility had an infection control plan for 2010 and 2011, and that the information collected was presented in quality meetings. She presented a copy of the previous infection control plan for 2010 through 2011.

Review of the infection control plan showed that the following data was tracked by the previous infection control nurse: surgical site infections, central line infections, employee flu vaccine immunization and declination (refusal) rates, hospital acquired infections, SCIP (Surgical Care Improvement Project) data, multi drug resistant organisms, tuberculosis surveillance, prevention and control, and reportable diseases and conditions.

There was no evidence in the infection control plan that housekeeping was monitored for infection control practices such as cleaning patient rooms between patient use, terminal cleaning of isolation rooms after a patient is discharged, and proper disinfectant use according to the manufacturer's directions.

There was no evidence in the infection control plan that dietary staff was monitored for handwashing and gloving techniques for food handling, cool down procedures for leftover food and proper food storage.

There was no evidence in the infection control plan that operating room staff was observed for proper cleaning and sterilizing equipment according to manufacturer's instructions and no evidence that cleaning of the operating rooms was done correctly.

2. During a review of Pharm 1's employee health file on 4/19/12 with HR 2 it was noted that Pharm 1 filled out a tuberculosis questionnaire when she was hired in April of 2011. One of the questions was whether the employee had ever had a positive tuberculosis skin test. Pharm 1 wrote that she had a previous positive tuberculosis skin test. There was no follow up chest X-ray to confirm that Pharm 1 was free of tuberculosis.

In a concurrent interview with HR 2, she stated that a chest X-ray should have been done since Pharm 1 informed the facility that she had a previously positive tuberculosis skin test.

During a review of the infection control plan for 2010 and 2011 on 4/19/12 it was noted that all Employee Health screens of new hires include screening for tuberculosis. Any employee with a new positive skin test is referred to...(name of clinic).. for evaluation.


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3. A record review, on 4/16/12, at 1:45 PM, indicated that Patient 1 was admitted on 4/13/12, with diagnoses which included, a left patella (kneecap) fracture and a right ankle fracture. Patient 1 had surgery to repair the fractures.
During an observation on the Medical Surgical Unit, on 4/17/12, at 9:10 AM, an observation of Patient 1 revealed that the patient was on oxygen which was being humidified with a bottle of sterile water. There was no date or time listed on the bottle or the oxygen tubing, to indicate how long they had been used on the patient. Additionally, Patient 1 had an intravenous line (IV) on the left antecubital area (in front of the elbow), which had no date on the IV site or the tubing.

During an interview, with RN 2, on 4/17/12, at 9:10 AM, she stated that Patient 1's oxygen tubing and the sterile bottled water should have been labeled with the date and time by the Respiratory Department. RN 2 stated that Patient 1's IV site and tubing, should also have been labeled with the date, the time and the initial of the person who inserted the IV. RN 2 stated that she was unsure when Patient 1's IV site was inserted but she assumed it was "Possibly from the other hospital she was transferred from," on 4/13/12.

An interview, on 4/17/12, at 10:10 AM, with RT 1 and RT 2 was conducted. When asked what the process was regarding dating and timing oxygen tubing and sterile water for humidifying the oxygen, they stated that they do not date and time oxygen tubing or sterile water bottles because it is not a policy. RT 1 and RT 2 stated that the facility had no policy to address dating and timing of tubing and sterile water. When asked when the tubing and sterile water were applied, RT 2 stated, "Well, she was admitted on 4/13/12, she's probably been on it since then."

An interview was conducted on 4/19/12, at 10:35 AM, with the Infection Control Registered Nurse (ICRN), regarding the dating and timing of tubing for the oxygen and the IV tubing, the IV site and the sterile water for humidifying the oxygen. She stated that they should all have been dated, timed and initialed to indicate when they were applied because it was an infection control issue. She stated that the facility did have a policy for the dating and timing of oxygen tubing.



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4a. During the initial tour of the kitchen on 4/16/12 between 12:45 and 2:00 PM, several previously cooked potentially hazardous food (PHF) items were noted in the refrigerator and freezer: a container of shredded beef, dated 4/14/12, a vegetable breakfast burrito, dated 4/16/12, a thawing container labeled chili con carne, dated 3/21/12, a thawing container labeled turkey apple mix, dated 12/27/11, potatoes from breakfast, dated 4/16/12, bacon from breakfast, dated 4/16/12, frozen beef, dated 4/14/12, frozen sliced roast beef, dated 3/28/12, a frozen package labeled chili glazed pork loin, dated 2/7/12, a frozen container labeled pasta primavera, dated 4/15/12 and a frozen fish pie, dated 3/19/12.

During a concurrent interview with the Food Service Manager (FSM), she verified all items had been cook in the facility then stored in the refrigerator or freezer for future use. She stated that she had recently implemented a procedure for monitoring the cool down of previously cooked PHF and she directed the surveyor to a log.

A review of the hospital's document titled "Leftover Temperature Log" dated 1/1/12 through 4/15/12 showed six items listed. None of the items observed during the survey were listed on the document. Also, the directions on the document stated, "Food temperatures need to be logged 2 hours after being refrigerated. At that time, the food item must be below 70 degrees F (Fahrenheit)." There was no direction to monitor the temperature after 2 hours.

A review of the hospital's policy titled, "Leftover Cooling Procedures" not dated, "Cooked potentially hazardous food shall be cooled...within 2 hours from 140 degrees F to 70 degrees F and then within an additional 4 hours from 70 degrees F to 41 degrees F." It further stated, "Logging shall be completed daily to track the temperatures of leftover food items that are refrigerated for later use."

A review of the hospital's policy titled, "Cold Food Storage" not dated, revealed that all leftover dishes may be stored in the refrigerator for 3 days, and was not to be frozen.

During an interview with the FSM on 4/16/12 at approximately 3:00 PM, she validated that the items found during the initial tour of the kitchen were not on the Leftover Temperature Log. She further stated that she did not know that the food service workers (FSW) were not monitoring the cooling process for leftover foods. When queried why the log did not require the FSWs to document the temperature of the food beyond the 2 hours, she stated that she thought it just needed to be below 70 degrees F in 2 hours. She didn't know that it needed to be at 41 degrees or below within an additional 4 hours. She stated that she was not aware of the policy that leftover food was not to be frozen.

According to the 2009 FDA Food Code, cooked, potentially hazardous food shall be cooled within 2 hours from 135 degrees F to 70 degrees F, and within a total of 6 hours from 135 degrees F to 41 degrees F. It further states that if food is not cooled in accordance to this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

When there is a lack of documented monitoring of the cooling of potentially hazardous foods, there is no way to ensure that the food was safely cooled within the timeframes required. Therefore there is no way to ensure that the food is safe and will not cause food borne illness.

b. During the initial tour of the kitchen on 4/16/12 between 12:45 and 2:00 PM, multiple items were observed in the refrigerator with no date monitoring to determine the "use-by" or expiration dates: an open can of sweet red peppers covered with plastic wrap, multiple open packages of cheeses (bleu, swiss, feta, cheddar, parmesan), an open jar of capers, an open jar of ground ginger packed in oil, an open jar of jelly, a container of pesto sauce, a container of minced garlic (minced in the facility), six gallon sized open containers of salad dressings, frozen chicken breasts in the refrigerator, two frozen turkey breast roasts and 2 pork tenderloins labeled "Freeze or use by 4/9/12". In the freezer the following were stored without date monitoring: an uncooked beef roast in a ziplock bag, containers of clam chowder, pie crusts, individual servings of carrot cake, salmon filets, sausage links, 3 containers of pesto sauce, a bag of veggie burgers and a bag of egg rolls. All of the listed items were removed from their original packaging and not dated.

In the refrigerator there were multiple items that were dated but there was no staff guidance regarding "use-by" or expiration dates: an open package of swiss cheese, dated 3/24/12, an open package of shredded mozzarella cheese, dated 3/14/12, an open jar of sun dried tomatoes, dated 2/25/12, a container of honey butter (made in the facility), dated 3/21/12, one gallon containers of pickle relish and dill pickle slices, dated 8/27/11, a gallon container of Thousand Island salad dressing, dated 12/16/11 and 2 boxes of uncooked bacon dated, 3/20/12 and 3/27/12.

During a concurrent interview with the FSM, she validated that all of the above items lacked staff guidance on "use-by" or expiration dates. She further stated that the hospital did not have policies that provided staff guidance for the shelf life of the food items observed and where the manufacturer did not provide it on the packaging, except for the bacon. She stated that the standard of practice for the hospital was that open containers of salad dressing were good for one month after opened. She was unable to explain why the Thousand Island dressing was opened 4 months earlier and had not been discarded.

A review of the hospital's policy titled, "Cold Food Storage" not dated, revealed that if foods were removed from their original box for storage, the item shall be labeled with a delivery date and an expiration date if available on the packaging. Also, when items are pulled from the freezer into the refrigerator, it shall be labeled with a "pull date" (date it was placed from the freezer to the refrigerator). For bacon, the policy stated it had a shelf life of 7 days in the refrigerator.

During the continued interview with the FSM, she was unable to state how her staff could monitor the shelf life of the food observed without dating and/or without policies that provided guidance to the staff when manufacturer's expiration dates were not available.

In the dry storage area there was a container of brown sugar with several slices of bread inside the container on top of the sugar.

During the interview with the FSM on 4/16/12 at 1:50 PM, she revealed that there was no monitoring of how long the bread was stored with the brown sugar. She was unable to state how long the bread had been in the container. She also stated that she didn't know how long the bread could be safely stored in the container. The facility had no system for monitoring this process.

c. During the initial tour of the kitchen on 4/16/12 between 12:45 and 2:00 PM, the dry storage area was observed with multiple unsealed packages: an open box of baby food oatmeal, a package of spaghetti noodles, a large bag of dry brownie mix and a bag of dry buckwheat pancake mix.

During a concurrent interview with the FSM, she stated that the packages should be confirmed sealed shut. She validated that the open packages had the potential to attract pests.

According to the 2009 Food Code, foods shall be protected from cross contamination by storing the food in packages, covered containers, or wrappings.

d. During the initial tour of the kitchen on 4/16/12 at 2:00 PM with the FSM, the dishmachine room was observed to have a floor drain where there was no air gap maintained for the pipe draining into it. The observation was validated by the FSM.

According to the 2009 Food Code, to prevent the backflow of contaminated water during times of negative pressure into the water supply, an air gap must be maintained between the water supply inlet and the flood level rim of the plumbing fixture (floor drain).

e. During the initial tour of the kitchen on 4/16/12 with the FSM at 12:45 PM, a bulk storage bin in the cook's area was observed to have a moderate buildup of dried brown residue. The FSM verified the finding.

Also noted in the cook's area there was a microwave with a brown residue at the back of the oven. The FSM confirmed that the microwave was not clean and stated that the policy was to clean it daily after lunch and after dinner.

During a concurrent interview with Food Service Worker 1 (FSW 1), he stated that the microwave had not been used that day. He was unable to state why the microwave was not clean.

On 4/16/12 at 1:50 PM in the kitchen the dry food storage room was noted to have an accumulation of dirt and trash in the corners and under the shelves.

During a concurrent interview with the FSM she stated that the room was supposed to be swept daily. She stated that she did not check to see if the staff had swept the corners.

A review of the kitchen's document titled, "Daily Cleaning Checklist" undated, showed that the floors were to be swept twice a day (after lunch and dinner) and mopped daily after dinner. It further shows that the microwave was to be cleaned daily. The bulk storage bin was not listed on the cleaning schedule.

The FSM was unable to explain the findings. She stated that she was in the kitchen daily, but did not notice that these areas were not clean.

f. During an interview with FSW 2 on 4/16/12 at 2:10 PM, regarding manual ware washing in the three compartment sink, he explained the process. He stated that he routinely washed pots and pans in these sinks. He demonstrated how he fills the third sink with water and pushes the sanitizer button once to dispense the proper amount of sanitizer into the water. When asked how he knew that one push of the button was adequate to give the sanitizer the effective concentration, he stated that he always pushes the button once. He further stated that he never checked the concentration of the sanitizer in the sink to ensure that the concentration was effective.

During a concurrent interview with the FSM, she stated that he is supposed to check the concentration during each use to ensure the pots and pans were being properly sanitized to prevent food borne illness.

Also, the posted instructions on the sanitizer dispenser directed the staff to push the button three times to deliver the appropriate amount of sanitizer into the sink of water. FSW 2 stated he had not noticed the instructions.

Without checking the concentration of the sanitizer solution and not adding the appropriate amount of sanitizer to the water, the hospital was unable to ensure that the pots and pans were being effectively sanitized every time FSW 2 washed them in the three compartment sink.

g. During an interview with the Infection Control Registered Nurse (ICRN) on 4/18/12 at 2:00 PM, she stated that she took over as ICRN in the middle of December 2011. She stated that she had not identified any of the food safety and sanitation deficient practices observed in the survey. She further stated that she had conducted a quick screen of the dietary department in terms of infection control from the retail aspect. She stated that she had not gone inside the kitchen to conduct surveillance. She agreed that ensuring food safety and sanitation should be a part of the infection surveillance activities at the hospital. She was unaware of any infection control surveillance activities in the past involving dietary service.

Based on observations, record reviews and interviews, the hospital failed to ensure the that the nutrition needs of the patients were met in accordance with recognized dietary practices and orders of the practitioner responsible for the care of the patients when:

1. The dietary services failed to ensure safe and sanitary practices were utilized in the storage, preparation and distribution of food to patients, staff and visitors;

2. The quality of the food served was maintained when commercially dried spices were not monitored for freshness;

3. The dietary management and staff had routine competency evaluations and job specific orientations to ensure knowledge of safe dietary practices;

4. The hospital failed to develop and maintain a disaster food plan and supplies to meet the needs of the patients and staff during a disaster;

5. The hospital failed to utilize a diet manual that provided the medical, nursing and dietary staff guidance on the specific diets that the hospital provided. It also failed to ensure the menus met the current national standards for recommended dietary allowance when the menus had not been analyzed for all nutrients including (but not limited to) vitamins, minerals, trace elements and fiber;

6. The hospital failed to obtain required approval for many dietary policies and procedures;

7. The nutrition needs of 2 of 6 patients reviewed for nutrition care (Patients #16 and 18) were not met;

8. The physician orders for diets for Patient #17 were not specific and allowed nursing to determine the diet order instead of the practitioner lawfully responsible for the care of the patient;

9. The dietary services failed to participate in the hospital's Performance Improvement Plan by failing to collect data to measure, track and analyze quality indicators for any of the deficient practice observed during the survey.

These failures had the potential to contribute to: food borne illness in the patients, staff and visitors; a decrease in the quality of the food provided to the patients affected; an increased risk for malnutrition in patients and staff in the event of a disaster; an increased risk for the nutrition needs of the patients not being met; a lack of guidance for the medical, nursing and dietary staff with regards to the diets provided at the hospital; the medical staff and governing body not having oversight regarding the policies and procedures in the dietary department; and the deficient practices in the dietary department being allowed to continue and jeopardize the health and safety of the patients, staff and visitors who ate at the hospital.

Findings:

1. Food safety and sanitation:

a. During the initial tour of the kitchen on 4/16/12 between 12:45 and 2:00 PM, several previously cooked potentially hazardous food (PHF) items were noted in the refrigerator and freezer: a container of shredded beef dated 4/14/12, a vegetable breakfast burrito dated 4/16/12, a thawing container labeled chili con carne dated 3/21/12, a thawing container labeled turkey apple mix dated 12/27/11, potatoes from breakfast dated 4/16/12, bacon from breakfast dated 4/16/12, frozen beef dated 4/14/12, frozen sliced roast beef dated 3/28/12, a frozen package labeled chili glazed pork loin dated 2/7/12, a frozen container labeled pasta primavera dated 4/15/12 and a frozen fish pie dated 3/19/12.

During a concurrent interview with the Food Service Manager (FSM), she verified all items had been cook in the facility then stored in the refrigerator or freezer for future use. She stated that she had recently implemented a procedure for monitoring the cool down of previously cooked PHF and she directed the surveyor to a log.

A review of the hospital's document titled "Leftover Temperature Log" dated 1/1/12 through 4/15/12 showed six items listed. None of the items observed during the survey were listed on the document. The directions on the document stated, "Food temperatures need to be logged 2 hours after being refrigerated. At that time, the food item must be below 70 degrees F (Fahrenheit)." There was no direction to monitor the temperature after 2 hours.

A review of the hospital's policy titled, "Leftover Cooling Procedures" not dated, "Cooked potentially hazardous food shall be cooled...within 2 hours from 140 degrees F to 70 degrees F and then within an additional 4 hours from 70 degrees F to 41 degrees F." It further stated, "Logging shall be completed daily to track the temperatures of leftover food items that are refrigerated for later use."

A review of the hospital's policy titled, "Cold Food Storage" not dated, revealed that all leftover dishes may be stored in the refrigerator for 3 days, and was not to be frozen.

During an interview with the FSM on 4/16/12 at approximately 3:00 PM, she validated that the items found during the initial tour of the kitchen were not on the Leftover Temperature Log. She further stated that she did not know that the food service workers (FSW) were not monitoring the cooling process for leftover foods. When queried why the log did not require the FSWs to document the temperature of the food beyond the 2 hours, she stated that she thought it just needed to be below 70 degrees F in 2 hours. She didn't know that it needed to be at 41 degrees or below within an additional 4 hours. She stated that she was not aware of the policy that leftover food was not to be frozen.

According to the 2009 FDA Food Code, cooked, potentially hazardous food shall be cooled within 2 hours from 135 degrees F to 70 degrees F, and within a total of 6 hours from 135 degrees F to 41 degrees F. It further states that if food is not cooled in accordance to this Code requirement, pathogens may grow to sufficient numbers to cause food borne illness.

When there is a lack of documented monitoring of the cooling of potentially hazardous foods, there is no way to ensure that the food was safely cooled within the timeframes required. Therefore, there was no way to ensure that the observed food was safe and would not cause food borne illness.

b. During the initial tour of the kitchen on 4/16/12 between 12:45 and 2:00 PM, multiple items were observed in the refrigerator with no date monitoring to determine "use-by" or expiration dates: an open can of sweet red peppers covered with plastic wrap, multiple open packages of cheeses (bleu, swiss, feta, cheddar, parmesean), an open jar of capers, an open jar of ground ginger packed in oil, an open jar of jelly, a container of pesto sauce, a container of minced garlic (minced in the facility), six gallon sized open containers of salad dressings, frozen chicken breasts in the refrigerator, two frozen turkey breast roasts, 2 pork tenderloins labeled "Freeze or use by 4/9/12". In the freezer the following items were stored without date monitoring: an uncooked beef roast in a ziplock bag, containers of clam chowder, pie crusts, individual servings of carrot cake, salmon filets, sausage links, 3 containers of pesto sauce, a bag of veggie burgers and a bag of egg rolls. All of these items were removed from the original packaging and not dated.

In the refrigerator there were multiple items that were dated but were without staff guidance regarding "use-by" or expiration dates: an open package of swiss cheese dated 3/24/12, an open package of shredded mozzarella cheese dated 3/14/12, an open jar of sun dried tomatoes dated 2/25/12, a container of honey butter (made in the facility) dated 3/21/12, one gallon containers of pickle relish and dill pickle slices dated 8/27/11, a gallon container of Thousand Island salad dressing dated 12/16/11 and 2 boxes of uncooked bacon dated 3/20/12 and 3/27/12.

During a concurrent interview with the FSM, she validated that all of the observed items lacked staff guidance on "use-by" or expiration dates. She further stated that the hospital did not have policies that provided staff guidance on the shelf life of the food items observed and when the manufacturer did not provide such a date on the packaging, except for the bacon. She stated that the standard of practice for the hospital was that open containers of salad dressing were good for one month after being opened. She was unable to explain why the Thousand Island dressing was opened 4 months earlier and had not been discarded.

A review of the hospital's policy titled, "Cold Food Storage" not dated, revealed that if foods were removed from their original box for storage, the item shall be labeled with a delivery date and an expiration date if available on the packaging. Also, when items are pulled from the freezer into the refrigerator, they shall be labeled with a "pull date" (date it was placed from the freezer to the refrigerator). For bacon, the policy stated it had a shelf life of 7 days in the refrigerator.

During the same interview with the FSM, she was unable to state how her staff could monitor the shelf life of the food observed without dating and/or without policies that provided guidance to the staff when manufacturer's expiration dates were not available.

In the dry storage area there was a container of brown sugar that was observed with several slices of bread inside the container on top of the sugar.

An interview with the FSM on 4/16/12 at 1:50 PM revealed that there was no monitoring of how long the bread was stored with the brown sugar. She was unable to state how long the bread had been in the container. She also stated that she didn't know how long the bread could be safely stored in the container. The facility had no system for monitoring this process.

c. During the initial tour of the kitchen on 4/16/12 between 12:45 and 2:00 PM, the dry storage area was observed with multiple packages that were not sealed: an open box of baby food oatmeal, a package of spaghetti noodles, a large bag of dry brownie mix and a bag of dry buckwheat pancake mix.

During a concurrent interview with the FSM, she stated that the packages should be confirmed sealed shut and she validated that the open packages had the potential to attract pests.

According to the 2009 Food Code, foods shall be protected from cross contamination by storing the food in packages, covered containers, or wrappings.

d. During the initial tour of the kitchen on 4/16/12 at 2:00 PM with the FSM, the dishmachine room was observed to have a floor drain where there was no air gap maintained for the pipe draining into it. The observation was validated by the FSM.

According to the 2009 Food Code, to prevent the backflow of contaminated water during times of negative pressure into the water supply, an air gap must be maintained between the water supply inlet and the flood level rim of the plumbing fixture (floor drain).

e. During the initial tour of the kitchen on 4/16/12 with the FSM at 12:45 PM, a bulk storage bin in the cook's area was observed to have a moderate buildup of dried brown residue. The FSM verified the finding and stated that she expected it to be clean.

In the cooks area there was a microwave with a brown residue at the back of the oven. The FSM confirmed that the microwave was not clean and stated that the policy was to clean it daily after lunch and after dinner.

During a concurrent interview with Food Service Worker 1 (FSW 1), he stated that the microwave had not been used that day. He was unable to state why the microwave was not clean.

In the kitchen on 4/16/12 at 1:50 PM, the dry food storage room was noted to have an accumulation of dirt and trash in the corners and under the shelves.

During a concurrent interview with the FSM she stated that the room was supposed to be swept daily. She stated that she did not check to see if the staff had swept the corners.

A review of the kitchen's document titled, "Daily Cleaning Checklist" undated, showed that the floors were to be swept twice a day, after lunch and dinner, and mopped daily after dinner. It further showed that the microwave was to be cleaned daily. The bulk storage bin was not listed on the cleaning schedule.

The FSM was unable to explain the findings. She stated that she was in the kitchen daily, but did not notice these areas were not clean.

f. During an interview with FSW 2 on 4/16/12 at 2:10 PM, regarding manual ware washing in the three compartment sink, he explained the process. He stated that he routinely washed pots and pans in these sinks. He demonstrated how he fills the third sink with water and pushes the sanitizer button once to dispense the proper amount of sanitizer into the water. When asked how he knew that one push of the button was adequate to ensure the sanitizer was at the effective concentration, he stated that he always pushes the button once. He further stated that he never checked the concentration of the sanitizer in the sink to ensure that the concentration was effective.

During a concurrent interview with the FSM, she stated that he was supposed to check the concentration to ensure the pots and pans were being properly sanitized to prevent food borne illness.

Also, the posted instructions on the sanitizer dispenser directed the staff to push the button three times to deliver the appropriate amount of sanitizer into the sink of water. FSW 2 stated he had not noticed the instructions.

Without checking the concentration of the sanitizer solution and not adding the appropriate amount of sanitizer to the water, the hospital was unable to ensure that the pots and pans were being effectively sanitized every time FSW 2 washed them in the three compartment sink.

2. Quality of the food:

During the initial tour of the kitchen on 4/16/12 at 12:45 PM, multiple containers of spices were either not dated or had delivery dates greater than two years old. Eight containers were noted to have no dates, six were noted to have delivery dates greater than two years old and two were noted to have dates greater than 3 years.

During a concurrent interview with the FSM, she stated that the hospital did not have a policy for monitoring the shelf life of the spices. She stated that she didn't know how long the shelf life was.

The standard of practice is to monitor the shelf life of commercially dried spices and herbs because, even though they don't spoil, they lose their potency over time and will not flavor the food as intended.

3. Staff competency and training:

During a review of the FSW employee files on 4/19/12, all 8 dietary employee files were reviewed. It was noted that none of the files contained documentation of job or department specific orientation. Also, there were no job specific competency evaluations for the four employees that had worked in dietary department for at least one year.

During an interview with the HR Director on 4/19/12 at 9:00 AM, he stated that hospital did not have a policy that required employees to have job specific orientations or competency evaluations.

During an interview with the FSM on 4/19/12 at 10:40 AM, she verified her employees did not have competency evaluations. She also verified that all but one employee did not have job specific orientation. She stated that the FSW hired in February of this year had a documented department specific orientation that was not in his employee file. That employee no longer was employed at the hospital. She was unable to state how she was able to demonstrate that the dietary employees were properly oriented to the department and were competent in their jobs without evaluation and documentation.

4. Disaster Food Plan:

During a concurrent observation and review of the hospital's policy titled' "Disaster Menus" (policy not dated) on 4/17/12 at 11:30 AM, the hospital's disaster food plan was reviewed. The plan did not specify how many people it was developed to feed during a disaster. The plan did not include a beverage at lunch. It depended on entrees at both lunch and dinner that would require recipes which were not included in the plan.

During a concurrent interview with the FSM, she stated that the hospital's plan was to feed 100 people during a disaster. She stated that this number included patients and staff. She verified that the plan did not specify who would be fed, did not include a beverage at lunch and did not contain recipes for the entrees at lunch and dinner. She stated that the disaster plan was only available on her computer. She was unable to state how the plan would be retrieved and implemented during a disaster where the computer was not available.

The disaster food supply was noted to be missing items or had inadequate quantities of items to meet the plan: 493 of 600 planned servings of dry milk were on hand, 48 of 100 planned servings of chili con carne were on hand, 63 of 100 planned servings of soup were on hand, 150 of 300 planned packets of graham crackers were on hand, 360 of 600 planned servings of fruit juice were on hand, 0 of 100 planned fig newton cookies were on hand, 60 of 100 planned rice crispy treats were on hand and inadequate servings of applesauce and pineapple chunks were available. There was no written plan to indicate how patients with chewing and swallowing difficulties would receive puree food if it was required.

During the observation, some of the disaster food was stored in a room that was not a part of the licensed building. The key to the room where these supplies were stored was not marked indicating what the key was for.

The FSM verified the findings. She stated that the disaster food policy/plan had not been approved by the medical staff or the governing body and there was no plan that had been approved. She was unable to state how the hospital would feed the patients and staff without a comprehensive, detailed plan and without adequate supplies.

5. Nutrition Analysis of the menus and the diet manual:

During an interview with the FSM on 4/17/12 at 2:30 PM, she stated that the hospital does not have a nutrition analysis of the menus for the patient. She stated that in the absence of a nutrition analysis, she evaluated the nutritional adequacy of the patient menus utilizing the food guide pyramid and ensuring the appropriate amount of serving from each food groups were present. She stated that the regular diet provided a minimum of 2000 calories, but did not know how much protein it provided. She did not have an analysis of the amount of fat, including the types of fat in the low fat or cardiac diets. She also did not know the amount of sodium in the low sodium diet.

She further stated that the hospital approved diet manual was the American Dietetic Association Nutrition Care Manual (ADA NCM). She was unable to show how the ADA NCM provided guidance to the medical, nursing and dietary staff on the specific diets provided at the hospital. She verified that the ADA NCM was a general reference for nutrition care, but did not serve as a diet manual that defined the hospital specific diets served. She stated that for diabetic diets, the hospital utilized carbohydrate counting instead of specific calorie defined diets. She was unable to demonstrate in the ADA NCM where this was stated. The same was true for the low fat, low sodium, cardiac, soft and renal diets served at the hospital.

A review of the hospital's policy titled' "Nutrition Care Manual" dated 11/2011, revealed that the purpose was to provide a current and professionally accepted medical nutrition therapy resource for the staff of the dietary department and members of the health care team. It also stated that the nutrition care manual serves as a guide for the diets recognized at the hospital. It stated that the current diet manual was the web based ADA NCM.

Without a diet manual that clearly defines the diets routinely ordered and prepared in the hospital, and without a nutrition analysis of the menus served, the hospital was unable to ensure that the nutrition needs of the patients were met in accordance with current national standards, such as the current Recommended Dietary Allowances (RDA) or the Dietary Reference Intake (DRI) of the Food and Nutrition Board of the National Research Council. Further, the physicians lacked guidance in ordering diets for their patients when the diets in the hospital were not clearly defined.

6. Policies and procedures not approved:

During a review of the hospital's policy and procedure manual for the dietary department it was noted that many policies had not received the required approval by the medical staff or the governing body: the disaster menu policy, the cold food storage policy, the leftover cooling procedures policy and the manual warewashing policy.

During an interview with the FSM on 4/17/12 at 11:45 AM, she stated that she was in the process of having the policies approved. She stated that these policies had not been reviewed by the medical staff or the governing board.

7. Nutrition needs of a high risk patient not not met:

a. A review of the medical record for Patient #18 revealed that the patient was admitted to the hospital on 3/4/12 with diagnoses that included left elbow cellulitis (infection) and immune problems. A review of the physician's orders showed diet orders on 3/4/12 for a regular diet and on 3/8/12 for a two gram sodium diet (low salt diet). The patient was discharged home on 3/12/12.

A review of the Dietary Nutrition Assessment dated 3/5/12, completed by the registered dietitian, revealed that there were no estimated nutrition needs documented on the assessment. It further revealed that the patient's stated height was six foot four inches and his stated weight was 250 pounds. There was no measured height and weight. The nutrition plan documented by the registered dietitian (RD) was to continue to cater to the patient's food preferences and encourage good food intake, especially fruits and vegetables for lower calorie intake. The assessment stated that the patient was eating an average of 80 percent of his meals.

During an interview with the RD on 4/18/12 at 4:30 PM, she validated that there was no assessment of the patient's estimated nutrition needs. She stated that it must have been an oversight because her usual practice was to estimate the needs of the patients. She further stated that in the case of Patient #18, his estimated needs should have been at least 2400 calories. She further stated that the regular diet ordered for the patient only provided about 2000 calories. Also, since the patient was eating 80 percent of his diet, he was only taking in about 1600 calories, about two thirds of his estimated needs. She was unable to state how the patient could meet his calorie needs on a regular diet. She further confirmed that without an evaluation of the patient's estimated nutrition needs, the nutritional assessment and plan were not accurate.

The standard of practice in assessing the nutrition status of a patient is to determine the patient's estimated nutrition needs. This is done in order to determine a nutrition plan of care that meets the patients' needs

b. A review of the medical record for Patient #16 revealed that the patient was admitted to the hospital on 3/20/12 with diagnoses that included an infected wound on the right foot and diabetes. A physician diet order on admission was 1800 calorie ADA (diabetic diet).

A review of the Dietary Nutrition Assessment dated 3/22/12, completed by the RD, showed that the patient's calorie needs were 2000 -2500 a day and his protein needs were 65 - 80 grams a day. The plan for the nutrition care of the patient did not address the discrepancy in the amount of calories of the physician ordered diet (1800) and the assessed calorie needs (2000 - 2500).

During an interview with the RD on 4/18.12 at 4:30 PM, she was unable to explain why the assessment did not include a recommendation to increase the calories in the diet for Patient #16. She verified that the patient's diagnosis of a wound infection in his foot would increase his calorie needs to aid with healing and the patient was not getting adequate calories on the ordered diet. She was also unable to state how much protein was provided in an 1800 calorie ADA diet. She didn't have a means of knowing if the patient's protein needs were met on that diet.


8. Physician's diet orders not specific:

A review of the medical record for Patient #17 revealed that the patient was admitted to the hospital on 1/18/12 with a clinical impression of small bowel obstruction. The patient had bowel surgery on 1/18/12 and had an order for NPO (nothing by mouth) until 1/21/12. On 1/21/12 at 9:40 AM, a physician's diet order indicated, "start clear liquid diet, advance as tolerated". The order did not indicate the end diet to advance to. The same day at 1:00 PM, a physician's diet order indicated, "diet as tolerated" and another order to "d/c (discharge the patient) home." There was no specific diet ordered, even though the patient had abdominal surgery 3 days earlier.

During an interview with the RD on 4/18/12, she stated that "diet as tolerated" is not an acceptable diet order; the order needed to specify the diet. She also stated that it is the usual practice for the nursing staff to interpret these diet orders without a physician's order.

According to the California Code of Regulations Title 22, 70272(e), "Therapeutic diets shall be provided as prescribed by a person lawfully authorized to give such an order.." All diet orders must be prescribed by the practitioner responsible for the care of the patient. "Diet as tolerated" is not a specific diet order.

9. No Performance Improvement:

During an interview with the FSM on 4/18/12 at 4:10 PM, she stated that she is working on a project to improve the standard of care and patient satisfaction of patients admitted with a diagnosis of diabetes. She stated that an interdisciplinary team has met a couple of times to address issues such as revising sliding scale insulin orders. She stated that her department had not collected data to measure, analyze, or track quality indicators and assess processes of care or operations. She stated that the dietary department did not report to the quality committee on any of the findings of deficient practice identified in this survey process.

A review of the hospital's most current Performance Improvement Plan, dated 2008, revealed that the philosophy of the plan was to support the systematic organization-wide approach that was used to plan, design, measure, assess and improve organizational performance. The plan further stated that the hospital leaders adopted the "Plan, Do, Check and Act methodology for performance improvement, in which problems were identified, indicators were selected to be measured, data was collected and compiled, the data was analyzed and a plan of action for a solution was implemented and analyzed for effectiveness.

During an interview with the Director of Quality on 4/19/12 at 6:45 PM, he stated that the deficient practices identified in the dietary department during the survey had not been identified by the quality committee. He was unable to explain why the FSM did not conduct performance improvement studies. He verified that the FSM did not have an understanding of the hospital's Performance Improvement Plan and did not understand the culture of performance improvement concepts in general.

Without participating in the hospital's performance improvement plan, deficient practices in the dietary services department were allowed to continue and jeopardize the health and safety of the all the patients, staff and visitors who ate at the hospital.

Based on interview and record review, the facility failed to ensure that 2 of 9 sampled physician credential files had required documentation to indicate that the physicians (Physicians 1 and 2) were re-appointed (evaluated) to indicate that the physicians were qualified to carry out all responsibilities specified by the facility's "Bylaws and Rules," and to provide patient care. This failure had the potential to affect the quality of care provided to patients that Physicians 1, 2 and 3 cared for.

Findings:

1. A record review, on 4/19/12, at 9 AM, of Physician 1's credential file, revealed that he was a Family Practice physician. Physician 1's credential file had no documented evidence that he had been reappointed and granted privileges to provide patient care and practice at the facility. Physician 1's last reappointment date was on 10/06/09.

During an interview, on 4/19/12, at 5 PM, with the Medical Staff Coordinator, she stated that Physician 1's reappointment was overdue and had been practicing at the facility without privileges being granted. She stated that physicians are reappointed every 2 years and that they were working on getting the physician reappointed.

A record review, on 4/19/12, at 5 PM, of the facility "Medical Staff Bylaws," indicated the following:

"Basis for Reappointment - Recommendation for reappointment to the Medical Staff and for renewal of privileges shall be based upon the reappraisal of the member's performance at this hospital and in other settings. The reappraisal is to include confirmation of adherence to Medical Staff membership requirements as stated in these Bylaws, the Medical Staff Rules, the Medical Staff, and Hospital policies and the applicable department rules. Such reappraisal should also include relevant member-specific information from performance improvement activities and, where appropriate, comparisons to aggregate information about performance, judgment and clinical or technical skills ..."



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2. A record review, on 4/19/12, at 9:00 AM, of Physician 2's credential file, revealed that he was a Obstetric and Gynecology physician. Physician 2's credential file had no documented evidence that he had been reappointed and granted privileges to provide patient care and practice at the facility. Physician 2's last reappointment date was on 3/25/10.

During an interview, on 4/19/12, at 1 PM, with the Medical Staff Coordinator, she stated that the medical credential files were out of date. She stated that physicians are reappointed every 2 years and that they were working on getting the physician reappointed.

A record review, on 4/19/12, at 5 PM, of the facility "Medical Staff Bylaws," indicated the following:

"Basis for Reappointment - Recommendation for reappointment to the Medical Staff and for renewal of privileges shall be based upon the reappraisal of the member's performance at this hospital and in other settings. The reappraisal is to include confirmation of adherence to Medical Staff membership requirements as stated in these Bylaws, the Medical Staff Rules, the Medical Staff, and Hospital policies and the applicable department rules. Such reappraisal should also include relevant member-specific information from performance improvement activities and, where appropriate, comparisons to aggregate information about performance, judgment and clinical or technical skills ..."

Based on record reviews and staff interviews, the hospital failed to obtain and monitor measured heights and weights on 6 of 6 patients reviewed for nutrition care (Patients # 15, 16, 17, 18, 19 and 20). All weights on these patients were stated weights, not actual weights. This failure had the potential to contribute to an inaccurate assessment of the patients' nutrition status, inaccurate dosing of medications and a lack of monitoring of patients with fluid overload and those receiving nutrition intraveneously.

Findings:

The medical records for Patients #15, 16, 17, 18, 19 and 20 were reviewed for nutrition care. The review of each of these medical records revealed that all of the heights and weights were stated and not measured.

Patient #17 was on parenteral nutrition (nutrition given directly into the bloodstream) for three days and never had her weight measured. The statndard of practice is to monitor the weight of patients on parenteral nutrition to monitor for fluid overload.

Patient #18 was screened for nutrition status by nursing and determined to be at high nutrition risk due to an infected wound and never had a measured weight. The patients nutrition assessment was based on the stated weight, not an actual measured weight. During the hospital stay, the patient's nutritional intake was questionably inadequate and weight monitoring would have provided information to more accurately assess his nutrition status. (cross refer C-0279)

Patient #19 had surgery and never had a measured weight. The anesthesia dosing during surgery was based on the weight of the patient and required a measured weight.

Patient #20 was admitted with a diagnosis of dementia (a progressive mental condition characterized by chronic personality disintegration, confusion, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses) and lower extremity edema (swelling). According to the history and physical, the patient had a chest x-ray which indicated congestive heart failure (a condition that reflects abnormal pumping of the heart. Failure of the heart to pump blood efficiently results in fluid overload, dilation of the heart muscle. Increased pressure in the left side of the heart causes fluid in the lungs. Increased pressure in the right side of the heart causes fluid with edema in the legs). Patient #20's weight was not measured during her hospital stay. Her weight was listed as "stated" despite the patient's diagnosis of dementia.

The hospital's policy titled, "Standards of Patient Care - Nursing Procedures", dated 3/21/12, revealed that it was the hospital's policy that the nursing staff shall follow the recommended guidelines in Lippincott's Nursing Procedures and Skills when performing all patient care procedures..." The Lippincott's Nursing Procedures stated that a patient's weight is routinely measured during admission to a health care facility An accurate record of the patient's weight is essential for calculating dosages of drugs, anesthetics and contrast agent; assessing the patient's nutritional status; and determining the height-weight ratio. Because the body weight provides the best overall picture of fluid status, monitoring it daily also proves important for patients receiving sodium-retaining or diuretic medications.

A review of the hospital's policy titled, "Total Parenteral Nutrition" dated 4/2011, revealed that daily monitoring/routine nursing care for patients receiving parenteral nutrition included: "A scaled weight will be obtained at baseline and daily at 6:30 AM.

During an interview with RN 5 on 4/19/12 at 11:25 AM, she stated that the hospital beds have scales on them, allowing weights to be obtained without the patient having to get out of bed.

During an interview with RN 6, charge nurse for Patient #20, on 4/19/12 at 11:30 AM, she stated that patients were not weighed unless there was a physician order to do so. She further stated that a patient on a diuretic medication would not be weighed unless there was fluid overload. The charge nurse was not knowledgeable regarding the hospital's policy on measured weights of the patients.

The actual weight for Patient #20 was measured on 4/19/12 and was 114 pounds. The weight in the medical record was recorded as 130 pounds as a stated weight on admission. The patient's medication doses, anesthesia dosing for surgery and nutritional assessments were all based on the stated weight of 130 pounds since no measured weight was available.

Based on interview and record review, the facility failed to ensure that the Registered Nurse administered a medication ordered by a physician for 1 of 20 sampled patients (Patient 10). This failure contributed to Patient 10 not receiving a medication that the physician ordered to help minimize the development of blood clots.

Findings:

A record review, on 4/18/12, at 9 AM, of Patient 10, indicated that the patient was admitted on 3/7/12 for complaints of chest pain and shortness of breath. Patient 10 was transferred to another facility for higher level of care.

A record review, on 4/18/12, at 9 AM, of Patient 10's physician orders dated 3/7/12, at 12:30 PM, indicated that the physician ordered to administer Lovenox (A medication used to prevent blood clots). Next to the order was a hand written note which documented, "Not given." There was no medication administration record (A document that nurses use to record the medications administered to patients) to indicate that the medication was administered.

A record review of Patient 10's physician orders and an interview, were conducted on 4/18/12, at 9:30 AM, with the Quality Improvement / Utilization Review personnel. She stated that she remembered reviewing the chart and wrote an incident report on it because she had identified that the medication was missed. She stated that she had instituted a process in which nurses have a "Time out" period to ensure that all physician orders were completed before a patient gets transferred out of the facility.

A record review, on 4/18/12, at 1:30 PM, of the facility policy titled, "Administration of Medications, revised 12/8/10," documented the following, "...All medications must be administered by appropriately licensed, registered or certified personnel ...Each dose of medication shall be accurately recorded in the patient's medical record ..."

Based on interview and record review, the facility failed to ensure that a care plan for 4 of 20 sampled Patients, (Patients 1, 13, 14 and 19), was kept current and revised to reflect the care needs of the patient. This failure contributed to the potential for Patients' 1, 13, 14 and 19 to not have their needs met.

Findings:

1. A record review, on 4/16/12, at 1:45 PM, indicated that Patient 1 was admitted on 4/13/12, with diagnoses which included, a left patella (kneecap) fracture and a right ankle fracture. Patient 1 had surgery to repair the fractures.

A record review, on 4/16/12, at 2:30 PM, of Patient 1's care plan, revealed that a care plan was generated on 4/14/12, for alteration in comfort because Patient 1 had complaints of pain. No other care plan was found to address the following patient concerns: Nausea, narcotic use (Morphine-for pain), post op surgery concerns such as potential for bleeding and potential for infection, Foley catheter use as well as the use of blood thinners and the use of a sequential compression devise (SCD) to help minimize the potential for blood clots. Patient 1 was awaiting discharge to another facility for rehabilitation needs however, no care plan was found to address Patient 1's discharge needs.

An interview, on 4/16/12, at 2:30 PM and a concurrent record review, of Patient 1's care plan and medical record was conducted with RN 1. When RN 1 was asked if Patient 1's care plans were specific to the patient's problems and needs, she stated, "None other than alteration in comfort." RN 1 also stated that Patient 1 had complaints of nausea, was using SCD's, had been on morphine, blood thinners and did have surgery but did not have care plans developed to address those needs.

An interview and a concurrent record review were conducted of Patient 1's medical record and care plans, on 4/16/12, at 2:40 PM, with the Medical Surgical Manager. The manager confirmed the findings and stated that the nurses did not revise and update Patient 1's care plan. When asked if the care plans reflected Patient 1's needs, the Medical Surgical Manager stated, no and that the expectation was that nursing revise and update the care plans as the patient needs arise. She stated that it was the responsibility of the nurses.

2. A record review, on 4/18/12, at 9:25 AM, indicated that Patient 13 was born on 3/10/12, at 4 AM at the facility. Patient 13 remained in the facility until 3/12/12 and was transferred out to another hospital for higher level of care due to respiratory complications.

A record review and an interview were conducted, on 4/18/12, at 1:40 PM, with RN 4 of Patient 13's care plans. RN 4 stated, "Don't see one and should have had one because it looks by the documents and notes that the baby had some issues and was transferred out to another hospital for higher level of care."

During an interview, on 4/18/12, at 2:30 PM, with the Quality Improvement/Utilization Review personnel, she stated that the facility had no care plans developed for babies.

3. A record review, on 4/18/12, at 9:50 AM, of Patient 14, indicated that the patient was admitted on 3/13/12 with a diagnosis of rib fracture and pneumothorax (punctured lung). Patient 14 was discharged on 3/16/12.

A record review, of Patient 14's care plans and a concurrent interview were conducted on 4/18/12, at 10 AM, with the Director of Quality. He stated that Patient 14's care plan did not reflect the patient's condition and needs and that it was not modified for the patient. He also stated that it was a generic care plan; it did not have a measurable outcome and contained no evaluation methods. He stated that Patient 14's care plan did not identify Patient 14's problem.

4. A record review, on 4/18/12, at 1:30 PM, of Patient 19, indicated that the patient was born on 4/16/12, at the facility. Patient 19's discharge orders were postponed because the patient's bilirubin levels were elevated (A condition which can cause yellowing of the skin and can contribute to increased tiredness and poor feeding).

A record review, of Patient 19's care plans and a concurrent interview were conducted on 4/18/12, at 1:40 PM, with RN 4. She stated that Patient 19's care plans were generic and were not modified for the patient. RN 4 also stated that she was unable to modify it to reflect Patient 19's needs because, "It is the way the computer system is set up." RN 4 stated that the care plan contained no nursing diagnosis or the patient's needs, it did not contain an outcome, and did not have an evaluation.

A record review, on 4/16/12, at 3:50 PM, of the facility policy for "Nursing Care Plan, effective January 1, 2011," instructed facility staff to initiate patient care plans per "Lippincott Procedure ..."

A record review, on 4/16/12, at 3:50 PM, of "Lippincott Procedure," for "Care Plan Preparation, revised on March 31, 2012," revealed the following: "...Nurses update and revise the plan throughout the patient's stay and the document becomes part of the permanent patient record ...A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the doctor or other members of the health care team, planning patient discharge and documenting patient care. In addition, the care plan can be used as a management tool to determine staffing needs and assignments ...Customize a standardized care plan to avoid standardizing your patient's care and to allow you to address your patient's individual concerns. Long-term goals may not be met during hospitalization, so your planning should address post-discharge and home care needs. Interventions may include coordinating home care services ...Documentation of the patient's progress (or lack of it) is required by The Joint Commission and other regulatory agencies that monitor health care quality. Document all pertinent nursing diagnoses, expected outcomes, nursing interventions, and evaluations of expected outcomes."

Based on interview and record review the facility failed to ensure that the quality assurance review included all patient care services of the hospital.

The facility failed to have an effective quality assurance program by not evaluating all patient care services affecting patient health and safety. The patient care services that were not evaluated by quality included infection control surveillance, the organ, tissue and eye procurement program and dietary services. These failures had the potential to contribute to patients developing infection from inadequate surveillance, the potential for an organ or tissue donation to be missed and continued deficient practices in the dietary service department that had the potential to jeopardize the health and safety of all patients, staff and visitors who ate at the hospital. (cross refer C-0278 and C-0279)

The other patient care services that were not evaluated by quality included all employees that did not have (in their employee files) the training/education and unit specific competencies required for specific departments such as the ED (Emergency Department), OB and L&D (Obstetric Department and Labor and Delivery), Respiratory Therapy (RT) and Medical Surgical & Telemetry Departments. The facility failed to ensure that a Registered Nurse who worked in OB and Labor and Delivery, had an active training certificate for Pediatric Advanced Life Support (PALS). These failures had the potential for staff to be involved in the delivery of patient care without the necessary training and education required.

The cumulative effect of these systemic problems contributed to the facility being unable to ensure that they provided safe and effective patient care.

Based on interview and record review the facility failed to have an effective quality assurance program evidenced by the facility not evaluating all patient care services affecting patient health and safety. The patient care services that were not evaluated by quality included infection control surveillance, the organ, tissue and eye procurement program and dietary services. These failures had the potential to contribute to patients developing infection from inadequate surveillance, the potential for an organ or tissue donation to be missed and continued deficient practices in the dietary service department that had the potential to jeopardize the health and safety of all patients, staff and visitors who ate at the hospital. (cross refer C-0278 and C-0279)

The other patient care services that were not evaluated by quality included all employees that did not have (in their employee files) the training/education and unit specific competencies required for specific departments such as the ED (Emergency Department), OB and L&D (Obstetric Department and Labor and Delivery), Respiratory Therapy (RT) and Medical Surgical & Telemetry Departments. The facility failed to ensure that a Registered Nurse who worked in OB and Labor and Delivery, had an active training certificate for Pediatric Advanced Life Support (PALS). These failures had the potential for staff to be involved in the delivery of patient care without the necessary training and education required. (cross refer to C-0154)


Findings:

1. During a record review on 6/18/12 of the facility organ, tissue and eye procurement agreement and policies it was noted that there was no provision for a facility review of the organ, tissue and eye procurement program.

In an interview with QI/UR (Quality Improvement/Utilization Review) staff on 6/18/12 at 11:45 AM, she stated that data from the organ, tissue and eye procurement program is not reported in the quality meetings.

2. A review of the infection control plan on 4/19/12 showed that the following data was tracked by the previous infection control nurse: surgical site infections, central line infections, employee flu vaccine immunization and declination (refusal) rates, hospital acquired infections, SCIP (Surgical Care Improvement Project) data, multi drug resistant organisms, tuberculosis surveillance, prevention and control, and reportable diseases and conditions.

There was no evidence in the infection control plan that housekeeping was monitored for infection control practices such as cleaning patient rooms between patients, terminal cleaning of isolation rooms after a patient is discharged, and proper disinfectant use according to manufacturer's directions.

There was no evidence in the infection control plan that dietary staff was monitored for handwashing and gloving techniques for food handling, cool down procedures for leftover food and proper food storage.

There was no evidence in the infection control plan that operating room staff was observed for proper cleaning and sterilizing equipment according to manufacturer's instructions and no evidence that cleaning of the operating rooms was done correctly.

In an interview on 4/18/12 at 2:00 PM with ICRN (Infection Control Registered Nurse), she stated that there was no data from infection control regarding surveillance of facility infection control practices presented in the quality meetings.

3. A record review, of the employee file for RN 4, revealed that her date of hire was 8/11/08, to work in the OB & L & D Units. RN 4's employee file revealed no documented evidence that she received unit specific competencies and there were no annual evaluations in RN 4's employee file.

During an interview, with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RN 4 did not receive a unit specific competency.

4. A record review, of the employee file for RT 1, revealed that her date of hire was 12/20/07 and was hired to work in the Respiratory Department. RT 1's employee file revealed no documented evidence that she received unit specific competencies, there was no annual evaluation of RT 1 and her PALS certificate expired on January 2012.

During an interview and a concurrent record review of RT 1's employee file, with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RT 1 did not receive a unit specific competency. He confirmed that RT 1's PALS certificate expired on January 2012.

5. A record review, of the employee file for RT 2, revealed that her date of hire was November 2011 and she was hired to work in the Respiratory Department. RT 2's employee file revealed no documented evidence that she received unit specific competencies.

During an interview and a concurrent record review of RT 2's employee file, with the Human Resource Director, on 4/19/12, at 9:15 AM, he stated that RT 2 did not receive a unit specific competency. Additionally, he stated that none of the facility employees received unit specific competencies and that they only received the general ones that the facility provides upon hire to all of their staff.

6. During a review of Pharmacist (Pharm) 1's employee file with HR 2 on 4/19/12 it was noted that there was no competency evaluation for Pharm 1. There was no unit specific orientation documentation for Pharm 1.

In a concurrent interview with HR 2, she acknowledged that Pharm 1 did not have a competency evaluation or a unit specific orientation.

7. During a review of ICRN's employee file with HR 2 on 4/19/12 it was noted that there was no annual competency evaluation for ICRN.

In a concurrent interview with HR 2, she acknowledged that ICRN did not have an annual competency evaluation.

In an interview on 4/19/12 at 9:50 AM with the Director of HR, he stated that there was no policy for doing employee competencies. He stated that he "Doesn't have a feel for who is competent or who is not."

In an interview with the Director of Quality on 4/19/12 at approrximately 6:45 PM, he stated that the CNO had said in a meeting that the employee competencies were not being done correctly, but it had not been reviewed in quality meetings.



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8. During an interview with the FSM on 4/18/12 at 4:10 PM, she stated that she is working on a project to improve the standard of care and patient satisfaction of patients admitted with a diagnosis of diabetes. She stated that an interdisciplinary team has met a couple of times to address issues such as revising sliding scale insulin orders. She stated that her department has not collected data to measure, analyze, or track quality indicators and assess processes of care or operations. She stated that the dietary department does not report to the quality committee on any of the findings of deficient practice identified in this survey process.

A review of the hospital's most current Performance Improvement Plan dated 2008, revealed that the philosophy of the plan was to support the systematic organization-wide approach that was used to plan, design, measure, assess and improve organizational performance. The plan further stated that the hospital leaders adopted the "Plan, Do, Check and Act methodology for performance improvement, in which problems were identified, indicators were selected to be measured, data was collected and compiled, the data was analyzed and a plan of action for a solution was implemented and analyzed for effectiveness.

During an interview with the Director of Quality on 4/19/12 at 6:45 PM, he stated that the deficient practices identified in the dietary department during the survey had not been identified by the quality committee. He was unable to explain why the FSM did not conduct performance improvement studies. He verified that the FSM did not have an understanding of the hospital's Performance Improvement Plan and did not understand the culture of performance improvement concepts in general.

Without participating in the hospital's performance improvement plan, deficient practices in the dietary services department were allowed to continue and jeopardize the health and safety of the all the patients, staff and visitors who ate at the hospital.