HospitalInspections.org

Based on interview, and document review, the hospital failed to have a quality appraisal and performance improvement program that addressed the complexity and scope of Food and Dietetic Services resulting in failure to identify quality issues in the transcription of physician ordered diets.

Findings:

It was noted that during the survey from 8/8-8/11/11, for two of two patients reviewed (Patients 12 and 13) there was a delayed response by the physician to RD recommendations for nutrition interventions (Cross Reference A630). It was also noted that for these two patients there was no nursing care plan specific to each patients' clinical and nutritional status.


On 8/11/11 at 9 a.m., the quality appraisal and performance improvement (QAPI) activities for 6/19 through 5/11 were reviewed. In an interview on 8/11/11 at 9:50 a.m., with Administrative Staff H she was asked to describe the performance improvement activities related to dietetic services. Additionally, a hospital document titled, "Physician Responsiveness to Dietitian Recommendations" for 2/26-5/18/11 was reviewed. It was noted that during this timeframe there were 29 recommendations written. Of those, 22 were implemented which resulted in an overall compliance of 75%. In an interview on 8/11/11 at 9 a.m., with Administrative Staff D, and Administrative Staff G, they were unsure why there was a significant difference in the hospitals' data and the data obtained from the survey regarding the review of RD recommendations by the physicians. They also stated that during the past 30 days the compliance of physician review of RD recommendations was greater than 90%.

16932

Based on patient and staff interviews, and medical record and document review, the hospital failed to ensure that nursing dietary screening assessments were effective at identifying patients at nutritional risk for 2 of 2 patients reviewed, resulting in a delay in the evaluation by the RD of patient's at high risk for nutritional problems. Patients 5 and 13)

Findings:

1. During an interview on 8/8/11 at 1:30 p.m., Patient 5 was in bed with a dressing on the right knee. Patient 5 stated that she had surgery for a knee replacement done in February and had developed an infection in the knee after the surgery. She had been on antibiotics for a long time but the wound was not healing well. Additionally, since the surgery six months ago, she had lost 40 pounds.

Review of the medical record on 8/9/11 at 3:30 p.m., indicated that a nursing nutritional assessment of Patient 5 was completed on the day Patient 5 was admitted. The assessment included the following criteria: weight loss of greater than 15 pounds in three months, severely underweight, pressure ulcer present, older than 85 years having surgery, and, pregnant. The nurse documented that Patient 5 met none of the criteria and therefore, did not trigger for a dietary consult. There was no entry on the care plan for nutritional issues.

During interview on 8/9/11 at 4:00 p.m., Administrative Staff E and Administrative Staff G acknowledged that for a patient to have the best chance of prompt effective wound healing, adequate nutrition was very important. Both Admin E and G also acknowledged that Patient 5 had nutritional concerns that the screening assessment did not identify. Specifically, Patient 5 had a long standing surgical wound infection and had lost 40 pounds in 6 months.



17065

2. Patient 13 was admitted for a total hip replacement with a secondary diagnosis of diabetes. Admission diet order dated 8/4/11 was for a regular diet. Admission medication order dated 8/4/11 included Lantus insulin 40 units every morning. A nutrition risk screening dated 8/4/11 noted the patient was not at nutritional risk. Patient 13's dietary intake beginning on 8/5/11 was noted to be 0-15% for the first 4 days of admission with an average intake of 5% per meal. There was no indication that nursing staff contacted the RD, despite poor intake.

In an interview on 8/10/11 at 2:30 p.m., Administrative Staff E stated that nursing staff was instructed to contact the RD if a patient's meal intake was less than 50% for several meals.

Based on medical record review, and nursing staff interview, the hospital failed to ensure the development of an accurate nursing care plan that fully described measurable patient outcomes for identified problems for 2 of 2 patients reviewed for nutrition care. (Patients 12 and 13) Failure to develop comprehensive patient care plans may result in lack of ongoing assessment of potential and/or identified problems, compromising clinical status.

Findings:

1. Record review on 8/10/11 indicated that Patient 12 was admitted with diagnosis including a bladder infection, low blood calcium levels, diabetes and acute renal failure. Admission orders dated 8/6/11, was for an 1800 calorie diabetic diet, and a sliding scale insulin regimen. An admission nutrition screening dated 8/6/11, noted that the patient was experiencing weight loss. A comprehensive nutrition assessment dated 8/7/11, noted that Patient 12 lost 13 pounds during the previous 13 weeks.

The comprehensive nutrition assessment noted that the RD recommended the implementation of a nutritional supplement twice each day as well as suggested the addition of Levemir (a medication to facilitate better blood sugar control). At the time of the nutrition assessment the patient had a fair appetite, however, beginning on 8/8/11 staff failed to record dietary intake. Additionally, the average intake for 5 meals on 8/9/11 and 8/10/11 was 45%. Review of Patient 12's blood sugars from 8/6 to 8/10/11 revealed values ranging from 151-267 milligrams/deciliter. There was no indication the nursing staff notified the RD when Patient 12, who had a history of weight loss, demonstrated a change in nutritional intake status.

Review of Patient 12's nursing care plan dated 8/6/11, revealed that the goal was to ensure nutritional requirements were met with interventions to include an initial and follow up nutrition assessments, calorie count, and a nutrition teaching record. With the exception of the initial nutrition assessment none of the other interventions were implemented despite Patient 12's compromised dietary intake and reported history of weight loss.

In an interview on 8/10/11 at 10:45 a.m., Registered Dietitian K stated that the RD's documented recommendations on the assessment, however, they did not routinely document the plan on the patient care plan. In a concurrent interview Administrative Staff E stated that the care plans were part of the electronic medical record where specific interventions were prepopulated depending on the patient's assessment. RD K and AS E acknowledged that the care plan was not modified for Patient 12's specialized nutritional needs. It was also noted that despite an admission diagnosis that included diabetes and elevated blood sugar values, there was no diabetes care plan developed.

2. Patient 13 was admitted for a total hip replacement with a secondary diagnosis of diabetes. The admission diet order dated 8/4/11 was for a regular diet with nourishments per protocol. Admission medication orders dated 8/4/11, included Lantus insulin 40 units every morning. A nutrition risk screening dated 8/4/11 noted the patient was not at nutritional risk. Patient 13's dietary intake beginning on 8/5/11 was noted to be 0-15% for the first 4 days of admission with an average intake of 5% per meal. On 8/9/11 Patient 13 experienced a blood sugar of 91 milligrams/deciliter (mg/dl) which resulted in an order to give orange juice and recheck the patient's blood sugar every 15 minutes until it was greater than 100 mg/dl.

Review of Patient 13's nutritional care plan dated 8/4/11, noted that nutritional interventions were to include a nutrition assessment, calorie count, nutrition teaching as well as follow up nutrition assessments. With the exception of the nutrition assessments, there was no indication that the remaining interventions were accurate and/or implemented. Additionally, despite a secondary diagnosis of diabetes with documented episodes of low and high blood sugars, there was no diabetes care plan developed.

Based on observation, interview, and document review, the hospital failed to ensure that dietary services met the needs of all patients as evidenced by failure to:

1. Provide organized dietetic services as evidenced by development of service that did not meet current standards of practice (See A 620).

2. Ensure comprehensive disaster planning. (See A 701)

3. Develop performance improvement activities that accurately reflected the scope and nature
of the services. (See A 265)

4. Ensure safe and effective food storage/production practices. (See A 749)

5. Develop comprehensive organizational structure to ensure the nutritional needs of patients
were met. (See A 628, A 629, A 630, A 631)

6. Ensure maintenance of equipment per manufacturers' instructions. (See A 724)

7. Ensure the development of policies that ensured that patient diets were ordered only

by practitioners responsible for care of the patient (See A 619).




The cumulative effect of these systemic problems resulted in the inability of the hospitals food and nutrition services to direct and staff in such a manner to ensure that the nutritional needs of the patients were met in accordance with practitioners orders and acceptable standards of practice.

Based on interview and hospital document review, the hospital failed to ensure an organizational process that met the standard of practice as evidenced by: 1. Development of a policy that allowed registered dieticians(RD's), a non-licensed allied health professional, the discretion to change physician ordered diets; and 2. the development of guidance for hand sanitizer use that did not reflect the current standard of practice. Failure to ensure these organizational processes may put patients at risk for receiving diets not ordered by the physician which may further compromise their clinical status, and could expose patients to contaminated food due to lack of effective handwashing.

Findings:

1. During document review on 8/11/11 at 8:30 a.m.,, inconsistencies in the following policies were noted:

a. Hospital policy dated 8/10 and titled, "Diet Orders, Interpreting Non-Specific" indicated that, "The Dietitian may opt to establish a caloric requirement into the diet Rx (therapy)..." Implementation of this policy would change the physician ordered diet. While the RD may make recommendations to the licensed practitioner responsible for the care of the patient, RD's are not authorized to change physician ordered diets.

2. Review on 8/11/11 at 8:30 a.m., of hospital policy updated 11/30/10 titled, "Sanitation Regulation" indicated that sanitizing gel application may be substituted for re-washing of hands if the hands have no food or other visible particles on them. The policy also indicated examples such as handling money, opening locker, picking up a contaminated item, and wiping hands on an apron. It was also noted that the summary guidance was based on the California Retail Food Code and the USDA Food Code. The acceptable standard of practice for the use of hand antiseptics would be to apply only to hands that have been cleaned as specified by ? 2-301.12 of the USDA Food Code. It would also be the standard of practice to wash hands after handling soiled equipment and utensils (Food Code, 2009).

In an interview on 8/11/11 at 9 a.m., with Administrative Staff E she stated that within the past month there was a change in dietary management staff and was unsure whether or not policies were reviewed to ensure they met the standards of practice.

Based on food storage observations, dietary staff interview, and dietary document review, the hospital failed to ensure foods were stored per manufacturers guidance as evidenced by: 1. Foods stored at higher temperatures than manufacturer's recommendations, 2. Development of a policy without consideration for manufacturer's product guidance, and 3. Chemicals mixed, stored, and tested that did not follow manufacturer's guidance. Failure to follow manufacturer's guidance may result in bacterial growth associated with foodborne illness, further compromising the clinical status of patients.

Findings:

Main Hospital Campus

1. During the initial tour on 8/8/11 at 1:20 p.m., in the walk-in refrigerator there were packages of sliced ham and roast beef as well as a 5 pound container of cottage cheese. The internal probed temperatures of the items were both 43?F. On the side of the box the manufacturer's recommendation for storage temperatures for the roast beef was 28-34?F and for the turkey it was 28-36?F.

In a concurrent interview, Dietary Management Staff Z stated that she was aware that safe food handling practices would be to store foods under 41?F but was unaware that manufacturers may have more stringent recommendations. In an interview on 8/9/11 at 11:30 a.m., Dietary Staff L stated that she recorded the refrigerator temperature at approximately 4:30 a.m., after the unit was closed during the night. Similarly a second temperature was recorded shortly before staff left for the night after the unit would have been closed for several hours. While these temperatures may reflect the ambient air temperature, they were not reflective of actual food temperatures.

2. During the initial tour on 8/8/11 at 1:20 p.m., the walk-in refrigerator contained items such as garlic, ginger, cheese and cottage cheese that were opened, with no open dates. Each was labeled with use by dates ranging from 8/12- 9/5/11. In a concurrent interview Dietary Staff CC was asked to describe how staff determined the "use by" date. She stated that the previous food services manager developed a use by date system. Concurrent review of the hospital policy document, dated 7/20/11 and titled, "Last Good Date System" indicated that foods which were removed from a can, the freezer, prepared on site may be held for up to 6 days. This guidance included meats, vegetables, custards, house made salads such as potato, macaroni, or egg. The facility policy guided that all frozen items could be held for 1 year whether they were opened or unopened.

In a follow up interview on 8/10/11 at 9 a.m., Administrative Staff D stated she was told that the source document for the Last Good Date System was the United States Agriculture Department Food Code, 2009. The U. S. Food and Drug Administration (FDA) publishes the Food Code, a model that assists food control jurisdictions at all levels of government by providing them with a scientifically sound technical and legal basis for regulating the food service segment of the industry within institutions such as hospitals (Food Code, 2009). The Food Code provides general guidance for food safety; however does not provide holding times for specific food items.

General Campus

3. During general food storage observations on 8/9/11 at 2:30 p.m., it was noted that the hospital was storing quaternary ammonia sanitizer in the dry food storage area. It was also noted that the quaternary ammonia appeared to be stored in a clear 1-gallon water bottle. In a concurrent interview with Dietary Supervisor CC she stated that the sanitizer solution was delivered from the main hospital to the campus once or twice a week depending on usage. The surveyor asked Dietary Supervisor CC how hospital staff ensured the effectiveness of the sanitizer. She stated that there was no mechanism in place to test sanitizer effectiveness once it left the hospital since there were no test strips. On 8/9/11 at 2:45 p.m., Dietary Supervisor CC obtained test strips from the main hospital; it was noted that there was no chemical reaction. As a comparison the surveyor saturated the chemical test strip with plain water obtained from the cafeteria sink. It was noted there was no discernable difference between the strip that was immersed in the sanitizer and that immersed in water.

In an interview on 8/10/11 at 10:30 a.m., Vendor BB stated that the manufacturer recommended that sanitizer mixed by the hospital be tested on a daily basis. He also stated that the manufacturer would not recommend storing premixed sanitizer in a clear gallon plastic container.

Based on trayline observations, dietary staff interview, and dietary document review, the hospital failed to ensure that menus met the nutritional needs of inpatients as evidenced by lack of: 1. Nutritional analysis of the alternate food items offered to patients, and 2. Lack of a pediatric menu. Failure to develop comprehensive nutritional analysis and/or menus may result in unmet nutritional needs.

Findings:

1. During trayline on 8/8/11 at 4:45 p.m., Patient 16 had a consistent carbohydrate diet. Dietary staff plated a burrito containing beans and rice, soup, pudding, and a nutritional supplement all of which contained carbohydrates. The patient selected the burrito instead of the main entree of roast beef. During hospital document review on 8/9/11 at 9:30 a.m., RD M was asked to describe how the hospital determined the nutritional analysis of the menus. She stated that the hospital had contracted with a vendor to perform a nutritional analysis of the non-select menu items and that the menu analysis did not include the alternate items that patients may select. She acknowledged that it may be difficult to consistently follow physician ordered diets without a complete nutrient analysis of all menu items.

2. During menu review on 8/10/11 at 4 p.m., the surveyor asked RD M to provide the hospital's pediatric menu. She stated that while the hospital admitted pediatric patients, there was no specified pediatric menu that was appropriate to the various age groups. She stated that dietary staff would give pediatric patients a regular menu and adjust the portion sizes. They also would offer pediatric patients items such as hamburgers if they requested it. RD M acknowledged that without a specified menu it would not be possible to develop a nutrient analysis to ensure that the nutritional needs of pediatric patients would be met.

Based on trayline observations, dietary staff interview, and dietary document review, the hospital failed to ensure that 4 patient diets (Patients 12, 14, 15, and 17) were ordered by the physician responsible for the care of the patient. Modifying physician ordered diets may compromise the clinical status of patients.

Findings:

1. Patient 12 was admitted with diagnosis including a bladder infection, low blood calcium levels and acute renal failure. Admission diet order dated 8/6/11 was an 1800 calorie diabetic diet. During a dining observation on 8/10/11 beginning at 12:15 p.m., with Patient 12 it was noted that her physician ordered diet was a consistent carbohydrate diet.

In an interview on 8/11/11 at 9:30 a.m., RD M stated that an 1800 calorie diet would be interpreted as a consistent carbohydrate diet. Review of an undated hospital document titled, "Diet Order Change for Patients with Diabetes" revealed that if a physician ordered an 1800 calorie diet the calorie value of the carbohydrate controlled diet could range 1600-2000 calories.

Review of Patient 12's blood sugars from 8/6 to 8/10/11 revealed values ranging from 151-267 milligrams/deciliter.

For non-critically ill patients, there is no clear evidence for specific blood glucose goals; however, data suggest that outcomes are better in hospitalized patients with fasting glucose <126 mg/dl and all random glucoses <180-200 (Standards of Medical Care In Diabetes, 2009).

2. Patient 17 was admitted with diagnosis including chest pain. Admission diet order dated 8/10/11 was NPO (nothing my mouth). Additional progressions of diets were as follows: 8/3/11 Clear liquid, 2000 calorie ADA diet; 8/4/11 Advance diet as tolerated to regular, 2 gram potassium restriction; 8/4/11 2000 calorie ADA, 2 gram potassium restriction, and the final order on 8/6/11 was an 1800 calorie ADA diet.

Review of the hospital document titled, "Current Diets" dated 8/8/11, revealed that instead of the physician ordered 1800 calorie diet the patient received a diet with 2 gram potassium and 2 gram sodium restrictions.

b. Patient 14 was admitted with diagnosis including sepsis and cellulitis. The admission diet order dated 8/10/11 was for an 1800 calorie diet. A subsequent diet order dated 8/2/11 was for a cardiac diet, and on 8/8 the order was changed to a standard carbohydrate control 1800 calorie diet.

Review of the hospital document titled, "Current Diets" dated 8/8/11 revealed that instead of the physician ordered diet the patient received an 1800 calorie cardiac diet, a more restrictive diet than was ordered by the physician.

c. Patient 15 was admitted with diagnosis including acute congestive heart failure. The admission diet orders dated 8/2/11 was for a 1600 calorie ADA diet. Subsequent orders were as follows: 8/4/11 low phosphorus, 1600 calorie diet; 8/7/11 2 grams, standard carbohydrate controlled diet.

Review of the hospital document titled. "Current Diets" dated 8/8/11, revealed that instead of the physician ordered diet the patient received a 2 gram sodium, 1600 calorie diet. Review of the undated hospital document titled, "Diet Order Change for Patients with Diabetes" revealed that the calorie value of the carbohydrate controlled diet could range from 1600-2000 calories.

In an interview on 8/11/11 at 9:50 a.m., Administrative Staff H was asked to describe the performance improvement activities related to dietetic services. She stated that currently monitoring was being done on cool down temperatures, dish machine temperatures, and food temperatures in the cafe and patient trayline. She stated that diet entry accuracy had not been identified as a problem and that there were no performance improvement activities related to diet accuracy.

Based on medical record review, administrative and dietary staff interview, and dietary document review, the hospital failed to ensure the nutritional needs of 2 of 2 patients (Patients 12 and 13) reviewed for nutritional care by failing to provide timely follow up for nutrition interventions. Failure to develop systems for timely nutritional intervention may compromise the nutritional and clinical status of patients.

Findings:

1. Record review on 8/10/11 indicated that Patient 12 was admitted with diagnosis including a bladder infection, low blood calcium levels and acute renal failure. Admission diet order dated 8/6/11 was an 1800 calorie diabetic diet. An admission nutrition screening dated 8/6/11 noted that the patient was experiencing weight loss. A comprehensive nutrition assessment dated 8/7/11 noted that the patient's admission height was 5 feet 5 inches and weight was 130 pounds. Patient 12 also reported that she had lost 13 pounds during the previous 13 weeks.

The comprehensive nutrition assessment noted that the RD recommended the implementation of a nutritional supplement twice each day as well as suggested the addition of Levemir a medication to facilitate better blood sugar control. As of 8/10/11 there was no indication that the physician reviewed the RD's recommendations. It was also noted that while the patient had a fair appetite at the time of the RD assessment (8/7/11) on 8/8/11 nursing staff failed to record dietary intake. Additionally the average intake for 5 meals on 8/9 and 8/10 was 45%. There was no indication the nursing staff notified the RD when Patient 12, who had a history of weight loss, demonstrated a change in nutritional status.

In an interview on 8/10/11 at 11:30 a.m., RD K was asked to describe the process for follow up on RD recommendations. She stated that the policy was to wait 48 hours before following up on the status of recommendations. In an interview on 8/10/11 with Administrative Staff D she stated that the average length of stay was 4 days. Delays in follow up for nutritional intervention may result in patients being discharged prior to follow up. In a concurrent interview with Administrative Staff E she stated that the RD could advise nursing staff of patient recommendations which could have facilitated physician notification.

2. Record review on 8/10/11 indicated that Patient 13 was admitted for a total hip replacement with a secondary diagnosis of diabetes. Admission diet order dated 8/4/11 was for a regular diet with nourishments per protocol. Admission medication order dated 8/4/11 included Lantus insulin 40 units every morning. A nutrition risk screening dated 8/4/11 noted the patient was not at nutritional risk. Patient 13's dietary intake beginning on 8/5/11 was noted to be 0-15% for the first 4 days of admission with an average intake of 5% per meal.

In a comprehensive nutrition assessment dated 8/5/11, the RD noted that the patient had decreased appetite, difficulty chewing, increased post-surgical nutritional needs and decreased intake. The RD recommended the diet be changed to a mechanical soft, low consistent carbohydrate diet with the addition of a nutritional supplement with all meals, and the addition of a multi-vitamin/mineral supplement. These recommendations were documented on the undated form titled, "Registered Dietitians Recommendation Orders." The physician reviewed the form on 8/8/11 (3 days later).

In an interview on 8/10/11 at 11:30 a.m., RD K was asked to describe the process for follow up on RD recommendations. She stated that the policy was to wait 48 hours before following up on the status of recommendations. In an interview on 8/10/11 with Administrative Staff D she stated that the average length of stay was 4 days. Delays in follow up for nutritional intervention may result in patients being discharged prior to follow up. In a concurrent interview with Administrative Staff E she stated that the RD could advise nursing staff of patient recommendations which could have facilitated physician notification.

While the hospital had a policy that the RD would follow up within 48 hours of recommendations, but it was noted that the policy was not implemented. Despite early identification of a nutritional problem, the implementation of the policy would not allow for timely nutrition interventions as patients may not receive the intervention for up to 3 days after the identification of a problem.

Based on trayline observations, dietary staff interview, and dietary document review, the hospital failed to have a diet manual that defined and accurately reflected the most common physician ordered diets. Lack of a comprehensive diet manual that reflected physician ordered diets may result in inaccurate guidance to dietary and hospital staff when meeting the nutritional needs of patients as well as less than optimal provision of nutrition for hospitalized patients.

Findings:

During trayline observation on 8/8/11 at 4:45 p.m., Patient 13 had a low consistent carbohydrate diet and Patient 16 had a consistent carbohydrate diet. Both received the same meal. Similarly Patient 18 who had a physician ordered dysphasia II diet, and Patient 19 with a physician ordered mechanical soft diet, both received whole slices of pot roast. In an interview on 8/9/11 beginning at 9:30 a.m., with RD M she stated that the hospital utilized the American Dietetic Association Nutrition Care Manual as the diet manual. The surveyor asked RD M to locate descriptions of the above named diets that included guidance for nursing, physicians and dietary staff specific to the hospital's menu. She acknowledged that the information in the nutrition care manual provided general guidelines for therapeutic diets, however, the manual did not offer diet patterns for the diets commonly ordered by the physician at the facility.

It was noted that while the nutrition care manual had sections on each of these diets, the information in the manual was not specific to the hospital's routinely ordered diets and menu. The section of the manual titled, "Carbohydrate Control Diet" was a conceptual description of the diet. The manual did not delineate the low, standard, and high consistent carbohydrate that the hospital offered. Similarly, the nutrition care manual did not have a mechanical soft diet, but was limited to a diet that might be used after esophageal surgery. The surveyor also asked RD M to describe why patients with mechanical soft diets received mashed potatoes and full slices of meat. She acknowledged that the nutrition care manual did not provide this level of guidance.

Based on dietary and administrative staff interview, the hospital failed to ensure adequate potable water supplies and comprehensive dietary staff training to be utilized in the event of a disaster.

Findings:

On 8/9/11 beginning at 2:30 p.m., disaster preparedness was reviewed at the General Campus. It was noted that while the hospital had a supply and menu of food items, there were no tube feeding supplements on the campus. It was also noted that while the hospital purchased four 55-gallon drums for water storage, the drums were stored empty in the original shipping box. In a concurrent interview with Administrative Staff D she stated that there was an external water storage tank; however was unsure of its location. After attempting to locate the storage tank AS D stated that there was no tank. In a concurrent interview with DS CC and DS L they stated that they had not received training for implementation of a disaster menu.

Based on contracted and hospital staff interview and hospital document review, the hospital failed to 1) ensure the preventative maintenance for the ice machines was performed per manufacturers' guidance and 2) ensure the maintenance of one cafeteria salad bar to ensure safe food holding temperatures were maintained. Failure to maintain hospital equipment may result in foodborne illness as a result of compromised food safety and effectiveness of the equipment.

Findings:

1. On 8/9/11 at 9 a.m., maintenance of the hospitals' ice machines was reviewed. In a concurrent interview with Engineering Staff, he stated that the preventive maintenance was contracted out. In an interview on 8/9/11 at 11 a.m., with Vendor DD he was asked to describe the preventive maintenance (PM). He stated that every 3-6 months he would perform the PM based on the documents he was given by the hospital. He stated that for the interior cleaning process he would use nu-calgon? nickel safe as the ice machine cleaner and would be followed by the nu-calgon? IMS-2 sanitizer. He further stated that he supplied the chemicals and would use the same chemicals on all of the machines. Review of the manufacturers' specifications for the ice machine cleaner revealed that the active chemical was citric/phosphoric acid. Similarly the sanitizing solution was a 200 parts/million (ppm) of quaternary ammonia.

Review of hospital document titled "Equipment Last Test Dates Report" dated 6/1/11 revealed that the hospital had 3 different brands of ice machines. It was also noted that while some of the manufacturers' recommended the use of phosphoric/citric acids and quaternary ammonia; not all of the manufacturers; recommended this combination. While the hospital was performing routine maintenance, the chemicals used were not consistently per the manufacturers' recommendations.

2. On 8/10/11 beginning at 4:30 p.m., food storage practices in the cafeteria was reviewed. It was noted that in the salad bar there were items that were stored in the food danger zone. The food danger zone is defined as temperatures between 41-135?F, temperatures that may support the growth of bacteria associated with foodborne illness (Food Code, 2009). There were hard boiled eggs with an internal temperature of 52?F, chicken pasta salad with a temperature of 45?F and potato salad with a temperature of 47?F. In a concurrent interview with DS J she stated that she put out these items approximately 30 minutes prior. She also stated that temperatures were taken at 3 p.m.. Review of the hospital document titled "Cafe Food Temps Record Sheet" for 8/10/11 noted that the temperature of these items was recorded as below 41?F. In a concurrent interview with DS CC she stated that they were instructed to put ice in the cooling unit. The hospital was unable to demonstrate that the use of ice in place of cold air circulation for this unit was acceptable per manufacturers' guidance.

Based on interview, and document review, the hospital failed to implement policies and procedures designed to reduce the risk of spreading infections and communicable diseases by failing to ensure that: 1. All healthcare workers (HCW), were screened annually for tuberculosis (TB), and 2. One of one patients was screened for methicillin resistant staphylococcus aureus ( MRSA), as directed in their policy and procedure. (Patient 3)

Findings:

1. On 8/8/11 at 3 p.m., a tour was conducted of the women's services department. During the tour, Allied Health Professional J was observed seeing patients on the nursing unit and interacting with hospital staff.

On 8/9/11 at 1 p.m., a request was made for a list of physicians and allied health professionals (Nurse Midwife, Nurse Practitioner, and Physician Assistant), who were delinquent with their annual screening.

On 8/9/11 at 2:30 p.m., the list of physicians and allied health professionals who were delinquent with their annual TB screening was provided. A review of the delinquent TB list revealed that Allied Health Professional J's, TB screening was due 3/9/11. It was noted that 15 additional physicians and allied health professionals were also listed as being delinquent with their TB screenings, dating from 11/16/10 to 6/30/11.

During an interview on 8/9/11 at 3 p.m., Medical Staff B stated that due to changes in the medical staff office personnel, the hospital had dropped the ball by failing to ensure that all physicians and allied health professionals were screened annually for TB.

According to the Communicable Disease Center (CDC) Guidelines for Preventing the Transmission of Mycobacterium (M), tuberculosis (In Health-Care Setting, 2005, page 10, "the classification of medium risk should be applied to settings in which the risk assessment has determined that HCW will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. tuberculosis. The recommendations for medium risk included, "All HCWs should receive baseline TB screening (checked to identify presence of the disease) upon hire, using two-step TST (TB skin test) or a single BAMT (alternate test), to test for infection," and "After baseline testing for infection, HCWs should receive TB screening annually."

2. On 8/8/11 at 3 p.m., Patient 3's medical record was reviewed. Documentation in the medical record disclosed that the patient was admitted to the hospital on 8/4/11 with a diagnosis of clotted dialysis catheter and end stage renal disease (ESRD).

Documentation in the medical record also disclosed that Patient 3 was to be screened for MRSA within 24 hours of admission.

A review of the laboratory section of the medical record (electronic and printed), contained no evidence that Patient 3 was screened for MRSA within 24 hours of admission.

During a concurrent interview, Administrative Staff I confirmed that Patient 3 wasn't screened for MRSA within 24 hours of admission.

On 8/8/11 at 4 p.m., the hospital's policy and procedure dated, 4/11, titled, "Methicillin Resistant Staphylococcus Aureus (MRSA) Management" was reviewed. On page 6 of the policy and procedure, hospital staff were directed that, "The following patients will have a MRSA screen of the nares done within 24 hours of admission... All inpatients that receive dialysis..."



15347

Based on dietetic services observations, dietary staff interview and dietary document review, the hospital failed to ensure effective foodservice practices as evidenced by 1) inadequate sanitizer strength at the manual pot and pan washing sink and 2) storage of chemicals in food storage areas.

Findings:

St Joseph Campus

1) On 8/8/11 beginning at 3:25 p.m., the manual dishwashing process was observed. The surveyor asked DS AA to describe the process. He proceeded to demonstrate the wash, rinse and sanitize step. DS AA also demonstrated testing the strength of the sanitizer. It was noted that the sanitizer was less than the manufacturers' requirement of 200 parts/million (ppm). DS AA further explained that he filled the sink with sanitizer at 3 pm, and that it would be changed out every 45-60 minutes while dishes were actively being washed. It was noted that the strength of the sanitizer was below manufacturers' recommendations 30 minutes after being changed. Concurrent review of the sanitizer log for August 2011 confirmed that at 3 p.m., the sanitizer level was recorded as 300.

In an interview on 8/9/11 beginning at 11:30 a.m., with Vendor BB he stated that the hospital had two different types of quaternary ammonia sanitizer. He stated that the quaternary product in the pot and pan sink had specific temperature parameters; the sanitizer was most effective when mixed with water at 75?F. He further stated that if the water was significantly colder or warmer the sanitizer would not be as effective. He also stated that the test strips would be different depending on which version of quaternary ammonia sanitizer was utilized.

Review on 8/11/11 at 12 p.m., of the hospitals ' training records revealed that while staff received training on the correct procedure for testing sanitizer there was no indication that the temperature limitations or use of the correct strips were included in the in-service.

General Campus

2) During general food storage observations on 8/9/11 at 2:30 p.m., it was noted that the hospital was storing quaternary ammonia sanitizer in the dry food storage area. It was also noted that the quaternary ammonia appeared to be stored in a clear 1-gallon water bottle. In a concurrent interview with Dietary Supervisor CC she stated that the sanitizer solution was delivered from the main hospital to the campus once or twice a week depending on usage and that they thought that putting the chemicals on a shelf would be acceptable. The surveyor asked Dietary Supervisor CC how hospital staff ensured the effectiveness of the sanitizer. She stated that there was no mechanism in place to test sanitizer effectiveness once it left the hospital since there were no test strips. On 8/9/11 at 2:45 p.m., Dietary Supervisor CC obtained test strips from the main hospital; it was noted that there was no chemical reaction. As a comparison the surveyor saturated the chemical test strip with plain water obtained from the cafeteria sink. It was noted there was no discernable difference between the strip that was immersed in the sanitizer and that immersed in water.

In an interview on 8/10/11 at 10:30 a.m., Vendor BB stated that the manufacturer recommended that sanitizer mixed by the hospital be tested on a daily basis. He also stated that the manufacturer would not recommend storing premixed sanitizer in a clear gallon plastic container. The standard of practice would be to ensure that foods are stored separately from all chemicals (Food Code, 2009).