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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 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 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 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.