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Based on medical record review and document review, in 5 out of 14 patient records surveyed, the hospital failed to ensure that an appropriate medical history and physical examination (H&P) was completed within 30 days prior to surgery.

Findings:

See A 0952

395

Findings:

Patient 11 was admitted with diagnosis including alteration in mentation, chronic renal failure and possible congestive heart failure. A comprehensive admission assessment dated 9/3/12 noted that the patient had difficult chewing; however there were no nutrition risk triggers.

Nursing shift assessment dated 9/3/12 and timed 22:53 noted that Patient 11 had hypoactive bowel sounds in all quadrants. Decreased bowel sounds would be expected during sleep or with the implementation of certain medications, decreased or absent bowel sounds often indicate constipation (Rosen's Emergency Medicine: Concepts and Clinical Practice, 7th edition, 2009). Nursing shift assessments beginning 9/4 - 9/9/2012 continued to document hypoactive bowel sounds. It was also noted that on 9/5 and on 9/8/12 the patient complained of constipation. Additional review of nursing summaries beginning on 9/3/12 through 9/9/12 failed to note any bowel movements.

Review of Patient 11's medication administration record revealed that on 9/6/12 the physician ordered milk of magnesia (a suspension of magnesium hydroxide) used as a laxative. While there was an order for the milk of magnesia every evening as needed, the medication administration record from 9/6-9/7/12 failed to note completion of the physicians' order. There were no additional interventions until 9/8/12 at 19:28 at which point the physician ordered 10 mg of bisacodyl suppository and sennoside 2 tablets twice/day as needed, both medications intended to relieve constipation. While nursing staff was consistently documenting the hypoactive bowel sounds there was no indication that staff acted upon the abnormal finding nor notified the physician in a timely manner.

In an interview on 9/11/12 at 4 pm, with Administrative Staff 5 she stated that it would be the responsibility of nursing staff to effectively evaluate patients gastrointestinal system each shift and to chart when the assessment fell outside normal parameters. She also stated that the amount of time that elapsed between interventions intended to relive the constipation were too long. Administrative Staff 5 also stated that the hospital did not have a specific bowel care protocol rather relied on the patient assessment policy. Hospital policy titled "Plan for Assessment and Care of the Patient" dated 4/08 noted that the purpose of the assessment "outline the process and mechanism ...assess and provides for the individual healthcare..of the patient ..."

Based on medical record review and document review, in 4 out of 14 patient records surveyed, the hospital failed to enforce its policies and rules intended to ensure that all medical record entries are legible and authenticated.

Findings:

On 9/11/12 at 10 am, review of the records of Patients 104, 112, and 113 demonstrated that the preoperative history and physical examination entries were illegible. The postoperative note in Patient 104's record was also illegible. In interview with Staff K on 9/11/12 at 11 am, it was confirmed that the entries were illegible.

On 9/11/12 at 2 pm, review of Patient 111's record demonstrated that the postoperative orders were not signed.

Document review of the hospital medical staff rules and regulations dated 1/10 on 9/12/12 demonstrated the requirement that all entries in the patient's medical record shall be legible, accurate, dated, timed, and signed by the responsible practitioner.

Review of hospital policy "Handwriting" dated 6/08 on 9/12/12 at 11:30 am demonstrated that requirement that individuals with chronically poor and difficult to interpret handwriting are encouraged to improve their writing.

628

Based on dietary staff interview and dietary document review the hospital failed to ensure the nutritional needs and/or the physician ordered diets were implemented per physicians' orders and standards of practice as evidenced by 1) the lack of a comprehensive nutritional analysis of patient menus and 2) the lack of nutritional analysis for the hospitals' vegetarian and pediatric menus. Failure to complete a nutritional analysis of the menu may result in unmet patient nutritional needs further compromising the medical status of inpatients.

Findings:

1a. The Dietary Reference Index (DRI) published by the National Academy of Sciences, Institute of Medicine (NAC/IOM) is intended as a reference guide to health professionals in the daily planning of nutritional needs of groups and individuals. The DRI is comprised of macronutrients such as calories, protein, fat, carbohydrates, cholesterol and fiber as well as greater than 30 micronutrients (vitamins and minerals-NAC/IOM, 2005).

On 9/11/12 beginning at 9 am, the hospitals' menu and accompanying nutritional analysis was reviewed with Dietary Management Staff (DMS). It was noted that while the hospital developed an analysis of some of the macronutrients, the analysis did not include all micronutrients. The analysis did not include Vitamins D or E, pantothenic acid, choline, copper, manganese, selenium and zinc. It was also noted that the Vitamin B-1 content of the diets with the exception of the renal was listed as 119 milligrams per day. The recommended dietary intake recommended by the Food and Nutrition Board ranged from 0.2 - 1.4 mg/day. The listed content of the menu was 100 times the recommended intake. There was no indication that the facility fully reviewed the menus to ensure accuracy.

In an interview on 9/12/12 beginning at 10 am, with Administrative Staff 4 she stated that the contracted foodservice vendor developed a subcontract with for the completion of a nutritional analysis of the hospitals' menus and diets. She also stated that she was assured by the contractor as well as hospital staff that the analysis was complete.

Review of the contracted vendors' "Management Agreement" dated 12/4/11 revealed that the vendor agreed to "comply with all applicable laws ..." Review of the hospital document titled "Consultant Agreement" dated 12/1/11 confirmed that the contracted vendor established a subcontract with a Registered Dietitian as a "consultant to support the Food and Nutrition Services" there were no defined scope of the subcontract.

b. Review of the document titled "St Joseph Hospital Eureka Patient Menu Nutrition Information" dated 9/12/12 revealed that the menus were a list of all the foods being served across multiple diets on any particular day. In particular the pediatric diet did not have an associated non-select menu that ensured the nutritional needs of age specific pediatric patients were met. Similarly the carbohydrate consistent diet was presented as a compilation of all three meals rather than each meal individually for the full week. The standard of practice in diabetes meal planning, utilizing a carbohydrate consistent diet, would be to ensure that the carbohydrate content would be comparable from day to day at breakfast, each day at lunch and each day at dinner as well as snacks (Diabetes Care, January 2004). Development of a consistent carbohydrate analysis that was limited to the compilation of carbohydrates within a 24 hour period would not ensure that the current standard of practice, which was adopted by the hospital, was consistently implemented.

*c. During trayline on 9/10/12 from 5-5:30 pm, it was noted that there were three patients with physician ordered vegetarian diets. In an interview on 9/12/12 at 10 am, with Dietary Management Staff she stated that if patients had a physician ordered vegetarian diet the patient would select the vegetarian entrees that were part of the menu. She also stated that there was no nutritional analysis for a non-select vegetarian menu and acknowledged that without an analysis it would not be possible to ensure that patient nutritional needs were met.

629

Based on medical record review, dietary staff interview and dietary document review the hospital failed to ensure nutritional supplements, implemented by the Registered Dietitian, were ordered by the physician.

Findings:

Patient 10 was admitted to the hospital with a diagnosis of a non-healing cervical fracture. Medical record review was conducted on 9/11/12 beginning at 10 am. Physician ordered diet dated 9/4/12 was for a consistent carbohydrate diet. A comprehensive nutrition assessment dated 9/4/12, completed by the Registered Dietitian (RD), noted that the patient had poor dietary intake for the greater than 5 days. It was also noted that the patient had difficulty swallowing and was in the process of being evaluated by speech therapy. The RD assessment also recommended the addition of a protein shake, twice each day.

In a concurrent interview with RD 1 she stated that the hospital developed a listing of standard shake recipes. RD 1 also stated that as an RD she would select the shake that was most consistent with the patients' medical condition. As an example she may choose the carnation instant breakfast shake made with diet shake mix for a patient with diabetes. Concurrent review of the document titled "SJH Standard Shake Recipes" dated 12/1/11 revealed that there were 11 shake selections. It was noted that some of the shakes had the addition of protein powder. Additionally four of the other shake recipes contained ingredients that were described by the manufacturer as therapeutic nutrition drinks or were supplements whose primary ingredient were amino acids. The RD also stated that she would not obtain a physicians' order for these supplements.

Based on medical record review, dietary staff interview and dietary document review the hospital failed to ensure the diet manual fully reflected the medical nutrition therapy implemented by the hospitals' Registered Dietitians.

Findings:

Patient 10 was admitted to the hospital with a diagnosis of a non-healing cervical fracture. Medical record review was conducted on 9/11/12 beginning at 10 am. Physician ordered diet dated 9/4/12 was for a consistent carbohydrate diet. A comprehensive nutrition assessment dated 9/4/12, completed by the Registered Dietitian (RD), noted that the patient had poor dietary intake for the greater than 5 days. It was also noted that the patient had difficulty swallowing and was in the process of being evaluated by speech therapy. The RD assessment also recommended the addition of a protein shake, twice each day.

In a concurrent interview with RD 1 she stated that the hospital developed a listing of standard shake recipes. RD 1 also stated that as an RD she would select the shake that was most consistent with the patients' medical condition. As an example she may choose the carnation instant breakfast shake made with diet shake mix for a patient with diabetes. Concurrent review of the document titled "SJH Standard Shake Recipes" dated 12/1/11 revealed that there were 11 shake selections. It was noted that while some were made solely from food ingredients such as ice cream, milk, fruits and yogurt other recipes included the addition of protein powder, therapeutic nutrition drinks or the addition of amino acids. The RD also stated that she would not obtain a physicians' order for these supplements.

Review of the hospitals' diet manual dated 6/2012 failed to include a mechanism or parameters for the addition of these shakes to patient meal trays.

Based on observation, interview, and medical record reviews the facility failed to provide an environment to avoid sources and transmission of infections and communicable disease as evidenced by the hospital's failure to have effective systems in place to ensure: 1. Hinged surgical instruments were effectively sterilized; 2. Endoscopes were cleaned in a manner to prevent cross-contamination; 3. Participating Physicians were screened for vaccine preventable diseases; 4. Monitoring of food temperatures prior to serving to ensure safe food handling practices with the potential for the spread of infections and foodborne illnesses to patients.

Findings:

1. During the initial tour of the hospital's sterile processing department area on 9/12/12 at 9:15 a.m., multiple pairs of hinged instruments of various types, (e.g. mayo scissors), were in the closed position in sealed peel pouches (Peel pouches are flexible packaging materials that combine a paper or synthetic barrier material and a transparent plastic film).

During an interview on 9/12/12 at 9:15 a.m., Staff Q was shown the instruments with blades closed in the peel pouches and he stated the blades should've been processed in the open position. Staff Q acknowledged he could not ensure the instruments were sterilized unless the blades were open. Staff Q indicated the hinged instruments would need to be inspected and reprocessed if found in the closed position.

During an initial tour of the hospital's perioperative sterile supply room on 9/12/12 at 4:40 p.m. with Staff R, multiple pairs of hinged instruments of various types, (e.g. mayo scissors) ,were in the closed position in sealed peel pouches. In a concurrent interview, Staff R acknowledged the presence of the hinged instruments in the closed position and stated, " However, about 50% to 75% of the hinged instruments in the supply room were in the open position."

The 2012 Perioperative Standards and Recommended Practices published by AORN were reviewed. Direction was given that, "Cleaned surgical instruments should be organized for packaging in a manner to allow the sterilant to contact all exposed surfaces and instruments with hinges should be opened..."

Failure of the hospital to sterilize hinged instruments in accordance with nationally accepted infection control guidelines placed surgical patients at risk for exposure to serious life-threatening infectious agents.

2. During a tour of the hospital's endoscopy area decontamination room on 9/11/12 at 10:40 a.m. a technician was observed cleaning an endoscope in a sink immediately adjacent to a counter where two automatic endoscope reprocessors (AERs) were located. The top lids of the AERs were fully open and water from the sink where the tech was cleaning used endoscopes was observed splashing into the AER nearest the sink. The AER nearest the sink was observed to contain a black hair, and the second AER had yellow/green with small brown particle stains on the right rim of its internal surface.

During an interview on 9/11/12 at 10:45 a.m. Staff S acknowledged the hair and stains in the respective AERS. Staff S indicated she was not aware they were using the sink for the purpose of cleaning the used endoscopes. Staff S acknowledged the potential of cross contamination to the AERs from the results of the cleaning activities (water and by-products) performed in the sink located immediately adjacent to the AERS.

The 2012 Association of Perioperative Registered Nurses (AORN) guidelines on ...." Flexible endoscopes should be decontaminated in an area physically separated from locations where clean items are handled and .... Physical separation of decontamination areas from areas where clean items are handled minimizes the risk of cross-contamination. Cross-contamination can result when soiled items are placed in close proximity to clean items or placed on surfaces upon which clean items are later placed. Aerosols created during cleaning can also cause cross-contamination. "

3. The hospital failed to have an effective system in place to ensure physician personnel were consistently screened for infectious diseases, including blood borne pathogens in accordance with nationally accepted infection control standards.

During an interview on 9/13/12 at 10:15 am, Staff T indicated the hospital required participating physicians to get a flu shot during flu season or they can decline, and they require them to have annual screening for tuberculosis. Staff T indicated the hospital did not require the physicians to be screened for /have Hepatitis B or measles, mumps, and rubella (immunity).

The CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis (in a Health-Care Setting, 2005, page 10, indicated "The classification of medium risk should be applied to settings in which the risk assessment has determined that health care workers (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 (skin test) or a single BAMT (alternate test) to test for infection, and after baseline testing for infection, HCWs should receive TB screening annually."

The Occupational Safety and Health Administration (OSHA) requires Hepatitis B vaccine be offered to healthcare workers (HCWs) who have a reasonable expectation of being exposed to blood on the job.
According to the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Report (MMWR Volume 46, Number RR-18, December 26, 1997) documented on page 24: " Persons who work within medical facilities should be immune to measles and rubella. Immunity to mumps is highly desirable for all Healthcare Workers. Because any HCW (i.e., medical or nonmedical, paid or volunteer, full time or part time, student or nonstudent, with or without patient-care responsibilities) who is susceptible can, if exposed, contract and transmit measles or rubella, all medical institutions (e.g., inpatient and outpatient, public and private) should ensure that those who work within their facilities are immune to measles and rubella. Likewise, HCWs have a responsibility to avoid causing harm to patients by preventing transmission of these diseases. "
On page 25, the MMWR stipulated, " All HCWs should ensure that they are immune to varicella. "
On Page 22, the MMWR stipulated, " Any HCW who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids, or sharps should be vaccinated. "
4. Potentially Hazardous Foods (PHF's) are foods capable of supporting bacterial growth associated with foodborne illness. Safe food handling practices would ensure that time/temperature control parameters were maintained during preparation and storage of PHF's. PHF's include cut raw fruits and vegeatbles such as tomatoes and cantaloupe. The standard of practice would be to ensure cold storage of PHF's at 41 degrees Farenheit (F) or below, ( Food Code 2009).
On 9/10/12 beginning at 2:45 p.m., food storage practices in the cafeteria were reviewed. In the salad bar there was a container of uncooked, cut tomatoes with a temperature of 45 degrees F. In a concurrent interview with Dietary Management Staff (DMS) stated that the hospital developed a system to monitor temperatures of food held on the salad bar for breakfast, lunch and dinner. Concurrent review of the hospital document titled "Cafe Food Temps Record Sheet" dated 9/10/12, revealed that while the hospital was monitoring temperatures of some PHF's, the system did not include monitoring of the tomatoes. The DMS also stated that at breakfast cantaloupe was occasionally utilized; however was also not monitored. DMS acknowledged that the current temperature monitoring system did not comprehensively include a PHFs which were served.

Based on medical record review and document review, in 5 out of 14 patient records surveyed, the hospital failed to ensure that an appropriate medical history and physical examination (H&P) was completed within 30 days prior to surgery.

Findings:

On 9/10/12 and 9/11/12, review of 14 preoperative patient records demonstrated that the record of Patient 100 contained a preoperative H&P performed more than 30 days prior to the date of surgery. The record of Patient 104 was absent history of present illness. The record of Patient 105 was absent documentation of a physical examination except for the pelvic exam. The record of Patient 106 stated that there was no past medical history, although the form the patient filled out listed arthritis, neck pain, and liver disease secondary to autoimmune hepatitis. The record of Patient 113 was absent history of present illness and absent past medical history.

Review of the medical staff bylaws, rules and regulations on 9/11/12 demonstrated that the H&P must be present prior to surgery. In an elective situation, the procedure will not proceed until the appropriate H&P documentation has occurred. The H&P must include details of present illness, pertinent past medical and surgical history, and an appropriate assessment of cardiorespiratory status and must be performed within 30 days prior to the date of surgery.

On 9/12/12, review of hospital policy "Admission" last revised 8/11, demonstrated the requirement that every patient must have a"complete history and physician examination" before admission or within 24 hours after admission. Review of policy "Preparation of the Patient for Surgery" last revised 5/11, demonstrated the requirement that the patient will not be taken to the operating room until the chart is complete, including the
H&P and physical data: heart, respiratory, neurological, and gastro intestinal assessment.