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Based on observation, staff interview, and document review, the hospital failed to establish an adequate abduction prevention system to ensure the safety of newborn infants. These failures may result in unauthorized intrusion and abduction of newborn infants

Findings:

On 3/20/13 at 10:00 am, tour of the hospital's maternity unit demonstrated that there was no locked barrier to prevent unauthorized persons from entering the unit from other areas within the hospital. A door to the outside of the building was locked and fitted with an alarm. The nursery was locked. Except for a sign declaring the unit to be a restricted area, however, there was nothing to prevent an unauthorized person from entering a room where a rooming-in mother and baby were sleeping and removing the baby.

During staff interview on 3/20/13 at 11:00 am, Staff Nurse M stated that there is usually a nurse at the nurses' station, directly across the hall from the birthing rooms. That nurse would be responsible for ensuring that no unauthorized person could enter a birthing room, but the nurse might have duties that required attention in one of the other birthing rooms, leaving the hall unguarded.

On 3/20/13, review of the instructions for mothers, titled "Keeping Your Baby Safe in the Hospital", which explained methods to prevent unauthorized access to their infants, demonstrated that it is the duty of the mother and family to prevent abduction by making sure that anyone who "wishes to take your baby from the room" wears a badge identifying them self as an OB (obstetrical) Nurse.

Based on staff interview, policy and document review, the facility failed to report a bankruptcy action that was filed, to the Department. The failure to report and provide a plan put patients at risk for receiving substandard care and treatment due to the facility's financial debt and potential inability to pay bills for patient needed services.

Findings:

During an interview on 3/18/13 at 1:35 p.m., the Interim Chief Executive Officer stated that the facility filed for bankruptcy on 10/17/12, and was not sure if it was reported to CDPH (California Department of Public Health) by the former Chief Executive officer.

During an interview on 3/19/13 at 9:10 a.m., The Interim CEO (Chief Executive Officer) stated that he could not find documentation that the department was notified, and also stated that there was sufficient cash flow and not a disruption in service, but the facility took on too much debt and filed Bankruptcy. The CEO stated that the facility did a debt adjustment plan, to take out creditors and the court appointed an ombudsman to monitor Patient care.

During an interview on 3/21/12 at 11:15 a.m., the Quality Risk Manager GG stated that the hospital going into bankruptcy should have been reported to the Department of Public Health and agreed that it was a unusual occurrence, in which circumstances could affect patient's care.

During an interview and review of administrative policies on 3/21/12 at 2 p.m., the Patient Services Manager stated that they had a policy, dated 2008 "Disruption of Services" which indicated there were certain times when the facility needed to notify the "State", but there was no policy which specifically indicated to report to the Department if the hospital filed for bankruptcy.

Review of an AFL (All facility Letter) from CDPH to General Acute hospitals and long term heath care facilities, dated 9/9/08 which dealt with the financial budget problems and the effect on facilities, indicated that hospitals should notify CDPH as soon as possible of financial difficulties, current or potential which could result in the closure of the facility, or transfer or discharge of residents and clients. The AFL indicated that regulations require facilities to report to the Department any unusual occurrence which threatens the welfare, safety or health of patents, personnel or visitors and also indicated that receiving updates would allow the CDPH to document the nature and extent of the problem so that the facility's operations can be supported.

Based on observations, staff interview, medical record review, and document review, the facility failed to ensure that written policies and procedures were followed and the provision of services for nutritional services requirements were met as evidenced by:

Dietetic Services
1) Raw meat was thawed and stored longer than facility policy dictated. (Cross Reference C279);
2) Drawer Liners were cracked that stored food production utensils. (Cross Reference C279);
3) Dietary Staff did not properly sanitize patient meal carts. (Cross Reference C279);
4) Dietary staff did not wash their hands and touched surfaces and objects while preparing
foods. (Cross Reference C279);
5) Licensed staff put a patient meal tray on an overbed table with a patient urinal. (Cross
Reference C279);
6) Dietary Department kept expired foods that were inconsistent with manufacturers' recommendations. (Cross Reference C279);

Nutrition Care
7) Registered dietitian and licensed staff did not assess and develop nursing plans of care with effective interventions for patients who were high risk for weight loss and were malnourished to prevent further weight loss and malnourishment. for 2 of 5 patients. (Patient 2 and Patient 153) (Cross Reference C279);
8) The hospital did not have diet manual that included all specific physician ordered diets.(Cross Reference 279)
9) The hospital menus were not analyzed to meet current nutritional standards. (Cross Reference C279);
The therapeutic diet menus did not match the food that was plated during trayline. The plated food was essentially the same for all therapeutic diets. (Cross Reference C279);
10) The hospital did not develop a disaster preparedness plan to ensure that they had enough food supply that did not include standardized portions in the event of a disaster. (Cross Reference C279);
11) The hospital did not develop a policy and procedure for safe thawing of meat and the facility practices did not meet the standard of practice for potential hazardous foods. (Cross Reference C279);

12) The nursing staff assess patient meal intakes to determine if the patient was provided adequate nutrition and provide effective measures to meet the patient's nutritional needs. (C295)

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 as evidence by 1) Raw meat was stored longer than the hospital policy dictated; 2) Drawer liners were cracked that were used to store food production utensils; 3) Patient meal carts were not properly sanitized; 4) Dietary staff did not wash their hands during meal preparation and touched other surfaces and objects; 5) A patient meal tray was placed on an overbed table with a patient urinal; 6) Expired food was kept beyond the manufacturer's recommendations; 7) Registered dietitian did not assess and develop nursing plans of care for patients with weight loss and that were malnourished; 8) There was no diet manual that included specific physician ordered diets: 9) Diet menus were not analyzed to meet current nutritional standards. Patients were plated the same diet; 10) The hospital did not develop a disaster plan to ensure adequate food supply to include standardized portions in the event of a disaster; 11) The hospital did not develop a policy and procedure for safe thawing of meat for potentially hazardous foods; 12) Patient meal intakes were not assessed to ensure adequate nutrition was provided to meet the patient needs.

Based on observation, interview and record review, the hospital failed to deliver pharmaceutical services to meet the needs of the patients when medications were not controlled and distributed in accordance with standards of practice, Federal and State laws as evidenced by:

1. The hospital failed to ensure there was a physician's order for a Duragesic (fentanyl, topical opioid for pain control) patch for 1 of 2 patient records. This failure resulted in the potential for the patient being exposed to the avoidable side effects of a Duragesic patch.

2. The hospital's surgery department failed to ensure intravenous (IV, directly into a vein) medications were prepared on a clean surface. The department prepared IV medications on a counter top next to a working hopper (white porcelain bowl used to flush urine). This failure resulted in the potential, from 1/1/13 through 3/19/13, for 416 patients to be exposed to avoidable infections from potentially contaiminated IV medications.

3. The hospital failed to ensure patient's own medications were not administered, and not stored, in the outpatient family practice clinic. For three patients, the outpatient clinic administered, and stored, patient's own medications. This failure resulted in the potential for outpatients to be exposed to avoidable adverse effects of medications.

4. The hospital failed to ensure sterile (germ free) intravenous (IV, directly into a vein) compounded (mixed) medications were assigned beyond use (expiration) dates that were supported by USP 797. The hospital compounded IV medications and assigned beyond use dates that were not supported by USP 797. This failure resulted, from 1/1/13 through 3/19/13, in the potential for 582 patients to be exposed to 821 compounded IV medications with unsupported beyond use dates.

5. The hospital failed to ensure sterile (germ free) intravenous (IV, directly into a vein) compounded (mixed) medications were labeled with storage directions. The hospital pharmacy did not label compounded IVs with storage directions. This failure resulted in the potential for patients to be exposed to medications at other than labeled strength.

6. The hospital failed to ensure the implementation of the policy and procedure for monitoring the storage temperature of medications. The medication storage temperatures were not monitored when the PACU, infusion center and outpatient services departments were closed. This failure resulted in the potential for patients to have received medications at other than labeled strength.

Findings:

1. A medical record review, on 3/20/13 at 10:36 a.m., showed Patient 52 was admitted to the hospital on 12/14/12 at 2042. Further record review showed she was discharged from a hospital acute care bed and admitted to a hospital swing (skilled nursing facility) bed on 12/18/12. Continued record review identified a progress note, dated 12/19/12 at 10:15 a.m. Review of the progress note showed "Nurse found Duragesic Patch 100 + 25 mcg (microgram) on back...must have been on over 5 days...leave off Duragesic for now..." Review of the medical records, from 12/14/12 at 2042 to 12/19/12 before 10:15 a.m. did not show a physician's order to continue the Duragesic patch 125 mcg, or an order to discontinue the Duragesic patch 125 mcg.

During a concurrent interview and medical record review, on 3/20/13 at 12:07 p.m., Registered Nurse (RN C) was asked to describe the hospital's process for a patient bringing in (wearing) their own Duragesic patch. RN C stated that the nurse was responsible for assessing the patient's skin, and if a patch was present the nurse was to contact the physician for an order to continue or discontinue the medication. RN C reviewed the chart and acknowledged that it did not contain an order to continue or discontinue the patch prior to 12/19/12 at 10:15 a.m. RN C stated that it was the hospital's expectation that there was an order to continue or discontinue the patch prior to 12/14/12 at 10:15 a.m.

The hospital's policy and procedure for Patient's Own Medications (number 315.4028, revised 4/05) showed Procedure: B. "A patient's own medications can be used only after the following conditions are met:, 3. "A valid and complete order for each medications, which includes the drug name, strength, directions and the words "may use own medication..."

According to LexiComp, a nationally recognized drug information source, the U.S. Food and Drug Administration (FDA) issued a boxed warning (the strongest label warning) on fentanyl regarding "...Respiratory depression (a condition of having a breathing rate that becomes too low to ventilate the lung) and death may occur..."

2. During a concurrent tour and interview, on 3/20/13 at 3 p.m., in the surgery department, the post-anesthesia care unit (PACU, area to recover from the effects of anesthesia) was identified. Inspection of the PACU showed it contained a hopper with a faucet. Registered Nurse (RN D) acknowledged that the hopper was used to flush urine. Further inspection of the PACU showed a countertop within 5 inches of the hopper. The hopper and counter top was not separated by a barrier. In the storage cabinets above the counter top were IV medications. RN D stated that IV medications were prepared on the counter top for patients in the surgery department.

During an interview, on 3/21/13 at 9:25a.m., the Infection Control Officer was asked if it was the hospital's expectation for IV medications to be prepared on a counter top next to a working hopper. The Infection Control Office stated it was not the hospital's expectation to prepare IV medications, on a countertop, next to a working hopper.

During an administrative record review, of documents provided by the hospital, from 1/1/13 through 3/19/13, showed the surgery department took care of 416 patients.

3. During a concurrent tour and interview, on 3/19/13 at 2 p.m., in the hospital's outpatient Family Practice clinic, the west lab was identified. Inspection of the west lab showed it contained a medication storage area. Inspection of the medication storage area showed three medications stored by the hospital's clinic. Each of the medications was labeled by a community pharmacy (patient's own medication). Medication one was cynaocobalmin (vitamin) for Patient 58. Medication two was testosterone (steroid hormone) for Patient 59. Medication three was testosterone for Patient 60. Both of the testosterones were labeled with a CIII (schedule 3 controlled substance (medications with a potential for abuse)). None of the patient's own medications had any markings to show they were reviewed by the hospital and approved for administration. Registered Nurse E stated that the hospital administered the medications to the patients during clinic visits.

During an interview, on 3/20/12 at 10:36 a.m., the Director of Pharmacy stated that the administration of the patient's own medications, in the Family Practice clinic, did not follow the hospital's policy and procedure for patient's own medications.

An administrative record review, of the hospital's policy and procedure for Patient's Own Medications (number 315.4028, revised 4/05) showed Procedure B. "A patient's own medications can be used only after the following conditions are met:...2. The medication is NOT a controlled substance...5. The contents of the containers have been examined and positively identified by the patient's physician or by the hospital pharmacist...6. After making the above determinations, the pharmacist will place a sticker on each container to verify these criteria have been met."

4. During a concurrent tour and interview, on 3/19/13 at 10:55 a.m., on the medicine, surgery, and swing bed nursing unit, a medication refrigerator was identified. Inspection of the contents of the medication refrigerator showed a pharmacy compounded IV of 2 grams of magnesium in 50 milliliters of normal saline (salt water). The magnesium IV was labeled with a prepared date of 3/14/13 and an expiration date of 3/28/13 (14 days from the day it was compounded). Registered Nurse A acknowledged the IV was labeled with a prepared date of 3/14/13 and an expiration date of 3/28/13.

A concurrent tour and interview, on 3/19/13 at 11:30 a.m., in the night locker (medication storage area), a medication refrigerator was identified. Inspection of the contents of the medication refrigerator showed it contained compounded IV medications. Inspection of the oxytocin (hormone) 20 units in 1 liter lactated ringers (electrolyte) showed a prepared date of 3/14/13 and an expiration date of 3/28/12 (14 days). Inspection of the bumetamide (used to increase urine production) 1 milligram in 4 milliliters showed a prepared date of 3/10/13 and an expiration date of 3/24/13 (14 days). The Director of Pharmacy acknowledged the prepared and expiration dates on the two IV medications.

During a concurrent tour and interview, on 3/19/13 at 4 p.m., in the pharmacy sterile IV compounding room, two IV mixing hoods (equipment to provide germ free area) were identified. One of the hoods was used for mixing non-hazardous medications. The other hood (biological safety cabinet) was used for mixing hazardous (chemo) medications. The front of both hoods was open to the pharmacy. The two IV mixing hoods were located inside a segregated compounding area that was used only for making IV medications. The Director of Pharmacy acknowledged the IV hoods were located inside of a segregated area. The hospital was requested to provide documentation showing the compounding room was certified at ISO Class 7 (measurement of air quality). The documentation was not provided prior to the end of the survey.

During an administrative record review, of the hospital's policy and procedure for Beyond-Use Dates for Compounded Sterile Products (CSP) (Number 315.5050, undated) showed Policy: "The Pharmacy will only prepare immediate-use, Low-risk and Medium risk sterile products as defined by USP 797 ...Unless otherwise referenced, all beyond-use dates will adhere to USP 797 standards for low-risk and medium-risk compounded sterile products."

An administrative record review, of the United States Pharmacopeia 797 (USP <797>), a nationally recognized compounding information source, Guidebook to Pharmaceutical Compounding-Sterile Preparations (2008, pg. 33) showed Low-Risk Level CSPs with 12-Hour or Less BUD "If the PEC (hood)...is a biological safety cabinet (BSC) that that cannot be located within an ISO Class 7 buffer area, then only low-risk level nonhazardous...CSPs...may be prepared, and administration of such CSPs shall commence within 12 hours of preparation or as recommended in the manufacturers' package insert, whichever is less."

USP<797> defines a segregated compounding area as "A designated space, either a demarcated area or room, that is restricted to preparing low-risk level CSPs with 12-hour or less BUD. Such area shall contain a device that provides unidirectional airflow of ISO Class 5 air quality for preparation of CSPs and shall be void of activities and materials that are extraneous to sterile compounding."

During an administrative record review, of documents provided by the hospital, from 1/1/13 through 3/19/13, showed the hospital pharmacy mixed 821 IVs and the hospital departments took care of 582 patients.

5. During a concurrent tour and interview, on 3/19/13 at 10:45 a.m., on the medicine, surgery, and swing bed nursing unit, a medication refrigerator was identified. Inspection of the contents of the medication refrigerator showed it contained pharmacy compounded IV medications. Inspection of Patient 154's IV ceftriaxone (antibiotic) did not show it contained storage directions on the label. Inspection of Patient 55's IV magnesium did not show it contained storage directions on the label. Registered Nurse A acknowledged the IV medications did not have storage directions on the labels.

Administrative record review, of the hospital's policy and procedure for Admixture Preparation (number 315.5022, revised: 4/03) did not show the label was to contain storage directions.

During an administrative record review, of ASHP (American Society of Health-System Pharmacists, a nationally recognized professional organization of hospital pharmacists) Guidelines on Quality Assurance for Pharmacy-Prepared Sterile Products (ASHP website, 2013), showed Quality Assurance for Risk Level 1, RI 1.9 Labeling, "Sterile products should be labeled with at least the following information:...6. Storage requirements...."

6. During a concurrent tour and interview, on 3/20/13 at 3 p.m., in the surgery department, a blanket warmer (warming cabinet) was identified. Inspection of the contents of the blanket warmer showed intravenous (IV, directly into a vein) fluids and irrigation solutions. Inspection of the blanket/irrigation warmer temperature record, 1/1/13 through 3/19/13, did not show, temperatures were documented on the weekends when the department was closed. Registered Nurse D stated the department did not have a process to monitor the temperature of the warmer when the department was closed.

During an administrative record review, of the hospital's monthly refrigerator (medication storage) temperature logs for PACU (post-anesthesia care unit (area to recover from the effects of anesthesia)), Infusion (infusion center) and OPS (outpatient services) did not show the temperatures were documented when each department was closed. The review period was 3/1/13 through 3/20/13.

During an administrative record review, of the hospital's policy and procedure for Blanket and Solution-Warming Cabinet Temperatures (number 235, New: 9/20/12) showed Procedure: 1. "Log warming cabinet temperatures daily."

During an administrative record review, of the hospital's policy and procedure for Storage Conditions (number 315.205, revised 1/10) showed Procedure: C. Refrigerator monitoring: 3. "Drug storage refrigerators and freezers shall be fitted with minimum/maximum thermometers. In departments not open 7 days per week, the minimum and maximum temperature ranges should be checked at the time of the first temperature monitoring for the week."

Based on observation, staff interview, document, record and policy review, the facility failed to ensure that policies for preventing infection was followed when:

1. The hospital failed to ensure that one contractor hired to provide clinical nutrition services completed all hospital required health screening. Failure to ensure required health screenings may put patients and staff at risk for developing undiagnosed communicable diseases such as tuberculosis and chicken pox.

2. The facility stored supplies, such as containers of media for cultures, on the floor in the laboratory department which could lead to contamination of supplies.

3. Facility housekeeping staff filled a container of wipes with a disinfectant, but did not label the container and staff were unable to identify the chemical in the container. This failure may result in the surfaces not being properly disinfected.

4. One housekeeping staff member ( House Keeper Q) did not remove her gloves after retrieving soiled linen in plastic bags form a patient's room, touched other surfaces and objects and did not wash her hands. The failure to ensure staff removed contaminated gloves and washed hands after removal of gloves could have led to cross contamination of clean surfaces.

5. Temperature and humidity were not monitored in the gastroenterology (digestive procedures) suite. There temperature and humidity 2 were not monitored consistently in 2 operating room suites (OR) which could lead to development of infectious organisms if temperature and humidity controls were not in the appropriate range.

6. A sterile packed drainage catheter located in radiology procedure room expired. The use of expired items decreased the manufacturer's assurance on the sterility and integrity of the product.

7. Clean traction equipment was stored on the floor in a closet which could have lead to contamination of equipment from placement on the floor where staff walked.


Findings:

1. During an a interview and concurrent record review on 3/20/13 at 2:45 p.m., the hospitals records for contracted food and nutrition services staff was reviewed with Human Resources (HR) Staff G. It was noted that the hospital had entered into a contract for Registered Dietitian services. Concurrent review of the contracted employee's file revealed that the hospital had not obtained health information prior to the employee beginning work. In a concurrent interview with HR Staff G she stated that usually a contractor provides a full package of all required information; however this particular contractor, whom was new to the hospital, did not provide the same level of information. HR Staff G confirmed that the hospital policy was not followed in this instance.

The "Orientation Checklist" dated 1/25/13 and signed by the contracted employee revealed that while general employee requirements such as confidentiality and abuse reporting were complete; the health screening component was not complete. It was also noted that the signature on the form denoted that the employee understood the requirements and that unclear points would be clarified with the department manager. There was no indication that the health screening elements were clarified and/or obtained from the contracted employee.

Hospital policy titled Registry/Traveler Guidelines dated 7/30/08 noted that the hospital required health screening documentation that included a physical exam, tuberculosis screening, immunization history, background check, drug screens and profiles with references and skills inventory.



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2. During an observation of the microbiology lab room on 3/18/13 at 2:05 p.m., there were several cardboard boxes on the floor, under counters which contained culture medium bottles. The laboratory storeroom also had several boxes on the floor with red garbage bags and other supplies.

During an observation on 3/20/13 at 4:10 p.m., the microbiology lab room and lab store room still had boxes of culture medium bottles and red garbage bags on the floor.

During an interview on 3/21/13 at 9:20 a.m., the Infection Control Officer stated that the items should be off the floor to prevent contamination and thought that because there were deliveries of supplies and that was the reason that supplies were on the floor.

On 3/21/13, review of the facility "JACHO/DHS/OSHA"9 (accrediting and certification agencies) revealed continual survey readiness meant that no boxes of supplies should be stored on the floor.

3. During an observation on 3/18/13 at 2:20 p.m., there was a blue container with solution, on the counter in the lab which read "Wettask." During a concurrent interview, the Infection Control Officer stated that the housekeepers refill the "Wettask" container with a cleaning solution, but he was not sure of what solution was in the container as there was no label on the container. The container came with wipes and was meant to be filled with cleaning solution.

During an interview on 3/21/13 at 9:30 a.m., the Infection Control Officer stated that the housekeeping staff should put labels on the "Wettask" container so they know what solution is in the container.

The "Storage and Measurement of Products" policy, dated 4/08, indicated that all cleaning supply containers should be properly labeled.

4. During an observation on 3/19/13, Housekeeping Staff Q came out of a patient room and held a clear bag of linen. Housekeeping Staff Q had blue gloves on and came out and opened the linen disposal closet door and placed the linen bag into a linen cart. Housekeeping Staff Q handled her name tag and wheeled her housekeeping cart down the hall with the same blue gloves on. Housekeeping Staff Q then handled the keys in her pocket and unlocked and opened the door to where cleaning products were mixed and stored. Housekeeping Staff Q then removed her gloves and placed then in a bin on the side of the cart, she then touched her uniform, pulled her pants up and touched her cart as she showed the disposable mops that were used to clean the isolation rooms.

During an interview on 3/21/13 at 9:40 a.m., the Infection Control Officer stated that the facility was monitoring hand washing for better compliance. The Infection Control Officer stated that they were training staff to wash hands before they put gloves on and after they take gloves off to prevent cross contamination.

The facility policy titled, "Handwashing and Hand Hygiene"# 170.1050 revised 10/2008, indicated that the purpose of hand washing was to remove dirt, organic material and transient microorganisms from the hands so as to decrease the risk of cross contamination. All healthcare workers must wash their hands after removing gloves.

The policy for "Personal Protective Equipment" revealed that all personal protective equipment should be removed prior to leaving the work area and should be worn when handling or touching any contaminated surface or equipment.

5. During an interview on 3/20/13 at 12:40 p.m., Registered Nurse D (OR or Operating Room Manager) stated that the GI lab did not have a device to monitor the temperature and humidity. Registered Nurse D stated that the previous OR Manager had been doing the temperature and humidity readings and she did not see that readings were done consistently. Review of temperature and humidity records for OR Rooms 1 and 2 from May 2012 through March 2013 indicated that temperature and humidity were not monitored on weekends, holidays and missed other days in May through Dec 2012. The log also indicated high humidity readings on some days such as Sept 17,18,19, 20 with readings of 62,64,65,62% humidity and Acceptable range humidity readings listed as 30-60%. There were no documentation for corrections made for the high humidity readings.

During an observation and concurrent interview of OR suite 1, on 3/21/13 at 3:20 p.m., Registered Nurse D stated that the digital monitor for temperature and humidity did not provide a 24 hour graph read out for weekend or days when there was no surgery.

The 2012 "Perioperative Standards And Recommended Practices" provided by Registered Nurse D, indicated that Relative Humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms and endoscopy rooms. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed. Humidity should be monitored and recorded daily using a log format. The standards indicated that temperature should be monitored daily and maintained between 68 degrees to 73 degrees Fahrenheit within operating room suites. The standards indicated that heating, ventilation and air conditioning systems dilute and remove contaminants from the air and control airflow patterns.

6. During an observation on 3/18/13 at 3:30 p.m., of the radiology fluoroscopy room, there was a tall rack, next to a patient procedure table with various catheters and stents on it. One device called a "Multipurpose drainage Cannula Set" had a manufacturer's expiration date of April 2012.

During an interview on 3/18/13 at 3:35 p.m., Physician A stated that staff check for outdates and stated "We don't keep expired items". Physicain A stated that this type of catheter could stay in a patient a week and was used to drain a abscess (collection of infectious fluid).

During an interview on 3/21/13 at 9:40 a.m., the Infection Control officer stated that pharmacy staff usually check expiration dates and that staff do a survey and one of the things they look for are expiration dates. Review of the "JCAHO/DHS/OSHA" continuous survey readiness that meant there should be no expired supplies.

Review of the "Joint Practice Guideline For Sterile Technique during Vascular and Interventional Radiology Procedures" Dec 2012 article, from Society of Interventional Radiology, indicated that according to AORN (Association of Operating Room Nurses) all items introduced into a sterile field should be sterile and introduced by a method that maintained the items sterility and integrity. Items should be inspected for for expiration dates, package integrity and sterile processing indicators. If a item is expired, it should not be used in order to ensure the sterility and integrity of the product.

7. A concurrent tour and interview, on 3/19/13 at 10:25 a.m., on the medicine, surgery, and swing bed nursing unit, a small storage closet was identified. Inspection of the closet showed that it contained pieces of traction equipment. Some of the traction equipment was stored on the closet floor. Registered Nurse A stated that the traction equipment was cleaned in the patient rooms and the excess pieces were placed in the closet. Registered Nurse B stated that it was not the hospital 's expectation for clean traction equipment to be stored on the closet floor.

During an interview, on 3/21/13 at 9:30, Infection Control Officer was asked if it was the expectation of the hospital for clean traction equipment to be stored on the closet floor. The Infection Control Officer stated that it was not the hospital 's expectation for clean traction equipment to be stored on the closet floor. The Infection Control Officer stated that staff should not store any equipment on the floor that could come in contact with the patient's skin to maintain good infection control practice.

The Facility "JCAHO/DHS/OSCHA Continual Readiness Survey" for infection control, from 9/13/12 indicated that nothing should be stored on the floor.

Based on observation, staff interview, medical record review, and document review the facility failed to ensure that the nutritional needs of inpatients were met in accordance with recognized dietary practices as evidenced by:

1) Raw meat was thawed and stored longer than facility policy dictated;
2) Drawer liners were cracked that stored food production utensils;
3) One Dietary staff (Dietary Staff I) did not properly sanitize patient meal carts;
4) One Dietary staff (Dietary Staff J) did not wash their hands and touched surfaces and objects while preparing foods;
5) Licensed staff put a patient meal tray on an overbed table with a patient urinal;
6) Dietary Department kept expired foods that were inconsistent with manufacturers' recommendations;
7) Registered Dietitian (RD) and licensed staff did not assess and develop nursing plans of care were with effective interventions for patients who were high risk for weight loss and were malnourished to prevent further weight loss and malnourishment. for 2 of 5 patients (Patient 2 and Patient 153);
8) The hospital did not have diet manual that included all specific physician ordered diets;
9)The hospital menus were not analyzed to meet current nutritional standards;
The therapeutic diet menus did not match the food that was plated during trayline. The plated food was essentially the same for all therapeutic diets.;
10) The hospital did not develop a disaster preparedness plan to ensure that they had enough food supply and did not include standardized portions in the event of a disaster;
11) The hospital did not develop a policy and procedure for safe thawing of meat and the facility practices did not meet the standard of practice for potential hazardous foods.


Findings:


1) During initial tour on 3/19/13 at 8:44 a.m., it was noted there were 2 containers of meat, all of which was fully thawed, which included ground beef dated 2/26 and a use by date of 3/23; stew meat dated 3/12 with a use by date of 3/23 and pork loin labeled with a use by date of 3/23. In a concurrent interview with Dietary Staff (DS) H she was asked to describe the dating system. She stated that the older date on each of the packages was the date the item was put into the freezer. She also acknowledged that all of the items were likely pulled over the weekend and were to be used in the ensuing several days. She also stated that the 3/23 (5 days after thawing) use by date was standardized timeframe for any type of thawing meat.

Review of the departments' policy titled "Storage of Food" dated 2/13 revealed that the facility policy for raw meat storage did not exceed 2 days under refrigeration.

2) During general kitchen observations on 3/19/13 beginning at 8:55 a.m., it was noted that the 3-drawer unit adjacent to the stove had cracked liners in the drawers. It was also noted that the first 2 drawers contained food production utensils.

Materials that are used in the construction of utensils and food-contact surfaces shall be finished to have a smooth, easily cleanable surface; and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition (Food Code, 2009).

3) During an observation on 3/19/13, Dietary Staff I was cleaning the patient meal carts. Dietary Staff (DS I) was noted to spray a stainless steel cleaner on the outside of the cart. In a concurrent interview she was asked to describe the cleaning process. She stated that at the end of each meal she sprayed the product (pointing to the stainless steel cleaner) both inside and outside of the cart after which it was wiped down. Dietary Staff I was asked if there were any other products that were used for cart cleaning; to which she replied there was not. In a follow up interview with DS I she stated that until recently she functioned as a certified nursing assistant within the hospital. She further stated that for orientation to the department she spent 1 day with another employee who was also assigned to the dishroom.

The 2009 Food Code indicated that food contact surfaces and utensils shall be sanitized.

During an interview and concurrent document review on 3/20/13 at 2 p.m., it was noted that the binder which was presented as in-service training and competency evaluation contained a tab with each of the employees' names on individual tabs which was being maintained by DS H. It was also noted that under the tab with DS I's name it contained a single line entry that stated that DS H had discussed the dishwashing position description. There was no documentation of departmental orientation, competency evaluation and/or training for DS I. In an interview on 3/20/13 beginning at 2:35 p.m., with Human Resources (HR) Staff G she stated that while HR files contained general hospital orientation such as hospital safety policy; position specific orientation and/or competency was maintained at the departmental level.

The "Food and Nutrition Services Staff Meeting Minutes" dated 2/25/13 revealed that dietary staff were instructed on sanitation of equipment/utensils. While staff was instructed on the general concept of sanitation there was no training specific to cleaning in place equipment; rather the training focused on the use of the dishwasher.

4) During general food production observations on 3/19/13 beginning at 10 a.m., it was noted that DS J was preparing patient food. It was noted that he put his glasses on the cutting board and later continued to use the cutting board for food production activities. In a follow up observation on 3/19/13 beginning at 12 p.m., with the presence of the Infection Control Officer, it was noted that DS J went to answer the phone and returned to food production activities without washing hands. Similarly in an additional observation on 3/19/13 at 12:10 p.m., DS J was observed handling the dinner rolls without the benefit of gloves.

In an interview on 3/19/13 at 12:20 p.m., the Infection Control Officer was asked to describe recent oversight of food production practices. He stated that he had increased his surveillance of the department in recent months. He also stated that handwashing was a hospital-wide focus. He further acknowledged that during the course of the observations he also noted numerous breaches in infection control principles.


The "Food and Nutrition Services Staff Meeting Minutes" dated 2/25/13 revealed that dietary staff were instructed on hand hygiene. While staff was instructed on when to wash hands; there was no documented competency evaluation.

The Food Code, 2009 indicated that except when washing fruits and vegetables, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.


5) During meal distribution observations on 3/19/13 at 12:30 p.m., it was noted that nursing staff were delivering patient meals. It was noted that while nursing staff placed the patient meal tray on the overbed table next to a full urinal. After placement of the meal tray she removed the urinal. There was no observed cleaning/sanitation of the surface prior to meal delivery.

6) During initial tour on 3/19/13 at 8:55 a.m., the following was noted:
a) In the dry storage area there was a bottle of a liquefied fiber supplement. It was noted that the bottle was opened on 11/3/12. Manufacturers' guidance on the bottle noted the expiration date of the product was 3 months after opening. Additionally there was a bottle of soy sauce, opened with no date. It was also noted that the manufacturers' guidance was to refrigerate after opening.
b) In units #2 and #3 dietary staff was storing bread products in the refrigerator. Manufacture's guidance for bread storage is to store either in the freezer or at room temperature. Storing bread in the refrigerator creates the amino acids in bread to be compromised creating a stale-like texture (University of California, Cooperative Extension).



7) Patient 2 was admitted with diagnosis including prostate cancer and sings symptoms of abdominal pain. Admission height was 5 feet 6 inches and weight was 125 pounds. A nursing admission assessment dated 3/9/13 and timed at 6 a.m., identified Patient 2 at nutritional risk due to extended poor intake and a depleted albumin (a measure of protein stores).

Patient 2's dietary intake from 3/10-3/18/13 noted an average intake of 26% for 11 recorded meals. It was also noted that during this timeframe Patient 2 had no documented intake for 12 meals. The first documented nutrition assessment was not completed until 3/16/13 (8 days after admission). The assessment noted that the patient was currently on a clear liquid diet, had poor dietary intake, was experiencing nausea/vomiting and had a recent unintentional weight loss of 25 pounds. The assessment also noted that the patient complained that the clear liquid diet was too sweet. There were no documented interventions to address this complaint.

In an interview and concurrent document review on 3/30/13 at 1:30 p.m., RD presented Patient 2's nutrition risk screening form. She stated that on her copy of the form, in the right hand corner, she wrote the word "done" and circled it. She further stated she was confident the assessment was completed. Verification was requested to show that the RD had electronically logged into Patient 2's medical record between 3/8 and 3/11. As of 3/21/13 the hospital was unable to provide such verification.


Patient 153's medical record (Acute Discharge to Swing Bed Doctors notes) indicated that Patient 153 was admitted to the swing bed (bed approved for short term post acute hospital skilled care) unit on 9/8/12, after discharge from a acute hospital admission. The Patient was initially admitted to the hospital with failure to thrive, poor nutrition, COPD (Chronic obstructive Pulmonary disease), decubitus ulcers (pressure sores), and acute alcoholism. Patient 153 was admitted to the swing bed for rehabilitation, physical and occupational therapy and continued treatment of of decubitus ulcers. Patient 153's facility intake and output notes,dated 9/9/12, indicated weight 68.9 lbs and ate 10 % of his meal.

The "Nutrition Screen for Risk Factors" nursing assessment, dated 9/8/12, indicated that Patient 153 had high risk factors such as Stage 3 to 4 pressure ulcers , difficulty chewing, weight loss greater than 10% in the last 6 months. The form indicated that nutrition consult was needed because the patient was high risk. The physician orders dated 9/8/12 indicated that a nutrition consult was ordered. The Dietitian's nutritional assessment dated 9/10/12 indicated that that the patient's ideal body weight was 142 lbs. Nutritional therapy weekly goals included improved protein, maintenance of weight and nutritional support. The dietitian's note indicated that the patient's nutrition was inadequate. Supplements were added to the meals. The dietitian's note indicated Patient 153 was bedfast so there was potential for increased skin breakdown. The notes indicated that Patient 153 was to be monitored weekly. The electronic nurse's record notes, dated 9/16/12 at 01:36 p.m., indicated that patients weight was 65 lbs. (this was down from 68.9 lbs on 9/9/12. There were no more weights recorded before patient was transferred to a long term facility on 9/19/12. There were no additional dietary nutritional assessments in the record since 9/10/12.

The physician discharge summary dated 9/19/12, indicated that the patient was discharged on 9/19/12 to a skilled nursing facility. The summary indicated that Patient 153 had multiple medical problems including, decubitus ulcers, chronic malnutrition. The discharge summary indicated that Patient 153 was hospitalized for a long time, that it was a struggle for the facility to improve his condition, and he was given all nutritional supplement treatment for medical conditions. The Discharge Summary indicated that Patient 153's condition was "reasonable", he was alert and oriented with no respiratory distress and would need to continue treatment for decubitus care and require nutritional support at the skilled nursing facility.

During an interview on 3/21/13 at 9:45 a.m., The Registered Dietitian stated that she was covering for the facility dietitian at the time that this patient needed the assessment. The Registered Dietitian stated that the patient should have had weekly weights and that she did do the initial assessment. The Registered Nurse stated that she should have done another assessment 7 days after the first one to assess if goals have been met or if changes needed to be made. The Registered Dietitian stated that she could not find where she provided another assessment in the electronic records.

The 6th edition of "Clinical Nursing Skills and Techniques" supplied by the Patient Services Manager as a guide for nurses to follow for patient care, indicated that patients who are identified as being at risk should have a nutritional assessment by a Registered Dietitian and that the nutritional care plan should be reevaluated based on the individual clients needs.

The facility Policy for "Nutrition Assessment, Counseling and Diet Instruction." revised 2/13, indicated that reassessment of the nutrition care plans for high risk patients is every 1-3 days and moderate to low risk is is every 3-5 days. Monitoring by the dietitian for acceptance of the plan is ongoing.



8) During trayline observation on 3/19/13 at 11:50 am, the following physician ordered diets were noted: 2 gram sodium restriction and a dysphagia level II texture modification (a sodium restricted diet and a diet modified for swollowing problems). In a concurrent interview DS H stated that while there was an old diet manual in the kitchen the hospital purchased an on-line diet manual.

During an interview on 3/20/13 at 1:15 p.m., Registered Nurse K was asked how nursing staff accessed the hospitals' diet manual. He replied that the manual was put online. RN K concurrently attempted to access the manual utilizing a link on the hospitals' intranet. It was noted that while he was able to get to the log in page, the log in function did not work. He also stated that he was not provided training on access the diet manual.

During a concurrent interview on 3/20/13 at 1:15 p.m., Registered Dietitian (RD) was asked to attempt access to the online document. It was noted that the attempted access failed. The RD stated that while she had access to the manual in her office, she did not have access within the hospital. She additionally stated that to her knowledge the hospital purchased one license for electronic access and that was why it was likely staff within the hospital were unable to access the document. The RD also stated that to her knowledge the online manual was not modified to accurately reflect the hospitals diets and menu.

The undated hospital print out revealed that there were 22 separate physician ordered diets in the electronic medical record system. A diet manual would ensure inclusion of all of the specific hospitals' physician ordered diets; met the current standards of practice; included a comprehensive description of the therapeutic diets offered by including the purpose of the diet, indications of the diet, nutritional adequacy of the diet and sample meal plans that were consistent with the hospitals' menu.

The "Diet Manual" dated 2/13/13 revealed that the hospital planned to use a Nutrition Care Manual as the hospitals ' diet manual. While the online document had some of the guidelines, not all the guidelines were present for each physician ordered hospital diet which would allow for hospital and/or dietary staff to use the document as a comprehensive resource to order and/or prepare patient diets.

The hospital's "Plan of Correction" dated 1/22/13 noted that the hospital purchased a diet manual. It was noted that the document referred to the purchase of the Nutrition Care Manual, which was not developed or modified to function as a diet manual in that it did not have specific guidelines to prepare all patient meals.


9) During trayline observation on 3/19/13 at 11:20 am, it was noted that there were several physician ordered therapeutic diet including a 2 gram sodium restricted diet and various levels of carbohydrate consistent diet. It was also noted that while the hospital had different menus that were given to patients to self-select their food, the foods being plated were essentially the same through all of the therapeutic diets.

During interview and concurrent document review on 3/19/13 at 3 p.m., Information Technology (IT) Staff L stated that he was assisting the supervisor of the food services department in developing a nutrition analysis. He stated that the hospital recently purchased a computer program and that the menus were in the process of being analyzed. It was noted that the hospital currently entered the menus for a regular diet as well as sodium restricted diet. There were no other diets in the nutritional database.

During an interview on 3/20/13 at 9 am, RD stated that the average demographic for the hospital population was males and females over the age of 50. It was also noted that during the survey the inpatient roster included a pediatric patient as well as 2 post-partum (shortly after child birth) patients.

The hospitals analysis for the regular diet revealed that with the exception for choline values the analysis was comprehensive; however it was noted that the benchmark value for the analysis was limited to females ages 50 and over. There was no benchmark value specific to men, pregnant and post-partum women or children all of which had the potential to be admitted to the hospital. It was also noted that while some of the nutrients met the RDA/DRI (Recommended Dietary Allowances and Dietary Reference Intake) values for females, the menu was substantially low in Vitamin E, folate, Vitamin K, Chromium, molybdenum, chromium and potassium (essential nutrients, vitamins and minerals in food).

The Registered Dietitian also acknowledged that, the registered dietitian, approved the menus and that they would meet the nutritional needs of patients as well as follow parameters specified in the hospitals' diet manual. She additionally stated that the department did not have a policy that ensured the menus met the nutritional needs of patients. While the hospitals; menus were evaluated for the complete array of macro and micro nutrients (nutrient amounts) specified by the Food and Nutrition Board of the National Research Council based on one segment of the hospitals' inpatient demographics it was noted that the menu did not fully meet the standard of practice for nutritional adequacy.

The "Plan of Correction" dated 1/22/13 revealed that the hospital had purchased a nutrition analysis software program to analyze all patient menus. It was also noted that the completion date of the project was designated as 3/8/13.

The standard of practice would be to ensure institutional menus were analyzed for the nutritional components to meet the current national standards including the RDA (Recommended Dietary Allowances) and the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council (Academy of Nutrition and Dietetics). The recommended intakes based on the RDA/DRI are specific for age and gender.


10) During an interview and concurrent document review on 3/20/13 the hospitals' feeding plan for disaster preparedness was reviewed with DS J. He stated that he was not familiar with the plan; however was aware of a food supply to be implemented in a disaster. It was noted that the hospitals' food supply included canned items such as chili, beef stew, canned fruit peanut butter and dry milk as well as nutritional supplements. It was also noted that while the hospital developed a regular menu for the most part it did not include any standardized portions. It was also noted that not all of the items were part of the hospitals' inventory. The menu called for items such as vegetable juice, canned tuna and chicken salad; potato chips, canned pudding and cake. While it was noted that there was canned tuna it was limited to 6 small cans. It was also noted that the plan did not designate the number of patients and employees that the food supply was intended to feed.

During an interview on 3/20/13 at 5 p.m., Quality Improvement Staff GG stated she was unsure of the number of patients and staff the hospital was preparing to care for in a disaster. She also stated that in a recent disaster drill the hospital guided home health agency patients to come to the hospital if they did not have electricity in their home. It was also noted that while the hospital had developed a disaster preparedness plan for dietetic services the plan was not included in the hospitals' disaster manual. Similarly the hospital identified a water storage tank that was adjacent to the building. It was noted that the guidelines for the procedures for failure of essential equipment was also not part of the hospital wide disaster manual. Additionally it was noted that the last time the hospitals' disaster manual was reviewed and/or revised was in 2006.

11) During review of the department's policy and procedure manual on 3/19/13 at 8:50 am, it was noted that policy titled "Food Safety-HACCP" (Hazard Analysis Critical Control Points) revised 2/13 guided staff on methods for thawing frozen foods which included the option to thaw submerged in cold running water. While the policy included this method it did not include time/temperature parameters for food safety when utilizing running water as a method of thawing.

Safe thawing of potentially hazardous foods, which are defined as those capable of supporting bacterial growth associated with foodborne illness, include the use of complete submersion under running water with the following specified parameters: 1) at a water temperature of 21oC (70oF) or below; 2) with sufficient water velocity to agitate and float off loose particles in an overflow, and 3) for a period of time that does not allow thawed portions of a raw animal food requiring to be above 41oF, for more than 4 hours including: (a) the time the food is exposed to the running water and the time needed for preparation for cooking, or b) the time it takes under refrigeration to lower the food temperature to 41oF (Food Code, 2009).

Based on observation, interview and record review, the facility failed to post Zone 1 and Zone 2 warning signs in the Diagnostic Imaging Center. The hospital did not post Zone 1 and Zone 2 warning signs from the hospital entrance, through the main hallway, to the Zone III sign. This failure resulted in the potential for patients and employees to be exposed to avoidable injuries from magnetic fields.

Findings:

During a concurrent tour and interview, on 3/18/13 at 3:35 p.m., the entry from the hospital to the Diagnostic Imaging Center was identified. On the other side of the entry was a long main hallway. Inspection of the Diagnostic Imaging Center showed procedure rooms and offices to the right and left of the main hallway. At the end of the main hallway was a MRI (magnetic resonance imaging, a powerful magnet is used to produce images of the body) Zone III warning sign. The hospital's MRI scanner magnet room was entered through a doorway in zone III. Physician A inspected the pathway, from the entryway to the MRI Zone III warning sign. Physician A stated that the pathway did not have signs posted for entering Zone I and Zone II.

During an administrative record review, of the hospital's policy and procedure for Safety Zones (new: 2/13) showed Procedure:, 1. "Zone 1 includes all areas accessible to the general public", and 2. "Zone 2 indicates the interface between publicly-accessible Zone 1 and the restricted Zones 3 and 4..." Continued review showed "Zone 3 is the region in which free access by unscreened non-MR personnel or ferromagnetic objects or equipment can result in serious injury or death. ZONE 3 IS STRICTLY RESTRICTED."

Based on staff interview, medical record review, and document review, the hospital failed to ensure assessment of dietary intake with effective interventions for 1 of 5 patients (Patient 3) that were at risk for malnutrition. This failure may have resulted inadequate nutrition and that Patient 3's nutritional needs were not identified and met.

Findings:

1. Patient 3 was admitted with sepsis (an infection in the blood) and a kidney infection as well as symptoms of nausea and vomiting. A comprehensive nursing admission assessment dated 3/16/13 noted that the patient required feeding assistance and had no dentures. An admission nutrition screening dated 3/16/13 did not note any nutrition risk triggers. Admission diet order dated 3/14/13 was a soft diet. Review of average dietary intake from 3/15-3/19/13 revealed that for 11 meals with documented intake the patients' average consumption was 15%. It was also noted that the patient had either no intake or refused meals for a 3 additional meals. There was no referral to the Registered Dietitian (RD) despite poor dietary intake. In an interview on 3/20/13 beginning at 1:30 p.m., with the RD she stated that she was not notified that the patient was not eating. In an interview on 3/20/13 at 3:45 p.m., Director of Patient Services stated that while the hospital did not have a policy that specifically addressed nutritional intake it would be the expectation that nursing completed shift assessments and would document and act upon any identified issues.

The hospital's policy and procedure for "Patient Assessment and Reassessment" dated 3/09 guided staff that "8. Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care ..."

Based on staff interview, medical record review, and document review, the hospital failed to ensure comprehensive care planning was developed and that identified concerns had effective inteventions and plans for resolution with measurable goals and timetables for 2 of 5 patients (Patients 1 and 2). This failure may result in the patients' not receiving adequate nutrition to meet their needs.

Findings:

1. Patient 1 was admitted with diagnosis including difficulty swallowing and a recent history of poor dietary intake. Admission height was 5 feet 4 inches and weight was 287 pounds. Admission diet order was a pureed diet. A nutrition assessment dated 3/11/13 revealed that the patient's dietary intake was fair, ranging from 50-75% consumption of meals. A follow up nutrition assessment dated 3/13/13 noted that the patients' dietary intake was poor. There was a recommendation to implement a nutritional supplement if intake was less than 50%. An additional assessment dated 3/15/13 continued the nutritional supplements with a recommendation to implement nutrition support should the decreased intake continue. Review of dietary intake from 3/11-18/2013 documented an average intake of 19% for 14 meals. It was also noted that there were also 9 meals where the patient either refused the meal or had 0% consumption.

During an interview on 3/20/13 at 3:45 p.m., Registered Dietitian (RD) acknowledged that she had not been developing comprehensive care plans for patients with identified nutritional issues. The RD also stated that she had not received any training on the development of nutrition care plans since the hospital transitioned to the electronic medical record.

Patient 1's care plan revealed there was no care plan addressing the patients' nutritional issues.

The hospital policy titled, "Development of Nursing Care Plan" dated 4/09 revealed that there was an expectation that each patient who is in the hospital for greater than 23 hour "must have the patient needs or problem identified by the multidisciplinary team as appropriate." The policy also guided staff to develop a care plan that included the nursing diagnosis; patient goals or expected outcomes and identify interventions to meet goals.

The hospital's "Plan of Correction" dated 1/22/13 noted that the hospital had discussed with the RD the need to develop nutrition care plans.

2. Patient 2 was admitted with diagnosis including prostate cancer and symptoms that included abdominal pain. Admission height was 5 feet 6 inches and weight was 125 pounds. A nursing admission assessment dated 3/9/13 and timed at 6 am, identified Patient 2 at nutritional risk due to extended poor intake and a depleted albumin (a measure of protein stores).

Patient 2's dietary intake from 3/10-3/18/13 noted an average intake of 26% for 11 recorded meals. It was also noted that during this timeframe Patient 2 had no documented intake for 12 meals. The nutrition assessment dated 3/16/13 noted that the patient was currently on a clear liquid diet, had poor dietary intake, was experiencing nausea/vomiting and had a recent unintentional weight loss of 25 pounds. The assessment also noted that the patient complained that the clear liquid diet was too sweet. There was no development of a nutrition care plan that included goals, interventions or evaluation to implemented treatments despite the patient being identified at high nutritional risk.

The development of a patient care plan is an integral component of the care process. A comprehensive care plan would consist of measurable goals, implementation of interventions and evaluation of the goals (Lippincott's Nursing Procedures, 5th edition).

Based on staff interview and medical record review, the hospital failed to ensure 2 of 5 patients (Patients 1 and 5) that staff accurately dcoumented nutritional supplements. This failure to ensure complete document of nutrition interventions may result in ineffective treatment modalities further compromising medical status.

Findings:

1. Patient 1 was admitted with diagnosis including difficulty swallowing and a recent history of poor dietary intake. Admission diet order was a pureed diet. A nutrition assessment dated 3/11/13 revealed that the patient's dietary intake was fair, ranging from 50-75% consumption of meals. A follow up nutrition assessment dated 3/13/13 noted that the patients' dietary intake was poor. There was a recommendation to implement a nutritional supplement if intake was less than 50%. An additional assessment dated 3/15/13 continued the nutritional supplements with a recommendation to implement nutrition support should the decreased intake continue. Review of dietary intake from 3/11-18/2013 revealed that there was no documentation of the nutrition supplements.


Patient 5 with admission diagnosis of atrial fibrillation (an abnormal heart rhythm) with who was admitted with symptoms that included difficulty swallowing as well as nausea and vomiting. Patient 5 also had a physician ordered supplement. There was no documentation of the acceptance or effectiveness for this nutrition intervention.


During an interview on 3/20/13at 3:30 p.m., RD stated that nursing did not document nutritional supplement consumption in the chart and that in order to get that information she would interview nursing staff. She also acknowledged that since the information was not documented she could only rely on verbal information that when speaking with an individual nurse may not completely reflect the patients' consumption over several days and various shifts.