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Based on observations and interviews, the hospital failed to maintain one walk-in freezer to prevent the accumulation of ice on the floor, surrounding the condenser, on the ceiling of the freezer, on the door gasket and on the racks containing frozen food. This failure had the potential to result in slips and falls from the ice on the floor and improper function of the freezer leading to the potential for unsafe food storage.


Findings:


During an observation of the Dietary Department on 5/14/13 at 9:15 a.m., the walk-in freezer had an excessive accumulation of ice on the floor, surrounding the condenser, on the ceiling of the freezer, on the door gasket and on the racks containing frozen food. In a concurrent interview with Food Service Worker B (FSW B), he verified the observation and said that the maintenance staff was aware that the freezer would accumulate ice occasionally but he had not informed them of this new accumulation of ice.


During an interview on 5/14/13 at 9:25 a.m., Maintenance Staff stated that he was not informed of this accumulation of ice in the walk-in freezer. He stated that when the temperature of the freezer was turned down, ice would build up. He stated that the amount of ice observed was more than what he was used to seeing. He verified that the accumulation of ice indicated that the freezer was not functioning properly and was a safety hazard to the staff walking in the freezer

28135

Based on observations, interviews and record reviews, the facility failed to ensure that written policy and procedures were followed and the provision of services for nutritional services requirements were met when:
1. A can opener blade had sticky crusty food build up on the blade, a blender had food on the blades, and meal carts were not sanitized. These failure can result in cross contamination. (Refer to C-0279)
2. Shelves that stored food in the walk-in refrigerator were rusted. These failures can result in cross contamination of foods. (Refer to C-0279)
3. One Food Service Worker (Food Service Worker B) did not practice appropriate hand washing and touched other surfaces and clothing when handling food. These failures can result in cross continuation of foods (Refer to C-0279)
4. A filled trash receptacle in the dish washing area was not appropriately covered when not in use and resulted in unsanitary conditions. (Refer to C-0279)
5. The Dietary Department kept expired foods that were inconsistent with the manufacturer's recommendation. These failures can result in food borne illness. (Refer to C-0279)
6. The maintenance staff was not notified of an excessive accumulation of ice on the floor, ceiling, door gasket and around the condenser in the walk-in freezer. This failure may result in food borne illness. (Refer to C-0222 and C-0279)
7. The Dietary Department did not have adequate food and supplies on hand to carry out the disaster food plan in the event of a disaster. These failures can result in the hospital not having the necessary food to be self sustaining during a disaster. (Refer to C-0279)
8. 3of 20 patients did not have a nutrition analysis of the patient menus indicated they did not meet the requirements for several nutrients such as Vitamin D, Vitamin E, Vitamin K, Folate, Potassium, and fiber in order to provide adequate nutrition for a vulnerable patient population for Patients 3, 9, and 16. (Refer to C-0279)
9. 4 of 20 patients did not have appropriate nutrition assessments for wound healing when patients received less than the required caloric and protein intake to maintain adequate nutrition for Patients 3, 9, 11, 16. (Refer to C-0279)
10. 1 of 20 patients had diet order for diabetic patient diet that were not consistent with the patient's assessed nutritional needs. 1 of 20 patients had a recommendation from the registered dietitian to the physician for nutritional supplements but staff did not follow up on the recommendation for Patients 10 and 19. These failures resulted in patients were not provided adequate nutrition. (Refer to C-0279)
11. 2 of 20 patients did not receive timely nutrition assessments for 5- 6 days and were not provide adequate nutrition for Patients 5 and 9. (Refer to C-0279)
12. 2 of 20 patients did not have nutrition care plans for Patients 8 and 18. These failures resulted a failed plan of providing adequate nutrition. (Refer to C-0279)
13. 2 of 20 patients were not screened by nursing to identify potential nutrition risks according to the facility policy for Patients 18 and 20) These failures resulted in a delay in providing at risks patients with the proper nutrition. (Refer to C-0279).

The cumulative effect of these systemic problems resulted in the inability of the hospital's food and nutrition services to direct and staff in such a manner to ensure the nutrition needs of the patients were met in accordance with acceptable standards of practice that may cause cross continuation of food, food borne illness, inadequate nutrition in already compromised patient population, and insufficient disaster food and supplies as evidenced by:

1. A can opener blade had sticky crusty food build up on the blade, a blender had food on the blades, and meal carts were not sanitized. These failure can result in cross contamination. (Refer to C-0279)
2. Shelves that stored food in the walk-in refrigerator were rusted. These failures can result in cross contamination of foods. (Refer to C-0279)
3. One Food Service Worker (Food Service Worker B) did not practice appropriate hand washing and touched other surfaces and clothing when handling food. These failures can result in cross continuation of foods (Refer to C-0279)
4. A filled trash receptacle in the dish washing area was not appropriately covered when not in use and resulted in unsanitary conditions. (Refer to AC-0279)
5. The Dietary Department kept expired foods that were inconsistent with the manufacturer's recommendation. These failures can result in food borne illness. (Refer to C-0279)
6. The maintenance staff was not notified of an excessive accumulation of ice on the floor, ceiling, door gasket and around the condenser in the walk-in freezer. This failure may result in food borne illness. (Refer to C-0222 and C-0279)
7. The Dietary Department did not have adequate food and supplies on hand to carry out the disaster food plan in the event of a disaster. These failures can result in the hospital not having the necessary food to be self sustaining during a disaster. (Refer to C-0279)
8. 3 of 20 patients did not have a nutrition analysis of the patient menus indicated they did not meet the requirements for several nutrients such as Vitamin D, Vitamin E, Vitamin K, Folate, Potassium, and fiber in order to provide adequate nutrition for a vulnerable patient population for Patients 3, 9 and 16. (Refer to C-0279)
9. 4 of 20 patients did not have appropriate nutrition assessments for wound healing when patients received less than the required caloric and protein intake to maintain adequate nutrition for Patients 3, 9, 11, 16. (Refer to C-0279)
10. 1 of 20 patients had diet order for diabetic patient diet that were not consistent with the patient's assessed nutritional needs. 1 of 20 patients had a recommendation from the registered dietitian to the physician for nutritional supplements but staff did not follow up on the recommendation for Patients 10 and 19. These failures resulted in patients were not provided adequate nutrition. (Refer to C-0279)
11. 2 of 20 patients did not receive timely nutrition assessments for 5- 6 days and were not provide adequate nutrition for Patients 5 and 9. (Refer to C-0279)
12. 2 of 20 patients did not have nutrition care plans for Patients 8 and 18. These failures resulted a failed plan of providing adequate nutrition. (Refer to C-0279)
13. 2 of 20 patients were not screened by nursing to identify potential nutrition risks according to the facility policy for Patients 18 and 20) These failures resulted in a delay in providing at risks patients with the proper nutrition. (Refer to C-0279).

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28135


Based on observations, interviews and record reviews, the hospital failed to ensure the nutritional needs of the patients were met in accordance with recognized dietary practices when:

1. A can opener blade had sticky crusty food build up on the blade, blender had food on the blades, and meal carts were not sanitized. These failure can result in cross contamination.

2. Shelves that stored food in the walk-in refrigerator were rusted. These failures may result in cross continuation of foods.

3. One Food Service Worker (Food Service Worker B) did not practice appropriate hand wash his hands and touched other surfaces and clothing when handling food. These failures can result in cross continuation of foods.

4. A filled trash receptacle in the dish washing area was not appropriately covered when not in use and unsanitary conditions.

5. The Dietary Department kept expired foods that were inconsistent with the manufacturer's recommendation. These failures can result in food borne illness.

6. The maintenance staff was not notified of an excessive accumulation of ice on the floor, ceiling, door gasket and around the condenser in the walk-in freezer. This failure may result in food borne illness.

7. The Dietary Department did not have adequate food and supplies on hand to carry out the disaster food plan in the event of a disaster. These failures can result in the hospital not having the necessary food to be self sustaining during a disaster.

8. 3 of 20 patients did not have a nutrition analysis of the patient menus indicated they did not meet the requirements for several nutrients such as Vitamin D, Vitamin E, Vitamin K, Folate, Potassium, and fiber in order to provide adequate nutrition for a vulnerable patient population. (Patients 3, 9, 16)

9. 4 of 20 patients did not have appropriate nutrition assessments for wound healing when patients received less than the required caloric and protein intake to maintain adequate nutrition. (Patients 3, 9, 11, 16)

10. 1 of 20 patients had diet orders for diabetic patient diet that were not consistent with the patient's assessed nutrition needs. 1 of 20 patients had recommended to the physician nutritional supplements but staff did not follow up on the recommendation (Patients 10 and 19) These failures resulted in patients were not provided adequate nutrition.

11. 2 of 20 patients did not receive timely nutrition assessments for 5- 6 days and were not provide adequate nutrition. (Patients 5 and 9)

12. 2 of 20 patients did not have nutrition care plans. These failures resulted a failed plan of providing adequate nutrition. (Patients 8 and 18)

13. 2 of 20 patients were not screened by nursing to identify potential nutrition risks according to the facility policy. These failures resulted in a delay in providing at risks patients with the proper nutrition. (Patients 18 and 20)

These failures had the potential to result in food borne illness and inadequate nutrition in and already medically compromised patient population.

Findings:

1. During a tour of the Dietary Department on 5/14/13 between 9:20 and 10:20 a.m., a table mounted can opener and a church key style can opener were both noted with a buildup of sticky and crusted food residual on the piercing portion of the blades.

During a concurrent interview on 5/14/13 at 9:20 a.m. and 10:20 a.m., Food Service Worker B (FSW B) confirmed the finding and stated that neither can opener was used very often. He stated that they should be clean and sanitized whenever it is dirty. He verified that the can openers were used to open the larger cans of soup when needed and that the dirty can openers could potentially cross contaminate those soups.

The standard of practice for the maintenance of can openers is to keep the piercing parts of the can openers clean to prevent cross contamination (2009 Food Code).

During an observation of the Dietary Department on 5/14/13 at 9:20 a.m. and 10:20 a.m, was a blender cup with residual food particle on the blade. The Food Service Manager (FSM) verified the finding and indicated that the blender cup was not clean and should not have food on it.

During an interview on 5/14/13 at 11:45 a.m., FSW C stated that he wiped the patient food carts after each meal with Oasis 137 (a cleaner solution). She stated that no other products were used to clean the carts after each meal.

During an interview on 5/16/13 at 7:40 a.m.,the Infection Control Coordinator (ICC) stated that the product used on the patient meal carts, Oasis 137, was a cleaner/sanitizer.

A review of the manufacturer's information on Oasis 137 indicated that it was a cleaner, not a sanitizer.

During a follow-up interview on 5/16/13 at 10:00 a.m., the ICC stated that he had reviewed the manufacturer's information on Oasis 137 and it indicated that it was not a sanitizer. He stated that the dietary staff should be using a sanitizer in addition to the cleaner after each meal on the carts.

2. During an observation of the Dietary Department on 5/14/13 at 9:15 a.m. in the walk-in refrigerator shelves used to store the food were noted to be rusted. The finding was verified by the Chief of Patient Care Services. She stated that the shelves were old.


According to the 2009 FDA Food Code, materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, and nonabsorbent, sufficient in weight and thickness to withstand repeated warewashing, finished to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.


3. During an observation in the Dietary Department on 5/14/13 at 10:15 a.m., FSW B was observed wiping his face with his hands then placing his hands in the pockets of his pants. He then continued to work in the food preparation area without washing his hands. Later the same day at 12:00 p.m., FSW B was again observed to have his hands in the pockets of his pants, then continued to take food out of the refrigerators in preparation for trayline without washing his hands. At 12:20 p.m. the same day, FSW B was observed picking up a can that dropped on the floor. He was observed at the handwashing sink but did not wash his hands for 15 seconds.

During a concurrent interview on 5/14/13 at 12:20 p.m., FSW B stated that he used soap to wash his hands. He verified that he did not follow the requirements for 15 second duration of handwashing with soap.

During an interview on 5/16/13 at 8:00 a.m., the Chief of Patient Care Services stated that FSW B had a habit of putting his hands in his pockets. She was not aware that he did not wash his hands after placing them in his pockets.

The hospital's policy titled, "Personal Hygiene and Health of Nutrition Personnel" revised 2/13 revealed that "all nutrition service personnel must... avoid touching face and hair when preparing food. If hair/face is touched, employee must wash hands immediately." It also stated they must "wash hands before starting work, after using the restroom, or being in contact with dirty surfaces..." And the nutrition service personnel must "avoid wiping hands on aprons."


The hospital's policy titled, "Handwashing and Hand Hygiene Observation Tool" (undated) revealed that the duration for hand washing with soap was to be 15 seconds.



4. During an observation of the Dietary Department on 5/14/13 at 9:40 a.m., a filled trash receptacle in the dish washing area was not covered. The trash receptacle was not in use and contained food waste.

During a concurrent interview, the FSM (Food Services Manager) stated that the dietary staff who was assigned to wash dishes was scheduled to come in at 11:00 am. She confirmed that the trash can was not in use and should be covered.

According to the 2009 FDA Food Code, receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered inside the food establishment if the receptacles and units contain food residue and are not in continuous use.



5. During an observation of the Dietary Department on 5/14/13 at 8:50 a.m., 4 individual portion containers of sugar-free chocolate pudding were noted to have a manufacturer's use by date of 5/9/13. The Food Service Manager (FSM) confirmed that the puddings were expired. She stated that the puddings should have been discarded on the use by date. She stated that it was the responsibility of all dietary staff to monitor for expired product and discard it. She was unable to explain why the puddings had not been discarded 5 days earlier.



6. During a tour of the Dietary Department on 5/14/13 at 9:15 a.m. the walk-in freezer, had an excessive accumulation of ice on the floor, surrounding the condenser, on the ceiling of the freezer, on the door gasket and on the racks containing frozen food. During a concurrent interview Food Service Worker B (FSW B) verified the observation and said that the maintenance staff was aware that the freezer would accumulate ice occasionally but he had not informed them of this new accumulation of ice.


During an interview with Maintenance Staff the same day at 9:25 a.m., he stated that he was not informed of this accumulation of ice in the walk-in freezer. He stated that when the temperature of the freezer was turned down, ice would build up. He stated that the amount of ice observed was more than what he was used to seeing. He verified that the accumulation of ice indicated that the freezer was not functioning properly and was a safety hazard to the staff walking in the freezer.





7. On 5/14/13 at 9:45 a.m., the hospital's policy titled, "Disaster/Emergency Feeding" (revised 4/13) was reviewed with a concurrent observation of disaster food storage. On page 5 of 7, the policy contained a supplies list which stated that "supplies will be available to serve 100 persons per meal." Attached was a four day menu. The review of the disaster food storage revealed there were not adequate supplies to furnish the supplies list.

The plan required 20 pounds of sliced meats, there were 14 pounds.
The plan required 2 cases of tuna (in pouches), there was two thirds of one case.
The plan required 48 loaves of bread, there were 28 loaves.
The plan required 100 packages of Macaroni and Cheese, there were 90 packages.
The plan required 400 cookies, there were 100.
The plan required 3 cases of jelly, there was one and one half.
The plan required 1 case of oyster crackers, there was one half of a case.
The plan required 2,000 nine inch foam plates, there were 1,500.
The plan required 3,000 12 ounce foam cups, there were 1,000.
The plan required 1,000 8 ounce foam bowls, there were none.
The plan required 1 case of trash bags, there was less than 1 case.




During concurrent interviews on on 5/14/13 at 9:45 a.m., FSM and FSW B were unable to explain why there were not adequate supplies to carry out the disaster food plan. The FSM verified that there were not sufficient supplies on hand to meet the needs for the planned menu.




8. During the review of patients medical records 5/14/13 through 5/15/13, three patients (Patients 3, 9, and 16) were noted to have pressure ulcers (bed sores).There were no vitamin and mineral supplements ordered.


During an interview on 5/14/13 at 3:45 p.m., the Registered Dietitian (RD) stated that adequate vitamins and minerals would be required to promote wound healing.


The hospital's nutrition analysis of the patient menus dated 4/2013 indicated that all the menus for the regular and therapeutic diets did not meet the Dietary Reference intakes/Recommended Dietary Allowances (DRI/RDA) for some vitamins. The menus did not meet the DRI/RDAs for Vitamin D, Vitamin E, Vitamin K and Folate. They also didn't meet the DRI/RDAs for potassium, or dietary fiber.


The standard of practice would be to ensure institutional menus were analyzed for the nutritional components to ensure they meet the current national standards including the DRI/RDAs of the Food and Nutrition Board of the National Research Council (Academy of Nutrition and Dietetics).


During an interview on 5/16/13 at 12:30 p.m., the FSM stated that she ran a nutrition analysis on all the menus for the various age groups that the hospital served. She then stated that she "ran out of time" to ensure that the menus met the DRI/RDAs.




9.a. The medical record for Patient 11 was reviewed on 5/15/13. The patient was admitted to the hospital on 5/1/13 with diagnoses that included two chronic stage IV pressure ulcers (bed sores) on her trunk area. Stage IV pressure ulcers are where the pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.


A review of the Diet Assessment dated 5/3/13 completed by the RD indicated that the patient's "Nutritional needs estimated at Calories: 15-1600; Protein: 60 grams." The patient's weight was 130 pounds and height was 64 inches. The estimated needs were equivalent to 25-27 calories per kilogram (kg) of weight and 1 gram of protein per kg of weight.


During an interview on 5/15/13 at 4:00 p.m., the RD verified that she calculated 25-27 calories per kg and 1 gram protein per kg. She was unable to state what standard of practice she used to determine the patient's calorie and protein needs.


A review of the hospital's Nutrition Care Manual, update 2013, indicated that for the "assessment of macronutrient requirements for the treatment of pressure sores...it is recommended that patients receive 35 to 50 kcal (kilocalories/calories-this is a standard formula to estimating nutritional needs) per kg body weight per day total calories, 1.2 to 1.8 g (grams) protein per kg body weight per day total protein."

Patient 11's required caloric intake was (35 X 59 kg =2,065 to 50 x 2,950 calories per day). Patient 11 received less than the required caloric intake. Patient 11's protein intake requirements were (1.2 X 59 kg =70.8 to 1.8 x 59= 106.2 grams of protein per day). Patient 11 received less than was required for at patient at risk for wound healing.

During a follow-up interview on 5/15/13 at 4:15 p.m., the RD verified that her assessment of the patient's need were too low to meet the patient's needs for wound healing. She was unable to state how many calories or grams of protein Patient 11's diet provided. She was unable to state how she was able to determine if the patient was able to meet the increased calories and protein needs required for wound healing.


9b. The medical record for Patient 9 was reviewed on 5/15/13. The patient was admitted to the hospital on 5/10/13. A review of the Nursing Assessment: Nutrition Triggers form dated 5/10/13 indicated that the patient had a Stage II (open skin) pressure ulcer which indicated increased nutrition risk. The medical record indicated that the patient's height was 6 feet 4 inches and he weighed 217.4 pounds.


The Diet Assessment dated 5/13/13 completed by the RD indicated that the "Nutritional needs estimated at Calories: 2,500; Protein: 75 grams." The assessment further indicated that the patient had "a stage 2 ulcer" and he was on a regular diet. There were no recommendations to supplement the patient's diet with additional calories or vitamins and minerals.


During an interview on 5/15/13 at 3:30 p.m., the RD stated that to estimate the nutrition needs of the patient, she used 25 calories per kg and less that 1 gram of protein per kg.. She stated that she should have estimated his protein needs at 90 grams instead of 75 grams. She further stated that she should have used 1-1.2 grams of protein per kg. She stated that the hospital's regular diet provided about 2,000 calories. She was unable to state how the patient could consume the needs that were estimated in the assessment (2,500 calories) when his diet only provided about 2,000 calories. She also verified that 2,500 calories estimated needs was 25 calories per kg body weight. This was inadequate to meet the patient's needs for wound healing according to the hospital's Nutrition Care Manual.

Patient 9's estimated caloric requirements according to the hospital policy were supposed to be 35 cc X 98.8 kg = 3,458 to 50 X 98.8 kg. =4,940 calories per day. The protein requirements were 1.2 X 98.8 kg. = 118 to 1.8 X 98.8 kg. =177 grams of protein per day for Patient 9 who was at risk for wound healing.


9c. The medical record for Patient 16 was reviewed on 5/14/13. The patient was admitted to the hospital on 5/12/13. The Nursing Assessment: Nutrition Triggers form dated 5/13/13 indicated that the patient had a Stage II pressure ulcer which indicated increased nutrition risk. The patient's height was 6 feet and his weight was 228.6 pounds.


The Diet Assessment dated 5/14/13 completed by the RD indicated the patient's "Nutritional needs estimated at Calories: 1,800; Protein: 75 grams." It further indicated that the patient's ideal body weight (IBW) was 180 pounds. The diet order was for a regular diet. There were no recommendations to supplement the patient's diet to provide increased nutrition for wound healing.


During an interview on 5/14/13 at 3:45 p.m., the RD stated that the amount of protein patients with stage II pressure ulcer should get was 1-1.2 grams per kg and 25 calories per kg. She said she calculated the patient's nutrition need using his IBW. She further stated that his needs should have been 2,050 calories and 78 grams of protein. She was unable to state what standard of practice she used for determining the nutrition needs of patients with pressure ulcers.


The hospital's Nutrition Care Manual, update 2013, indicated that for the "assessment of macronutrient requirements for the treatment of pressure sores...it is recommended that patients receive 35 to 50 kcal (kilocalories/calories) per kg body weight per day total calories, 1.2 to 1.8 g (grams) protein per kg body weight per day total protein."



Patient 16's caloric requirements were supposed to be 35 X 103.9 kg. = 3,636 to 50 X 103.9 kg. = 5,195 calories per day. The protein intake was supposed to be 1.2 X 103.9 kg. = 124 to 1.8 X 103.9 kg = 187 grams of protein per day for Patient 16 who was at risk for wound healing.




9d. Patient 3's record on 5/15/13, indicated that she was a 73 years old women. Patient 3 was admitted on 5/14/13 with a diagnosis of osteomyelitis (infection in the bone) of the left foot which resulted in the amputation of the 5th toe. The consultant report dated 5/14/13, indicated that she had a poorly healing left lower extremity wound and had been in the swing bed unit (hospital transition unit between acute care and long term care) before admission to the acute care bed.


The lab report on 5/10/13, indicated that her albumin (measurement of protein in the blood) was 2.4 (normal range 3.4-5.0).


The Physician orders, dated 5/14/13, indicated that she was on a regular diet and no supplement were ordered.

A nutrition assessment screening tool was filled out on Patient 3 when she was admitted to the swing bed unit on 5/8/13 and it was faxed to the dietitian. A diet assessment was done by the dietitian on 5/9/13 which indicated that the patient was able to eat and her intake was good as she ate 51 to 74% of the meal. Her estimated calories were 1500 with 55 gms of protein. Her usual body weight was 150 lbs and the assessment indicated that she had a unstagable foot wound (unable to determine depth of wound) upon admission. The assessment indicated that the nutrition therapy goal was to promote wound healing and strategies for achieving goals indicated to assist with preferences and encourage appropriate intake. The assessment indicated that the dietitian discussed the need for protein for wound healing and encouraged animal protein at each meal.



During an observation and interview on 5/16/13 at 11:10 a.m., Licensed Staff A removed a bed sheet, that was over a metal device that held the sheet off Patient 3's legs and feet. Patient 3 was a elderly women who had her left foot bandaged with a white gauze wrap. Patient 3 stated that she had a infection in her foot and had to have her "little toe cut off". Patient 3 stated that the food was good and she ate, but she was not on any special diet or supplements.



The facility provided Nutrition Care Manual updated 2013, indicated that the general recommendation for protein intake was 1.0 g kg to 1.2 kg per day for elderly patients. According to the Nutrition Care Plan, Patient 1 who weighed 150 lbs should have received 68.1-81.7 gms of protein instead of the 55 gms that the dietitian indicated.



The caloric requirements according to the hospital's policy and procedure was supposed to be 35 X 68.1 kg = 2,383 to 50 X 68.1 kg = 3,405 calories per day for Patient 3 who was at risk for wound healing.



During an interview on 5/16/13 at 4 p.m., the dietitian stated that she encouraged the patient to select menu items that were high in protein. The Dietitian stated that she realized that the protein amounts she calculated did not meet the protein needs of the patient.



10.a. The medical record for Patient 19 was reviewed on 5/15/13. The patient was admitted to the hospital on 4/25/13 with diagnoses that included moderate Diabetic Ketoacidosis (a potentially life-threatening complication in patients with diabetes when the blood sugars get very high).



The Diet Assessment dated 4/27/13 completed by the RD indicated the patient's "Nutritional needs estimated at Calories: 2,200; Protein: 56 grams." It further indicated that the patient's diet order was a Consistent Carbohydrate Diet 180 grams (a diabetic diet with 180 grams of carbohydrates a day).




The hospital's "Diet Order Formulary" (undated) revealed that the 180 gram Consistent Carbohydrate diet provided approximately 1,450 calories.



During an interview on 5/15/13 at 2:00 p.m., the RD was unable to state how the patient could meet the estimated nutrition needs of 2,200 calories when the diet provided approximately 1,450 calories. She verified that she did not recommend nutrition intervention(s) to increase the patient's diet to meet the estimated needs.



10b. The medical record for Patient 10 was reviewed on 5/16/13. The patient was admitted to the hospital on 5/11/13.


The Nursing Assessment: Nutrition Triggers form dated 5/11/13 indicated that the patient was age 90 or above which indicted an increased nutrition risk.



The Diet Assessment dated 5/13/13 completed by the RD indicated that the patient's food intake was poor on a soft diet. The "Nutritional needs were estimated at Calories:1,600; Protein: 50 grams." A follow-up note by the RD dated 5/14/13 indicated that the patient ate 50% of her meal. It further stated that the MD ordered a liquid nutritional supplement to improve her nutritional intake. A review of the MD orders showed that there was no order for a nutritional supplement.


During an interview on 5/16/13 at 10:00 a.m., the RD stated that she spoke to the MD and asked him to order a supplement. She verified that she did not check to see if the order was written before writing her note stating there was an order.



11.a. The medical record for Patient 5 was reviewed on 5/16/13. The 86 year old patient was admitted to the hospital on 5/7/13 with diagnoses that included early small bowel obstruction (a partial or complete blockage of the small intestine). A review of the physician orders indicated that the patient was NPO (nothing by mouth, no food or drink) for 6 days on 5/13/13 when the RD completed the first Diet Assessment.



The Diet Assessment dated 5/13/13, indicated that the RD was aware that the patient was NPO for 3 days on 5/10/13, but did not complete an assessment until 5/13/13. Parenteral nutrition (nutrition given to the patient intravenously, directly into the blood) was started on 5/13/13 after the Diet Assessment.


During an interview on 5/16/13 at 8:30 a.m., the RD stated that the hospital's policy was to complete an assessment on patients who have been NPO for 3 days. She stated that on 5/10/13, when the patient had been NPO for 3 days, she noted that the MD wrote a new order to continue the NPO order, so she didn't do an assessment at that time. She verified that a comprehensive assessment should have been completed in order to determine if an alternative means of nutrition.


11b. The medical record for Patient 9 was reviewed on 5/15/13. The 94 year old patient was admitted to the hospital on 5/10/13 with diagnoses that included fever and diarrhea. The Nursing Assessment Nutrition Triggers form dated 5/10/13 indicated that the patient had a Stage II pressure ulcer (partial thickness loss of dermis presenting a shaallow open ulcer with a red pink wound bed, without slough i.e. skin tears, tape burns, blister) which indicated increased nutrition risk.


The Diet Assessment by the RD indicated it was completed on 5/13/13, 3 days after the Nursing assessment indicated the patient was at nutrition risk due to increased nutrition needs for wound healing.


During an interview on 5/15/13 at 3:20 p.m., the RD stated that the Diet Assessment should have been completed within 48 hours of notification that the patient was at increased nutrition risk. She stated that the assessment should have been completed on 5/12/13 but there was no RD working on 5/12/13. She verified that the patient was at increased nutrition risk due to increased needs for wound healing and his advanced age.

The hospital's policy titled, "Nutrition Assessment, Counseling, and Diet Instruction" (revised 2/13) revealed that, "the registered dietitian will assess patients at risk within 48 hours of notification of risk."


12.a. The medical record for Patient 8 was reviewed on 5/15/13. The patient was admitted to the hospital on 5/7/13 with diagnoses that included swelling and pain of the knees with inability to walk, massive obesity and chronic stasis dermatitis (superficial skin irritation and/or darkening and/or thickening of the skin at the ankles or legs caused by inadequate blood flow). On 5/10/13 the patient was admitted to swing bed status (skilled nursing or lower level of care within the hospital). A physician order for a cardiac (heart healthy) diet was noted on 5/10/13.


The Diet Assessment dated 5/10/13 completed by the RD indicated that the patient's appetite was decreased because of pain and she was "taking a stool softener for constipation and also [was] open to more fiber in [her] diet." The assessment further stated "Will monitor intake on 5/13/13."


The medical record did not reveal a nutrition care plan in the interdisciplinary plan of care. There was no care plan that indicated the patient would benefit from additional fiber in her diet or that she had a poor appetite and was at an increase nutrition risk.



During an interview on 5/15/13 at 5:00 p.m., the RD verified that there was no nutrition care and stated that she must have forgotten to write a care plan. She stated that it was the hospital policy to write a nutrition care plan in the interdisciplinary care plans when there was a nutrition risk.


The hospital's policy titled, "Nutrition Assessment, Counseling and Diet Instruction" (revised 2/13) revealed that all swing bed patients were to be assessed by the dietitian within 72 hours of admission to a swing bed. It further stated that the nutrition care was to be documented on the interdisciplinary patient care plan in the medical record.



12b. Patient 18's closed medical record was reviewed on 5/15/13. Patient 18 was admitted on 4/17/13 and discharged on 4/20/13. The "Emergency Department Report" indicated that he was admitted with fever, chills and head pressure and was admitted with diagnoses including Pneumonia, hypertension, and hypercholesterolemia (high cholesterol or fat in the blood). The physician indicated that he had a high glucose (sugar in the blood) reading of 277 (normal less than 100) and albumin (measure of protein in the blood) of 2.2.


The lab summary report for 4/19/13 indicated an Albumin level of 2.0 and on 4/20/13, there was an albumin level of 2.2. Review of the physician orders indicated that the patient was on a low sodium diet.


Patient 18's medical record did not indicate that there was a nutrition plan of care by the dietitian or nurses.



During an interview on 5/14/13 at 11:20 p.m., Licensed Nurse D stated that nutritional needs of the patient should be addressed in a care plan and included in a care plan may be the addition of supplements, assistance with feeding and monitoring lab work and education.



The "Development Of Nursing Care Plan" revised 4/09, indicated that, the admitting registered nurse will initiate a plan of care for patient care based on patient care needs and patient care standards that are consistent with the interventions of other disciplines. The plan of care should include physical problems or needs, patient education and discharge planning needs.



The "Scope of Nutrition Services" last reviewed 5/11/13, indicated under assessment and care of the patient that nursing completed an initial nutrition screen to identify patients at nutritional risk and the registered dietitian conducted a comprehensive nutrition assessment and developed a nutrition care plan for patients at risk.



The "Nutrition Assessment, Counseling and Diet Instruction" policy last reviewed on 5/11/13, indicated that the patient's nutritional requirements shall be summarized and used in the development of a Nutrition Care Plan. Included in the plan are short and long term goals of nutrition therapy, education of the patient/caregiver, and discharge planning.






13.a. The medical record for Patient 20 was reviewed on 5/15/13. The patient was admitted to the hospital on 5/3/13 with a diagnosis of cholecystitis (an inflammation of the gallbladder), and had surgery on 5/3/13.

The physician orders indicated that the patient was on a clear liquid diet containing minimal nutrition from 5/3/13 until she discharged on 5/6/13.


There was no Nursing Assessment: Nutrition Triggers form completed. Also there was no Diet Assessment completed. The patient was discharged on a clear liquid diet to follow at home.



During an interview and concurrent document review on 5/15/13 at 1:00 p.m., the Chief of Patient Care Services verified that there was no Nursing Assessment: Nutrition Triggers form completed for Patient 20's hospital stay. She stated that when the patient came to the hospital, the surgery was scheduled to be an outpatient procedure. Later the patient remained in the hospital and was admitted as an inpatient. She stated that the nurses must have missed completing the Nursing Assessment: Nutrition Triggers form. She verified that all patients admitted to the hospital were required to have the form completed and forwarded to the dietitian.


The instructions on the Nursing Assessment: Nutrition Triggers form revealed that "Nutrition screens completed as part of the admission process will be sent on to the dietitian for review..."



13b. Patient 18's closed medical record was reviewed on 5/15/13. Patient 18 was admitted on 4/17/13 and discharged on 4/20/13. The "Emergency Department Report" indicated that he was admitted with fever, chills and head pressure and was admitted with diagnoses including Pneumonia, hypertension, and hypercholesterolemia (high cholesterol or fat in the blood). The physician indicated that he had a high glucose (sugar in the blood) reading of 277 (normal less than 100) and albumin (measure of protein in the blood) of 2.2.


The lab summary report for 4/19/13 indicated a Albumin level of 2.0 and on 4/20/13, there was a albumin level of 2.2. Review of the physician orders indicated that the patient was on a low sodium (salt) diet.



Patient 18's closed record did not indicate that a "Nutrition Screening And Assessment" form titled "Nursing assessment: Nutrition Triggers" was filled out by the registered nurse. The form indicated several triggers or indicators, when the form should be sent to the dietitian for referral. Albumin less than 2.5 gm/dl or diabetes out of control or as a new onset, were indications or triggers for referral. There was no referral to the dietitian or notes of dietitian assessment in the record.



During an interview on 5/16/13 at 10:10 a.m., Licensed Staff A stated that staff filled out the "Nutrition Screening and Assessment' fo