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Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to identify and assess patients who were at risk for altered nutritional status. Findings:

A hospital policy titled, Nutrition Screening, Assessment and Reassessment, documented, "... Clinical Nutritional Services will be responsible for routine nutrition screening and assessment of hospitalized patients...

Patients with positive Nutrition Screen scores upon Admission Assessment will be seen within 72 hours of notification... TPN, tube feedings, patients in Intensive Care Units with positive Nutrition Screen Scores (excluding cardiac surgery/post-operative patients) will be seen within 48 hours of notification... Nutrition Consults... will be seen within 48 hours of notification...

Nutrition Assessment will be completed by a registered dietitian:...

3.2 if patient is found to be at nutrition risk per the Admission Assessment nutrition screen...

3.4 if the patient has an extended hospital stay (greater than seven days) and has not otherwise been assessed...

3.6 for all patients receiving nutritional support (tube feeding, total parenteral nutrition, peripheral parenteral nutrition)...

3.10 for pregnant patients not admitted for delivery...

3.11 patients who have decubitus/pressure ulcers..."

1. Patient #1 was admitted for fetal growth retardation and pre-term labor. No nutritional screen or assessment was found in the clinical record. The patient was re-admitted 12 days later for emergency cesarean section of twins and was hospitalized for five days. No nutritional screening or assessment was documented for the second admission.

2. Patient #2 was admitted with a diagnosis of an unintentional weight loss of 35 lbs. A nutritional assessment was ordered but was not completed prior to the patient's discharge.

3. Patient #3 was admitted as an obstetrics patient. After delivery, she was diagnosed with pneumonia, a clostridium difficile infection, diarrhea, poor appetite and weight loss. The patient did not have nutritional screening or a nutritional assessment by a clinical dietitian.

4. Patient #4 was an adolescent male treated in the intensive care unit for a head injury. The clinical record documented the patient was not eating. There was no nutritional screening or assessment documented in the clinical record.

5. Patient #6 was admitted with a history of uncontrolled diabetes, skin ulcers, unintentional weight loss, sepsis, fever and loss of dentition. A nutritional assessment was ordered but not completed prior to discharge.

6. Patient #15 was admitted with diagnoses which included diabetes mellitus, hypertension, morbid obesity, surgical site infection and diarrhea. The admission nutritional screening did not trigger a nutritional assessment.

7. Patient #16 was admitted with orders for daily weights. The patient had a PEG tube with tube feedings. The admission nutritional screening did not trigger a nutritional assessment. A nutritional consultation was performed 13 days after admission.

8. Patient #19 was admitted with a history of peptic ulcer disease, diverticulitis, anemia and weight loss greater than 8 percent in one month. The patient had undergone a bowel resection and splenectomy and was on a clear liquid diet for five days. The nutritional screen did not trigger a nutritional assessment. A nutritional assessment was later documented six days after admission and one day prior to discharge.

9. In an interview 10/17/2012 Staff E, a dietitian, told surveyors the clinical dietary staff relied on the nutrition screening by the nursing staff to trigger a nutrition consult, a physician order for a consult, or clinical staff to contact them with nutritional concerns. Staff E told surveyors the nutrtion screening process was in the electronic documentation. Staff E did not know if there was a separate process for obstetrics (OB) patients (components of the OB assessments are scanned into the system and are not electronically linked into the computerized system). Staff E told surveyors once a nutrition screen triggers a nutritional consult the dietitians have seventy two hours to complete the assessment.

Based on observation, policy and procedure review and staff interview, it was determined the hospital failed to follow policies and procedures related to:

a. proper inspection and certification of electrical equipment in the OR; and

b. surgical staff preparedness and training in emergency procedures.

The hospital also failed to fully develop the surgical attire policy and procedure to include guidance for surgical attire worn outside of the department. Findings:

On 10/16/12 and 10/17/12, tours of the surgical areas were conducted. The following observations were made:

1. A lithotripsy machine did not have a clinical engineering inspection and certification tag.

2. A C-arm had an expired current clinical engineering tag.

Clinical engineering staff were made aware of the findings. No comment was made.

3. During the tour, CRNA #1 was asked if he knew the location of the department medical gas shut off valves. He stated he did not. When he was shown the shut off valves, he stated he did not know how to turn them off in an emergency.

4. At various times during the survey, surgery department staff were observed in surgical attire (uncovered, i.e., no lab coat or other appropriate covering) outside the surgery area. Surgery department staff were observed in surgical attire in the hospital lobbies, common halls and hospital cafeteria. The staff were observed returning to the OR and they did not change into different surgical attire.

Staff were also observed outside of the surgery department wearing surgical shoe covers. The staff were seen in various common areas of the hospital and they returned to the OR without changing their shoe covers.

A review of the Dress Code Policy for Surgery had no guidance on covering or changing surgical attire when leaving and returning to the department and had no information on changing shoe covers when they are worn outside of the department.