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Based on interview, clinical document and record review, the hospital failed to ensure a Registered Nurse (RN) evaluated patient care on an ongoing basis for 4 of 20 Patients (patients 4, 9, 11, and 17) when patient weights were found to have significant variances from day to day and were not verified or validated by nursing staff.

This failure had the potential to compromise the nutritional and medical status of patients.

Findings:

a. On 5/5/15 starting at 4:48 p.m., Patient 4's record was reviewed. She was admitted on 5/2/15 with diagnoses that included diabetes, and not eating for the last three days. Her admission weight was recorded at 11:01 a.m. at 140 pounds, and at 17:29 p.m. at 131.5 pounds. There was no indication in the record as to possible reasons for the 8.5 pound weight loss in six hours. Her weight was recorded on 5/4/15 at 150.75 pounds and on 5/5/15 at 149 pounds. There was no indication in the record as to why there was a 10 pound weight increase in two days, and the physician was not notified of the change. There was no indication that attempts were made to determine why there was such a large variance in recorded weights.

b. On 5/5/15 Patient 9's record was reviewed. He was admitted from the Emergency Department on 4/24/15 with diagnoses that included sepsis, hypotension, pneumonia, and acute kidney injury. His initial weight on 4/24/15 indicated 165 pounds. On 4/26/15 his weight was recorded at 181 pounds. There was no documentation in the record as to possible reasons for the 16 pound weight increase in two days.

A review of Patient 9's nutritional intake indicated between 4/29/15 to 5/5/15 he ate nothing for five days and his intake for the three days he did eat ranged from 20 to 100 percent (average of about 50 percent). Registered Dietitian 1 (RD 1) noted in a nutrition assessment dated 5/4/15 that the patient was refusing to eat and recommended TPN (total parenteral nutrition, complete nutrition provided directly into the blood through a vein) which was started on 5/5/15.

c. On 5/5/15 Patient 11's record was reviewed. She was admitted from the Emergency Department on 4/17/15 with diagnoses that included hypoxia, bronchiostasis, and chronic obstructive pulmonary disease. Her initial weight was recorded on 4/17/15 at 153 pounds and at 194 pounds on 4/19/15. On 4/20/15 her weight was recorded at 91 pounds. There was no documentation in the record as to why there was such a huge variance/discrepancy in the documented weights.

Weights documented in the record were:
4/17/15 153 pounds
4/19/15 194 pounds
4/20/15 91 pounds
4/21/15 92 pounds
4/22/15 90 pounds
4/25/15 90 pounds
4/28/15 83 pounds
4/29/15 83 pounds
4/30/15 115 pounds
5/1/15 118 pounds
5/2/15 123 pounds
5/3/15 124 pounds
5/4/15 116 pounds

There was no documentation in the record to indicate an attempt to re-weigh the patient or possible explanations for weight variances.

A review of Patient 11's Nutrition Assessment dated 5/2/15 indicated under the comments section, "Weights documented range from 74-194 pounds. Spoke with patient and husband. Patient's arms and chest were visible. Patient appears underweight. Difficulty eating at times due to what sounded like some sort of esophageal spasming causing stricture which occurs sporadically. Lunch tray was observed. Pt (patient) ate a few bites of a tuna sandwich, but most of the bread was not eaten. Pt also had an Ensure (nutritional supplement) and pudding that had not been eaten yet."

A review of Patient 11's meal intakes indicated they ranged from 25-100 percent.

d. On 5/6/15 Patient 17's record was reviewed. He was admitted on 4/23/15 with diagnoses that included dehydration and non-compliance of taking antibiotics for an infection from 4/18/15. On 4/24/15 the record indicated his weight was 220 pounds. On 4/25/15 his documented weight indicated 203 pounds, On 4/26/15 his documented weight indicated 220 pounds. There was no explanation in the record to indicate why this weight variance occurred.

A review of the data entry screens for these dates indicated on 4/24/15 no source for how the weight was obtained, on 4/25/15 it indicated a bed scale was used, on 4/26/15 no source for how the weight was obtained was documented.

During a concurrent interview Registered Nurse 1 (RN 1) stated nurses were not supposed to over-ride the source for obtaining weights when recording weights. She further stated that if a nurse entered a weight that was significantly different from the previous entry, a note appears on the screen indicating the discrepancy and prompting the nurse to review the entry for accuracy.

During an interview with RD 1 on 5/5/15 at 2:05 p.m., she stated she used the initial weight and subsequent weights to conduct patient nutritional assessments. She further stated it was important for documented weights to be accurate in order to develop an appropriate care plan for each patient who was at nutritional risk.

A review of the hospital policy dated 4/14 entitled "Clinical Housewide Manual, Patient Care Standards" indicated under Section II Guidelines: ...Standards for clinical practice are modeled after a. Clinical Nursing Skills: Basic to Advanced Skills... was the standard used by the hospital to weigh patients.

A review of the hospital policy "Clinical Nursing Skills, Chapter 4 Admission, Transfer, Discharge, Measuring Height and Weight" did not indicate what nurses should do if there was a significant weight variance from the previous measurement.

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Based on observation, interviews, and document review, the hospital failed to ensure there was a full-time Director of Food and Nutrition Services who was responsible for the daily management of the department and who assured policies and procedures were maintained when:

There were deficiencies found in safe food storage, handling, refrigeration and sanitation practices.

These failures resulted in the potential for growth of microorganisms (germs) in food which could lead to food-borne illness and compromise the health of patients.

Findings:

On 5/5/15 at 8:35 a.m., during the initial tour of the kitchen in the presence of Food Production Manager (FPM), the following items were observed:

a. In walk-in refrigerator 4, a box dated 3/2/15 containing ginger roots. The ginger roots were covered with white and green fuzzy substances. The FPM validated the finding, stating the ginger roots should have been removed from the refrigerator.

b. In walk-in refrigerator 4, two sealed bags of fresh broccoli florets dated 3/30/15 and two sealed bags of cauliflower with a use-by date of 5/2/15. The FPM stated fresh produce was good for seven days after receipt and items should be discarded if not used by the use-by-date. The Storeroom Clerk stated the broccoli was received over the weekend and the person filling-in for him put the wrong date label on them. He further stated the broccoli should have been labeled 4/30/15.

c. In walk-in refrigerator 4, eggplant in a container dated 4/22/15, one eggplant was a brownish color and felt very soft when touched. Eggplant in a container dated 4/27/15, one eggplant was a brownish color and felt very soft when touched. FPM validated the finding and stated the eggplant dated 4/22/15 should have been used before those in the container marked 4/27/15. She stated the cooks obtained their own items from storage, and were trained to use old product first.

d. In walk-in refrigerator 4, a box of potatoes wrapped in foil with no date on the box, a box containing six fresh grapefruit with no date on the box, and one box of fresh oranges with no date on the box. The FPM validated the finding and stated all items located in the refrigerator should have both received and use-by dates on them.

e. In walk-in refrigerator 4, a box of sliced zucchini with a pack date of 4/30/15 and a received date of 3/30/05. The Storeroom Clerk stated the zucchini was received over the weekend and the person filling-in for him put the wrong date label on the item.

f. In walk-in refrigerator 5, a bag of corn tortillas with a use by date of 4/19/15. The bag was mixed in with a box of newer corn tortillas. The Storeroom Clerk stated the tortillas should not have been mixed in with the newer tortillas and should have been discarded on 4/19/15.

g. In walk-in freezer 2, a pan containing several individually packaged items labeled "leftovers meat". FPM stated the items were "eye of round" beef. In the same freezer, a pan containing several individually packaged items labeled "leftovers". The FPM stated the items in the second pan were sliced roast turkey. She stated the labeling system used by the hospital allowed the user to specify the name of the item being labeled.

h. In walk-in freezer 2, one box of vegetables and one box of cookie dough that were uncovered, exposing the contents to air. The FPM validated the finding, and stated staff were trained to ensure items were covered and sealed after opening them.

A review of the hospital policy and procedure dated 10/13/14 entitled "How to Label a Food Item", indicated all stored food items should be labeled, and labels should include the product name, opened date, and use-by date.

A review of the hospital policy entitled "Storage" indicated, "Rotate products in storage areas using the FIFO (first in first out) method." It further stated, "Keep all items covered."

A review of hospital training documents entitled "Huddle Meeting Agenda" dated 3/18/15, 3/19/15, 3/23/15, 3/24/15, 3/25/15, 3/30/15, 3/31/15, 4/1/15, 4/3/15, 4/6/15, 4/7/15, 4/8/15, 4/9/15, 4/16/15, 4/13/15, 4/21/15, 4/29/15, and 5/1/15 indicated the topic, "Storage guidelines (everything labeled, dated, book with dates) new label guns, prep 'n print (label system), expired products, chemicals, tickets," was included on the agenda for each of these dates.

According to the FDA Food Code 2013 (3-302.11 and 3-302.12) opened items must be protected from contamination by either resealing or placing them in a sealed container, and items removed from their original packaging must be labeled with their common name.

i. In walk-in refrigerator 1, a pan of chicken tortilla soup dated 5/4/15 with a temperature of 46 degrees Fahrenheit (F) (a measure of temperature). The Food and Nutrition Services Director validated the finding, stating the soup was leftover from the hospital cafeteria, and should have been placed in the blast-chill refrigerator and monitored for time and temperature on the "Cooling Temperature Log" to ensure it met cool-down standards.

A review of the hospital document entitled, "Cooling Temperature Log" indicated the chicken tortilla soup was not included.

A review of the hospital document entitled, "Food Safety Training - Cooling" indicated, "Associates must cool all TCS (time control safety) (foods that could cause food-borne illness if not handled properly) foods to the proper temperature. Use a blast chiller if one is available. Monitor temperatures every two hours using a clean, sanitized, and calibrated digital thermometer. Record the date, product name, and temperature of each product on the Cooling Log at three intervals: at the beginning of the cooling process, two hours after the cooling process begins, and after the product has cooled completely."