HospitalInspections.org

Based on review of the facilities policy and procedures, review of contract services, observations, medical record review, advocacy log review, dietary manual review, job description, ServSafe certification review, and staff interviews, the facility failed to have an effective governing body by failing to have a current written contract for Food and Nutritional services, to document an incident for improvement opportunities for 1 of 1 medication errors and incorrect meal tray for a diabetic patient and to identify and investigate patient complaints and grievances, to evaluate contract for Dietary services, to have a current ServSafe certification for the individual verifying meals are correctly prepared in the kitchen, to have dietary oversight by the dietitian, to ensure a correct diet was served to the patient with diet restrictions in 2 of 2 patients (Patient #8 and Patient #11), to have a diet manual authorized by the dietitian.

The findings included:

1. The facility staff failed to have a current written contract for Food and Nutritional Services.

~ cross refer to 482.12(e) Contracted Services, Tag 0083

2. The facility staff failed to identify a medication error and evaluate and implement improvement opportunities for 1 of 1 diabetic patients reviewed (Patient #8); failed to evaluate and implement improvement opportunities after a discovery of delivery of incorrect diets for 2 of 3 patients with specialty diets (Patients #8 and
#11); and failed to investigate and analyze a patient complaint regarding patient safety for 1 of 2 complaints reviewed regarding patient safety (Patient #10)..

~ cross refer to 482.21(a), (c)(2), (e)(3) Patient Safety, Tag 0286

3. The facility staff failed to review contract dietary services to ensure resolutions to patient's complaints were evaluated and working effectively.

~ cross refer to 482.21 QAPI, Tag 0308

4. The facility staff failed to have a current ServSafe certification for the individual verifying meals are correctly prepared in the kitchen.

~ cross refer to 482.28(a)(1) Director of Dietary Services, Tag 0620

5. The facility staff failed to have a qualified dietitian available for dietary oversight and consultation.

~ cross refer to 482.28(b)(2) Qualified Dietitian, Tag 0621

6. The facility failed to ensure a correct diet was served to patients with diet restrictions.

~ cross refer to 482.28(b)(2) Diets, Tag 0630

7. The facility failed to have a diet manual authorized by the dietician.

~ cross refer to 482.28(b)(3) Therapeutic Diet, Tag 0631

Based on reviews of facility contracts, and staff interviews, the governing body failed to ensure a current, written dietary contract was in place to provide and evaluate Food and Dietary Services according to acceptable standards for a facility census of 14 (fourteen) behavioral health patients.

The findings included:

Review 06/01/2023 of the facility contract provided for Food and Dietary Services revealed a contract between Hospital C and Agency #B that expired January 2022. Interview on 06/01/2023 at 1518 with Executive Director (Ex Dir #2) revealed Agency #B was not providing services to the facility. Review revealed Agency #A was currently providing services to the facility and there was not a written contract between Hospital #C and Agency #A. Review of the expired contract per interview 06/01/2023 at 1518 revealed the contract was being used as a guide for Agency #A. Review of the contract revealed, "... 3. The Contractor shall provide all nourishment and supplement orders during the delivery of lunch service 1130 AM Monday, Wednesday, and Friday ... 5. The Purchaser is responsible for providing appropriate carts, trays and other reusable supplies as required ... 7. The Contractor will provide Clinical Nutritional Assessment through a Licensed Dietitian at an hourly rate ... This Dietitian will provide nutritional assessments for all patients and implement and monitor nutrition care plans. Also the Dietitian will provide nutritional education materials when needed. This service will be provided on Monday, Wednesday and Friday as needed only ... 9. ... this Contract shall extend from date of this Contract through January 31, 2022 for a thirty six month term ...10. Contractor agrees to: *Consult and participate with (Facility Name) for dietary performance improvement projects. *Document a temperature log for all prepared meals to ensure food is within safe temperature range before (Facility Name) staff picks-up meals. Dietary will submit temperature logs to (Facility Name) on a monthly basis ... *Cause the meal production to be supervised by a dietitian or an individual who is certified in ServSafe or Food Services Production and furnish Purchaser's area Agency office with said Supervisor's credentials upon request ...11. Purchaser agrees to: *Evaluate Contractor's performance on an annual basis to include but not limited to: patient complaints, timeliness of providing dry food and beverages when requested, preparing meals within safe temperature range, and submitting temperature logs weekly ..."

Interview on 06/01/2023 at 1518 with Ex Dir #2 revealed he had not evaluated the Food and Dietary contract since he had been at the facility. The Ex Dir #2 had been at the facility since July 04, 2022. Interview revealed reviewing the expired Food and Dietary contract that was currently being used as a guide by Agency #A revealed there are several things that are not correct and are not being provided by Agency #A, current agency providing meals. Interview revealed there was a verbal contract in place between the hospital and Agency # A that used the contents of the expired contract with Agency #B as the agreement and verbal contract. Follow up interview on 06/02/2023 at 1024 with Ex Dir #2 revealed the verbal contract between Hospital #C and Agency #A began December 2021.

Based on policy and procedure review, Performance Improvement, Quality Assurance and Patient Safety Plan Year: 2023, incidents review, complaint forms, Advocacy Log review, observation. medical record reviews, and staff interviews, facility leadership failed to maintain an effective quality assessment and performance improvement program for identifying and investigating patient complaints and grievances and to evaluate contracted services provided for patient care.

Findings include:

1. The facility staff failed to renew/receive a contract for dietary services to ensure resolutions to patient's complaints were evaluated and working effectively.

~ cross refer to 482.21(a), (c)(2), (e)(3) Patient Safety, Tag 0286

2. The facility staff failed to identify a medication error and evaluate and implement improvement opportunities for a diabetic patient; failed to evaluate and implement improvement opportunities after a discovery of delivery of incorrect diets for patients with specialty diets; and failed to investigate and analyze a patient complaint regarding patient safety.

~ cross refer to 482.21 QAPI, Tag 0308

Based on review of policy and procedure, medical record, incident report log, Advocacy Log review, observations, and interviews with staff, facility staff failed to identify a medication error and evaluate and implement improvement opportunities for 1 of 1 diabetic patients reviewed (Patient #8); failed to evaluate and implement improvement opportunities after a discovery of delivery of incorrect diets for 2 of 3 patients with specialty diets (Patients #8 and
#11); and failed to investigate and analyze a patient complaint regarding patient safety for 1 of 2 complaints reviewed regarding patient safety (Patient #10).

The findings included:

1. Review on 06/05/2023 of policy titled "TITLE: CRITICAL INCIDENT REPORTING" with revision date of 02/21, revealed "POLICY: In accordance with its risk management program, (Named facility) will provide an effective process to guide reporting of critical incidents including both internal and external reporting. Critical incidents are defined as those incidents falling into one of the following categories: ....10. Any other serious adverse event... PROCEDURE: 1. Staff should immediately notify the Clinical Director or Administrator On-Call of any critical incidents. 2. The Clinical Director or designee will notify the Medical Director and physician on-call immediately...."

Review of the closed medical record of Patient #8 revealed a 36 year old insulin dependent diabetic female admitted on 05/09/2023 under involuntary commitment for being a danger to herself. Review of admission orders written on 05/09/2023 at 1757 revealed "Tresiba (long acting insulin) 60 units sub Q (subcutaneous) QD (every day). Review of MAR (medication administration record) revealed "5/10/23 0900 Tresiba unavailable." Review of the MAR revealed the nurses initials were circled on the line of 05/10/2023 at 0900 to indicate the insulin was not administered (16 hours and 15 minutes after the insulin was ordered).

Request for interview on RN #8 who documented the insulin was not available.

Review of incidents and medication logs revealed no incident or medication error report was documented. Review revealed there was no follow up of this medication error to identify the preventative actions for unavailable insulin.

Review of the quality log revealed no evidence of follow up of Tresiba. Review revealed no evidence of quality indicators of monitoring of administration of Tresiba.

Interview on 06/05/2023 at 1745 with CNO #5 revealed the nurse documented that the Tresiba was not available. Interview revealed the nurse circled her initials on 05/10/2023 on the MAR. The interview revealed the circled initials indicated the insulin was not given. Interview revealed the RN #8 did not complete the incident report. Interview revealed an incident report should have been completed.

2. Closed medical record review on 06/01/2023 of Patient #8 revealed a 36 year old female admitted on 05/09/2023 for psychoses. Physician orders signed on 05/09/2023 revealed "Diet: Diabetic". Patient #8 was discharged on 05/19/2023.

Review of two photographs supplied by the Executive Director (Ex Dir #2) dated 05/17/2023, 8 days after admission revealed a meal that was served to Patient #8. Review of the meal trays in the pictures revealed one of the meal trays included meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice, and a cake slice. Per interview on 06/01/2023 at 1518 with Ex Dir #2 this was the regular meal tray. Review of the second picture revealed the same foods from the first tray, meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice and two pieces of white bread. Per interview on 06/01/2023 at 1518 with Ex Dir #2 this was the diabetic meal tray.

Interview on 06/01/2023 at 1515 with Ex Dir #2 revealed the pictures from Patient #8's meal were sent to the Ex Dir #2 by the staff with concerns about the contents and accuracy of the diet. Interview revealed the meal was incorrect for a diabetic patient. Interview revealed the meal was served to Patient #8. Interview on 06/01/2023 at 1515 with Ex Dir #2 revealed Ex Dir #2 had notified Contract staff #11 of the incorrect diabetic diet. Interview revealed there was no posting of diet menus for staff to use to verify correct specialty diets were delivered to patients. Interview revealed there was no monitoring of diets to verify correct meals were served to the patients. Interview revealed there were no other actions taken to verify correct meals were being delivered to the patients in the facility.

Interview on 06/05/2023 at 1620 with Contract Dietitian #4 revealed there was not a dietician on site. Interview revealed there was no dietitian at the kitchen where the meals were prepared or on site at the hospital. Interview revealed there was no dietician evaluating the accuracy of diet trays.

Interview on 05/31/2023 with MHT #6 revealed there was no posting of correct meals or snacks for specialty diets. Interview revealed MHT #6 was not certain of the correct snack for the diabetic patient.

3. Observation of the facility's tray delivery area on 06/05/2023 at 1212 revealed MHT #13 bringing in 2 large black cloth bags with torn fabric on the seams of each bag, exposing the lining of each delivery bag. The meals were removed from the black bag by MHT #13. Observation revealed the meals were packaged in styrofoam, compartmentalized containers with no patient names or identifiers on the containers. Observation revealed one of the trays was placed on the counter for it to be delivered to a specific patient. Observation revealed there was no label or writing on the tray to indicate the patient's name or type of diet. Observation revealed a white erase board on the wall beside the door. Observation revealed the board contained the room numbers with a diet. Observation revealed written on the white board was "room 12A (Patient #11) Allergy-Gluten."

Interview on 06/01/2023 at 1020 with Executive Dir #2 revealed no one was monitoring and verifying meals for accuracy. Interview revealed no documentation of the quality data for meal accuracy.

Interview on 06/05/2023 at 1745 with CNO #5 revealed the patient did receive the incorrect tray. Interview revealed an incident report should have been completed. Interview revealed no one was verifying diet meals for accuracy.



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4. Review on 06/05/2023 of the Performance Improvement, Quality Assurance, and Patient Safety Plan Year:2023 not dated revealed " ... Quality services are services that are provided in a safe, effective, patient-centered, timely, equitable, and recovery-oriented fashion ... ... is committed to the ongoing improvement of the quality of care its consumers receive, as evidenced by the outcomes of that care ... continuously strives to ensure that: ... Risk to consumers, providers, and others is minimized ..."

Review of the facility policy titled "Patient Complaint and Grievance Process" reviewed 02/2021 revealed "... *A concern is not a complaint or grievance if the patient is currently in the hospital, and has not yet tried to resolve the issue with the involved staff or department. The Nurse Manager or designee will work with the patient for resolution. If the concern is unresolved and it is a matter of patient's rights, quality of care or patient safety, the matter may be considered a complaint and will be referred to the Clinical Director for follow up ... *All complaints from patients that call or write to the hospital after discharge are considered grievances because the issues were not resolved during their stay. These grievances will be forwarded to the Executive Director or designee for appropriate follow up ..."

Review of the Advocacy log from 01/19/2023 through 05/22/2023 revealed an incident entered on 04/17/2023 for Patient #10 stating "... Issue of Concern ... Patient complains that roommate and male patient had sex in her room and she did not feel safe ... Resolution: (CNO #5) is investigating the incident ... Date of Resolution: (Blank) ... Comments: (Blank)"

Interview on 05/31/2023 at 1515 with Human Resource (HR) #14 revealed CNO #5 "got that complaint" and HR #14 had "not received any information back." Interview revealed there was a patient advocate box in one of the group rooms. Interview revealed the patient filled out the form and either placed it in the box or it was given to a staff member. Interview revealed the box was checked daily for forms. Interview revealed HR #14 reviewed the complaints and checked to see if the patient was still located in the facility. If the patient had not been discharged and was still located in the facility, HR #14 interviewed the patient about the complaint. Interview revealed HR #14 gave all the information to CNO #5 and Ex Dir #2. Interview revealed CNO #5 or the Ex Dir #2 would investigate and when finished, he/she would let HR #14 know the outcome to put on the log and if a letter needed to be mailed.

Interview on 06/01/2023 at 1100 with CNO #5 revealed the patient's complaint was addressed however CNO #5 was not able to provide any information regarding the investigation. Interview revealed CNO #5 did not have any documentation of the outcome and stated the patient that complained was experiencing an increase in manic behavior. Interview revealed CNO #5 felt that if the patient complained directly to her, she would have handled it right then. Interview revealed if CNO #5 was not told directly, the Patient Advocate talked with them and gave the information to CNO #5. Interview revealed it was addressed at that time. Interview revealed sometimes the patient was called on the telephone and the complaint was addressed. Interview indicated that once the complaint was addressed the resolution was documented on the complaint form and sent to HR #14 to put on the log. Interview revealed that when a patient had been discharged, CNO #5 had to contact them via telephone.

In summary, Patient #10 filed a complaint regarding not feeling safe related to the patient's roommate. There was no evidence of an investigation. There was no evidence that the complaint was analyzed to evaluate opportunities to ensure safety.

Based on review of the Performance Improvement, Quality Assurance and Patient Safety Plan Year: 2023, Advocacy log, complaint forms and staff interviews, the facility staff failed to review contract dietary services to ensure resolutions to patient's complaints were evaluated and working effectively.

The findings included:

Review on 06/05/2023 of the Performance Improvement, Quality Assurance, and Patient Safety Plan Year:2023 not dated revealed "... is committed to the ongoing improvement of the quality of care its consumers receive, as evidenced by the outcomes of that care ...Continuous Improvement. Processes must be continually reviewed and improved. Small incremental changes do make an impact, and providers can almost always find an opportunity to make things better ... Performance Improvement (graph) ... Transport/temperature of meals ..." Review revealed an "X" in the boxes for the months February through December for the Transport/temperature of meals part of the graph indicating for those months data should be gathered and reported.

Review of the Advocacy log and complaint forms from 01/19/2023 through 05/22/2023 revealed 17 (seventeen) food and dietary complaints. A complaint and resolution that were both dated 03/20/2023 revealed "Patient complaints (sic) about the food; not specifics (sic) were given. The resolution revealed "food items have been added to help with dietary needs such as strawberries, bananas, grapes, and P&J (peanut butter and jelly) sandwiches between hot meals." The Advocacy log revealed 7 (seven) complaints concerning the food and dietary were filed after the resolution for the 03/20/2023 food and dietary complaint. Review revealed the complaints referenced a need for "more food choices", "need a better dietitian", "the food is horrible ... always cold ... need to upgrade the meal service & (and) quality of food ...", "... food here is not so great and at times it is very hard to eat it ..." "Bread is hard, cheese is burnt, potatoes are hard and difficult to east (sic) ... mixed veges (vegetables) - w/ (with) fruit ... apples sauce was mixed in w/food - was unable- to eat the food because of the apple sauce mixed in ..."

Interview on 06/01/2023 at 1518 with Executive Director (Ex Dir) #2 revealed there had been an increase in patient complaints about the food. Interview revealed the facility had added food items like fruits, (i.e., strawberries and bananas). Interview revealed Ex Dir #2 did not follow up or evaluate resolution of adding additional food items.

Interview on 06/05/2023 at 1750 with CNO #5 revealed she was unaware the Performance Improvement, Quality Assurance, and Patient Safety Plan Year:2023 had the section Transport/temperature of meals. Interview revealed CNO #5 had not collected data for Transport/temperature of meals.

Based on observations, policy review, medical record review, and interviews with staff, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide oversight of food and nutritional needs for behavioral health patients.

The findings include:

1. Nursing staff failed to supervise and ensure correct diets were served to patients with diet restrictions and failed to monitor food consumption of meals and snacks based on the diet ordered.

~cross refer to 482.23(b)(3) Nursing Services, Tag 0395

2. The facility failed to administer insulin as ordered for 1 of 1 patients requiring insulin (Patient #8).

~ cross refer to 482.23(c)(1), (c)(1), & (c)(2) Nursing Services, Tag 395

Based on observations, review of medical records, and interviews with staff, nursing staff failed to supervise and
ensure correct diets were served to patients with diet restrictions for 2 of 3 patients (Patient #8 and #11), and failed to monitor food consumption of meals and snacks based on the diet ordered for 1 of 1 diabetic patient (Patient #8).

The findings included:

Observation of the food tray delivery area on 05/31/2023 at 1155 revealed MHT #10 arrived with 2 large black cloth bags with torn fabric on the seams of each bag, exposing the lining of each delivery bag. The patient meals were removed from the black bag by MHT #6. The meals were packaged in styrofoam, compartmentalized containers with no patient names or identifiers on the containers. MHT #6 opened and viewed the meals. The individual trays were given to the patients as they approached the door. A white board listing room numbers and ordered diets was located on a wall in the area where the trays were being passed out. Observation of the kitchen and dining area revealed no nurse observed the delivery of the trays or meal consumption.

1. Review of closed medical record of Patient #8 revealed a 36 year old diabetic female admitted on 05/09/2023 under involuntary commitment for being a danger to herself. Review of physician orders dated 05/09/2023 at 1145 revealed an order for a Diabetic diet. Review of physician orders dated 05/09/2023 at 1240 revealed "Accucheck x1 (bedside fingerstick to determine glucose results for one time) when pt. arrives to facility." Review of the MAR
(Medication Administration Record) revealed fingerstick results of "387." Review of the physician orders dated 05/09/2023 at 1757 revealed "Tresiba (long acting insulin) 60 units subQ (subcutaneous) QD (every day). Sliding scale insulin protocol with accuchecks TID (three times daily)." Review of MAR revealed "05/10/2023 at 0900 "Tresiba unavailable." Review of MAR on 05/10/2023 revealed fingerstick result of 399 requiring 10 units of Humalog insulin. Review of physician orders dated 05/11/2023 at 1203 revealed "D/C (discontinue) Tresiba. Lantus 48 units subq Q (every) AM." Review of physician orders on 05/12/2023 at 1500 revealed "Lantus 6 units sub Q now-BS (blood sugar) 404." Review of physician orders on 05/12/2023 at 1555 revealed "D/C Accuchecks TID. Start Accuchecks QID (four times daily) with sliding scale coverage." On 05/15/2023 at 1910, "Give 12 units of Humalog now. BS 443." Review of physician orders dated 05/16/2023 at 1244 revealed "Lantus 52 units subq Q AM." Review of the electronic and handwritten Patient #8's MAR dated 05/19/2023 at 0700 revealed no documentation of fingerstick results. Review revealed the MAR did not have any documentation of the results of the fingerstick for the 0700 time. Patient #8 was discharged home on 05/19/2023 at 1150.

Review of two photographs provided by the Executive Director (Ex Dir #2) dated 05/17/2023, (8 days after the patient's admission) that showed a meal that was served to Patient #8. Review of the meal trays in the two pictures revealed one of the meal trays included meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice, and a cake slice. Per interview on 06/01/2023 at 1518 with the Ex Dir #2 this was the regular meal tray. Review of the second picture revealed the same foods from the first tray, meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice, with and two pieces of white bread instead of the cake. Per interview on 06/01/2023 at 1518 with Ex Dir #2 this was the diabetic meal tray.

Interview on 06/01/2023 at 1515 with Ex Dir #2 revealed the pictures from Patient #8's meal were sent to the Ex Dir#2 by the staff with concerns about the contents and accuracy of the diet. Interview revealed the diabetic diet was not correct and accurate. Interview revealed the Ex Dir #2 was unsure who sent the pictures to the Ex Dir#2.

Interview on 06/02/2023 at 1050 with RN #7 revealed there was a concern that Patient #8 did not receive the correct meal tray. Interview revealed she had reported concerns to management before about the patients' diets. Interview revealed the concerns "felt like falls on deaf ears." Interview revealed the meal on 05/17/2023 did not contain foods that were correct for a diabetic diet. Interview revealed the meal was not correct for the diabetic patient. Interview revealed the diet contained too many carbohydrates for the diabetic patient.

Interview on 06/05/2023 at 1320 with PA #1 revealed Patient #8 was ordered a diabetic diet on admission on 05/09/2023. Interview revealed the PA #1 was notified by staff of the concerns about the meal tray on 05/17/2023. Interview revealed concern regarding the appropriateness and correct foods of the tray. Interview revealed there were two photographs of Patient #8's meals were sent to the Ex Dir #2 on 05/17/2023, 8 days after admission. Interview revealed the concern regarding the meal for Patient #8 not being correct was discussed with the Ex Dir #2 on 05/17/2023. Interview revealed no follow up from dietitian or Ex Dir #2 was provided to the PA #1 regarding menus for the diabetic patient. Interview revealed incorrect meal trays "would make sense why patient (#8's) fasting blood sugars were high."

Review of the incident log revealed no incident or adverse event documented related to Patient #8 receiving an incorrect diet.

Interview on 06/01/2023 at 1515 with Ex Dir #2 revealed Ex Dir #2 had notified the contract agency Director of the incorrect diabetic diet, Interview revealed there were no other actions taken to verify meals were being delivered according to the patient's ordered diet. Interview revealed there was no posting of diet menus for staff to use to verify correct specialty diets were delivers to patients. Interview revealed there was no monitoring of diets to verify correct meals were served to the patients.

Interview on 06/05/2023 at 1745 with CNO #5 revealed there is no documentation of meal consumption in Patient
#8's chart. Interview revealed meal consumption should be documented.

Interview on 05/31/2023 with MHT #6 revealed there is no posting of correct meals or snacks for specialty diets. Interview revealed MHT #6 is not certain of the correct snack for the diabetic patient.

2. Observation of the facility's tray delivery area on 06/05/2023 at 1212 revealed MHT #13 bringing in 2 large black cloth bags with torn fabric on the seams of each bag, exposing the lining of each delivery bag. The meals were removed from the black bag by MHT #13. Observation revealed the meals were packaged in styrofoam, compartmentalized containers with no patient names or identifiers on the containers. Observation revealed one tray was placed separate on the counter to be delivered to one patient without labeling or patient's name or type of diet. Observation revealed a white erase board on the wall beside the door. Observation revealed the board contained the room numbers with a diet. Observation revealed "room 12A (Patient #11) Allergy-Gluten."

Review on 06/05/2023 of medical record of Patient #11 revealed a 39 year old female admitted on 06/02/2023 for psychosis with medical diagnosis of Celiac Disease (long term autoimmune disorder, primarily affecting the small intestine, where individuals develop intolerance to gluten, present in foods such as wheat, rye and barley).
Interview on 06/05/2023 at 1220 with MHT #13 revealed the tray does not have a patient's name or type of diet on the tray. Interview revealed the employee at the meal preparation area told MHT #13 that the meal was gluten free. Interview revealed MHT #13 did not know the name or titled of the employee who gave the meal to MHT #13. Interview revealed MHT #13 could not verify the meal was Gluten free. Interview revealed there were no references or resources to verify a gluten free diet.

In summary, findings of the survey revealed facility staff failed to have a process in place to validate correct diets were delivered for patient consumption. Nursing staff failed to supervise meals to ensure correct diets were delivered and failed to monitor meal and snack consumption for a diabetic patient. Review of Patient #8's closed medical record revealed the patient received additional insulin due to elevated finger stick blood sugars that were not controlled during her stay.

Based on review of policy, review of medical records, and interviews with staff, the facility failed to administer insulin as ordered for 1 of 1 patients requiring insulin (Patient #8).

The findings included:

Review of policy titled "Insulin Administration" with a revision date of 01/22 revealed "POLICY: Insulin injections will be administered in accordance with the following procedures by a nurse only...Record on the MAR (Medication Administration Record) the time of the injection and the amount of the insulin."

Review of a closed medical record of Patient #8 revealed a 36 year-old insulin dependent diabetic female admitted on 05/09/2023 at 1145 under involuntary commitment for being a danger to herself. Review of admission orders written on 05/09/2023 at 1757 revealed "Tresiba (long acting insulin) 60 units sub Q (subcutaneous) QD (every day). Sliding scale insulin protocol with accuchecks TID (three times a day)." Review of MAR (medication administration record) revealed "5/10/23 0900 Tresiba unavailable." Review of the MAR revealed RN #9's initials were circled on the medication line on 05/10/2023.

Request for interview with RN #9 revealed RN #9 was not available.

Interview on 06/05/2023 at 1745 with CNO #5 (Chief Nursing Officer) revealed the nurse documented that the Tresiba was not available. Interview revealed RN #9 circled her initials on 05/10/2023 on the MAR. The interview revealed the circled initials indicated the insulin was not given. Interview revealed the physician order to administer the Tresiba was not completed by the nurse because the medication was not available. Interview revealed no documentation of notification of the physician.

Based on review of the dietary contract, dietary therapeutic manual review, personnel file information reviewed, job description, medical record reviews and staff interviews, the hospital failed to ensure contract dietary services were supervised and services provided in an organized manner, and failed to maintain a current written contract for Food and Nutritional Services.

The findings included:

1. The facility staff failed to have a current written contract for Food and Nutritional Services.

~ cross refer to 482.12(e) Contracted Services, Tag 0083

2. The facility staff failed to have a current ServSafe certification for the individual verifying meals are correctly prepared in the kitchen.

~ cross refer to 482.28(a)(1) Director of Dietary Services, Tag 0620

3. The facility staff failed to have a qualified dietitian available for dietary oversight and consultation.

~ cross refer to 482.28(b)(2) Qualified Dietitian, Tag 0621

4. The facility failed to ensure a correct diet was served to patients with diet restrictions.

~ cross refer to 482.28(b)(2) Diets, Tag 0630

5. The facility failed to have a diet manual authorized by the dietician.

~ cross refer to 482.23(b)(3) Therapeutic Diet, Tag 0631

Based on reviews of facility contracts, job description, ServSafe Certification review, and staff interviews, the facility staff failed to have a current ServSafe certification for the individual verifying meals are correctly prepared in the kitchen. The facility had a census of 14 (fourteen) behavioral health patients.

The findings included:

Review of the facility contract provided for Food and Dietary Services revealed a contract with Agency #B that expired January 2022. Interview on 06/01/2023 at 1518 with the hospital's Executive Director (Ex Dir) #2 revealed Agency #B was not providing services to the facility. Interview revealed Agency #A was currently providing services to the facility and there was not a written contract between Hospital #C and Agency #A. Interview with the hospital Ex Dir #2 revealed there was a verbal contract in place between the hospital and Agency #A that used the contents of the expired contract with Agency B as the agreement and verbal contract. Review of the expired contract that per interview is being used as a guide for Agency #A, revealed "... 3. The Contractor shall provide all nourishment and supplement orders during the delivery of lunch service 1130 AM Monday, Wednesday, and Friday ... 5. The Purchaser is responsible for providing appropriate carts, trays and other reusable supplies as required ... 7. The Contractor will provide Clinical Nutritional Assessment through a Licensed Dietitian at an hourly rate ... This Dietitian will provide nutritional assessments for all patients and implement and monitor nutrition care plans. Also, the Dietitian will provide nutritional education materials when needed. This service will be provided on Monday, Wednesday and Friday as needed only ... 10. Contractor agrees to: *Consult and participate with (Hospital Name) for dietary performance improvement projects. *Document a temperature log for all prepared meals to ensure food is within safe temperature range before (Hospital Name) staff picks-up meals. Dietary will submit temperature logs to (Hospital Name) on a monthly basis ... *Cause the meal production to be supervised by a dietitian or an individual who is certified in ServSafe or Food Services Production and furnish Purchaser's area Agency office with said Supervisor's credentials upon request ...11. Purchaser agrees to: *Evaluate Contractor's performance on an annual basis to include but not limited to: patient complaints, timeliness of providing dry food and beverages when requested, preparing meals within safe temperature range, and submitting temperature logs weekly ..."

A request was made on 06/01/2023 and on 06/02/2023 for the Job Description for the Food Service Director, Contract Staff #11's position. As of 06/05/2023 at 1900, the Job Description for Contract Staff #11's position was not provided.

Review of the Job Description provided on 06/08/2023 at 1455 for Contract Staff #11 revealed "Food Service Director ... Essential Functions, Duties, and Responsibilities ... Oversee the appropriate quantities of food are prepared and served according to facility or site plan ... Knows and complies with client's contractual obligations ... Responsible for any state or other inspection of food service operation ... Associated Knowledge, Skills and Abilities ... ServSafe Certified ..." Review revealed the Job Description was not dated and was not signed by Contract Staff #11.

A request for ServSafe certification for Contract Staff #11 was made on 06/01/2023 at 1315. A request during interview on 06/02/2023 at 1346 with Contract Staff #11 was made for a copy of the expired ServSafe certificate. As of 06/05/2023 at 1900, the expired ServSafe certification was not provided.

Telephone interview on 06/02/2023 at 1346 with Contract Staff #11 revealed he had a ServSafe certification. Interview revealed the ServSafe certification he thinks expired about 2 (two) months ago (04/2023). Interview revealed Contract Staff #11 got his ServSafe certification prior to the move to the company in 2019/2020. Interview revealed the ServSafe certification is good for 2 (two) years and then it has to be renewed.

Review on 06/05/2023 of the ServSafe certification provided for Contract Staff #11 revealed the certification was obtained 06/03/2023 (one day after telephone interview acknowledging his certification had expired.) with an expiration date of 06/03/2028.

Telephone interview on 06/07/2023 at 1114 with Executive Director (Ex Dir) #2 revealed the ServSafe certificate that was provided for Contract Staff #11 was the only certificate he has. Contract Staff #11 did not have ServSafe certification prior to the date on the provided certificate of 06/03/2023.

Based on reviews of facility contracts, job description, medical record review of a diabetic patient (Patient #8), photograph review and interviews with staff and patients, the facility staff failed to have a qualified dietitian available for dietary oversight and consultation affecting a facility census of 14 (fourteen) behavioral health patients.

The findings included:

Review on 06/01/2023 of the contract, untitled, revealed "THIS AGREEMENT, made and entered into this the 22nd day of January, 2019 (Revised May 1, 2019) by and between (Hospital #C), Inc. a non-profit corporation, hereinafter referred to as 'PURCHASER' and (Named Health Care system [Agency B], Incorporated, hereinafter referred to as 'Contractor,' being a corporation duly licensed and existing under the law of the state of North Carolina....7. The Contractor will provide Clinical Nutritional Assessments through a Licensed Dietitian...This Dietitian will provide nutritional assessments for all patients and implement nutrition care plans. Also, the Dietitian will provide national education materials when needed. This service will be provided on Monday, Wednesday and Friday as needed only...9. Either party may cancel this Contract upon ninety days written notice to the other party. If not so canceled, this Contract shall extend from date of this Contract through January 31, 2022, for a thirty-six-month term (expired 16 months ago)." Review of contracts revealed no other dietary contract was provided.

Interview on 06/01/2023 at 1515 with the hospital's Executive Director (Ex Dir #2) at 1518 revealed Agency #B was not providing services to the facility. Interview revealed Agency #A was currently providing services to the facility and there was not a written contract between Hospital #C and Agency #A. Interview with the hospital Ex Dir #2 revealed there was a verbal contract in place between the hospital and Agency #A that used the contents of the expired contract with Agency #B as the agreement and verbal contract.

Review on 06/05/2023 of the job description for Consulting Dietitian #3 titled "Regional Dietitian" with Revision date of December 2013 revealed "Responsible for approving crafted diets of contracts and educating individuals on the benefits of maintaining proper dietary standards. Tasks may include, Review and approve menus and menus cycles developed by the Diet Technician and ensure they meet contract specifications..."

Review on 06/05/2023 of the policy titled "Consulting Dietician" with revision date of 05/2023 revealed "POLICY: It is the policy of (named facility) to provide dietician services to develop, supervise, and coordinate all dietician activities. PROCEDURE: (Named Hospital #C) contracts with (Agency #A) a licensed dietician for all dietician services and activities...."

No diabetic diet menus were provided for rotating diet menus upon request.

Open record review on 06/01/2023 of Patient #8 revealed a 36 year old female admitted on 05/09/2023 for psychoses. Physician orders signed on 05/09/2023 revealed "Diet: Diabetic". Patient #8 was discharged on 05/19/2023 at 1150.

Review of two photographs supplied by the Ex Dir #2 dated 05/17/2023, 8 days after admission revealed a meal that was served to Patient #8. Review of the meal tray(s) in the pictures revealed one of the meal trays included meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice, and a cake slice. Per interview on 06/01/2023 at 1518 with Ex Dir #2 this was the regular meal tray. Review of the second picture revealed the same foods from the first tray, meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice, with two pieces of white bread. Per interview on 06/01/2023 at 1518 with Ex Dir #2 this was the diabetic meal tray.

Interview on 06/02/2023 at 1050 with RN #7 revealed there was a concern that Patient #8 did not receive the correct meal tray. Interview revealed she had reported concerns to management before about the patients' diets. Interview revealed the concerns "felt like falls on deaf ears." Interview revealed the meal on 05/17/2023 did not contain foods that were correct for a diabetic diet. Interview revealed the meal was not correct for the diabetic patient. Interview revealed the diet contained too many carbohydrates for the diabetic patient.

Interview on 06/05/2023 at 1320 with PA #1 revealed Patient #8 was ordered a diabetic diet on admission on 05/09/2023. Interview revealed PA #1 was notified by staff of the meal tray on 05/17/2023. Interview revealed a concern regarding the appropriateness of the tray. Interview revealed the two photographs of Patient #8's meals were sent to Ex Dir #2. Interview revealed the concern regarding the meal for Patient #8 not being correct was discussed with the Ex Dir #2. Interview revealed no follow up from dietitian was provided to PA #1 regarding menus for the diabetic patient. Interview revealed incorrect meal trays "would make sense why patient (#8's) blood sugar was high."

Phone interview on 06/01/2023 at 1255 with Contract Dietitian #3 (from Agency #A) revealed no recollection of receiving phone calls regarding Patient #8's diet. Interview revealed Contract Dietitian #3 was a contract dietitian who was responsible for developing diets for the facility. Interview revealed there was no consult for Patient #8.

Virtual interview on 06/05/2023 at 1620 with Contract Dietitian #4 (from Agency #A) revealed the dietitian was not available for consults. Interview revealed dietary consults are currently not available.

Based on review of observations, medical records, photograph review, and interviews with staff, the facility failed to ensure a correct diet was served to patients with diet restrictions in 2 of 3 sampled patients (Patient #8 and #11).

The findings included:

1. Closed record review on 06/01/2023 of Patient #8 revealed a 36 year old female admitted on 05/09/2023 for psychoses. Physician orders signed on 05/09/2023 revealed "Diet: Diabetic". Patient #8 was discharged on 05/19/2023.

Review of two photographs supplied by the Executive Director (Ex Dir) #2 dated 05/17/2023, 8 days after admission revealed a meal that was served to Patient #8. Review of the meal trays in the pictures revealed one of the meal trays included meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice, and a cake slice. Per interview on 06/01/2023 at 1518 with Ex Dir #2 this was the regular meal tray. Review of the second picture revealed the same foods from the first tray, meatballs, broccoli pieces, pineapple cubes, sweet and sour sauce on rice and two pieces of white bread. Per interview on 06/01/2023 at 1518 with Ex Dir #2 this was the diabetic meal tray.

Interview on 06/01/2023 at 1515 with Ex Dir #2 revealed the pictures from Patient #8's meal were sent to the Ex Dir #2 by the staff with concerns about the contents and accuracy of the diet. Interview revealed the meal was confirmed to be incorrect for a diabetic patient. Interview revealed the Ex Dir #2 was unsure who sent the pictures to the Ex Dir #2.

Interview on 06/02/2023 at 1050 with RN #7 revealed there was a concern that Patient #8 did not receive the correct meal tray. Interview revealed she (RN #7) had reported concerns to management before about the patients' diets. Interview revealed the concerns "felt like falls on deaf ears." Interview revealed the meal on 05/17/2023 did not contain foods that were correct for a diabetic diet. Interview revealed the meal was not correct for the diabetic patient. Interview revealed the diet contained too many carbohydrates for the diabetic patient.

Interview on 06/05/2023 at 1320 with PA #1 revealed Patient #8 was ordered a diabetic diet on admission on 05/09/2023. Interview revealed the PA #1 was notified by the nurses of concerns regarding the appropriateness of the meal tray for Patient #8. Interview revealed the photograph of Patient #8's meal and a regular diet meal were sent to Ex Dir #2. Interview revealed the concern of the incorrect diabetic diet was discussed with the Ex Dir #2. Interview revealed no follow up from the dietitian was provided to PA #1 regarding menus to the diabetic patient. Interview revealed no follow up was made by PA #1 with the Ex Dir #2 regarding the foods on the meal tray. Interview revealed incorrect meal trays "would make sense why Patient (#8's) blood sugar was high."

2. Observation of the facility's tray delivery area on 06/05/2023 at 1212 revealed MHT #13 bringing in 2 large black cloth bags with torn fabric on the seams of each bag, exposing the lining of each delivery bag. The meals were removed from the black bag by MHT #13. Observation revealed the meals were packaged in styrofoam, compartmentalized containers with no patient names or identifiers on the containers. Observation revealed one of the trays was placed on the counter for it to be delivered to a specific patient. Observation revealed there was no label or writing on the tray to indicate the patient's name or type of diet. Observation revealed 16 meals were removed from the black bags. Observation revealed a white erase board on the wall beside the door. Observation revealed the board contained the room numbers with a diet. Observation revealed written on the white board was "room 12A (Patient #11) Allergy-Gluten."

Review on 06/05/2023 of the medical record of Patient #11 revealed a 39 year old female admitted on 06/02/2023 for psychosis with medical diagnosis of Celiac Disease (long term autoimmune disorder, primarily affecting the small intestine, where individuals develop intolerance to gluten, present in foods such as wheat, rye and barley).

Interview on 06/05/2023 at 1220 with MHT #13 revealed the tray did not have a patient's name or type of diet on the tray. Interview revealed the employee at the meal preparation area told MHT #13 that the meal was gluten free. Interview revealed MHT #13 did not know the name or title of the employee who gave the meal to MHT #13. Interview revealed MHT #13 could not verify the meal was Gluten free. Interview revealed there were no references or resources available to verify a gluten free diet.

Based on therapeutic diet manual review and staff interview, the facility failed to have a diet manual authorized by the dietitian.

The findings included:

Review on 06/02/2023 of the hospital dietary department's current therapeutic diet manual, "Nutrition Care Manual, North Carolina Dietetic Association (NCDA), Inc. 2021" revealed the manual was dated November 2021. Review revealed no dietitian signature, indicating approval and review of the diet manual.

Virtual interview on 06/05/2023 at 1620 with Contract Dietitian #4 revealed the manual should be signed and reviewed by the assigned dietitian. Interview revealed the manual did not have a signature page from the dietitian.

Review of the dietary manual revealed no diabetic diet was listed on the index of the dietary manual. Review revealed the dietary manual did not contain a diabetic diet.

NC00195957