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Based on observation, interview, and document review, the hospital failed to ensure that data collected for dietary audits were accurate. There was no documented evidence to demonstrate that noncompliant findings were captured on the proper food storage and handling audits. Lack of documented noncompliance data impeded the hospital's ability to collect accurate data related food and nutrition services.

Findings:

On 3/28/16 at 8:20 A.M., a joint observation and interview of a Food and Nutrition Services refrigerator "Thaw shelf" was conducted with the Food and Nutrition Services Manager (DMS) 6. A box of cheese manicotti labeled "Keep Frozen" was observed on the thaw shelf. The DMS 6 removed the box from the shelf and disposed it in a trash can. During the interview, the DMS 6 stated that the cheese manicotti was pulled for use in a recipe over the weekend. The DMS 6 stated that the cheese manicotti should have been placed back in the freezer.

The hospital's Performance Improvement (PI) Plan, dated 12/2015, indicated the plan's goal and objectives coordinated and integrated all performance improvement to assure quality of care was delivered. The PI plan indicated comparative data was benchmarked, and emphasized as a framework for planned, systematic, organization-wide approach to planning, designing, measuring, assessing and improving processes and outcomes. In addition, the PI plan indicated data was systematically aggregated and analyzed, using statistical tools and techniques, on an ongoing basis to determine if levels of performance, patterns, or trends vary substantially from those expected, including if improvement was sustained.

On 3/29/16 at 7:30 A.M., the hospital's document titled Proper Food Storage and Handling Audit, dated 2/1/16 through 3/28/16, was reviewed. Proper Food Storage and Handling audits, dated 2/1/16, 2/8/16, 2/15/16, 2/22/16, 2/29/16, 3/7/16, 3/14/16 and 3/21/16 were initialed by Food and Nutrition Services (FNS) staff respectively. However, the audits did not contain a tally of identified noncompliance. In addition, the observation of the cheese manicotti was not documented or tallied as a noncompliance when it was identified during the 3/28/16 tour of the kitchen.

On 3/30/16 at 11:00 A.M., a quality assessment and performance improvement (QAPI) interview with the hospital's leadership was conducted. During the interview, the DMS 6 stated that the FNS audited and documented on a weekly basis. The DMS 6 acknowledged that the Proper Food Storage and Handling audits did not indicate a tally of noncompliant observations and findings. In addition during the interview, the DMS 6 and the Director of Nursing/Performance Improvement (PI) 1 acknowledged that the hospital's audits did not contain tallies of noncompliance related to proper food storage and handling. The DMS 6 and PI 1 further acknowledged that inaccurate data collection prevented the hospital's ability to accurately measure, analyze and track dietary data, in an effort to identify and sustain dietary and nutrition services performance, in accordance with the hospital's PI plan.

Based on medical record review, administrative and nursing staff interview, and document review, the hospital failed to ensure the nutritional needs, for 2 of 31 sampled patients (1, 3), were met in accordance with physician's orders and hospital policies when: 1) The nursing admission assessment failed to identify nutrition risk factors and a physician ordered calorie count was not implemented in a timely manner for Patient 1, and 2) Patient 3 who did not receive a reevaluation of weight in accordance with standard nursing care.

Findings:

1. Patient 1 was admitted with psychiatric diagnosis as well as diabetes, hypertension and Vitamin D deficiency. Medical record review was conducted on 3/29/16 beginning at 9:00 A.M. A History and Physical, dated 3/13/16, noted poor intake and weight loss. An emergency room nutrition screening completed on 3/13/16 noted that the patient was experiencing weight loss, had poor dietary intake and had not eaten in 3 days. Admission diet order, dated 3/13/16, was a No Concentrated Sweets Diet. The admission assessment, dated 3/13/16, completed on the admitting unit failed to note any of the nutritionally related risk factors. In a concurrent interview with Registered Nurse (RN) 4 she stated that admitting nursing staff would have access to all information entered into the electronic medical record. In a concurrent interview with Administrative Staff (AS) 1 she stated that any of the selected nutritional risk factors would generate the request for a nutrition assessment by the Registered Dietitian (RD). Review of dietary intake beginning on 3/14/16 revealed less than 50% intake on all meals, with multiple refusals.

On 3/17/16 (4 days after admission), the physician requested a nutritional consult. On 3/18/16, the physician ordered a calorie count. The calorie count was not initiated until 3/21/16, 3 days after the physicians' order. In a concurrent interview with AS 1 and RN 4, they stated that while nursing was the responsible party for collecting data for calorie counts, they relied on the RD to provide them the forms. The interview also revealed that the weekend coverage for Hospital B was provided remotely from Hospital A. When requests for a nutrition assessment was generated it would automatically print at Hospital A, rather than at Hospital B. Upon receipt of the assessment request by Hospital A, the diet clerk would fax the request to the Food Service Manager's office at Hospital B. AS 1 stated that the calorie count was initiated the following Monday. They acknowledged lack of access to forms delayed the initiation of the physicians' order.

The hospital's policy titled "Calorie Count", reviewed 7/13, revealed that the procedure was specific to Hospital A where trays were delivered with patient meal tickets that was used as the mechanism to document calorie intake. The procedure was not specific to Hospital B where patient meal tickets were not available. Review of hospital policy titled "Assessment, Inpatient Admission", reviewed 8/15, noted the intent of the assessment was to document and report significant findings as well as to identify needs and problems that will be the basis of the patient's care plan. While the procedure provided guidance to nursing staff on the general assessment, including elements such as screening for skin, falls and respiratory it did not include guidance in relationship to nutrition risk screening. The screening did provide a statement for ancillary department referral, however the screening did not provide an explanation of what that entailed.

2. Patient 3 was admitted to Hospital B with complaints which included depression, anxiety, weakness and pain. An emergency room admission assessment and nursing unit admission assessment both dated 3/20/16, failed to note any nutritional risk factors. Admission height and weight, dated 3/20/16, was documented as 5 feet 5 inches and weight was 167 pounds. It was also documented that this weight was taken on a hospital standing scale. A comprehensive nutrition assessment, dated 3/28/16, documented a weight of 173 pounds. As a result of the weight discrepancy, the Registered Dietitian (RD) requested a reweigh of the patient. In a concurrent interview with Administrative Staff 1, she stated that the reweigh request would be done via telephone call to nursing staff; however, there was no documentation of the communication. In an interview on 3/30/16 at 11:45 A.M., with Administrative Staff 2, she stated that if a significant change in weight was documented it would be the responsibility of nursing staff, as part of standards of nursing care, to evaluate and reweigh patients as necessary.

Hospital policy titled "Weight, Patient", reviewed 8/15, guided staff that Behavioral Health patients will be weighed on a weekly basis or more frequently if indicated by diagnosis.



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Based on observation, interview, record, and document review, the hospital failed to ensure that a nursing care plan was revised in accordance with their policy and procedure, to reflect nutritional and educational goals, for 1 of 31 sampled patients (14). A box of leftover food which belonged to Patient 14, was observed inside a refrigerator on the Medical Surgical unit. Patient 14's leftover food was not in accordance with the hospital's dietary recommendations for the patient. There was no documented evidence that staff were aware that food from an outside source had been brought in for Patient 14. In addition, there was no documented evidence that staff educated the patient related to recommended dietary needs during hospitalization.

Findings:

On 3/28/16 at 10:20 A.M., a joint interview and tour of the 5th floor Medical Surgical unit was conducted with the Director of Telemetry (DOT), Director of Surgery (DOS), and a charge nurse (Registered Nurse - RN) 15. A box of leftover undated food which belonged to Patient 14, was observed inside a refrigerator on the Medical Surgical unit. Patient 14's refrigerated food was identified as leftover Mexican food, by RN 15.

On 3/28/16 at 3:30 P.M., an interview was conducted with the DOT and Patient 14. Patient 14 stated that family brought a bean burrito and rice as well as other take out foods, in for the patient on more than one occasion. Patient 14 stated that he was aware of his prescribed diet orders. However, Patient 14 stated that he wanted to eat the food that had been brought in.

Patient 14 was admitted to Hospital A on 3/22/16 with diagnoses which included atrial flutter (irregular heart beat) and congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) per the History and Physical, dated 3/23/16.

Physician's orders, dated 3/22/16, indicated Patient 14 was placed on a cardiac low cholesterol, lowfat 3 gram sodium diet.

The hospital's policy and procedure titled "Plan of Care, Interdisciplinary", dated 5/2014, indicated that the care plan will be updated as pertinent information was obtained.

On 3/29/16 at 10:00 A.M., an interview and review of Patient 14's care plans were conducted with the DOT and RN 15. RN 15 and the DOT were not aware that Patient 14 had been receiving food from an outside source. Both the DOT and RN 15 acknowledged that the nutritional care plan was not revised in accordance with their policy and procedure. They both acknowledged that the care plan should have reflected any changes to the patient's prescribed diet or any diet noncompliance. The lack of a revised care plan did not ensure that staff were aware of the patient's noncompliance with his diet.

Based on observation, interview, record, and document review, the hospital failed to ensure that a Registered Nurse (RN) 16 who completed the hospital's preceptorship (department specific new employee orientation), was competent to perform all nursing tasks independently. RN 16 did not accurately complete an admission nursing nutritional assessment, for 1 of 31 sampled patients (7). The lack of assessment accuracy did not ensure that nursing communicated all aspects of the assessment to the interdisciplinary staff in an effort to sustain continuity of care.

Findings:

On 3/29/16 at 4:30 P.M., a tour of the Rehabilitation unit (patient care unit where physical, occupational and speech therapies are conducted) with the Director of Telemetry (DOT), Director of Surgery (DOS), Rehabilitation Manager (RM) and Registered Nurse (RN) 16.

On 3/29/15 at 4:50 P.M., an interview and review of Patient 7's medical record was conducted with the RM and RN 16.

Patient 7 was admitted to Hospital A on 3/17/16 with diagnosis which included severe protein-calorie malnutrition per the History and Physical, dated 3/18/16.

Patient 7's nursing nutritional assessment indicated "...yes to any of the questions above, click yes to the next question to order a nutritional consult." Patient 7's assessment indicated yes to three of the questions; however, the section to order a nutritional consult was marked "no".

During the interview, RN 16 stated the purpose of the nursing nutritional assessment was to assist staff with determining the appropriate nutritional needs for the patient. RN 16 acknowledged that the assessment criteria triggered a dietary consult. RN 16 acknowledged that he should have clicked yes to the next question which would have led to a nutritional consult order. In addition, RN 16 stated that he was a new employee who recently completed the hospital's preceptorship.

On 3/30/16 at 10:40 A.M., RN 16's employee file was reviewed with a Human Resources staff (HR) 1 and the RM. RN 16's "RN/LVN (Licensed Vocational Nurse) General Orientation Skills Summary"(Competency), dated 3/8/16- 3/26/16, was reviewed. The assessment legend indicated the following scores: 1: Minimal experience-need additional teaching/practice, 2: Moderate experience-can perform without supervision, 3: Experienced-Thorough knowledge, no supervision required. RN 16's competency related to admission assessment/documentation, indicated a score of 1 which was the employee's self assessment.

On 3/30/16 at 11:45 A.M., an interview was conducted with the RM. The RM acknowledged that RN 16's competency showed that RN 16's self assessment was scored as a 1 (minimal experience-need additional teaching/practice) for admission assessment documentation. He agreed that if RN 16 felt that he needed additional teaching/practice, RN 16 should not have been independently performing and documenting assessments. In addition, the RM acknowledged that Patient 7's assessment indicated yes to three of the questions which would have resulted in a nutritional consult order. The RM acknowledged that an accurately documented assessment was an essential part of nursing communication amongst the interdisciplinary staff involved in the patient's care.

Based on dietetic services observations, dietary staff interview, and dietary document review, the hospital failed to ensure policy/procedure development in accordance with acceptable standards of practice as evidenced by the lack of development of a consistent 3-step cleaning/sanitation process for fixed and mobile equipment. Failure to properly clean/sanitize equipment may result in potential chemical and/or bacteriological cross contamination of equipment.

In addition, the hospital failed to ensure that food storage in a "Grab and Go" refrigerator for self serving, was equipped with utensils for proper handling and infection prevention. A container of hard boiled eggs was observed without a serving utensil in the "Grab and Go" refrigerator. The lack of daily oversight, did not ensure that dietary staff maintained proper handling and infection prevention of self serving food items for self serve use.

Findings:

1. The standard of practice for cleaning of equipment utilized in dietetic services would be to include a distinct 3-step process that includes washing with detergent, rinsing with water, followed by a sanitation step and air drying. During sanitation review at Hospital A on 3/30/16 beginning at 9:10 A.M., Dietary Staff (DS) 3 described the cleaning process for patient meal carts. He stated that once the cart was emptied he would wipe it down with a sanitizer and place it back in service. He also stated that if there were food particles stuck on the cart he would scrub them off. DS 3 utilized the same procedure for cleaning stainless steel work surfaces.

Review of hospital policy titled "Cleaning and Sanitation Procedures- [Hospital A's name]", reviewed 1/16, revealed that not all of the procedures were consistent with the standard of practice. As an example cleaning of the steam jacketed kettle guided staff to scrub with a detergent solution followed by a sanitizer. There was no rinse step. Guidance for cleaning the stainless steel surfaces was also similar. Inconsistencies were also noted in other areas of the policy. There was no defined procedure for cleaning patient meal carts.



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2. On 3/28/16 at 8:30 A.M., a joint observation and interview of a Food and Nutrition Services refrigerator "Grab and Go" refrigerator located in Hospital A's public cafeteria was conducted with the Food and Nutrition Services Manager (DMS) 6. A container of hard boiled eggs was observed without a serving utensil in the "Grab and Go" refrigerator. The DMS 6 removed the container of eggs from the shelf and placed them in another refrigerator behind a counter for staff use only. During the interview, the DMS 6 stated that the hard boiled eggs were moved to the staff refrigerator after breakfast hours and provided to the public upon request. In addition, the DMS 6 acknowledged that the container did not have a serving utensil for removal.

On 3/30/16 at 11:00 A.M., a quality assessment and performance improvement (QAPI) interview with the hospital's leadership was conducted. The DMS 6 stated that the hospital did not implement the use of utensils for handling hard boiled eggs. In addition, he stated that staff were trained to observe the eggs for cross contamination and discard any eggs that appeared compromised. In addition, the Registered Dietitian (AS) 1 stated that the hard boiled eggs were not peeled and therefore, utensils were not provided for self serve use.

The hospital's policy and procedure titled "Food Serving and Display", dated 1/2016, indicated "B.6. Tongs, forks, spoons, picks, spatulas, scoops, disposable gloves and other suitable utensils shall be provided and shall be used by employees to reduce manual contact with food to a minimum. For self service by customers, similar implements shall be provided."

An excerpt from the California Food Code, 2013 follows: "Consumer self-service operations for ready to eat foods shall be provided with suitable utensils or effective dispensing methods that protect the food from contamination."

The hospital's policy and procedure in accordance with the California Food Code, 2013, were not implemented when utensils were not provided in an effort to reduce manual contact with food to a minimum and contamination.