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Based on medical record and document review and staff interview, the hospital failed to ensure the Dietetic Technician, Registered (DTR) provided nutrition care to two of 39 sampled patients (Patient 351 and 352) as per the State of California, Business and Professions Code at 2586.

Findings:

According to the State of California Business and Professions Code at 2586, a dietetic technician, registered under the "direct supervision" of a Registered Dietician (RD) may assist in the implementation or monitoring of services, but may not develop nutritional or dietary therapy or treatments.

1. Medical record review conducted on July 12, 2010, showed Patient 351 was admitted to the psychiatric unit on July 8, 2010 with diagnoses of bipolar disorder. On July 8, 2010 the physician ordered an 1800 calorie diabetic diet and a "RD Consult". Further review of the record showed the nurse admission assessment dated July 8, 2010, documented Patient 351 required referral to dietary. A review of the labs showed a random blood sugar of 215 mg/dl on July 7, 2010, and 206 on July 8, 2010.

A review of the document titled "Nutrition Services Adult Initial Assessment" dated July 9, 2010 showed the form had been completed by a Registered Dietetic Technician (DTR) and had identified hyperlipidemia, high blood pressure, alcohol abuse and uncontrolled type two diabetes as components of the "Patient Active Problem List". In addition, Patient 351 had gained 13 pounds based on the computerized weight history from October 28, 2009, (302 pounds) to July 7, 2010, (315 pounds). The weight history documented "possible weight loss prior to admit. Will monitor for trend." The assessment by the DTR showed Patient 351 was morbidly obese, but the nutrition risk was determined to be "low." There was no plan to address the morbid obesity other than to continue the diet and monitor.

In addition, the DTR had initiated and conducted therapeutic diet education on an ADA (American Diabetes Association) therapeutic diet. There was no physician order or protocol in the record to educate the patient on the therapeutic diet.

On July 12, 2010 at 2 p.m. the Clinical Nutrition Manager (CNM) stated it was the practice in the facility for the Registered Dietitian (RD) to co-sign the DTR assessments to show the assessment information had been reviewed as accurate. The RD stated that it was not her practice to verify or initiate the dietary therapy or treatment plan in the psychiatric unit. There was no evidence the DTR had referred to the RD for supervision or direction based on the assessment information as documented.

Further review of the facility policy and procedure titled "Nutritional Assessment and Reassessment" formulated September 2008, showed it was the facility practice for a "nutrition evaluation" to be conducted by a RD or a DTR. The policy showed the "Nutritional Plan of Care" is a component of the interdisciplinary plan of care. There was no provision in the policy and procedure to refer the assessment to the RD for development of diet therapy or dietary treatments.

2. Medical record review conducted on July 12, 2010 showed Patient 352 was admitted to the psychiatric unit on July 9, 2010, with diagnosis that included bipolar disorder and severe psychosis. The physician ordered Patient 352 a 1800 calorie diabetic diet. The initial nursing admission assessment dated July 9, 2010, showed the patient was five foot one and weighed 171 pounds.

A review of the document titled "Nutrition Services Adult Initial Assessment" dated July 9, 2010, showed the form had been completed by a Registered Dietetic Technician (DTR) and had identified type two diabetes mellitus, hyperlipidemia, previous alcoholism and drug use, nausea and vomiting, and gastritis without hemorrhage as part of the "Patient Active Problem List." The assessment by the DTR showed the patient estimated calorie needs as 1375 to 1650 calories. The DTR had identified the patient as "obese", but the nutritional risk was considered "low". There was no RD initiated treatment plan to address the discrepancy with the estimated calorie needs and the physician order or the patient's obesity.

In addition, the DTR had initiated and conducted therapeutic diet education on an ADA (American Diabetes Association) therapeutic diet. There was no physician order or protocol initiated in the record to educate the patient on the therapeutic diet.

Previously, on July 12, 2010 at 2 p.m., the RD stated it was the practice in the facility for the RD to co-sign the DTR assessments to show the assessment information had been reviewed as accurate. The RD stated that it was not her practice to verify or initiate the dietary therapy or treatment plan in the psychiatric unit since they were considered to be "No risk." as per the facility policy. There was no evidence the DTR had referred to the RD for supervision or direction based on the assessment information and plan of care as documented.

Further review of the facility policy and procedure titled "Nutritional Assessment and Reassessment" formulated September 2008, showed it was the facility practice for a "nutrition evaluation" to be conducted by a RD or a DTR. There was no provision in the policy and procedure to refer the assessment to the RD for development of diet therapy or dietary treatments. The policy had not instructed DTR staff to refer to the RD to initiate a treatment plan as per the Business and Profession Code 2586 (d).

On July 12, 2010, at 2:35 p.m., the RD verified she had not reviewed or had been asked by the DTR to review Patient 352 assessment or plan of care. At that time, the RD stated there were a number of free health plan education classes available to health plan members that she could have referred Patient 352 to take advantage of as an outpatient to address obesity and/or diabetes if she had reviewed the assessment/treatment plan.

Based on interview and record review, the governing body failed to be responsible for the effective operation of the grievance process for two of two reviewed complaints lodged at the facility (Patients 303 and 304), the grievance process failed to: 1. refer the complaints to the quality department for review in accordance with facility criteria and 2. ensure the Member Services Department investigated the complaint or grievance in accordance with facility policies.

Findings:

1A. Grievance 3805820 was filed on 3/25/10, by Patient 303, a woman with abdominal pain and a positive pregnancy test. The grievance report described dissatisfaction regarding an emergency room visit based on 1. amount of time spent in the emergency room, 2. unrelieved pain, 3. the failure of the obstetric physician to return the emergency room doctor's call, 4. the lack of a promised follow-up call to establish an appointment, and 5. the concern that the ER physician was inattentive, which she stated she felt may have contributed to a subsequent pregnancy loss.

According to the hospital grievance tracking documents, printed on 7/13/10, the grievance was referred to the emergency department.

The "Request for Investigative Review-Clinical" for the grievance that was sent to the emergency department was reviewed on 7/13/10. The "case summary" presented for review to the Ambulatory Care Department Manager did not include the patient ' s complaints about the obstetric physician failing to return the call, or the concern about the inattentiveness of the physician.

The Ambulatory Care Department Manager's review of the medical record and discussion with the nurse on duty included the observations that the obstetrician did not respond to the emergency room's call for two hours, and the assertion by the nurse who had been on duty that the emergency physician refused to provide narcotic pain medication to the patient.

The discharge instruction note documented by the nurse for Patient 303 indicated that at discharge the patient had pain "7/10" and "MD aware" .

No documentation was seen to indicate that the patient was offered pain relief medication or methods, or counseled about the refusal to give narcotic pain medications during pregnancy.

The medical record notes indicated that an obstetrician was paged at 11:44 a.m. At 2:11 p.m., there was still no response from the obstetrician paged two and a half hours earlier, nor from a second physician who had been paged.

During an interview with the Assistant Area Medical Director on 7/13/10 at 3:55 p.m., he stated that the obstetric physician did not return the emergency room call for two hours, when the call should have been returned within 30 minutes. He stated that the delay in returning the emergency department ' s call should be addressed with the obstetric physician. When asked if the issue had been identified by the hospital due to the grievance and addressed, he stated that it had not.

During an interview with the Assistant Area Medical Director on 7/13/10 at 3:50 p.m., he stated that the patient was seen for her symptoms on the following day, 3/26/10, in an obstetrics clinic. The member's grievance included the information that she was seen in a West Los Angeles location for her symptoms subsequent to her emergency room visit at the hospital.

According to the hospital grievance tracking documents, printed 7/13/10, the grievance was not referred to the quality department. The member services reviewer indicated that the grievance "did not meet criteria" for referral to the quality department.

On 7/13/10, the policy, "Complaints Referred to the Quality Department," effective 4/1/08, Appendix A, "Member Services Quality Complaint Screening Criteria" was reviewed. The criteria included, "ii. A second visit for the same diagnosis or chief complaint within 72 hours of an initial office or emergency department visit due to suspected wrong or missed diagnosis or inadequate treatment," and "iii. Delay in receiving breathing treatment or pain relief," and "D. Communication and/or transitions of care issues that may have led to inadequate treatment or care."

Patient 303's grievance was not forwarded to the quality department, even though she presented for a second visit for the same concerns within 72 hours of her emergency room visit and her grievance assertion that the physician had been inattentive, and that she felt this might have contributed to an adverse outcome.

Patient 303's grievance was not forwarded to the quality department due to delay in pain relief, even though she reported that she "was in a lot of pain" and "she was walking out the door with the same pain she was in when she got there" and "She is still in pain and is going to need to go back to the hospital" and her emergency room discharge note indicated she had pain 7/10 at the time of discharge and the nurse on duty stated that the physician refused to provide narcotic pain medication, and there was no indication that pain management medications or methods were offered to the patient.

Patient 303's grievance was not forwarded to the quality department due to communication/transition of care issues, even though she stated that the paged obstetrician had failed to contact the emergency department, and her medical record indicated that the first paged physician failed to return the call for two and a half hours, and a second paged physician had also failed to contact the emergency department before she left. She stated in her grievance that someone was to call her to set up a follow-up appointment, but they never did. The grievance was not sent to the quality department even though the physician did not discover the patient's insurance affiliation until "she was walking out the door ", which may have caused confusion about how she was to obtain a follow-up appointment and a delay in obtaining an obstetrician's consultation (the community obstetrician, not the HMO-affiliated obstetrician was paged, apparently in error).

The resolution letter to Patient 303, dated 4/22/10, was reviewed on 7/13/10. The letter stated in part, "Please be assured that we take your concerns seriously, and the issue you have raised will be addressed by the appropriate department(s) ... "

1B. Grievance 3775176 was filed on 3/8/10 on behalf of Patient 304. Patient 304 was a child who was brought to the emergency department by her father on 2/15/10 for symptoms including a cough and fever. The complainant, the child's mother, listed concerns including: 1. that the physician did not examine the patient's ears, 2. that her pain was unresolved, 3. that the patient was not medicated, 4. that she was seen in the hallway, and 5. that the actual cause of her symptoms, a foreign body in the ear, was not discovered in the emergency department, but at another facility.

During an interview with the Ambulatory Care Department Manager on 7/13/10 at 3:50 PM, he stated that he sent information regarding Complainant 1's concerns to the ER Director because, "he needs to educate his doctor" .

During an interview with the Director of Accreditation/Licensure and Regulatory Affairs on 7/18/10 at 4 PM, she stated that the grievance was referred to the emergency department, but not to the quality department. She stated that the Member Services reviewer found that it had not met the criteria for referral to the quality department.

On 7/13/10, the policy, "Complaints Referred to the Quality Department," effective 4/1/08, Appendix A, " Member Services Quality Complaint Screening Criteria" was reviewed. The criteria included, "ii. A second visit for the same diagnosis or chief complaint within 72 hours of an initial office or emergency department visit due to suspected wrong or missed diagnosis or inadequate treatment."

Patient 304's grievance was not forwarded to the quality department, even though the patient presented for a second visit for the same concerns within 72 hours of her emergency room visit.

Patient 304's grievance was not forwarded to the quality department due to suspected missed diagnosis even though the complainant stated that at the second facility, they " washed the ...ear out and pulled out a pinto bean which was causing the blockage."

The resolution letter to Patient 304, dated 4/22/10, was reviewed on 7/13/10. The letter stated in part, "Please be assured that we take your concerns seriously, and the issue you have raised will be addressed by the appropriate department(s) ..."

2. During an interview with the Director of Accreditation/Licensure and Regulatory Affairs on 7/18/10 at 4 p.m., she stated that the departmental managers were charged with resolving complaints through their choice of actions. There was no follow-up by the Member Services Department of whether the complaints were reviewed or identification of the steps taken by the manager to investigate the grievance.

Review of the email communication from the Member Services Department to the Emergency Department Manager and the CEO, Nursing Director and Medical Group Administrator dated 4/7/10, regarding the complaint filed on behalf of Patient 304 included the header, "NO RESPONSE required". The tracking document for Patient 304's complaint included a reference to the internal correspondence as "FYI," and case file listed the "Resolution description as "FYI sent...". There was no information on the tracking document about the steps taken to investigate the complaint by the department manager.

Review of the tracking document for Patient 303's complaint included a request for an investigative review of the case, but no documentation about investigative steps taken.

Internal email documents provided by the hospital gave evidence that investigative steps had been taken on behalf of Patients 303 and 304. The documents indicated that both Patient 303 and Patient 304's complaints were forwarded, at least in part, to the Emergency Room Director and discussed with the emergency room physicians who cared for them. The record of both patients' visits were reviewed, and Patient 303's care was also discussed with the nurse who had been on duty.

During an interview with the Ambulatory Care Department Manager on 7/13/10, at 3:50 p.m., he stated that he reviewed the complaints on behalf of the Emergency Department Manager, and that he forwarded complaints to the Emergency Room Director when he felt that there was an issue involving the physician, which he did in the case of Patient 304.

Review of the policies, "Complaint, Grievance, and Appeal Process and Resolution for Non-Medicare Members" revision 1/26/09, page 7, and "Medicare Grievance, Organization Determination, Reconsideration and Resolution Processes," revision 1/06/09, page 6, included the following proscription for investigation of complaints by the Member Services Program Representative:

"Investigation by the Program Representative includes documentation of:
a. the substance of the grievance, initial request for organization determination, or reconsideration
b. the date(s) of actions,
c. identify what actions were taken including any aspect of clinical care involved, (e.g., counseling, re-training, etc)
d. name and department of person providing the information, including title and specialty if applicable
e. and any required follow up instructions."

Based on interview and record review, the facility failed, for two of two grievances reviewed (Patients 303 and 304), to provide the complainant with information about the steps taken on behalf of the patient to investigate the grievances, creating the risk of an ineffective grievance process.

Findings:

During a review of the resolution letters mailed to Patient 303, the only explanation of actions taken was, "the concern was formally documented and forwarded to the Manager of the Emergency Department and the Hospital Administrator ...for review." The letter to Patient 304's mother stated, "Please be assured that your concerns have been documented and reviewed by the Department Administrator's in the Emergency Department, the Nursing director, the Medical Group Administrator and the Assistant Medical Group Administrator..." The letters did not indicate if any further action was taken on behalf of the patients, such as forwarding the complaint to the Emergency Room Director, review of the medical record or discussion of the concerns with ER clinical staff.

Internal email documents provided by the hospital indicated that both Patient 303 and Patient 304's complaints were forwarded, at least in part, to the Emergency Room Director and discussed with the emergency room physicians who cared for them. The record of both patients' visits were reviewed, and Patient 303's care was also discussed with the nurse who had been on duty. The letters to the complainants did not include information about those actions taken on behalf of the complainant to investigate the grievances.

During an interview with the Ambulatory Care Department Manager on 7/13/10 at 3:50 p.m., he stated that he reviewed the complaints on behalf of the Emergency Department Manager, and that he forwarded complaints to the Emergency Room Director when he felt that there was an issue involving the physician, which he did in the case of Patient 304.

During an interview with the Director of Accreditation/Licensure and Regulatory Affairs on 7/18/10 at 4 p.m., she stated that the departmental managers were charged with resolving complaints through their choice of actions. There was no follow-up by the Member Services Department of whether the complaints were reviewed or identification of the actual steps taken to investigate the grievance in order for the Member Services Department to report those steps taken in a resolution letter to the complainant.

Based on staff interview and document review, the hospital failed to analyze the Nutrition Services Quality Improvement (QI) data to identify opportunities for improvement and consider change that will lead to improvement.

Findings:

On July 14, 2010, starting at 11:40 a.m., a Quality Improvement interview was initiated.

A review of the Nutritional Services "Performance Improvement Activities and Indicators" from January 2009, through March 2010, showed the following:

* The patient satisfaction data was used as an indicator. The data collected included the following elements: flavor, politeness of staff, temperature of food and timeliness of service. According to the two summary reports dated October through December 2009 (4th Quarter) and January through March 2010, (1st Quarter), the data showed that timeliness of trays ranked "below average" for the region.

According to the two quarters of reports, the actions were to "monitor trends with meal service and late trays to evaluate for opportunities for improvements with timeliness." There was no analyses from either quarter (six months total) that documented what was analyzed what component of the system were problematic. There were no specific actions taken to improve performance of the criteria..

* The patient tray assessment QI data showed the indicator used was a compilation of data which included seven separate and distinct components: temperature; portion size; appearance; quality; taste; substitutions and missing items; and completeness and cleanliness. The indicator was one score for the tray assessment. The QI threshold was set as 90%. The facility had met the 90% goal for 15 of 15 months. According to the "Patient tray Assessment" form, 90% compliance was considered "satisfactory." The form also showed there was a % which corresponded to "excellent" as a quality rating in order to assess the quality of the tray.

On July 13, 2010 at 1:30 p.m.., the Clinical Nutrition Manager (CNM) was asked which component of the overall tray assessment was problematic based on the analysis of the data. The CNM verified she could not recall if there was a common reason why the tray assessments nor any potential areas for further improvement had been identified.

On July 13, 2010 at 2 p.m.., the Regional QI Director stated it is the corporate practice to evaluate the QI indicators and discontinue them once the threshold is met and maintained for an extended period of time. The QI Director was unable to explain why the QI team had not either analyzed the indicator any further to determine further areas of improvement or to determine if the QI indicator should be continued to be reported based on the QI Committee threshold.

* A review of the Nutritional Status QI criteria for implementation of RD recommendations by physicians showed the threshold to be 90%. In the third quarter of 2009, the criteria was met for one of three months. The action was to continue "Dear Doctor" notes and writing in "Team Communication" for nursing staff to relay the message.

Further review showed in the first quarter of 2010, only one of the three months had met the threshold again. Further review of the QI document showed there was no analysis of the potential reason other than "performance dropped." There ws no new action implemented. The action was the same as the last quarter of 2009, which was a continuation of "Dear Doctor" notes and the "Team Communication" for nursing. There was no analysis to show what kind of recommendations were not being implemented and a potential analyses why 12 of 15 months had not met the threshold from January 2009, through March 2010.

Based on interview and record review, for one of 39 patients, there was no history and physical exam completed upon admission, creating the risk of substandard care for that patient (Patient 301).

Findings:

During a review of medical records on 7/12/10, at 10:45 a.m., the record of Patient 301 was reviewed. The patient was admitted to observation on 7/10/10, at 8:29 p.m. There was no history and physical exam or update for the patient, completed upon admission, in the medical record. The only note seen from the physician was the procedure note for the delivery of a baby boy on 7/11/10.

During an interview with the CEO on 7/12/10, at 10:45 a.m., he stated that the expectation is that the physician will do a history and physical examination of the patient upon admission to the hospital.

During an interview with the Assistant Area Medical Director on 7/12/10 at 3 p.m., he stated that there was a rule requiring an updated history and physical exam be provided upon admission to the hospital, and there was no exemption to this rule for obstetric physicians.

During a review of the Rules and Regulations of the Professional Staff, approved 10/21/09, page 6, read, "A history and physical examination shall be completed within twenty-four (24) hours of admission by a practitioner who has been granted clinical privileges to perform the history and physical examination in this Hospital. If a history and physical examination have been performed within thirty (30) days prior to admission, a durable, legible copy of this report may be used in the patient's medical record to satisfy this requirement. Within 24 hours of admission, the attending physician will write an update note (i.e. interval H & P) addressing: (a) whether the history and physical is still current, and (b) the patient's current status, including, whether there have been any changes in the patient's status and the nature of those changes. The update note (i.e., interval H & P) must be on or filed with the report of the history and physical examination."

Based on interview, record review, and facility document review, the facility failed to ensure that the RN supervised and evaluated nursing care for 6 of 39 patients, by failing:

1. For three patients (Patients 158, 203, and 206), to ensure adequate assessments and interventions were implemented to both address and relieve the patients' pain, resulting in the patients' unresolved pain and discomfort;

2. For one patient (Patient 158 ), to reassess the patients' pain level after receiving intervention, according to facility policy and procedure. The failed practice resulted in the patients' unresolved pain and discomfort;

3. For one patient (Patient 157), to ensure the patient received intervention to sustain the patient's blood sugar level within normal range (70 to 150 mg/dl). The facility also failed to ensure the physician's order for Glucerna (tube feeding formula) was started, as prescribed by the physician. The failed practice resulted in the patient's blood sugar to drop to 58 mg/dl; and,

4. For one of two patients (Patient 106), to ensure a physician order was obtained for the use of oxygen therapy, according to facility policy.


Findings:

1a. On July 13, 2010, Patient's 158's record was reviewed. The patient was admitted to the facility on July 11, 2010, with diagnoses which included chest pain, chronic back pain, and fibromyalgia (muscle and connective tissue pain).

The patient had a pain medication ordered, dated July 11, 2010, at 3:46 p.m., for Dilaudid 2 mg IV every four hours as needed.

The "Flowsheet Data" was reviewed with the ANM. The facility used a pain scale from zero to ten (one being the least and ten being the worst pain). The record further indicated:

For July 11, 2010:

*5:23 p.m. - Pain rating of 8/10. The patient was medicated with Dilaudid IV. There was no evidence the patient's pain was resolved;

*8:31 p.m. - The patient stated a back and leg pain rating of 8/10. The LN performed "rubbing of body part (back)." There was no evidence the patient's pain was resolved;

*10:08 p.m. - The patient stated a back and generalized fibromyalgia pain of 10/10. The record also indicated the patient was grimacing in pain;

*10:12 p.m. - The patient was medicated with Dilaudid IV. The patient was reassessed at 10:35 p.m. and indicated the patient's pain level was within the acceptable level (approximately 4 1/2 hours from 5:30 p.m. and 2 1/2 hours from 8:31 p.m.).

For July 13, 2010:

*10:42 a.m. - The patient had a pain level of 9/10. The patient received Dilaudid IV at 11:43 a.m. (one hour after the patient complained of pain). There was no documented evidence interventions were offered that relieved the patient's pain and discomfort prior to medicating the patient.

On July 13, 2010, at 3:45 p.m., Patient 158's record was reviewed with the ANM. The ANM stated the interventions for pain should be immediate. Interventions should occur until the patient's acceptable pain level was achieved.

On July 14, 2010, the facility's policy titled, "Pain Management" effective June 2008, was reviewed. The policy indicated, "Policy: To ensure that patient are assessed for the presence of pain, and when present, receive appropriate pain management throughout their hospital stay and upon discharge."

The policy further indicated, "...8. A comfort goal will be set by the patient and the RN...Pain above the comfort goal will trigger a dose of analgesia or an increase in the dose or other appropriate intervention..."

1b. A review of Patient 203 ' s record was conducted on July 12, 2010. Patient 203 was admitted to the facility on July 7, 2010, with a diagnosis of chest pain.

A review of the facility document, " Pain Management, " was conducted on July 12, 2010. The policy indicated, " To ensure that patients are assessed for the presence of pain, and when present, will receive appropriate pain management throughout their hospital stay and upon discharge. "

The policy further indicated, "A comfort goal will be set by the patient and the RN, taking into account that pain ratings above "3" on a scale of 1-10 or a "2" on the "Faces" scale may interfere with essential activities such as coughing, deep breathing, ambulation, interacting with family and should be avoided. Pain above the comfort goal will trigger a dose of analgesia or an increase in the dose or other appropriate intervention ...Pain management is an interdisciplinary process. Some of these interventions may include, but not be limited to Touch (massage) Comfort measures (repositioning, postural support), Relaxation techniques (music, imagery) and Medications."

A review of the patient's pain management flowsheets indicated on:
July 7, 2010, at 3:44 p.m., a pain score of 7, no acceptable level of pain was documented, no intervention was indicated.
July 8, 2010, at 3:16 p.m., 4 p.m., and 5:56 p.m., pain scores of 6, 7, and 8 were documented, no acceptable level of pain was documented, no interventions were indicated.
July 9, 2010, at 5 p.m., a pain score of 3 was documented, no pain source was indicated.
July 10, 2010, at 1:34 a.m., a pain score of 8 was documented with an acceptable level of 2, no pain source, or intervention were documented.
July 11, 2010, at 6:10 a.m., 8 a.m., and 11 a.m., pain scores of 6, 6, and 9 were documented, no pain source,description or interventions were indicated. At 12:03 p.m., the patient ' s pain score was 10.

An interview was conducted with RN 6 on July 12, 2010, at 3 p.m. RN 6 stated that part of the patient's pain assessment is to document what the patient ' s acceptable level of pain is, where the pain is, and to indicate interventions taken.

1c. A review of Patient 206's record was conducted on July 14, 2010. Patient 206 was admitted to the facility on June 22, 2010, with a chief complaint of chest pain.

A review of the facility document, "Pain Management," was conducted on July 12, 2010. The policy indicated, "To ensure that patients are assessed for the presence of pain, and when present, will receive appropriate pain management throughout their hospital stay and upon discharge."

The policy further indicated, "A comfort goal will be set by the patient and the RN, taking into account that pain ratings above "3" on a scale of 1-10 or a "2" on the "Faces" scale may interfere with essential activities such as coughing, deep breathing, ambulation, interacting with family and should be avoided. Pain above the comfort goal will trigger a dose of analgesia or an increase in the dose or other appropriate intervention ...Pain management is an interdisciplinary process. Some of these interventions may include, but not be limited to Touch (massage) Comfort measures (repositioning, postural support), Relaxation techniques (music, imagery) and Medications. "

A review of the patient's pain management flow sheet, dated June 25, 2019, indicated at:
5:54 a.m., the patient had a pain score of 7, and an acceptable level for pain of 0. Further record review did not indicated the pain source, location, character of the pain or interventions used.

A review of the patient's pain management flow sheet, dated June 25, 2010, indicated at 12:05 p.m., a pain score of 4. Further record review did not indicate the acceptable level of pain, the pain source, location, character of the pain or interventions used.

An interview was conducted with RN 6 on July 14, 2010, at 2:30 p.m. RN 6 acknowledged that the pain source, location, the character of the pain, and interventions should be documented in the patient's record, and were not.



2a. On July 13, 2010, Patient's 158's record was reviewed. The patient was admitted to the facility on July 11, 2010, with diagnoses which included chest pain, chronic back pain, and fibromyalgia (muscle and connective tissue pain).

The patient had a pain medication ordered, dated July 11, 2010, at 3:46 p.m., for Dilaudid 2 mg IV every four hours as needed.

The "Flowsheet Data" was reviewed with the ANM. The facility used a pain scale from zero to ten (one being the least and ten being the worst pain). The record further indicated:

For July 11, 2010:

*5:23 p.m. - Pain rating of 8/10. The patient was medicated with Dilaudid IV. There was no evidence the patient's pain was resolved. There was no evidence the patient was reassessed after one hour; and,

*8:31 p.m. - The patient stated a back and leg pain rating of 8/10. The LN performed "rubbing of body part (back)." There was no documented evidence effective interventions were provided that resolved the patient's pain.


On July 13, 2010, at 3:45 p.m., Patient 158's record was reviewed with the ANM. The ANM stated the interventions for pain should be immediate. Interventions should occur until the patient's acceptable pain level was achieved. The ANM stated, when interventions for pain were provided to patient, the patient should be reassessed after one hour to ensure the pain was resolved or is within the patient's acceptable level.

On July 14, 2010, the facility's policy titled, "Pain Management" effective June 2008, was reviewed. The policy indicated, "Policy: To ensure that patient are assessed for the presence of pain, and when present, receive appropriate pain management throughout their hospital stay and upon discharge."

The policy further indicated, "...5...Reassessment will be done...within one (1) hour after administration of analgesia or pain intervention..."

3a. On July 13, 2010, Patient 157's record was reviewed. The patient was admitted through the ED on July 12, 2010, at 10:37 p.m. The patient was admitted with left sided weakness and facial drooping. The patient's diagnosis included history of CVA, diabetes, and has GT. The patient was placed on NPO. The patient did not have any intervention (TF or IVF) to maintain the blood sugar levels.

The patient was transferred and admitted to the M/S unit on July 13, 2010, at 3:20 a.m. (approximately 5 hours after ED visit). No intervention was provided to maintain the patient's blood sugar. The patient remained NPO (nothing to eat or drink by mouth).

The MAR dated July 13, 2010, at 6:19 a.m. (approximately 8 hours after ED visit), the patient's blood sugar was 58 mg/dl (normal range 70 to 140 mg/dl). The MAR further indicated the patient received D50W (IV medication to increase blood sugar) at 6:27 a.m.

On July 13, 2010, at 9:22 a.m. (approximately 11 hours after ED visit), Patient 157 was started with IVF hydration.

Further review of the "Physician's Order" dated July 13, 2010, at 2:45 a.m., indicated, "Pump 40 ml/hr Glucerna Select G Tube." The record did not have any evidence the tube feeding was started.

On July 13, 2010, at 1:55 p.m., the ANM and RN 152 were interviewed. RN 152 stated she called the physician to get an order for IVF hydration to maintain the patient's blood sugar while NPO. She stated, "I don't want it to go yoyo (for the blood sugar not to suddenly go up then down)." RN 152 stated when she started her shift at 7 a.m., she "wondered" why the patient was not on anything to prevent the blood sugar from dropping.

During a concurrent interview, the ANM stated Patient 157 should have been started with either IVF or TF to prevent the blood sugar from dropping.

3b. On July 13, 2010, Patient 157's record was reviewed. The patient was admitted through the ED on July 12, 2010, at 10:37 p.m. The patient was admitted with left sided weakness and facial drooping. The patient's diagnosis included history of CVA, diabetes, and has GT. The patient was placed on NPO. The patient did not have any intervention (TF or IVF) to maintain the blood sugar levels.

The patient was transferred and admitted to the M/S unit on July 13, 2010, at 3:20 a.m. (approximately 5 hours after ED visit). No intervention was provided to maintain the patient's blood sugar. The patient remained NPO.

The MAR dated July 13, 2010, at 6:19 a.m. (approximately 8 hours after ED visit), the patient's blood sugar was 58 mg/dl (normal range 70 to 140 mg/dl). The MAR further indicated the patient received D50W (IV medication to increase blood sugar) at 6:27 a.m.

On July 13, 2010, at 9:22 a.m. (approximately 11 hours after ED visit), Patient 157 was started with IVF hydration.

Further review of the "Physician's Order" dated July 13, 2010, at 2:45 a.m., indicated, "Pump 40 ml/hr Glucerna Select G Tube." The record did not have any evidence the TF was started.

On Jul 13, 2010, at 1:55 p.m., the ANM and RN 152 were interviewed. RN 152 stated she called the physician to get an order for IVF hydration to maintain the patient's blood sugar while NPO. She stated, "I don't want it to go yoyo (for the blood sugar not to suddenly go up then down)." RN 152 stated when she started her shift at 7 a.m., she "wondered" why the patient was not on anything to prevent the blood sugar from dropping.

During a concurrent interview, the ANM stated Patient 157 should have been started with either IVF or TF to prevent the blood sugar from dropping. The ANM stated the Glucerna TF should have been started as ordered by the physician.



18930

4. Patient 106 was an 84 year old female admitted to the facility March 23, 2010, through the ED with dyspnea (a distressful sensation of uncomfortable breathing that may be caused by certain heart conditions, strenuous exercise, or anxiety). The patient's other diagnoses included chronic kidney disease, aortic valve disorder, CVA, HTN, and glaucoma.

A review of the nurses' notes dated March 24, 2010 at 12:05 a.m., indicated, "...Patient's respiratory status maintained on oxygen 2LNC and activity as tolerated ..."

On July 14, 2010, at 9:50 a.m., a review of the nurses' notes dated March 25, 2010, at 10:31 p.m. was conducted. The nurses' notes indicated, "...Ambulated pt out of room to nurses station without oxygen. Pt. slightly fatigued, O2 saturation upon return to bed 90% on RA, 1L via NC placed, currently 94%..."

On March 28, 2010, at 11:59 a.m., the nurse documented, "HHN TX refused by pt. Pt alert and oigented (oriented) with no SOB SA (RA) O2 & @ 96 on 2L/M NC BS clear."

A further review of the nurses' notes dated March 28, 2010, at 12:28 p.m., indicated, "Ambulated with CNA without oxygen. Ambulated 150 feet with walker on room air, after checked oxygen sats and 93% on room air. Oxygen kept off, patient slightly short of breath with exertion."

On July 14, 2010, at 10 a.m., a review of the physician's orders was conducted. There was no documented physician's order in the record for the patient to use oxygen.

On July 14, 2010, at 10:05 a.m., in an interview with the NMMS, she agreed that oxygen needed a physician's order.

A review of the facility's P&P entitled, "Oxygen Administration" formulated June 2008, indicated the procedure for oxygen use was to verify orders by checking the patient's chart. The P&P's important points indicated, "Oxygen is a drug, as such, a physician must order it's use."

Based on interview, record review, and facility document review, the facility failed to ensure for one of 39 patients, (Patient 204), an interdisciplinary plan of care was implemented for swallowing precautions. This failed practice potentially placed Patient 204 at risk for aspiration (food or liquid entering the lungs, placing the patient at risk of developing pneumonia.)

Findings:

A review of Patient 204's record was conducted on July 13, 2010. Patient 204 was admitted to the facility on July 11, 2010, with a diagnosis of stroke. On July 12, 2010, at 12:25 p.m., Patient 204 had a, "Speech Pathology Clinical Swallow Assessment," completed.

The assessment indicated, "S/S of aspiration with thin liquids." The diet recommendations were indicated as, "Puree and Modification in liquid: Nectar thick liquids."

The "Compensatory Strategies And Swallowing Precautions," were indicated as, "Ensure that patient is fully awake and alert during meals, observe for signs of aspiration, position upright during meals and for 30 minutes after meals, provide one on one supervision, feed slowly, due to swallow, no straws, give liquids via teaspoon and controlled sips, alternate between liquids and solids, check for oral pocketing after meals, give meds whole or crushed in puree, not with liquid."

Review of Patient 204's record did not reflect a care plan which indicated compensatory strategies, or swallowing precautions to prevent aspiration of foods or fluids.

A review of the facility document, "Care Planning," was conducted on July 13, 2010. The policy indicated, "Care is planned to respond to each patient's unique needs, which include age-specific needs. The planning will be interdisciplinary and will involve the patient/family/significant others as appropriate ...Care plans need to address at least but not be limited to patient's hygiene, oral care, physical issues related to diagnosis, emotional and spiritual support and care, rehabilitative services, and nutritional needs."

An interview was conducted with RN 5 on July 13, 2010, at 10:30 a.m. RN 5 acknowledged that an individualized care plan for swallowing strategies or swallowing precautions should have been implemented and was not.

Based on interview and medical record review, the facility failed to ensure that the EKG completed in the emergency room was not readily available to the nursing staff, and the death note bore an incorrectly dated electronic signature, creating the risk of substandard health care for that patient and the risk of confusion about the date of death for one patient, Patient 302.

Findings:

During a review of the closed electronic medical record of Patient 302 on 7/13/10, an EKG ordered 1/19/10 at 9:45 a.m. was requested. During an interview with RN 301 on 7/13/10 at 2:10 p.m., she stated that she was unable to find a copy of the EKG in the system. During a concurrent interview with the DON, she stated that the EKG should have been scanned into the system, but that did not occur. The nurses searched the system for the EKG for approximately 20 minutes, but were unable to find it. The EKG was later located, but had not been readily available to the nursing staff members.

The death note for the patient, completed after the patient's death on 2/1/10, had an electronic signature by the physician dated 1/1/10.

During an interview with the DON on 7/13/10 at 2:05 p.m., she stated that the date on the signature was incorrect, and that the facility was unaware that the date on electronic signatures could be modified from the date that it was entered into the system.

Based on interview and record review, the facility failed, for Patient 154, to ensure the RN entered the phone conversation with the physician, regarding a possible infection, in the patient's medical record. The failed practice resulted in an incomplete and inaccurate record to ensure appropriate care was provided to the patient.

Findings:

On July 12, 2010, Patient 154's record was reviewed. The patient was admitted on July 6, 2010, with diagnoses which included CHF, COPD, diabetes, and obstructive sleep apnea (temporary absence of breathing). The blood culture collected on July 6, 2010, indicated the patient had an infection, but not an MRSA infection.

The RN's notes dated July 7, 2010, at 4:52 p.m., indicated, "Patient educated about their infection and isolation. Isolation booklet and one page summary of infection: MRSA given to patient ..."

On July 12, 2010, at 3:15 p.m., the record was reviewed with the ICN. The ICN stated Patient 154's record indicated the patient either had currently or history of MRSA infection, which could be indicated through the laboratory results or through the physician's documentation. The ICN was not able to find documented evidence Patient 154 had MRSA through the laboratory results or the physician's record.

The ICN stated RN 151 entered in the record indicating Patient 154 had MRSA infection. The ICN was not able to find any documentation where RN 151 would have taken the information from.

On July 14, 2010, at 9:45 a.m., Patient 154's record was reviewed with RN 151. RN 151 stated she got a call from Physician 151 on July 6, 2010, and received orders to start the patient on IV Vancomycin (antibiotic). The physician wanted to place the patient on contact isolation precaution for possible MRSA infection. The RN stated there was no final laboratory result that indicated the MRSA infection. RN 151 stated, "I should have documented that (conversation with physician)."

Based on inspection of Pediatric Crash Cart, inspection of medication rooms, interview, and document review, the facility failed to control drugs and biologicals in accordance with applicable standards of practice consistent with Federal and State law by failing to:

1. Include in the facility's Pediatric Crash Cart necessary IV syringes to complement the small amount of medications needed to be drawn out during code blue (life threatening cardiopulmonary emergencies) situations;

2. Account for medications stored in the ER refrigerator;

3. Follow the facility's policy and procedure related to identifying and verifying the use of patient's own medications in the facility;

4. Evaluate the pharmacists required to attend code blue for their competency in participation as code team members during pediatric and neonatal code blue; and,

5. perform various auditing procedures for controlled substances stored throughout the facility's Pyxis MedStations (Automated Drug Dispensing Cabinet: ADC) as stated in the facility's policy and procedure in order to timely identify drug diversion.


Findings:

1. During inspection of the facility's pediatric crash cart with the DOP on July 12, 2010 at approximately 11:15 a.m. in the ED (Emergency Department), it was noted that the cart contained medications for pediatric and neonatal medical emergency use including diphenhydramine (injectable drug used for anaphylactic reactions) 50 mg/ml and adenosine (injectable drug used for irregular heart rhythms) 3 mg/ml.

Following facility's P&T (Pharmacy and Therapeutics) Committee approved document entitled, "(The facility's name) Pediatric Emergency Reference Chart was reviewed:

For 3 kg pediatric patient:
injectable diphenhydramine dose: 0.06 ml (3 mg)
For 4 kg pediatric patient:
injectable diphenhydramine dose: 0.08 ml (4 mg)
For 8 kg pediatric patient:
injectable adenosine dose: 0.27 ml (0.8 mg)

During concurrent interview, Staff 400 stated that the pediatric crash cart did no contain the syringes to correctly measure out the exact amount of above medications during medical emergencies and acknowledged that appropriate syringes should have been available in the cart to prevent delay in treatment.

During concurrent interview, the Director of Pharmacy (DOP) acknowledged the need for the correctly sized syringes for eliminating the potential delay in treatment.

The DOP further stated that pharmacists were trained to attend all code blue (hospital emergency situations involving patients with cardiopulmonary problems) and they would bring a tackle box containing additional emergency drugs and syringes of various sizes including the ones used to draw small pediatric doses; however, the night pharmacists do not attend the code blue.

Review of the facility ' s policy and procedure entitled, " Pediatric Crash Cart/Content " confirmed that the smallest syringes available in the Pediatric Crash Carts were of 1-ml size which would not be appropriate for doses that would require drawing up 0.06 ml.


2. During inspection of the facility's ED medication storage area with the DOP on July 12, 2010 at approximately 11:15 a.m. in the ED (Emergency Department), it was noted the facility utilized automated dispensing cabinets (ADCs) called Pyxis MedStations for medications used throughout the facility. Attached to the Pyxis was the refrigerator used for medications requiring refrigeration.

ADCs keep accurate account of stocking/restocking and withdrawal activities and any discrepancies recorded and reported.

Spot check of following drugs in the refrigerator yielded discrepancies in the quantities of each drug present in the refrigerator and the quantities of each drug that should have been present in the refrigerator according to the Pyxis:

proparacaine 0.5 percent 15 ml
actual count: 1
Pyxis count: 2;

Xalatan 0.005 percent 2.5 ml
actual count: 4
Pyxis count: 2; and,

Diphtheria and Tetanus Toxoids Adsorbed
actual count: 6
Pyxis count: 9.

During concurrent interview, the DOP stated that the pharmacy maintained a par level for all medications that were stocked in the Pyxis and if drugs were not included in the daily report for drugs needed to be restocked the discrepancies won't be corrected until the pharmacist audit of all drugs performed on a monthly basis.

The DOP could not explain why the discrepancy occurred.

During concurrent interview, Staff 400 could not explain and resolve the discrepancy.


3. During inspection of the medication room of the Medical/Surgical station on July 12, 2010, at approximately 2 p.m., with the DOP, it was noted that on one of the overhead cupboard shelves, there was a medication called aminocaproic acid (drug used for bleeding) 500 mg that was brought in by the patient for his/her use.

The medication vial was packaged in a plastic bag with the facility's required prescription labeling attached. However, it was not clear whether the medication was identified and verified by the pharmacist for correctness as the space reserved for pharmacist's initial indicating it was verified by the pharmacist was left blank.

During concurrent interview, the DOP could not confirm whether the medication was verified by the pharmacist and who the pharmacist was that verified it.

The following facility's policy and procedure entitled, "Patient's Own Medication Brought Into The Hospital" was reviewed:

"...4. The contents of the containers have been examined, positively identified and the integrity evaluated by the patient's physician and/or the hospital's Pharmacist (marked with a verification sticker). Prior to use in the hospital, the medication verification must be documented by pharmacist or physician for accurate identification and labeling requirements..."


4. During an interview on July 14, 2010, at approximately 3 p.m., the DOP stated that the facility ' s pharmacists participated in code blue situations and that the pharmacists were annually tested for competency with tests consisting of series of situational questions. The DOP stated that all code blue situations were attended by the facility ' s pharmacists including pediatric and neonatal code blue situations. However, the DOP stated that the annual competency did not include the pharmacists ' competency on pediatric and neonatal code blue.

The facility ' s policy and procedure entitled, "Cardiopulmonary Resuscitation (CPR), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Neonatal Resuscitation Program (NRP) in compliance with medical center procedures by personnel" stated,

"Policy
I. The Code team consist of ...Pharmacist ...
Procedure I: Roles and Responsibilities of Code Team Members ...
Pharmacist
A. Brings extra medication tray of emergency drugs.
B. Assists in the administration of emergency medications according to ACLS/PALS/NRP guidelines."

The facility's document entitled, "(The Facility) Inpatient Pharmacy 2010 Pharmacist/Intern Adult Code Blue Competency" given to evaluate the pharmacist's annual competency was reviewed and it did not include review questions pertaining to pediatric and neonatal code blue situations requiring CPR.

During concurrent interview, Staff 403 confirmed that there was no annual competency given and stated for the past 2 years he/she did not have the opportunities to attend the code blue situations involving pediatric and/or neonatal patients.

Furthermore, the DOP stated that the facility did not require pharmacists be certified in ACLS, NRP, or PALS to be a participating member of the code blue team further validating the need for the pharmacists competency to be assessed and evaluated by the DOP.


5. During an interview on July 13, 2010, at approximately 2:15 p.m., Staff 402 stated that controlled substance usage of Pyxis MedStations (automated drug dispensing cabinet) by nursing staff and movement of all controlled substances were being monitored by the pharmacy department using the reports that were generated by the Pyxis.

Staff 402 stated that on a daily basis several Pyxis generated reports were reviewed including:

Override Report (report consisting of users manually accessing Pyxis stored medications by override before pharmacist review and release of drugs);
Documented Discrepancy Report (closed and resolved discrepancy report);
ADT (Admit, Discharge, Transfer) Info Report (manual patient entry in Pyxis report);
Open Discrepancy Report;
Users without Activity Report.

Staff 402 stated that weekly audit included reviewing the reports for high users and most used drugs, trending users with frequent override without physician orders, and unusual occurrences. The collected data would then go to Quality Department.

The following facility's policy and procedure entitled, "Automated Medication Dispensing System-Pyxis Monitoring Controlled Substance Utilization - Frequency, Analysis, and Use of Standard Reports" was reviewed:

"A. The Inpatient Pharmacy Director of designee shall generate, analyze, and utilize the information from Pyxis and Pyxis Reporter. The reports shall include, but may not be limited to, the following:

1. Pyxis Reports - Daily
a. All Station Events report, CII-CV
b. Open Discrepancies report
c. Discrepancies report
d. Profile Override report
e. User Modification Information report
f. Entered ADT Information report
g. User Without Activity report

2. Pyxis Reporter - Monthly
a. Controlled Substance Withdraws >2 at one time
b. Controlled Substance Discrepancy by User
c. Controlled Substance High Utilization Report
d. Controlled Substance High User Report

Further interview with Staff 402 yielded that Controlled Substance Withdraws >2 at one time and Controlled Substance Discrepancy by User were not reviewed since the profiling of the Pyxis Medstations which would allow access to medication only after pharmacist verification of the order and release of the ordered medications.

There was also documented evidence that monthly Controlled Substance High Utilization Report and Controlled Substance High User Report were not reviewed at least for the last two months.

Staff 402 stated the reason for not having been reviewing the monthly reports was that the facility was waiting for the Pandora reporting system to be implemented.

During concurrent interview, the DOP stated he was not aware of the reports not being reviewed and acknowledged that it was his responsibility to oversee the controlled substance audit as it was stated in the policy and procedure:

"E. The Inpatient Pharmacy Director has the ultimate responsibility to ensure all issues and discrepancies associated with the storage, dispensing, and administration of medications are resolved."

Based on observation, interview and facility document review, the facility failed to ensure warmed irrigation solutions were dated and disposed of according to manufacturers guidelines, and outdated drugs were disposed of. These failed practices could impact patient safety and the provision of medical care.

Findings:

1a. An observation of the OB operating room was conducted on July 12, 2010, at 10:10 a.m. A warming cabinet was observed. Located in the warming cabinet were three 1000 cc plastic containers of .9 NaCl solution, observed to be undated with no date and time the solutions were to be removed from the cabinet.

An interview was conducted with the AAM of the OB unit. The AAM stated the containers held irrigation solution which are to have a date reflecting the day and time they are to be removed from the cabinet.

Review of the facility provided document from Baxter Healthcare Corporation, "...regarding the intentional warming of our parenteral (intravenous,) and irrigation solutions in plastic containers." was conducted.

The warming recommendations indicated, "Solutions can be warmed in their overpouches to temperatures not exceeding: 1. 45?C (113?F) and for a period no longer than 14 days, or 2. 66?C (150?F) and for a period no longer than 72 hours. Once the (trade name,) plastic containers have been in the warming cabinet for their maximum time period, the containers should be removed from the warming cabinet and identified as having been warmed. They should not be subsequently returned to the warmer."

1b. An observation of the OB unit was conducted on July 12, 2010, at 10:30 a.m. Located in a storage room adjacent to the OR was a refrigerator. In the refrigerator was a container which contained three 1000 cc plastic containers of NaCl for intravenous use and one bottle of Novolin R Insulin. All four items had the same expiration date, February, 2010.

An interview was conducted with the OB AAM on July 12, 2010, at 11 a.m. The AAM stated the items in the refrigerator are used to treat malignant hyperthermia (OR emergency in which there is a dangerous rise in a patient's body temperature,) and they are all expired.

Based on observation, staff interview and document review the facility's food services department failed to ensure the daily management of the department by:
* failing to organize and implement a system to maintain the walk-in refrigerator to prevent cross contaminating conditions.
* failing to plan, organize and implement employee training based on departmental needs to ensure correct dish washing cleaning and sanitizing procedures are maintained.
* failing to plan, organize and implement employee training based on departmental needs to ensure the menu and therapeutic diets are served as planned by the Registered Dietician (RD).

Findings:

1. On July 12, 2010, a tour of the hospital kitchen was initiated. At 10 a.m., the produce walk-in refrigerator ceiling contained an area measuring approximately four feet by two feet in which gray, fuzzy projections were noted to be hanging from the ceiling. Directly blowing in front of the area was the refrigerator fan. Using a clean paper towel sweep, the gray projections could be easily removed with a sweeping movement. The walk-in refrigerator contained ready to eat produce which would not require any cooking.

At that time, the Food Services Director (FSD) stated the ceilings and walls in the walk-in refrigerators are to be cleaned either once a month or as needed. It is usually his practice to assign this extra cleaning as needed. When asked about other cleaning assignments in the department, the FSD stated those tasks are organized on a planned cleaning schedule. The FSD stated that he had conducted environmental rounds four days earlier and was unable to state why the refrigerator cleaning had not been delegated at that time. The FSD stated that he does not use a tool to conduct his departmental environmental tool. He stated the procedure is "nothing formal."

According to the 2009, "Food Code", non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. In addition, food shall be protected from contamination by storing it where it is not exposed to splash, dust or other contamination.

A review of the posted cleaning schedule showed the produce walk-in was to be swept and mopped daily, but there was no provision for the ceiling and walls. In addition, the cleaning schedule was to be initialed by staff when the cleaning task as per the posted frequency was completed.

According to the posted schedule dated July 4, 2010, through July 11, 2010, there was no staff initials verifying the cleaning of the departmental equipment/areas on 102 of 115 frequencies (89%) over the eight day period. Upon questioning the FSD was unable to explain why the cleaning schedules used to monitor staff had not been used consistently for the eight days.

2. a. On July 12, 2010 at 9 a.m. during the tour of the hospital kitchen, FSW 1 was asked to demonstrate the mechanical dish washing procedure. FSW 1 stated she checks the temperature of the water using the gauges on the top of the machine. FSW 1 stated she reads the wash cycle gauge by combining the bottom and the top number of the gauge to get the number she logs. She stated the temperature of the wash cycle was 175 degrees. Upon further questioning, FSW 1 stated she would notify her supervisor if the temperature did not meet the correct criteria.

Upon inspection of the gauge, one number referred to a Celsius Scale and the other number on the same gauge referred to a Fahrenheit scale. At that time, the FSD verified, FSW 1 had combined the readings of two different temperature measuring scales to determine the number to be logged.

A review of the "Dishwashing/Warewashing Machine Temperature Log" showed the wash cycle temperature requirement was for 160 degree Fahrenheit. Further review showed from July 1, 2010 to July 12, 2010, there were 33 of 33 (100%) entries across three different meal periods logged by six different employees logging the wash cycle temperature at either 175 or 180 degree F.

A review of the in-service training conducted by the FS Management staff showed during the entire year of 2009 through the survey date in 2010, no training had been conducted with regards to dish washing procedures.

b. During the tray line observation on July 12, 2010, food service staff had not made the beef tips according to the standardized recipe and had used incorrect portioning scoops to serve the beef tips and rice which resulted in the patients not receiving the correct nutrients based on the planned menu and/or the physician therapeutic diet order (Cross refer A-630.)

A review of the in-service training conducted by the FS Management staff showed during the entire year of 2009 through the survey date in 2010, no training had been conducted with regards to therapeutic diets and portion control.

c. On July 13, 2010 at 1:30 p.m., the FSD stated that the in-service program calendar is defined by the food service contractor in-service standards. The FSD was unable to state how he identifies additional facility specific training needs based on the needs of the facility. The FSD stated perhaps the defined training schedule was a minimum standard. At that time, the FSD verified that there had been no training by the departmental CNM, an RD, on any topics which would benefit from her expertise such as patient menus and therapeutic diets.

A review of the job description of the "Clinical Nutrition Manager" showed duties included '"manages and promotes food and nutrition programs and develops resources for nutritional education" and "ensures employees have appropriate, equipment supplies and resources to perform their jobs..."

On July 14, 2010, at 9:50 a.m., the CNM verified that the FSD was in fact the operations manager and the CNM expectation included staff education. The Food Services Regional Manager was unable to explain why the FSD directed training program did not include training and education by the CNM.

Based on observation, staff interview and document review, the hospital failed to ensure dietary staff were competent in the mechanical dish washing logging procedure.

Findings:

On July 12, 2010, at 9 a.m. during the tour of the hospital kitchen, FSW 1 was asked to demonstrate the mechanical dish washing procedure. FSW 1 stated she checks the temperature of the water using the gauges on the top of the machine. FSW 1 stated she reads the wash cycle gauge by combining the bottom and the top number of the gauge to get the number she logs. She stated the temperature of the wash cycle was 175 degrees. Upon further questioning, FSW 1 stated she would notify her supervisor if the temperature did not meet the correct criteria.

Upon inspection of the gauge, one number referred to a Celsius Scale and the other number on the same gauge referred to a Fahrenheit scale. At that time, the FSD verified, FSW 1 had combined the readings of two different temperature measuring scales to determine the number to be logged.

A review of the "Dishwashing/Warewashing Machine Temperature Log" showed the wash cycle temperature requirement was for 160 degree Fahrenheit. Further review showed from July 1, 2010, to July 12, 2010, there were 33 of 33 (100%) entries across three different meal periods logged by six different employees logging the wash cycle temperature at either 175 or 180 degree F.

A review of the in-service training conducted by the FS Management staff showed during the entire year of 2009 through the survey date in 2010, no training had been conducted with regards to dish washing procedures.

Based on observation, staff interview and document review, the hospital failed to:
* cook and serve patients the beef tips on Monday July 12, 2010, with the planned nutrition due to failure to follow the standardized recipe and follow the portion control guidelines.
* serve Patient 351, 352, 353 and 358 with the planned portion size to provide them with the physician ordered therapeutic diet.
* provide direct supervision to the DTR by the RD to address the nutritional needs of Patient 351 and 352.
* address the nutritional needs of Patient 351, 352, 353 and 354 as it related to obesity and it's potential impact on the patient nutritional/medical diagnosis.

Findings:

1. On July 12, 2010 at 9:30 a.m., Cook 1 stated that she was preparing beef tips for the lunch patient meal service. Cook 1 stated she was preparing enough to feed 40 patients and had used one five pound bag of diced beef.

A review of the facility beef tips recipe showed the cook should have used four pounds, six ounces of cooked beef for twenty servings (equal to eight pounds, 12 ounces of cooked beef for forty servings) rather than the five pounds she used for the 40 servings.

In addition, on July 12, 2010, starting at 11:25 a.m., the lunch meal service was observed. Cook 2 set-up her serving station using a scoop for the beef tips that provided a total of three ounces. There was only one pan of beef tips available on the tray line which was to be used for all the patients, regardless of therapeutic diet orders Cook 2 stated she used that scoop as directed by the "tally report." A review of the "tally report" showed the cook should have provided a three ounce meat portion with an additional one ounce of gravy.

On July 13, 2010, at 1:30 p.m. the FSD confirmed recipe compliance and portion control are essential to ensure patients receive the appropriate nutrition as planned by the RD. The FSD was unable to explain why the food service staff had not been trained on these components to ensure nutritional needs are met.

2. On July 12, 2010, starting at 11:25 a.m., lunch tray line service was observed. Cook 2 set-up the pans of rice using a four ounce scoop. According to the "tally report" the planned portion size for the rice was either 1/3 cup (one carbohydrate) or 2/3 cup (two carbohydrate).

According to the computerized "Patient List with Notes", Patients 351, 352 and 358 had physician orders for 1800 diabetic diets. On July 12, 2010, at 12 p.m., the Assistant DSS stated 1800 calorie diabetic patients should only be served a total of four carbohydrate servings at the lunch meal in order to provide consistent carbohydrates. Patient 353 had a physician order for 1800 diabetic 60 gram protein, two gram potassium, two gram sodium, low phosphorus, low cholesterol.

Patient 351 was served the following carbohydrate foods: a roll, eight ounces of 1% milk, a package of shortbread cookies, four ounces of rice, a fresh fruit cup and a bowl of chicken noodle soup.. This was equivalent to five carbohydrate servings.

Patient 352 was served the following carbohydrate foods: a roll, eight ounces of 1% milk, four ounces of rice, a fresh fruit cup, and a bowl of chicken noodle soup.. This was equivalent to five carbohydrate servings.

Patient 353 was served the following carbohydrate foods: a roll, four ounces of rice and a 1/2 cup of canned fruit. This was equivalent to three carbohydrate servings. According to the menu ticket, Patient 353 should have received the 2/3 cup of rice which would be equivalent to two carbohydrate servings.

Patient 358 was served the following carbohydrate foods: a roll, four ounces of rice and a fresh fruit cup. This was equivalent to three carbohydrate servings. A review of the printed menu ticket showed Patient 358 should have received 2/3 cup of rice which would have been equivalent to two carbohydrate servings.

On July 13, 2010 at 3:30 p.m., further review of the computerized menu system for the patients showed that patients 351 and 352 were to be served the beef tips with no rice. The Assistant DSS verified that perhaps the checker assumed that the beef tips assumed rice would be served. The Assistant DSS also verified Cook 2 had used the incorrect portioning scoop for the rice and was not following the menu.

3. Medical record review conducted on July 12, 2010, showed Patient 351 was admitted to the psychiatric unit on July 8, 2010, with diagnoses of bipolar disorder. On July 8, 2010 the physician ordered a 1800 calorie diabetic diet and a "RD Consult". Further review of the record showed the nurse admission assessment dated July 8, 2010, documented Patient 351 required referral to dietary. A review of the labs showed a random blood sugar of 215 mg/dl on July 7, 2010 and 206 on July 8, 2010.

A review of the document titled "Nutrition Services Adult Initial Assessment" dated July 9, 2010, showed the form had been completed by a Registered Dietetic Technician (DTR) and had identified hyperlipidemia, high blood pressure, alcohol abuse and uncontrolled type two diabetes as components of the "Patient Active Problem List". In addition, Patient 351 had gained 13 pounds based on the computerized weight history from October 28, 2009, (302 pounds) to July 7, 2010, (315 pounds). The weight history documented "possible weight loss prior to admit. Will monitor for trend." The assessment by the DTR showed Patient 351 was morbidly obese, but the nutrition risk was determined to be "low." There was no plan to address the morbid obesity other than to continue the diet and monitor.

In addition, the DTR had initiated and conducted therapeutic diet education on an ADA (American Diabetes Association) therapeutic diet. There was no physician order or protocol in the record to educate the patient on the therapeutic diet.

On July 12, 2010, at 2 p.m. stated it was the practice in the facility for the Registered Dietitian (RD) to co-sign the DTR assessments to show the assessment information had been reviewed as accurate. The RD stated that it was not her practice to verify or initiate the dietary therapy or treatment plan in the psychiatric unit. There was no evidence the DTR had referred to the RD for supervision or direction based on the assessment information as documented.

Further review of the facility policy and procedure titled "Nutritional Assessment and Reassessment" formulated September 2008, showed it was the facility practice for a "nutrition evaluation" to be conducted by a RD or a DTR.

4. Medical record review conducted on July 12, 2010 showed Patient 352 was admitted to the psychiatric unit on July 9, 2010, with diagnosis that included bipolar disorder and severe psychosis. The physician ordered Patient 352 a 1800 calorie diabetic diet. The initial nursing admission assessment dated July 9, 2010m showed the patient was five foot one and weighed 171 pounds.

A review of the document titled "Nutrition Services Adult Initial Assessment" dated July 9, 2010, showed the form had been completed by a Registered Dietetic Technician (DTR) and had identified type two diabetes mellitus, hyperlipidemia, previous alcoholism and drug use, nausea and vomiting, and gastritis without hemorrhage as part of the "Patient Active Problem List." The assessment by the DTR showed the patient estimated calorie needs as 1375 to 1650 calories. The DTR had identified the patient as "obese", but the nutritional risk was considered "low". There was no RD initiated treatment plan to address the discrepancy with the estimated calorie needs and the physician order or the patient's obesity.

In addition, the DTR had initiated and conducted therapeutic diet education on an ADA (American Diabetes Association) therapeutic diet. There was no physician order or protocol initiated in the record to educate the patient on the therapeutic diet.

Previously, on July 12, 2010, at 2 p.m., the RD stated it was the practice in the facility for the RD to co-sign the DTR assessments to show the assessment information had been reviewed as accurate. The RD stated that it was not her practice to verify or initiate the dietary therapy or treatment plan in the psychiatric unit. There was no evidence the DTR had referred to the RD for supervision or direction based on the assessment information as documented.

Further review of the facility policy and procedure titled "Nutritional Assessment and Reassessment" formulated September 2008, showed it was the facility practice for a "nutrition evaluation" to be conducted by a RD or a DTR.

On July 12, 2010, at 2:35 p.m., the RD verified she had not reviewed or asked by the DTR to review Patient 352 assessment or plan of care. At that time, the RD stated there were a number of free health plan education classes available to health plan members that she could have referred Patient 352 to take advantage of as an outpatient to address obesity and/or diabetes if she had reviewed the assessment/treatment plan.

5. Patient 354 was admitted on July 8, 2010, with diagnoses of lower GI bleed and anemia. The physician ordered a nutrition consult on July 9, 2010. According to the nutrition consult completed by the DTR and cosigned by the RD, Patient 354 had multiple medical problems. The assessment included obesity as a factor impacting nutrition. A review of the plan of care cosigned by the RD did not include any provisions to address obesity.

Previously, Patient 351, 352 and 353 had also been identified as obese by either the DTR or the RD. On July 13, 2010 at 10:30 a.m., the RD confirmed that obesity is a common issue of the patient demographic of the area. The RD confirmed obesity can be a contributing factor to many other conditions and it would be a beneficial nutritional component to address as it can positively impact many of the other medical conditions of the patient population served by the medical center.

Based on inspection of the refrigerator located in the Surgery Department, interview, and document review, the facility failed to meet the patients needs by not removing expired Steris Test agent for sterility testing of endoscopes from the refrigerator.


Findings:

During inspection of drug storage area in the Surgical Department with the DOP on July 12, 2010, at 1:30 p.m., it was noted that in the refrigerator in the room that was used to store MH (Malignant Hyperthermia) cart, one box of Biological Monitoring Kit for the Steris Process with the expiration of "2/8/10."

According to the manufacturer's Package Insert,

"The Verify Biological Monitoring Kit is intended for use with a liquid chemical sterile processing system, employing STERIS 20 Sterilant Concentrate. The Verify Biological Monitoring Kit provides independent confirmation that the STERIS 20 Sterilant Concentrate Use Dilution was sufficient to sterilize the biological indicator..."

During concurrent interview, Staff 401 stated that the kit was not used anymore because the facility had different machines to sterilized the colonoscopy and endoscopy scopes and acknowledged the kit was expired.

Based on interview and record review, the facility failed, for one of 39 patients (Patient 154), to ensure the patient's discharge planning evaluation contained accurate assessment and information. The facility transferred the patient to a Skilled Nursing Facility inaccurately indicating the patient had MRSA infection. The failed practice had the potential to result in the SNF to initiate inappropriate and unnecessary interventions with Patient 154.

Findings:

On July 12, 2010, Patient 154's record was reviewed. The patient was admitted on July 6, 2010, with diagnoses which included CHF, COPD, diabetes, and obstructive sleep apnea (temporary absence of breathing). The blood culture collected on July 6, 2010, indicated the patient had an infection, but not a MRSA infection.

The RN's notes dated July 7, 2010, at 4:52 p.m., indicated, "Patient educated about their infection and isolation. Isolation booklet and one page summary of infection: MRSA given to patient ..."

On July 12, 2010, at 3:15 p.m., the record was reviewed with the ICN. The ICN stated Patient 154's record indicated the patient either had currently or history of MRSA infection, which could be indicated through the laboratory results or through the physician's documentation. The ICN was not able to find documented evidence Patient 154 had MRSA through the laboratory results or the physician's record.

The ICN stated RN 151 entered in the record indicating Patient 154 had MRSA infection. The ICN was not able to find any documentation where RN 151 would have taken the information from.

On July 14, 2010, at 9:45 a.m., Patient 154's record was reviewed with RN 151. RN 151 stated she got a call from Physician 151 on July 6, 2010, and received orders to start the patient on IV Vancomycin (antibiotic). The physician wanted to place the patient on contact isolation precaution for possible MRSA infection. The RN stated there was no final laboratory result that indicated the MRSA infection.

On July 14, 2010, at 10:48 a.m., HS 151 was interviewed and stated she spoke with Physician 151 regarding Patient 154. The physician stated the patient was started on isolation precaution for possible MRSA infection on July 6, 2010. The physician received the blood culture final result on July 9, 2010, which indicated the patient did not have MRSA infection. HS 151 stated the patient should have been taken off the isolation precaution. The transfer record for the SNF should not have included the patient had MRSA infection.

On July 14, 2010, Patient 154's transfer record, sent to the SNF, was reviewed. The record indicated, "Infection: Methicillin Resistant Staphylococcus Aureus ...Contact Precautions."

Based on observation and interview, the hospital failed to ensure that a system for controlling infections was in place because hinged instruments were not sterilized in the open position, creating the risk of inadequate sterilization and the spread of infection for patients exposed to those instruments.

Findings:

During a tour of the labor and delivery department operating room on 7/12/10, at 9:45 a.m., a table contained a sealed pouch of Mayo scissors labeled with the date sterilized March 10, 2010, with the blades in a closed position.

During a concurrent interview with the Acting Labor and Delivery Assistant Manager, she stated that she noted that instruments arriving at the department in sterile packs could be in either the closed or open positions.

According to the Association for the Advancement of Medical Instrumentation, American National Standards Institute, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities, ST79:2006, hinged instruments should be sterilized in the open position.