HospitalInspections.org

28521

Based on inspections of the hospital's Medical / Surgical Unit's and the Surgery Department's crash carts, with staff interviews, and the review of the hospital's policy and procedure, the hospital failed to ensure-
1a. six Epinephrine 1:10,000 (10 ml)[used for allergic emergencies] were in the emergency crash cart with-
1b. the labeling on the outside of the crash cart drawers (used to identify the contents in the drawers) was mislabeled in the Medical / Surgical Unit; and
2. the yellow lock's number on the crash cart's check list that is initialed by the Surgery Department's staff did not mirror the lock's number that is secured in place directly on the medication drawer by the pharmacist.

The failures of this check and balance system had the potential for emergency drugs and supplies not being readily available for staff in treating patients in the event of medical / surgical emergencies.

Findings:

1a. An inspection of the Medical/Surgical's crash cart (used for transportation and dispensing of emergency medication/equipment at the site of an emergency with the intent to save a patient's life) with concurrent interview by the Director of Pharmacy occurred on 5/27/14 at 1:30 p.m.

One Epinephrine 1:10,000 (10 ml) was missing from the count indicated by the content list posted on the outside of the cart in the Medical Surgical Unit. The Director of Pharmacy corroborated the drug was missing from the cart.

1b. During the same inspection period of the crash cart, the Director of Pharmacy corroborated the labeling identifying the contents of the crash cart drawers did not reflect the items contained inside.



2. During inspection of the Surgery Department's crash cart with concurrent interview on 5/28/14 at 1:45 p.m., it was noted that the checklist used to monitor the contents of the crash cart was incorrect.

Specific to the medications stocked in the crash cart the process is as follows: The pharmacist, who after thoroughly checking the contents of the medication trays / drawers every 30 days and after each use applies a yellow breakable lock with an identification number etched on the lock.

The Surgery Department's staff is responsible for checking the contents of the crash cart daily when patient services are being provided. This monitoring includes ensuring the integrity of this yellow lock and by checking the identification number etched on the lock mirrors what is written on the checklist.

Staff wrote the number 1922404 on the checklist when they performed their check on 5/28/14. Administrative Staff KK corroborated that this number did not mirror the yellow identification tag (lock) number 1922431 on the crash cart's medication drawer during the inspection.

During a review of the policy and procedure titled, CODE BLUE, PEDIATRIC CODE WHITE, NEONATAL CODE WHITE dated as revised 2013 indicated, "...Each department is responsible for checking the Cart against the Crash Cart checklist each shift or day of service in non-shift departments."

Based on dietetic services observations the hospital failed to maintain consistent water temperatures at the handwashing sink in dietetic services. Failure to maintain water temperatures in safe operating conditions may result in inadequate hand washing and potential cross contamination during food production activities.

Findings:

A handwashing sink shall be equipped to provide water at a temperature of at least 38°C (100°F) through a mixing valve or combination faucet. Hot water generation and distribution systems shall be sufficient to meet the peak hot water demands throughout the food establishment (Food Code, 2013).

During general kitchen observation on 5/27/14 at 5 p.m., the surveyor noted that the water at the handwashing sink was cool. In a concurrent interview with DS O she stated that the water was "always cold." In a follow up observation on 5/28/14 beginning at 8:55 am, in the presence of Maintenance Staff (MS) P the water temperature was 108°F. He stated that the water system within the hospital was inconsistent because it was not continually circulated through the plumbing system. In a follow-up observation on 5/28/14 at 3:30 p.m., the water temperature at the handwashing sink was 81°F. In a concurrent interview with the Nutrition Services Manager she stated that she had not identified this as an issue. It was also noted that while the hospital had a policy titled "Hand Hygiene" dated 1/14 that guided staff on handwashing procedures, the policy did not address the water temperature requirements in dietetic services.






28521

Based on medical record review, pharmacy staff interview, pharmacy and nutrition document review the hospital failed to ensure an effective system to identify 1 of 3 patients (Patient 205), reviewed for nutrition care, for drug nutrient interactions.

Findings:

Patient 205 was admitted on 5/24/14 with diagnosis including congestive heart failure, acute renal insufficiency and fatigue. Medical record review was conducted beginning on 5/28/14. Admission history and physical dated 5/24/14 also noted that the patient had pneumonia (an infection of the lungs) chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breath, National Heart, Lung and Blood Institute (NHLBI), 2014), hypoxia (a low level of oxygen in the blood (NHLBI) and kidney insufficiency. Admission diet order dated 5/24/14 was a regular diet. It was also noted that on 5/27/14 at 1700 the physician ordered Coumadin (a blood thinner).

In an interview on 5/28/14 beginning at 9 am, with the Nutrition Services Manager (NSM) she was asked to describe the process for evaluating drug nutrient interactions for medications such as Coumadin. She stated that prior to every meal dietary staff printed out a list which depicted the patients on Coumadin. It was noted that the list did not contain Patient 205's name.

In an interview on 5/28/14 at 4:15 pm, with Pharmacy Staff Q, who was assigned as the medication safety officer and the Director of Pharmacy provided a document titled "Northern California PHA Warfarin [Coumadin] Patient List" it was noted the list was printed on 5/28/14 at 15:57. Patient 200's name was not on the list despite receiving a dose of Coumadin on 5/27/14 at 17:00 with an order to continue the medication until 6/26/14 at 17:00. In a group telephone interview on 5/28/14 at 5 pm and 5/29/14 at 8 am, with hospital Administrative Staff R and Information Technology Staffs S, T, U, V and W who were responsible for the electronic medical record they were unable to explain the omission of Patient 200's name from both the dietary drug-nutrient interaction list and the pharmacy warfarin patient list.

Hospital policy titled "Medication and Food/Drug Interaction" dated 12/13 revealed that it was the responsibility of the pharmacist "...for entering the patient's prescribed medications into the electronic database."

Based on dietetic services observations, dietary and administrative staff interview, medical record review and dietary and administrative document review the hospital failed to ensure effective nutrition services as evidenced by lack of:
1) comprehensive time/temperature control monitoring of potentially hazardous foods capable of supporting bacterial growth associated with foodborne illness; and
2) effective clinical nutrition care for 2 of 3 patients (Patients 200 and 201). Patient 200 who was admitted with nutritionally related diagnosis did not receive a comprehensive nutrition assessment. Patient 201 who was identified at nutritional risk due to poor intake, did not receive nutritional interventions.

Failure to develop comprehensive and effective nutrition services put patients at risk for worsening medical status.


Findings:

Food Services

1. Potentially Hazardous Foods (PHF) are those that are capable of supporting bacterial growth associated with foodborne illness. PHF's require time/temperature control for food safety. Cooked pasta is considered a PHF which requires temperature monitoring for food safety. Temperature monitoring of cooked PHF's ensure that the temperature reaches 70°F within 2 hours and to less than 40°F within an additional 4 hours (Food Code, 2013).

During initial tour on 5/27/14 beginning at 1 pm, it was noted that in the walk-in refrigerator there was leftover pasta salad. In a concurrent interview with the Nutrition Services Manager (NSM) she stated that the item was a salad bar item on 5/26/14. The same item would also be used for the patient menu at dinner on 5/27/14. She also stated that the item was cooked on a weekly basis. In an interview on 5/27/14 at 1:30 pm, with Dietary Staff (DS) X she stated that cooked food items that were used for multiple days would be monitored for cooldown. Concurrent review of hospital document titled "Cooling Log" dated 1/3/14-5/27/14 (a period of 20 weeks) revealed that the pasta, which was cooked weekly, was monitored only once during this time frame. It was also noted that the cooling log guided staff that all cooked foods should be monitored.

In an interview on 5/27/14 at 1:45 pm, with the NSM she stated that she was told by an outside contractor that this item did not require monitoring. In a follow up interview on 5/28/14 beginning at 9 am, with the NSM she stated that she reviewed the criteria for determining whether or not pasta required time/temperature monitoring and acknowledged that cooked pasta was a food that required monitoring.

Nutrition Care

2. Patient 205 was admitted on 5/24/14 with diagnosis including congestive heart failure, acute renal insufficiency and fatigue. Admission history and physical dated 5/24/14 also noted that the patient had pneumonia (an infection of the lungs) chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breath, National Heart, Lung and Blood Institute (NHLBI), 2014), hypoxia (a low level of oxygen in the blood (NHLBI, 2014) and kidney insufficiency. Admission diet order dated 5/24/14 was a regular diet.

A nursing nutrition admission screening dated 5/24/14 failed to note any of Patient 205's chronic diseases which resulted in a nutrition risk score of 2 which was considered to be low nutritional risk. Review of undated hospital electronic medical record screen shot titled "Document Nutritional Screening" noted that minor, chronic and severe disease problems were associated with a nutritional risk factors ranging from 1-3 points depending on patient diagnosis. Review of Patient 205's lab indicators revealed that during the course of hospitalization the blood, urea, nitrogen (BUN) level was elevating daily ranging from 28 milligrams/deciliter (mg/dl-a metric unit of measure) on 45/24/14 to 53 mg/dl on 5/28/14 (normal 8-26 mg/dl). The BUN is a measure of nitrogen in the blood which evaluates kidney function. Elevated BUN levels depict compromised kidney function (National Library of Medicine, 2014). Similarly the patients' creatinine level, also a measure of kidney function, was elevated ranging from 2.04 mg/dl on 5/13/14 to 1.9 mg/dl on 5/28/14 (normal - .61 mg/dl to 1.24 mg/dl). Glucose levels, which are indicative of diabetes (American Diabetes Association), were also elevated ranging from 154 mg/dl on 5/24/14 to 173 mg/dl on 5/28/14 (normal 70-130 mg/dl). The standard of practice would be to ensure that patient with diagnosis of renal failure and diabetes are offered the opportunity to receive a therapeutic diet in an effort to normalize blood chemistry (Therapeutic Diet Specifications for Adult Inpatients, Agency for Clinical Innovation, 2011).

In an interview on 5/28/14 beginning at 9:30 am, the Nutrition Services Manager was asked to describe the process for nutrition evaluation for patients who were not identified at nutritional risk. She stated that all patients regardless of nutritional risk would be evaluated by the 7th day of hospitalization. She also stated that nursing staff may also request a nutrition evaluation for patients. Additionally she also reviewed the patient diet list daily to evaluate diagnosis, admission date, height/weight, dietary intake and albumin (a measure of protein stores). She did not review any other nutritionally related lab indicators. She further stated that when she reviewed the diet list on 5/26/14 for Patient 200 she did not feel he was at nutritional risk. She also stated that based on the lab work and medical record review Patient 200 may have benefitted from a therapeutic diet.

In an interview on 5/28/14 at 10:45 am, with Administrative Staff EE stated it was the goal that nursing staff held daily care conferences, with a minimum of conferences 3-4 time/week, including weekends. She also stated other disciplines such as occupational and physical therapy participated depending on patient needs. She stated that the Registered Dietitian was usually not involved in the care conference.

Review of hospital policy titled "Patient Assessment and Interdisciplinary Plan of Care-Addendum A" revised 11/13 revealed that the summary of disciplines scope of assessment and reassessment included expectation of multiple disciplines such as medical, nursing, speech therapy, social services, discharge planning, respiratory therapy, pharmacy and spiritual health services. The policy did not define the role of assessment with respect to nutrition services. Hospital policy titled "Nutritional Screening and Assessment" dated 4/14 noted it was the role of the Registered Dietitian (RD) to prioritize patients for nutrition intervention based on changes in labs or other pertinent clinical data. It was also the responsibility of the RD to "...perform in-depth nutritional assessments on patients at risk ..."

3. Patient 206 was admitted with diagnosis including exacerbation of chronic obstructive pulmonary disease (COPD) and complaints of weakness for the previous 3 days. Admission history and physical dated 5/26/14 noted diagnosis of congestive heart failure. Admission diet order dated 5/26/14 was a cardiac, less than 2 gram sodium diet. Admission height was 5 feet 8 inches and weight was 101 pounds. Nursing nutrition screening dated 5/26/14 noted that patient's nutrition risk score was 8 which depicted a moderate nutritional risk.

Review of dietary intake for 8 meals from 5/26-5/28/14 revealed that Patient 206 had an average intake of 20%. A nutrition assessment dated 5/26/14 noted that the patient was below ideal body weight with a poor dietary intake. She also stated that during previous admissions the patient refused nutrition supplements; however did accept milkshakes but they were "too high in sodium for current diet." The assessment also noted that the patient had increased calorie needs based on his low weight status and increased energy needs of the COPD. Follow up was scheduled for the patient 3 times/week.

In an interview on 5/28/14 beginning at 2:45 pm with the Nutrition Services Manager the surveyor asked her to describe the rationale for lack of nutritional interventions (i.e. the milkshake) that may have been accepted by the patient in light of his poor dietary intake. She stated that she didn't want to provide any interventions in case the patient began eating over the course of the next several days; however would not follow up on the patient for 2-3 days after the initial assessment. She also acknowledged that based on documented dietary intake the inclusion of milk shakes would not have exceed the physician ordered therapeutic diet parameters.

The sodium content of 8 ounces of low fat milk is 150 milligrams. Eight ounces of ice cream contains 100 milligrams of sodium (United States Department of Agriculture, 2011) totaling 250 milligrams of sodium. Based on Patient 201's poor dietary intake, foods the patient was consuming and adequate monitoring of this patient at nutritional risk, inclusion of several milkshakes each day would not have exceeded the physician ordered therapeutic diet parameters. It was also noted that based on the poor dietary intake there was no evaluation of whether or not liberalization of the diet order would have promoted increased nutrient intake without compromising patient medical status.

Review of hospital document dated 5/26/14 titled "Patients Plan of Care" revealed that a care plan was developed by a Registered Nurse for inadequate oral intake; however the plan did not include specific and/or measurable goals and objectives. The plan consisted of RD monitoring activities for elements such as chewing ability, collaboration of team/patient rounds, modification of distribution/type/amount of food and nutrients.

In an interview on 5/28/14 at 3 pm, with Administrative Staff (AS) EE she stated that the care plan was in an electronic format. Once a problem such as inadequate oral intake was identified the developed care plan was pre-populated for suggested interventions. She also stated that the care planning process would allow staff to add additional interventions specific to each patient. AS EE also stated that the interventions listed on Patient 206's care plan were likely pre-populated. While an electronic care plan was developed there was no documentation of any interventions that were being implemented to mitigate the patients' inadequate oral intake.




28521

Based on medical record review, administrative staff interview and nursing document review the hospital failed to ensure effective nutrition admission screening procedures for 1 of 3 patients (Patient 205). The lack of effective admission screening resulted in lack of comprehensive nutrition assessment for Patient 205 who was admitted with multiple nutrition related diagnosis. Failure to develop an effective nutrition screening tool may result in absence or delay of nutrition assessment and may further compromise patient medical status.

Findings:

1. Patient 205 was admitted on 5/24/14 with diagnosis including congestive heart failure, acute renal insufficiency and fatigue. Admission history and physical dated 5/24/14 also noted that the patient had pneumonia (an infection of the lungs) chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breath, National Heart, Lung and Blood Institute (NHLBI), 2014), hypoxia (a low level of oxygen in the blood (NHLBI) and kidney insufficiency. Admission diet order dated 5/24/14 was a regular diet.

A nursing nutrition admission screening dated 5/24/14 failed to note any of Patient 205's chronic diseases. Review of undated hospital electronic medical record screen shot titled "Document Nutritional Screening" noted that minor, chronic and severe disease problems were associated with a nutritional risk factors ranging from a risk factor of 1-3 points depending on patient diagnosis.

In an interview on 5/29/14 at 10:10 am, with Administrative Staff (AS) EE she stated that the hospital reviewed the comprehensive completion of nursing admission screening and found the percent completed to be within acceptable parameters; however had not evaluated the quality of the screening. She also stated that after a recertification survey conducted in March 2014 nursing staff was reminded via a flyer dated 4/15/14 and titled "Staff Education-Nutrition Screening" to "...complete all 5 aspects of the Nutrition screen on admit ..." Nursing staff was also provided the policy titled "Nutritional Screening and Assessment" dated 3/14 which included an attestation that the Registered Nurse understood the policy. Administrative EE also stated that nursing staff was provided 6 hours of training on the electronic medical record update.

Review of hospital document titled "RN Acute Part A and Part B Training Guide" dated 12/10/13 and 1/12/14 respectively revealed that while training was provided on the computer program update, the training in relationship to nutrition services was limited to guidance on how to enter a diet order. There was no training in relationship to nutrition admission screening or the accuracy of the screening. As a result of lack of comprehensive and accurate identification of Patient 205's nutritional risk there was no provision of nutrition care services for a patient with multiple nutritional risk factors after 5 days of hospitalization.

Based on medical record review and nursing staff interview the hospital failed to ensure development of care plans that fully depicted patient medical needs for 1 of 3 patients (Patient 205) reviewed for nutrition care. Failure to develop comprehensive care plans may result in patients receiving inadequate care, further compromising medical condition.

Findings:

Patient 205 was admitted on 5/24/14 with diagnosis including congestive heart failure, acute renal insufficiency and fatigue. Admission history and physical dated 5/24/14 also noted that the patient had pneumonia (an infection of the lungs) chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breath, National Heart, Lung and Blood Institute (NHLBI), 2014), hypoxia (a low level of oxygen in the blood (NHLBI) and kidney insufficiency. Admission diet order dated 5/24/14 was a regular diet.

Review of Patient 205's lab indicators revealed that during the course of hospitalization the blood, urea, nitrogen (BUN) level was elevated ranging from 28-53 mg/dl (normal 8-26 mg/dl). The BUN is a measure of nitrogen in the blood which evaluates kidney function. Elevated BUN levels depict compromised kidney function (National Library of Medicine, 2014). Similarly the patients' creatinine level, also a measure of kidney function, was elevated ranging from 2.04-1.9 mg/dl (normal - .61 to 1.24 mg/dl). Glucose levels, which are indicative of diabetes (American Diabetes Association), were elevated ranging from 154-173 mg/dl (normal 70-130 mg/dl).

Review of Patient 205's interdisciplinary care plan dated 5/24/14 revealed there was no documented plan with respect to abnormal lab values; rather was limited to activity tolerance, fluid imbalance, hypoxia, depression, falls, angina and discharge readiness. Hospital policy titled "Patient Assessment and Interdisciplinary Plan of Care" dated 11/26/12 noted that "Each discipline involved with the care of the patient is responsible for contributing to the plan of care."

Based on medical record review, administrative staff interview and departmental document review the hospital failed to ensure evaluation of the quality of nutrition risk screening and the quality of nutrition care services as evidenced by lack of effective nutrition care of 2 of 3 patients reviewed (Patients 205 and 206). Failure to effectively assess nutrition care services may result in lack of effective nutrition care, may further compromise medical status, lengthen hospitalization stay and may contribute to increased readmission rates.

Findings:

1. During medical record review on 5/28/14 beginning at 9 am, it was noted that the nutrition risk screening completed at the time of admission did not accurately reflect the nutritional risk of 1 of 3 patients reviewed for nutrition care (Cross Reference C296). In an interview on 5/29/14 at 10:10 am, with Administrative Staff (AS) EE she stated that the hospital reviewed the comprehensive completion of nursing admission screening and found the percent completed to be within acceptable parameters; however had not evaluated the accuracy of the screening.

2. During medical record review on 5/28/14 beginning at 9 am, it was noted that Patients 205 and 206 did not receive comprehensive nutrition care planning. Patient 205 did not receive a nutrition assessment despite nutrition related chronic diseases. While Patient 206 received a comprehensive nutrition screening he did not receive nutrition interventions for identified nutritional problems (Cross Reference C279).

Review on 5/29/14 at 9 am of the departments' performance improvement parameters noted that while there was a system for assessment of registered dietitian consultation with respect to timeliness in relationship to hospital policy; however there was no system to evaluate the quality of the assessment in relationship to patient nutritional needs or defined standards of practice. In an interview and concurrent document review with Administrative Staff CC she acknowledged that in neither of the instances the quality of the process was evaluated.

Nutrition Department policy dated 1/14 and titled "Quality Control and Performance Improvement" noted that the department "assures quality through gathering data...and planning of improvement efforts..." It was also noted that all of the performance improvement procedures were related to food services. There were no defined procedures for evaluation of nutrition care services. Hospital policy dated 8/13 and titled "Plan for Improving Organizational Performance" noted that "at a minimum, the organization will collect data in the following areas...other aspects of performance that assesses processes of care, hospital service and operations..."