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Based on interview and record review, the facility failed to assess recent experience before granting surgical privileges in 1 of 6 sampled credentials files (Practitioner 1). Refer to A-341.

Based on interview and record review, the facility failed to document for one of 20 patients (Patient 12) whether or not the patient had executed an advance directive. The deficient practice limited facility staff's ability to determine which life sustaining treatments Patient 12 wished to receive/not receive during a medical emergency.

Findings:

Patient 12 was admitted to the facility on 5/17/13 with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease) (problem breathing).

During a review of Patient 12's medical record there was no documentation to indicate whether or not Patient 12 or the responsible party had executed an advance directive.

During an interview on 7/10/13 at 11:05 a.m., MRA 1 agreed there was no documentation regarding an advance directive in Patient 12's record. She stated, "I don't see the advance directive in the chart."

The facility policy and procedure titled "Advance Care Planning" (revised March 25,2008), indicated, "....An individual may appoint another person to be a health care agent or power of attorney for health care....Laguna Honda Hospital and Rehabilitation Center (Laguna Honda) is committed to providing residents information about their medical condition to facilitate their involvement in medical decisions, in an ongoing process called advance care planning....Residents are provided information about their rights to make medical decisions at the time of admission....Consistent with California law (CA Probate code Section 4600-4805, Advance Health Care Directives (AHCD) may be oral and documented in the medical record, or documented in a written advance care planning document attached to the medical record".

The facility policy and procedure titled "Advance Health Care Directives" (dated March 27, 2012) indicated "... Purpose: 1. To assure that medically indicated treatment decisions correspond with the wishes of individual patients whether expressed by patients or made by surrogates acting in the patients behalf...Procedure:.. b. Whether or not the patient has executed an Advance Directive will be ascertained and documented in the medical record..."

Based on interview and record review, the facility failed to clearly document the status of its performance improvement projects. Available records were ambiguous regarding what activities were planned in the future versus what activities had already occurred. The deficient practice had the potential to undermine planning and monitoring of performance improvement activities.

Findings:

Review of the facility's May 2013 report to its governing body indicated there was a section titled "GACH QAPI 2012-2013 Reports by Service Area". Some projects listed in the report included bullet points which discussed a "planned intervention" or "next steps" and which were written in future tense, but which were placed between other bullet points that had occurred in the past.

In an interview on 7/11/13 at 4:11 p.m., Staff C stated the entries written as future activities but listed on the report between past quarterly updates had already been completed.

Based on observation, interview, and record review, the facility failed to follow its policy that all deaths would be reviewed by the medical quality improvement (MQI) committee. The facility also failed to determine the number of distinct performance improvement projects. The deficient practices created the potential for the facility to miss opportunities to improve the quality of care and contributed to a blurred distinction between quality assessment (measuring performance) and performance improvement (doing something to change the results).

Findings:

1. Review of the facility's policy "PATIENT EXPIRATION" (revised 9/30/10) indicated, "All deaths are reviewed by the medical QI committee which shall assess the quality of care provided to the deceased throughout the hospital stay."

Review of the facility's list of patients for the past 6 months indicated Patient 11 had expired on 5/21/13. In an interview on 7/11/13 at approximately 4:15 p.m., Staff B stated Patient 21 had expired on 7/31/12 and that there had not been other deaths at the general acute care hospital in the past 12 months.

In an observation and interview on 7/11/13 at approximately 4:30 p.m., Staff A asked for the dates of the deaths, opened a yellow folder for each of the two dates, and stated that the MQI committee had not reviewed Patient 11's death or Patient 21's death.

Review of Staff A's folders indicated each contained a "Health Information Services Death Registry" for one month which included deaths at the facility (the general acute care hospital) as well as the skilled nursing facility at the same location. The log for July 2012 had check marks next to the names of several patients who had died but did not have a check mark next to Patient 21. The log for May 2013 had check marks next to the names of several patients who had died but did not have a check mark next to Patient 11.

2. Review of the facility's May 2013 report to its governing body indicated there was a section titled "GACH QAPI 2012-2013 Reports by Service Area" which listed both topics for which the facility had monitoring of performance indicators without any interventions (quality assessment) as well as topics for which the facility had measured performance indicators, completed interventions to change the results, and in some cases remeasured the performance indicators (performance improvement projects - both underway and complete). Some topics included bullet points which indicated a future intervention was planned, yet the planned intervention was placed between other bullet points which had occurred in the past. The report did not contain a statement indicating which of the listed topics were performance improvement projects and how many performance improvement projects were underway in total.

In an interview on 7/11/13 at approximately 3:45 p.m., Staff C stated she could do a hand count when she was asked how many performance improvement projects the facility was conducting.

Based on interview and record review, the facility failed to maintain provider-specific results of reviews by its medical quality improvement (MQI) committee then consistently consider those results, other available quality data, patient outcomes, and information regarding the scope and volume of each practitioner's activity at the time of medical staff reappointments. In 3 of 6 sampled credentials files (Practitioners 3, 4, and 5), the facility failed to examine the type and outcomes of each physician's work at the time of reappointment. In 2 of 6 sampled files (Practitioners 3 and 5), the facility failed to note whether or not the physician had been responsive to drug regimen reviews. In 1 of 6 sampled files (Practitioner 4), the facility failed to document whether or not mortality and quality improvement (QI) reviews had been done and whether or not those reviews had identified opportunities for improvement. In 1 of 6 sampled files (Practitioner 5), the facility failed to note whether or not peer reviews had been satisfactory. The deficient practices eliminated mechanisms by which the facility could examine what its physicians had been doing, what the quality of that work was, and thereby draw conclusions regarding whether or not applicants for reappointment had current competence in the privileges requested.

Findings:

1. Review of the facility's MQI minutes dated 7/16/12, 8/27/12, 9/18/12, 11/19/12, 12/17/12, 1/24/13, 2/25/13, 3/27/13, 4/29/13, 5/22/13, and 6/27/13 indicated that they listed the cases the committee had reviewed and that opportunities for improvement identified by the committee had been discussed with the responsible physician. The minutes also listed cases that had had been subjected to "SPECIAL REVIEWS". No summary by provider was present indicating how many cases had been reviewed and or the results of those reviews.

Review of "SPECIAL REVIEW LOG[S]" dated 2012 and 2013 indicated the documents listed the cases which had been reviewed, the concern, as well as the MQI's assessment. The log specified who had referred each case, but did not indicate which practitioner had been responsible for the patient's care. No summary of the results of the special reviews by provider was present.

In an interview on 7/10/13 at 9:40 a.m., Practitioner 4 stated the facility had made a decision not to track the results of the MQI reviews and special reviews by provider. She stated that such tracking may be done by each department chair, but that it was not documented. She stated that the results were not logged by provider but that provider-specific results could be created.

2. Review of Practitioner 3's credentials file indicated she was reappointed to the facility's medical staff on 7/19/11. A "REAPPOINTMENT DATA SUMMARY SHEET" (RDSS) approved by the chief of staff on 7/12/11 indicated "From: 2010 To: Present" chart reviews and peer reviews had been satisfactory, that "Mortality Reviews and Q1 [sic] Reviews" had been done and no "PI [performance improvement] issue" had been identified. The field on the form indicating whether or not Practitioner 3 had been responsive to drug regimen reviews (DRR's) was blank. There was no documentation indicating what services Practitioner 3 had performed at the facility or what the patient outcomes had been.

In an interview on 7/9/13 at 2:06 p.m., Staff A agreed the fields regarding Practitioner 3's responsiveness to DRR's were blank. In an interview on 7/9/13 at 2:36 p.m., Staff A stated none of the credentials files specified how many of what type of service each practitioner had provided.

Review of Practitioner 4's credentials file indicated she was reappointed to the facility's medical staff on 9/27/11. A RDSS approved by the chief of staff on 9/7/11 indicated that during an unspecified period, chart reviews and peer reviews had been satisfactory, and that Practitioner 4 had been responsive to DRR's. The fields on the form indicating whether or not "Mortality Reviews and Q1 [sic] Reviews" had been done and whether or not there had been a "PI issue" were blank. There was no documentation indicating what services Practitioner 4 had performed at the facility or what the patient outcomes had been.

In an interview on 7/9/13 at 2:43 p.m., Staff A agreed that the portions of Practitioner 4's RDSS addressing whether or not mortality and QI reviews had been done and whether or not there had been a PI issue were blank. He agreed that the RDSS form did not specify what the patient outcomes for Practitioner 4 had been.

Review of Practitioner 5's credentials file indicated she was reappointed to the facility's medical staff on 5/21/13. A RDSS approved by the chief of staff on 5/9/13 indicated "From: 6/2011 To: Present" chart reviews had been satisfactory, that "Mortality Reviews and Q1 [sic] Reviews" had been done and no "PI issue" had been identified. The fields on the form indicating whether or not peer reviews had been satisfactory and whether or not Practitioner 5 had been responsive to DRR's were blank. There was no documentation indicating what services Practitioner 5 had performed at the facility or what the patient outcomes had been.

In an interview on 7/9/13 at 2:43 p.m., Staff A agreed that Practitioner 5's RDSS did not specify her responsiveness to DRR's and that the credentials files did not specify the volume of each type of service each physician had provided.

Review of the facility's medical staff bylaws revised 10/2/12 indicated reappointment recommendations by the service chief were to be based on factors including quality information, clinical activity, current professional competence, as well as "ongoing and focused ('provider specific') continuous peer review quality improvement evaluations."

Based on interview and record review, the facility failed to document the procedure-specific experience of a newly appointed member of the medical staff in 1 of 6 sampled credentials files (Practitioner 1). The deficient practice eliminated mechanisms by which the facility could ensure new members of the medical had current competence to perform the privileges being requested.

Findings:

Review of Practitioner 1's credentials file indicated he was a dentist who was appointed to the facility's medical staff on 2/21/12. Practitioner 1's curriculum vitae indicated he completed additional training in oral and maxillofacial surgery (OMFS) in 1989 and had been working part-time as a dentist since 2006. Practitioner 1 was granted core privileges in general dentistry, which included "treatment for dental caries and traumatic injuries, prosthetic therapy, routine endodontic therapy, routine orthodontic therapy, routine periodontal therapy, intraoral biopsy, simple and surgical exodontias." No documentation was present in the file indicating how many of which procedures Practitioner 1 had performed recently at the time of his appointment, or whether his recent experience prior to his appointment had included each of the procedures in which he was granted privileges.

In an interview on 7/9/13 at 2:06 p.m., Staff A stated the facility did not have records of experience by procedure for general dentists. He stated Practitioner 1 was considered a general dentist who could do all the procedures listed.

Review of the facility's medical staff bylaws (revised 10/2/12) indicated, "the granting and scope of privileges depends upon... an individual's experience in categories of diagnostic and treatment areas..."

Review of the American Dental Association (ADA) webpage on dental specialties (http://www.ada.org/104.aspx) indicated "Specialties are recognized in those areas where advanced knowledge and skills are essential to maintain or restore oral health..." Review of the list of ADA recognized dental specialties (http://www.ada.org/495.aspx) indicated that OMFS, prosthodontics, endodontics, orthodontics, and periodontics were all separate dental specialties. Review of the American Association of Oral and Maxillofacial Surgeons website (http://www.aaoms.org/) indicated, "Oral and Maxillofacial Surgeons care for patients with problem wisdom teeth, facial pain, and misaligned jaws. They treat accident victims suffering facial injuries, place dental implants, care for patients with oral cancer, tumors and cysts of the jaws, and perform facial cosmetic surgery."

Based on interview and record review, the facility failed to follow its medical staff bylaws when it did not consider a newly appointed dentist's procedure-specific experience prior to granting privileges (refer to A-341), and when it did not consistently consider quality information, clinical activity, and peer review evaluations at the time of reappointment (refer to A-340). The deficient practices eliminated mechanisms of assessing the current competence of the facility's medical staff.

Based on interview and record review, the facility failed to include a requirement for medical histories and physical examinations (H&P's) in its medical staff bylaws. The deficient practice had the potential to allow facility practices on this topic to be easily changed.

Findings:

Review of the facility's medical staff bylaws (revised 10/2/12) indicated that there were no provisions regarding H&P's.

In an interview on 7/8/13 at approximately 2:45 p.m., Practitioner 4 stated there were no provisions in the bylaws regarding H&P's.

Based on interview and record review, the facility failed to include requirements regarding updates to medical histories and physical examinations (H&P updates) in its medical staff bylaws. The deficient practice allowed facility practices on this topic to be easily changed.

Findings:

Review of the facility's medical staff bylaws (revised 10/2/12) indicated that there were no provisions regarding H&P updates.

In an interview on 7/8/13 at approximately 2:45 p.m., Practitioner 4 stated there were no provisions in the bylaws regarding H&P updates.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of 20 patients whose records were reviewed (Patient 13). There was no signature of Patient 13 on the California Standard Admission Agreement and the notice of Medicare Rights The deficient practice limited the facility's ability to ensure that patients were aware of the conditions of admission and their medicare rights.

Findings:

Patient 13 was admitted to the facility on 1/9/13. During a review of the clinical record for Patient 13, the history and physical examination dated 1/9/13 indicated she was alert and oriented X 4. The patient's California Standard Admission Agreement dated 1/9/13, and notice of Medicare Rights dated 1/9/13 was not signed by Patient 13. A facility staff member had written "Unable to sign" where Patient 13's signature should have been.

During an interview on 7/15/13 at 1:30 PM, the Manager of Admissions stated, "The unable to sign signature should be followed up by the financial counselor. If it is followed up, it would be documented on the signature page... As the patient is getting better, the counselor should have come up to have the patient sign the form."

Review of the facility's policy and procedure, "Admissions & Eligibility Department, (revised January 2010) indicated, " ... Every patient has the legal right to decide upon medical treatment he/she is to be given. Therefore, every patient who is admitted to the hospital must sign the California Standard Admission Agreement for skilled nursing facilities and intermediate care facilities (SAA or often commonly referred to as a COA) form granting consent for hospital services and medical treatment...Laguna Honda Hospital Financial Counselors are responsible for securing signatures....The Financial Counselor will obtain the appropriate signature on the Terms and Conditions of Admission form. When this is not possible due to the patient being unable to sign due to a lack of decision making capacity or disability the Financial Counselor will conduct the needed follow-up and obtain the proper signature....When a patient's inability to sign is temporary, this should be documented and the A&E (admissions and eligibility) staff member is to ask the nurse to notify when the patient is able to sign. The A&E staff member should return to obtain the signature at a future date..."

Based on observation, interview and document review, the hospital failed to ensure that staff responsible for the preparation of compounded sterile products were competent in the proper operation of sterile compounding equipment. A pharmacy staff member was unable to demonstrate and describe the proper procedures in transferring compounding supplies into the compounding isolator.

Findings:

During a tour of the IV Room (where intravenous medications are prepared) located in the pharmacy at approximately 2:25 p.m. on 7/9/13, a compounding aseptic isolator (CAI) was observed in the IV room. A CAI is an isolator designed for compounding of pharmaceutical ingredients or preparations. It is designed to maintain an aseptic compounding environment within the isolator throughout the compounding and material transfer processes. Pharmacy Technician 1 (RPT 1), when asked to demonstrate and describe the proper use of the airlock chamber to transfer material from the ambient environment to the compounding work area of the isolator, was unable to state the proper procedures to transfer medications or supplies into the compounding isolator. RPT 1 indicated that medications and supplies placed in the airlock compartment could be immediately introduced into the aseptic compounding chamber. When asked by the surveyor if he needed to wait after placement of medications and supplies into the airlock chamber before opening the inner airlock door to introduce the material into the compounding chamber, RPT stated that no waiting is needed.

A review of the operation manual of the CAI showed that the airlock, when operated properly, minimizes contamination of the compounding environment from the material transfer process. HEPA (high efficiency particulate air) air supplied in the airlock at a velocity sufficient to remove trapped particles and maintain an ISO Class 5 (industrial standard to classify environment control level based on particle count and other measures). The operating instructions include:

13. Place compounding elements into the airlock, wipe down.
14. Remove hands from the airlock and close.
15. Wait at least 10 seconds before bringing compounding elements into work area.
16. Begin preparation.

RPT 1 did not demonstrate the proper operation of the CAI to minimize contamination of the compounding environment.

Based on interview and record review, the facility failed to maintain records of its inspections of lead aprons. The deficient practice removed accountability regarding inspections of safety equipment and had the potential to allow continued use of faulty equipment.

Findings:

Review of maintenance records in the radiology department indicated there was no record of periodic inspections of the lead aprons. In an interview on 7/10/13 at 2:08 p.m., Staff D stated there was no log of the lead apron inspections.

Based on food production observations, dietary staff interviews, and dietary document review, the hospital did not have a Director of Dietary Services (vacant position) and failed to ensure the interim Director of Dietary Services was fully responsible for the daily management of the dietary services as evidenced by:

1) Outdated and expired food products located in storage areas,
2) Thawed frozen juice products with no "use by" dates to determine length of storage, and
3) Stock rotation dating system where dates did not match the case received dates.
4) Insufficient emergency menu inventory to meet needs of resident/patient census

These failures had the potential to cause foodborne illness or result in the facility being unable to provide enough food to meet the nutritional needs of patients during an emergency or disaster.

Findings:

1 a) During the initial kitchen tour on 7/9/13 starting at 9:30 a.m., the following outdated or expired items were observed in the kitchen area:

Location Item Description Quantity Expiration Date
Freezer 1 Beef Puree 11 cases 6/1/13
Freezer 1 Pork Puree 3 cases 5/13/13
Produce Fresh Lemons partial case large brown soft spots
Refrigerator
Nourishment Vanilla Pudding Mix 1 case Jan 2012
Preparation Area (Prep)
Nourishment Prep Vanilla Pudding Mix 1 case 5/21/12
Nourishment Prep Vanilla Pudding Mix 1 case June 2012
Refrigerator 6 Light & Fit Yogurt 1 container 7/3/13 sell-by date
Refrigerator 7 Puree Green Bean 1 case 7/3/13 use by date
Main Storage Room Fanta Orange Soda Syrup 1 case 4/4/13 use by date
Main Storage Room Root Beer 1 case 5/8/13 use by date
Main Storage Room Sprite Zero 1 case 2/4/13 use by date
Cafeteria Light & Fit Yogurt 1 carton 7/6/13 sell by date
Display Refrigerator

During a concurrent interview, the Assistant Food Service Director (AFSD), stated the storeroom attendant position was responsible for checking stock for expiration dates, however, this position was vacant during the survey. During the vacancy, he stated that Chef 2 was responsible for managing stock rotation. He stated that Chef 2 should have removed the lemons from the produce refrigerator. He further stated he thought the vanilla pudding mix was no longer on the menu, and that it should have either been used or removed from storage.

A review of the hospital document entitled, "Storeroom Attendant Supplemental Job Requirements and Duties," page 5, item number 5 indicated, "...maximum shelf life for staples is one year and the shelf life is 72 hours for perishable foods."

2) During initial kitchen tour on 7/9/13 starting at 9:30 a.m., a case of individually packaged frozen juices were located in Refrigerator 4. Neither the case nor the juices had "use by" or "expiration" dates. During a concurrent interview, the AFSD stated that the product was received frozen from the vendor and was placed directly into the refrigerator to thaw. The manufacturer label indicated the juices were good for seventeen days after thawing. He stated once thawed; food service staff placed the juices on individual patients' trays and they were not sent to the units for between meal nourishments. He further stated a dating system was not necessary since the case was marked with a received from the vendor date, and the juices were used within seventeen-days of thawing.

On 7/10/13 starting at 11:30 a.m., accompanied by the Food Service Manager (FSM), AFSD, and Registered Dietitian 1 (RD 1), the unit galley kitchen stored products were observed. In galley kitchen # S 3034, the refrigerator contained one carton of previously frozen, thawed apple juice with no use by or expiration date label.

In galley kitchen #S 4036, the refrigerator contained 20 cartons of previously frozen, thawed cranberry juice cocktail, 12 cartons of orange juice, and 10 cartons of apple juice with no use by or expiration date labels.

In galley kitchen #S 6034, the refrigerator contained 5 cartons of previously frozen, thawed apple juice and 10 cartons of orange juice with no use by or expiration date labels.

During a concurrent interview, the AFSD could not say how long these juice cartons had been in these refrigerators and that nursing staff must have removed them from the residents' trays and placed them into the refrigerators.

A review of the hospital policy and procedures document entitled, "1.92 Daily Cleaning of Galleys", Procedure number 4, indicated, "The food service worker will check refrigerator and freezer and clean out any outdated products."

3) During initial kitchen tour observations and staff interviews on 7/9/13 starting at 9:30 a.m., a "date received/date pulled from the freezer/date to be used by" slip was taped on a case of Puree Green Beans. The case had a 7/8/13 sticker on it. The AFSD stated the date sticker indicated the date the facility received the product from the vendor. On the slip, the "date pulled from the freezer" line indicated, 6/26/13, and the "date to be used by" line indicated, 7/3/13. During a concurrent interview with Chef 1, he stated the green beans were good for seven days after removal from the freezer. He further stated that although the product was in the refrigerator, the cooks would not use it. The AFSD stated he did not know why the case had a 7/8/13 "received from the vendor" sticker on it.

A review of the hospital document entitled, "Storeroom Attendant Supplemental Job Requirements and Duties," page 5, item #4, indicated, " ...dates and labels food upon receiving, dates all products when removed from freezer, ..."

A review of the hospital document entitled, "1.63 "Sanitation inspections," dated 7/2009, indicated under procedure number 1, "Once a week a safety and sanitation inspection will be taken in two general areas as listed:

The Chefs will conduct the safety and sanitation inspection in the production and storage area. A "Mr.Clean" report will be completed and signed by the Chefs. It will be forwarded to the Assistant Food Service Director for review and signature.

The Supervisors will conduct the safety and sanitation inspection in each of the Galleys. A Sanitation Report will be completed by the Food Service Supervisor. It will be forwarded to th Food Service manager for review and signature."

A review of the document entitled, "Production Sanitation (Mr Clean)" indicated it did not include outdated or expired products as areas reviewed.


4) On 7/9/13 starting at 1:50 p.m., an observation and review of the Dietary Department's emergency/disaster plan menu and inventory was conducted. A review of the hospital document entitled, "Emergency Menu Inventory Sheet-7/14/11, indicated there should be 15 cases of Hash Corned Beef 6/10# on hand to meet emergency needs. The hospital had 13 cases. The Emergency Menu Inventory Sheet also indicated there should be 28 cases of Peanut Butter Creamy 12/18 oz on hand; there were 22 cases. During a concurrent interview, the AFSD stated the hospital had more than enough food on hand to meet the needs of the facility during an emergency or disaster, even though they could not show there was adequate inventory on hand to meet the needs according to the hospital's emergency menu planning guide.

A review of the hospital document entitled "Emergency Menu Inventory Sheet-7/14/11," indicated four columns labeled, "Item, Base Par, Emg.Needs, and New Par."

During an interview with the AFSD on 7/9/13 starting at 1:50 p.m., he stated the emergency food supplies are co-mingled with the hospital food supplies used for daily menu production. The base par column indicated the amount of inventory needed to meet the daily needs of the hospital. The Emg.Needs column indicated the amount of inventory needed to meet emergency needs. He stated the amount needed to be on hand at any given time was the amount specified under the Emg.Needs column. When asked the purpose of the "New Par" column, he could not state its purpose. For example, for the item "Asparagus," the base par column indicated 12 cases, the Emg.Needs column indicated 25 cases, the New Par column indicated 37. The amount on hand for the Asparagus was 28 cases.

Based on observation, interviews, and document review, the facility failed to ensure staff were competent to follow procedures during a fire. This failure had the potential to compromise hospital and staff safety.

Findings:

An observation and interview with the Cook regarding procedures to follow during a fire in the food preparation area was conducted on 7/9/13 at 2:45 p.m. The Cook was asked to demonstrate the procedures he would follow during a fire emergency. He incorrectly stated he would call the hospital's maintenance department if the Ansul automatic fire suppression system failed to discharge. He was unable to demonstrate which "red" alarm to pull to manually activate the Ansul system if it failed to automatically discharge. He could not distinguish between the audible alarm system pull and the Ansul system pull. He had to be instructed by his supervisor to look at his "fire plan" attached to his employee's hospital identification card worn on his uniform, before he could verbalize what actions he would take if there was a fire.

A review of the hospital wide fire safety inservice training indicated the Cook received training and competency testing on 5/14/13. The training included a section specifically for food service workers on how to use the Ansul system located in the kitchen.

A review of the hospital policy and procedure entitled "1.79 Fire and Fire Drills," indicated "A Fire Plan will be posted in designated areas in the Department. In addition, fire plan is attached on a separate card on all employees' hospital identification card. This plan will include Fire Alarm Station Locations, Emergency Exit Doors, and Fire Drill Procedures. All employees will participate in Fire Drills and Emergency Preparedness Inservices which includes Fire Prevention and Safety."

A review of the hospital "Department of Human Resources" class specification for cook, indicated under the section entitled "Knowledge, Skills, and Abilities," "...Required safety and health practices..."

Based on closed record review, hospital document review, and staff interviews, the hospital failed to ensure the physician's therapeutic diet orders matched the hospital approved diet manual and were provided to their patients as ordered. This failure had the potential of not meeting the therapeutic needs of patients and compromising their nutritional and medical status.

Findings:

During closed record review for Patient 1, the admitting physician's diet order dated 4/24/13 at 10 a.m., indicated "diabetic regular with thins." A review of the hospital's diet manual indicated it did not have a "diabetic" diet listed. A review of Patient 1's "Nutrition Screening and Assessment" form dated 4/24/13 indicated under the section entitled "Diet Order," NCS (No Concentrated Sweets). No diet order changes could be found indicating the "diabetic" diet was changed to "NCS" after a review of the entire record under the section entitled "Physician's Orders" or in any other section of the record.

During a closed record review for Patient 2, the admitting physician's diet order dated 2/20/13 at 9:45 a.m., indicated "regular cardiac diet with thins." A review of the hospital's diet manual indicated it did not have a "cardiac" diet listed. A review of Patient 2's "Nutrition Screening and Assessment" form dated 2/20/13 indicated under the section entitled "Diet Order," reg (regular) texture, NAS/low fat low chol (no added salt, low fat low cholesterol). No diet order changes could be found indicating the "cardiac" diet was changed to "regular texture, no added salt/low fat low cholesterol" after a review of the entire record under the section entitled "Physician's Orders" or in any other section of the record.

During an interview with Registered Dietitian 1 (RD 1) on 7/10/13 starting at 1 p.m., she stated the hospital protocol was that the RD assigned to a patient, as part of the initial nutrition screening and assessment, was to verify that the diet ordered by the physician matched the diets indicated in the hospital approved diet manual. If the diets did not match, the RD was to contact the physician to clarify the diet order and ask him to change it, or minimally, to make a notation in the record of the conversation and decision made. She did not know why this process was not followed for Patient 1 and 2.

During an interview with Registered Dietitian 2 (RD 2) on 7/11/13 at 8:25 a.m., she stated she translated the diets indicated for Patient 1 and 2 in the physician's orders to a diet that matched the hospital's diet manual (and computer system) without consulting with the physician first. She stated it was her practice to contact the physician to clarify the diet order if it did not match the hospital diet manual either via a telephone call or during care planning meetings. She could not state why there was no documentation in the record. She further stated she had talked to the physician, but had not asked her to change the diet orders in the record to match the hospital approved diets.

A review of the hospital's policy and procedures entitled "1.124 Diet Prescription Accuracy" revised 7/2009, and "1.125 ordering Procedures for Routine and Therapeutic Diets" indicated they do not specify the procedure to use if the diet ordered by the physician does not match the hospital approved diet manual. A review of the hospital policy and procedure entitled "1.20 Acute Ward Admissions/Transfers (Warm M7 only)" under the section "Procedure" item 5. "If the diet order requires adjustment from the standard computer models, contact he assigned RD or a staff RD in the office." Note: the naming conventions for the hospital diet manual diets match the computer model diets.

It is not within the scope of practice for registered dietitians to interpret or write diet orders for patients.

Based on interview and record review, the hospital failed to implement the nutrition care plan for one of three sampled patients (Patient 2). This failure had the potential to compromise the patient's medical and nutritional status.

Findings:

During closed record review for Patient 2, a note signed by Registered Dietitian 2 (RD 2) in the "Resident Care Plan" dated 2/20/13, indicated the patient had a deficit in their nutrition knowledge regarding their cardiac diet. The care plan indicated RD 2 would provide nutrition education to the patient and his family regarding his cardiac diet. A review if the record's "Integrated Progress Notes" entry dated 2/25/13 at 12:40 p.m., indicated the patient was given written information regarding his cardiac diet. It further stated, "Patient's family is responsible for patient's diet. Patient is confident his family does provide food that is compliant with cardiac diet."

In the same section of the record, RD 2 stated in an entry dated 3/4/13 at 11 a.m., that nutrition education was provided to the patient regarding needed food to assist with blood pressure control, lipid/cholesterol management, with atorvastatin (a medication used to control blood cholesterol levels) and weight loss ..."Will recommend discontinuing fat restriction and continue no added salt diet. Will continue to provide patient education regarding his diet choices to assist with blood pressure management."

There was no evidence found in the record that a recommendation was made to the physician to change the diet order, or that the diet order was changed. Further, there was no documentation that RD 2 counseled the patient's family regarding the patient's special dietary needs upon discharge.

On 7/11/13 at 8:25 a.m., during an interview with RD 2, she stated she changed Patient 2's diet to "no added salt" because he "didn't want to follow his diet, preferring high fat foods" and she thought he would be non-compliant after discharge. She confirmed she had not consulted with the physician prior to making this change. She confirmed that the patient would live with his family after discharge, and that he would not be responsible for purchasing or preparing his own meals. She stated she did not provide nutrition education or counseling to his family. She further stated that Patient 2 had assured her that he would pass the information she provided to him, onto his family. She stated she provided her business card with the handout educational materials, so the family could call her if they had questions regard his nutrition needs after discharge.

During a subsequent interview with Registered Dietitian 1 (RD 1), she stated it was the hospital's policy to follow the care plan, and not to make diet order changes without a physician's order. A written policy was not provided.

Based on food production observations, dietary and engineering staff interviews, and hospital and manufacturer document review, the hospital failed to 1) ensure the water in the hand washing sinks located in the dietary department reached adequate temperatures and 2) the condenser coil filters on the ice machines were replaced when they became torn and ripped.

These failures put patients at risk for foodborne illness, further compromising patient medical status.

Findings:

1) During initial kitchen tour on 7/9/13 starting at 9:30 a.m., while using the handwashing sink located directly across from the elevators as you enter the dietary area, the water was still cold after more than sixty seconds of continuous operation. The Food Service Manager (FSM) validated the observation.

During a follow-up observation of the kitchen on 7/10/13 starting at 2:10 p.m., the water in this same handwashing sink was still cold after more than 60 seconds of continuous running. Water temperatures for all the handwashing sinks in the dietary service area were tested. Their temperatures ranged from 100 degrees to 108 degrees Fahrenheit (F) within 60 seconds of operation.

According to the Federal Food Code 2009, handwashing water temperatures must be at least 100 degrees F.

2) During observation of ice machine cleaning process for the two ice machines located in the dietary service area on 6/9/13 at 2:15 p.m., when the Stationary Engineer 1 (ME 1) removed the panel from the condenser unit, sections of the air filters were torn away or ripped. In addition, they contained many white dusty appearing particles.

During a concurrent interview, the ME 1 stated they were changed "every once in a while."

During a concurrent interview, the Infection Control Nurse stated they needed to be replaced.

On 7/11/13 at 10:10 a.m., Stationary Engineer 2 (SE 2) stated he is responsible for cleaning and maintaining all the ice machines at the hospital. When asked about the observed condition of the condenser unit air filters, he did not state why they were torn, ripped, and appeared to have a whitish dusty substance on them, how often he inspected them, or how often he replaced them. He further stated that he had replaced them.

Based on interview and record review, the facility failed to follow national tuberculosis (TB) prevention guidelines regarding 2 of 6 sampled medical staff (Practitioners 1 and 5). The deficient practice had the potential to allow transmission of TB at the facility. The facility also failed to ensure that manufacturer's guidelines were followed for chemicals used to sanitize the outside of the ice machines. This failure had the potential to cause cross-contamination and foodborne illness in patients who ingested ice.


Findings:

1. Review of Practitioner 1's credentials file indicated he was appointed to the facility's medical staff on 2/21/12. Review of the facility's file containing TB screening records for the 6 sampled medical staff indicated no TB screening was documented for Practitioner 1.

Review of Practitioner 5's credentials file indicated she was reappointed to the facility's medical staff on 5/21/13. Review of the facility's file containing TB screening records for the 6 sampled medical staff indicated that Practitioner 5 had a chest x-ray completed 10/15/09 and a TB symptom questionnaire completed on 6/27/12. No documentation of a symptom questionnaire within the preceding 12 months was present. No documentation of a TB screening test [TB skin test (TST) or blood test (BAMT)] was present.

In an interview on 7/10/13 at 11:43 a.m., Practitioner 4 stated the facility could not obtain documentation of Practitioner 5's TST or BAMT.

Review of additional documentation presented by the facility on 7/11/13 indicated that the facility had obtained a facsimile transmission of Practitioner 1's TB screening from an adjacent area code on 7/10/13, 2 days after the start of the survey.

In an interview on 7/11/13 at 9:54 a.m., Staff C stated she would find out where the documentation regarding Practitioner 1's TB screening came from and that she thought the dentists' contract might include terms that the contractor is responsible for dentists' TB screening. At the conclusion of the survey on 7/15/13, the facility had not provided additional information regarding Practitioner 1's TB screening.

Review of the Centers for Disease Control and Prevention (CDC) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" indicated contract health-care workers (HCW's) should be included in TB screening programs. The guidelines stated all HCW's should receive a two-step TST or single BAMT upon hire unless they have documentation of either a prior positive test, prior treatment for TB, or a negative test within the past 12 months. The guidelines stated that a baseline CXR and annual symptom questionnaire was appropriate screening for those who had a positive TST or BAMT at initial testing. The guideline stated the TST or BAMT should be repeated for those with a prior positive test but no documentation.


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2. On 7/9/13, the hospital policy and procedure entitled "XVI Ice Machine & Refrigerator Cleaning effective June 2010" was reviewed. The section entitled "Procedure" indicated, " b. Pour disinfectant cleaner on clean rag and wipe clean all exterior surfaces ..., c. Wipe clean plastic ice and water dispensing units., d. Clean water drainage holding pan with disinfectant cleaner and warm water ...., e. Wipe clean all surfaces with dry clean rags."

On this same document, under the section entitled "Materials", indicated Virex 256. A review of the Material Safety Data Sheet indicated the product used by the hospital to disinfect the exterior of the ice machines is Virex II 256. The manufacturer's label for this product indicated, "All food contact surfaces such as appliances and kitchen countertops must be rinsed with potable water. Do not use on glassware, utensils, or dishes." Because it is ingested, ice is considered to be food, and anything the ice contacts could cause cross-contamination and foodborne illness.

During an interview with the Environmental Services Director on 7/11/13 at 10:25 a.m., he stated his staff follows the hospital's ice machine & refrigerator cleaning procedure by using a dry cloth to wipe the exterior of the ice machine after it is sanitized with the Virex II 256. After he called the manufacturer to get clarification on the proper use of the sanitizer, he validated that staff disinfecting the ice machine with this product, should use a wet (water only) cloth to wipe the exterior of the ice machine after sanitizing it, to ensure there is no cross-contamination.

Based on interview and record review, the facility failed to conduct annual training of new staff regarding organ and tissue donation. The deficient practice had the potential to limit staff knowledge necessary for successful tissue transplantation.

Findings:

Review of the facility's training records regarding organ and tissue donation indicated that they consisted of a handout from an undated slide presentation on the topic. No documentation was present indicating when the training had occurred or who had attended it.

In an interview on 7/12/13 at 10:32 a.m., Staff C stated the facility had not done training on organ and tissue procurement within the past year. In an interview on 7/12/13 at 1:14 p.m., Staff C stated she could not find the facility's records of who had attended the organ/tissue procurement training or when it had occurred.

Based on interview and record review, the facility failed to assess recent experience before granting surgical privileges in 1 of 6 sampled credentials files (Practitioner 1). Refer to A-341.

Based on interview and record review, the facility failed to ensure the physician functioning as the medical director of the respiratory service had documented training and experience relevant to leading the service. The deficient practice had the potential to reduce medical oversight of the service.

Findings:

In an interview on 7/8/13 at 11:49 a.m., when Practitioner 4 was asked who the medical director of the respiratory service was, she stated that the manager of that department was a respiratory therapist who reported to her. Review of the facility's organizational chart confirmed that the manager of the respiratory service reported to Practitioner 4.

Review of Practitioner 4's credentials file indicated there was no documentation of training and recent experience which addressed her qualifications to serve as medical director of the respiratory service.

In an interview on 7/9/13 at 2:43 p.m., Practitioner 4 acknowledged that her credentials file did not have documentation of training and experience relevant to respiratory therapy. She stated that she had documentation of experience in lab medicine which she felt was relevant.

Review of the additional documents presented by Practitioner 4 indicated that they included an agreement signed 11/23/10 which stated that the lab director of another facility would consult with Practitioner 4 regarding performance of lab services, including arterial blood gases (ABG's). An attached log indicated that on 9 occasions between 3/25/10 and 1/3/11, Practitioner 4 and the lab director had reviewed the facility's performance of lab tests including ABG's. No documentation was present regarding other aspects of respiratory therapy such as nebulizer treatments, positive airway pressure (a treatment for sleep apnea), or tracheostomies.

In an interview on 7/10/13 at 10:15 a.m., Practitioner 4 stated that her documented experience in lab medicine was relevant to the facility's performance of ABG's. She acknowledged that the document did not address nebulizer treatments, positive airway pressure, or care of patients with tracheostomies. She stated she would look into continuing medical education on the topics as well as logging her clinical experience caring for such patients.