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Based on observation, interview and record review, the dietary services supervisor (DSS) at Hospital B failed to ensure a system to determine competency for five cooks as it related to correct cool down procedures for potentially hazardous foods.

Findings:

On 5/7/13 at 1:40 P.M., at Hospital B, inside the kitchen was a walk-in refrigerator that contained a 2-3 gallon pot of "Beef Chili, dated 5/7/13." Cook 47 was asked to check the internal temperature of the beef chili which was 200 degrees Fahrenheit (F). The FSD asked the Retail Services Manager (RSM) for the cool down log for the beef chili, and the RSM said that there was no cool down log for that. The RSM went inside the walk-in refrigerator and observed the cooked beef chili, dated 5/7/13. The RSM verified that the beef chili was for the cafe but that "it shouldn't be in the refrigerator. It should've been cooked and remained hot."
The RSM stated the cook that had prepared the beef chili had gone home for the day, and could not state why the beef chili was in the walk-in refrigerator. The RSM verified that she was unaware that the cooked beef chili was in the walk-in refrigerator as it was not planned to be that way. The RSM further verified that there was not a dietary employee who would have known that there was a need to cool that down, as no one knew it was there except for the cook that had gone home for the day.
At that time, Hospital B's cool down log was requested. The log was entitled Hazard Analysis of Critical Control Points (HACCP) [hospital name] HACCP Log Cooling of Potentially Hazardous Food. The log that the facility chose to utilize had not provided complete guidance and proper instruction on safe cool down of potentially hazardous foods. The log indicated, "All potentially hazardous foods must be monitored by recording the internal temperatures as the item cools. Potentially hazardous foods include but are not limited to large cuts of meat, meatloaf, and stews. Cooked foods must be cooled from 140 degrees F. to 45 degrees F. within 4 hours or discarded."
Time/temperature control for food safety would include cool down monitoring of potentially hazardous foods (PHF). PHF's are those foods capable of supporting bacterial growth associated with foodborne illness (Food Code, 2009). Cool down monitoring would ensure that cooked potentially hazardous foods shall be cooled: 1) within 2 hours from 135?F to 70?F; and within an additional 4 hours from 70?F to 41?F) or less (Food Code, 2009).
The cool down logs were reviewed from 4/25/13 through 5/4/13 in which there were a total of 19 logged entries of PHFs that were cooled down, and 17 of 19 times were done incorrectly. The FSD identified that five different cooks were involved with the cool down log for the same time period in which it had not been done in accordance with safe food handling practices.
The DSS said, "I have not reviewed the logs since they have been implemented." Further, the DSS and the RSM verified that they have never observed the cooks checking time and temperature monitoring to ensure safe cool down of PHFs were done correctly for the health and safety of the patients.
According to the job description provided for the Patient Service Manager [DSS], "...develop and adhere to policies covering sanitary regulations and HACCP compliance. Responsible for overseeing the selection, training, and supervision of food service personnel. Evaluate performance of all employees supervised."

Based on interview and record review, the hospital failed to ensure that a therapeutic protein supplement was ordered for 2 of 43 sampled patients (Patient 48 and 49), by the practitioner responsible for their care.
Findings:

1. On 5/8/13 at 1:21 P.M., Patient 48's medical record was reviewed. Patient 48 was admitted to Hospital B on 5/2/13, according to the Facesheet. On 5/2/13, the physician ordered a "carb limited std" diet [carbohydrate limited standard diet], according to physician orders.
On 5/3/13 an initial nutrition assessment was completed for Patient 48 by a Registered Dietitian (RD 50). RD 50's plan included, "Add ... Beneprotein [a powdered protein supplement] BID [two times a day]."
The Clinical Nutrition Manager (CNM) reviewed the electronic order for beneprotein and confirmed that RD 50 ordered the Beneprotein without a physician's order. During the same record review, the CNM acknowledged that Beneprotein was not incorporated into the physician's diet order for a carbohydrate limited diet.
The CNM verified that the registered dietitians were not independent practitioners and were not allowed to order therapeutic treatment interventions for patient care. The CNM stated that she was unaware that an RD at the hospital was prescribing Beneprotein for patients without a physician's order.
2. On 5/8/13 at 3:00 P.M., Patient 49's medical record was reviewed. Patient 49 was admitted to Hospital A on 4/29/13. On 4/29/13, the practitioner responsible for the care of the patient ordered Patient 49 a carbohydrate limited diet.
On 4/30/13, Registered Dietitian (RD 51) completed a nutrition assessment for Patient 49. RD 51's nutrition plan included to provide beneprotein packets three times a day. RD 51 ordered the beneprotein three times a day on 4/30/13, without a physician's order.
On 5/8/13 at 3:36 P.M., RD 51 verified that she had ordered the beneprotein three times a day for Patient 49 without speaking with a physician to obtain an order. During the same record review, the Clinical Nutrition Manager (CNM) acknowledged that Beneprotein was not incorporated into the physician's diet order of carbohydrate limited diet.
The CNM verified that registered dietitians were not independent practitioners and were not allowed to order therapeutic treatment interventions for patient care, without a physician's order. The CNM stated that she was unaware that RD's at the hospital were prescribing Beneprotein for patients' without a physician's order.
On 5/9/13 at 11:00 A.M., the CNM stated that she spoke with all nine of the clinical dietitians that worked at the hospital yesterday evening to determine how many RD's were writing orders, and she had determined that it was limited to two RDs, in which she informed them that they do not have hospital privileges to write orders.

Based on interview and record review, Hospital A and B failed to ensure that nutrition care plans were detailed to reflect specific nutrition interventions, that were planned for patients to address an identified nutritional concern, in accordance with hospital policy, for 3 of 43 sampled patients (Patients 53, 48 and 54). Lack of specific individualized nutrition care plans is a barrier to the multidisciplinary healthcare team responsible for implementing and monitoring, the dietary and nutritional intake status of patients. In addition, Hospital A failed to ensure that nursing care plans were developed related to contact precautions and the head of bed position, of a patient at a 90 degree angle when eating and drinking for safety precautions, as ordered by the physician, for 2 of 43 sampled patients (Patients 32 and 53).

Findings:

1. On 5/7/13 at 11:10 A.M., Patient 53's medical record was reviewed.
Patient 53 was admitted to Hospital A on 4/12/13, according to the Facesheet. On 5/3/13, the physician ordered Ensure Plus three times daily for Patient 53. During the same record review, the clinical nutrition manager reviewed Patient 53's nutrition care plan and acknowledged that the care plan had not indicated that the patient was receiving Ensure Plus three times daily. The nutrition care plan indicated, "Goal: Adequate nutritional intake." The nutrition care plan had not indicated the specific planned nutrition intervention that was ordered for Patient 53.

According to the hospital's "Practice Guidelines for Documentation" (Revised 3/2013), "Interventions added to the Plan of Care should reflect individual needs and interventions appropriate for the patient or family, and will serve as communication between health care providers to direct care toward the achievement of the Expected Outcome (Goal) identified ... "

2. On 5/8/13 at 1:21 P.M., Patient 48's medical record was reviewed. Patient 48 was admitted to Hospital B on 5/2/13, according to the Facesheet. On 5/2/13 the physician ordered a "carb limited std" diet [carbohydrate limited standard diet], according to physician orders.

On 5/3/13, an initial nutrition assessment was completed for Patient 48 by a Registered Dietitian (RD 50). RD 50's plan included, "Add Glucerna TID [three times a day] and Beneprotein [a powdered protein supplement] BID [two times a day]." During the same medical record review, the clinical nutrition manager (CNM) verified that RD 50 ordered Beneprotein two times daily, and Glucerna three times daily. The CNM acknowledged that a nutrition plan of care had not been developed for Patient 48 at all. The CNM verified that the clinical dietitians had received training on 4/3/13, to develop a nutrition care plan when the RD planned a specific nutrition intervention for a patient. The CNM stated that the RD should have developed a nutrition care plan for Patient 48.

The hospital's policy and procedure entitled Nutrition Care Plan (Policy 14.9; reviewed 4/2011) indicated, "The Nutritional Care Plan consists of identification of nutritional problems, the provision of nutritional intervention activities and the evaluation of nutritional care. A multidisciplinary Nutrition Care Plan with measurable goals and actions are developed for all patients/residents determined to be nutritionally compromised ...6. The nutritional care plan is documented in the on-line (EPIC) plan of care, including the nutrition related problem, expected outcome, and planned intervention."

3. On 5/8/13 at 2:08 P.M., Patient 54's medical record was reviewed. Patient 54 was admitted to Hospital A on 5/6/13, with a diagnosis that included liver cirrhosis (a chronic disease in which normal liver cells are damaged and are then replaced by scar tissue) according to the Facesheet. On 5/6/13, Patient 54's physician ordered Beneprotein four times daily.

The Clinical Nutrition Manager reviewed Patient 54's care plans in the electronic medical record and said that there had not been a nutrition care plan developed for Patient 54 as of 5/8/13.

According to the hospital's "Practice Guidelines for Documentation" (Revised 3/2013), "Interventions added to the Plan of Care should reflect individual needs and interventions appropriate for the patient or family, and will serve as communication between health care providers to direct care toward the achievement of the Expected Outcome (Goal) identified ... "



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4. On 5/8/13 beginning at 1:20 P.M., a tour of the Neonatal Intensive Care Unit (NICU) was conducted with the Nursing Director of Critical Care (NDCC) and the Registered Nurse in charge (RN 31). Patient 32 was observed in his radiant warmer. On his bedside tray, there were yellow gowns, Cavi-wipes, hand sanitizer and a box of gloves. A staff member was wearing a yellow gown and had gloves on. There was no sign posted to indicate what type of isolation precautions Patient 32 was on.

An interview with RN 31 was conducted on 5/8/13, at 1:50 P.M. RN 31 confirmed that Patient 32's parent was not wearing a yellow gown and gloves as she was observed at the bedside assisting staff with patient care. She stated that Patient 32 was on contact isolation but also confirmed that a sign had not been posted. She stated that all staff, family and visitors should be wearing the gowns and gloves when touching the patient in accordance with the hospital's policy related to infection control practices.

A review of Patient 32's medical record was conducted on 5/8/13 at 3:30 P.M. Patient 32 was admitted on 4/10/13 with diagnoses that included sepsis and skin breakdown due to a candida (a fungal or yeast) infection per the ISCC (Infant Special Care) Admission Note dated 4/10/13. According to Physician's Orders dated 5/5/13 at 7:36 P.M., Contact Precautions were ordered. Per the same Orders, there were "Process Instructions" that read "Post green sign. Gloves and gown with patient and their environment. Use of dedicated equipment required."

An interview and joint record review with RN 32 was conducted on 5/8/13, at 2:23 P.M. RN 32 confirmed that there was physician's order in Patient 32's medical record for contact precautions on 5/5/13, at 7:36 P.M. She stated that it was the nursing staff's responsibility for the initiation or development of a care plan related to an identified problem such as contact precaution, all interventions implemented and education performed with patient and/or family. There was no documented evidence to demonstrate that a nursing care plan had been developed for Patient 32's contact precaution order from 5/5/13 to 5/8/13 (at this time).

A review of the hospital's "Practice Guidelines for Documentation," revision date of 3/2013, was conducted on 5/9/13. The Practice Guidelines indicated that "The Plan of care is a dynamic document and is revised with changes in patient condition and response to treatment or illness." Per the same guidelines, "Interventions added to the Plan of Care should reflect individual needs and interventions appropriate for the patient and family, and will serve as communication between health care providers to direct care toward the achievement of the Expected Outcome (Goal) identified." It also stipulated that "Implementation of interventions identified in the Plan of Care will be documented in the designated flow sheet section on the patient's record. Time frames for documentation are dependent on the patient's condition and Provider orders."

An interview with the NICU Nurse Manager (NNM) and the Director of Women and Infant Services (DWIS) was conducted on 5/9/13 at 9:20 A.M. The NNM and the DWIS acknowledged that a care plan should have been initiated or developed pertaining to Patient 32's contact precaution and all the interventions that were implemented in accordance with the hospital's practice.

5. A review of Patient 53's medical record was conducted on 5/7/13, beginning at 1:58 P.M. with Registered Nurse (RN 34). Patient 53 was admitted to Hospital A on 4/12/13, with diagnoses that included left knee and left hip pain per the History and Physical, dated 4/12/13. A Speech Therapy Clinical Bedside

Based on observation, interview, record and document review, Hospital A failed to ensure that the Registered Nurses (RNs) in the Neonatal Intensive Care Unit (NICU) implemented the hospital's Practice Guidelines for Documentation, for 1 of 43 sampled patients (Patient 32). There was no documented evidence to demonstrate that patient and family education were performed when Patient 32 was placed on contact precautions and infection control practices were implemented.

Findings:

On 5/8/13, beginning at 1:20 P.M., a tour of the NICU was conducted with the Nursing Director of Critical Care (NDCC) and the Registered Nurse in charge (RN 31). Patient 32 was observed in his radiant warmer. On his bedside tray, there were yellow gowns, Cavi-wipes, hand sanitizer and a box of gloves. A staff member was wearing a yellow gown and had gloves on. There was no sign posted to indicate what type of isolation Patient 32 was on.

An interview with RN 31 was conducted on 5/8/13, at 1:50 P.M. RN 31 confirmed that Patient 32's parent was not wearing a yellow gown and gloves as she was observed at the bedside assisting staff with patient care. She stated that Patient 32 was on contact isolation but also confirmed that a sign had not been posted. She stated that all staff, family and visitors should be wearing the gowns and gloves when touch the patient in accordance with the hospital's policy related to infection control practices.

A review of Patient 32's medical record was conducted on 5/8/13 at 3:30 P.M. Patient 32 was admitted on 4/10/13, with diagnoses that included sepsis and skin breakdown due to a candida (a fungal or yeast) infection per the ISCC (Infant Special Care), Admission Note dated 4/10/13. According to Physician's Orders dated 5/5/13, at 7:36 P.M., Contact Precautions were ordered. Per the same Orders, there were "Process Instructions" that read "Post green sign. Gloves and gown with patient and their environment. Use of dedicated equipment required." There was no documented evidence to demonstrate that patient and family education had been performed related to Patient 32's contact precaution and the hospital's infection control practices in the NICU.

An interview and joint record review with RN 32 was conducted on 5/8/13, at 2:23 P.M. RN 32 stated that it was the nursing staff's responsibility to document in the medical record all patient and family education performed in accordance with the hospital's practice. She confirmed that there was no documented evidence to demonstrate that Patient 32's family had been educated with regards to the patient's contact precaution order and the NICU's infection control practices related to contact precautions. She stated that all education should have been documented in the medical record.

A review of the hospital's Practice Guidelines for Documentation, revision date of 3/2013, was conducted on 5/9/13. The Practice Guidelines indicated that under interventions, "Patient and family education will be identified, evaluated and documented in the Patient Education Activity in Epic (hospital's electronic medical record system) by the discipline who initiates it; Epic flow sheets are a combination of a review tool and data entry tool."

An interview with the NICU Nurse Manager (NNM) and the Director of Women and Infant Services (DWIS) was conducted on 5/9/13, at 9:20 A.M. The NNM and DWIS acknowledged that the patient and/or family education related to contact precautions and the NICU infection control practices should have been documented in Patient 32's medical record in accordance with the hospital's Practice Guidelines for Documentation.