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Based on interview and record review, there was no documented evidence that one of 43 sampled patients (Patient 27 at Hospital B) was weighed every day of her hospitalization, as ordered by the physician.

Findings:

Patient 27 was admitted to Hospital B on 5/3/13, with a diagnosis of Cystic Fibrosis (a hereditary disorder that causes thick mucous to build up in the lungs), according to the Admission Facesheet. A review of Patient 27's medical record was conducted on 5/8/13, at 3:05 P.M. According to the admission History and Physical, dated 5/3/13, Patient 27's chief complaint prior to admission was dyspnea (difficulty breathing) and she "reports loss of several pounds (of weight) over past week." A physician's order to weigh the patient daily was written on 5/3/13. It was documented in the medical record that Patient 27 weighed 92 pounds on 5/3/13, the day of her admission. However, there was no documented evidence of Patient 27's weight on 5/4/13 or 5/5/13. Patient 27 was discharged on 5/6/13.

An interview was conducted with the Director of Nursing Quality (DONQ) on 5/8/13 at 3:40 P.M. The DONQ acknowledged that, in accordance with he physician's order, Patient 27 should have been weighed every day of her hospitalization and her weight should have been documented in the medical record. The only weight documented in Patient 27's medical record was on the day of her admission, 5/3/13.

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 Swallow Evaluation Note, dated 4/30/13, indicated that Patient 53 had no gag during this evaluation. Per the same note, it was recommended that Patient 53 be placed on a mechanical soft diet and for his HOB (head of bed) to be at 90 degrees for small bites and sips for patient safety purposes. The Note indicated that the discussion and agreement was confirmed with the RN and the physician. According to a Physician's Order dated 4/30/13, Patient 53's HOB was to be placed at a 90 degree angle when eating and drinking. There was no documented evidence to show that a nursing care plan was initiated or developed pertaining to the ordered HOB position when Patient 53 was eating and drinking.

An interview and joint record review with RN 53 was conducted on 5/7/13, at 2:55 P.M. RN 53 stated that Patient 53's HOB had been at 30 degrees and above. She stated that she was not aware of the physician's order related to HOB at 90 degrees when Patient 53 was eating and drinking. She was not able to provide any documented evidence to show that the physician's order had been implemented, as the documentation revealed that Patient 53's HOB was at 30 degrees and above. The 90 degrees option had not been selected from 5/1/13 to 5/7/13 during the times when Patient 53 would be eating and drinking. She acknowledged that a nursing care plan should have been initiated and developed to address Patient 53's HOB position while eating and drinking.

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 and joint record review with the Speech Pathologist (SP 31) was conducted on 5/9/13 at 11:31 A.M. SP 31 stated that her diet recommendation and HOB position was based on the safest way for Patient 53 to swallow. She stated that the RN and physician agreed with her plan which was documented in her Swallow Evaluation Note dated 4/30/13.

An interview with the Director of Regulatory Affairs (DRA) was conducted on 5/9/13 at 11:45 A.M. The DRA acknowledged that the physician's orders related to Patient 53's HOB at 90 degrees was not implemented as ordered. He also acknowledged that the nursing care plan related to Patient 53's HOB at 90 degrees when eating and drinking was not initiated or developed in accordance with the hospital's practice.

Based on interview, record and document review, Hospital B failed to ensure that 1 of 43 sampled patient's (Patient 16) oral and intravenous pain medication orders contained clear instruction for when either the oral or the intravenous pain medication should be administered. In addition, intravenous pain medication was administered to two of 43 sampled patients (Patient 31 at Hospital A, Patient 21 at Hospital B) without any documented re-assessment for the effectiveness of the pain medication.

Findings:

1. Patient 16 was admitted to the hospital on 5/6/13, for a Left Total Hip Replacement according to his admission History and Physical. A review of Patient 16's medical record was conducted on 5/7/13 at 10:55 A.M. On 5/6/13 at 10:40 A.M., a Physician's Assistant wrote orders for the following pain medication:

Hydromorphone (Dilaudid - a narcotic analgesic) 1 mg (milligram) intravenous every 4 hours PRN (when needed) for severe pain (pain score 7-10).

Oxycodone (Roxicodone - an opioid analgesic) 10 mg (milligrams) tab (tablet) every 4 hours PRN (when needed) for severe pain (pain score 7-10).

However, there were no instructions associated with the pain medication orders for the nursing staff to know whether to administer the intravenous pain medication or the oral tablet when Patient 16 reported pain of a score between 7 and 10.

A review of the hospital's policy and procedure, entitled "Medication Preparation, Labeling and Adminstration" and dated 4/21/2011, indicated that "The presecriber's medication orders will be reviewed and verified by a pharmacist prior to adminstration..." It was noted in Patient 16's electronic medical record (EMR) that these two pain medication orders had been reviewed and approved by a Pharmacist (Pharm 16) on 5/6/13 at 12:48 P.M.

An interview was conducted with Pharm 16 on 5/7/13 at 11:30 A.M. Pharm 16 acknowledged that she failed to enter administration instructions in the EMR when she reviewed the pain medication orders. Pharm 16 stated that she should have entered instructions to use the oral medication first if Patient 16 was tolerating oral intake. Pharm 16 agreed that without the instructions, the nursing staff had no parameters for when to administer the intravenous or the oral pain medication. Pharm 16 acknowledged that was a oversight on her part.

2. Patient 21 was admitted to Hospital B on 4/26/13, for treatment of a small bowel obstruction according to the Admission Facesheet. A review of Patient 21's medical record was conducted on 5/7/13 at 3:00 P.M. According to the physician's orders, Patient 21 was to receive the following pain medication:

Hydromorphone (Dilaudid - a narcotic analgesic) 1 mg. (milligram) IV (intravenous) every 4 hours PRN (if needed) for pain (7-10). According to the Medication Administration Record (MAR), Patient 21 received Dilaudid 1 mg. IV on:

4/26/13 at 12:17 P.M. for a pain score of 8
4/26/13 at 4:22 P.M. for a pain score of 8
4/26/13 at 8:27 A.M. for a pain score of 8

It was documented in the medical record that Patient 21 was assessed for the severity of her pain prior to the administration of each dose of Dilaudid. However, there was no documented evidence that Patient 21 was ever reassessed after receiving the three doses of Dilaudid to evaluate the effectiveness of the pain medication.

A review of the hospital's policy and procedure, entitled "Pain Management Policy" and dated 2/17/2011, indicated that "All patients have the right to prompt efforts for adequate control of pain arising from procedures, treatments, and disease...The patient's pain is re-assessed by the medical/nursing staff to determine the effectiveness of the pain management strategies within 1 hour following parenteral (intravenous, intramuscular or subcutaneous) administration of medication...every 1-2 hours until pain is controlled."

An interview was conducted on 5/7/13 at 3:40 P.M. with the Registered Nurse (RN 21) that administered the Dilaudid to Patient 21 on 4/26/13 at 4:22 P.M. RN 21 stated that it is the expectation of the nursing staff for the RN to reassess patients for the effectiveness of the Dilaudid within one hour of the administration of the intravenous pain medication.



22930

3. A review of Patient 31's medical record was conducted on 5/7/13, beginning at 10:55 A.M. Patient 31 was admitted to Hospital A on 4/16/13, with a diagnosis that included pyelonephritis (an inflammation of the kidney as a result of a bacterial infection) per the Admission Facesheet. Per Physician's Orders dated 4/16/13, Patient 31 was to receive Hydromorphone (Dilaudid - a narcotic analgesic) 1 mg (milligram) IV (intravenous) once for pain management.

According to the Medication Administration Record (MAR), Patient 31 received Dilaudid 1 mg IV on 4/16/13 at 8:08 P.M. for a pain score of 10. There was no documented evidence to show that Patient 31 was reassessed after the administration of Dilaudid to evaluate the effectiveness of the pain medication.

A review of the hospital's policy and procedure, entitled "Pain Management Policy" and dated 2/17/2011, indicated that "All patients have the right to prompt efforts for adequate control of pain arising from procedures, treatments, and disease...The patient's pain is re-assessed by the medical/nursing staff to determine the effectiveness of the pain management strategies within 1 hour following parenteral (intravenous, intramuscular or subcutaneous) administration of medication...every 1-2 hours until pain is controlled."

An interview with the Nursing Director of Critical Care (NDCC) was conducted on 5/7/13 at 11:52 A.M. The NDCC confirmed that there was no documented evidence to show that a reassessment of Patient 31's pain was performed after the administration of Dilaudid. She stated that the nursing staff should have reassessed Patient 31's pain within 1 hour after the administration of the intravenous pain medication in accordance with the hospital's policy.

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.

Based on observation, interview and record review, the Food Service Director at Hospital A failed to ensure that potentially hazardous foods were thawed in a safe manner in accordance with the hospital's expectations. At Hospital B, the dietary services supervisor (DSS) failed to ensure that potentially hazardous foods were cooled down correctly in accordance with safe food handling practices. Failure to ensure safe food handling had the potential for risk of foodborne illness further compromising the health status of medically fragile patients.

Findings:

1. On 5/7/13 at 10:15 A.M., at Hospital A, inside the kitchen was a "thaw box" that contained a pan of 20 pounds of raw chicken, undated. The Executive Chef stated that a dietary employee placed the chicken in the thaw box earlier that morning. The Executive Chef got the dietary employee (DE 46), and he stated, "I did not put the chicken in here this morning." DE 46 added that the chicken had already been there when he started his shift at 5:00 A.M.
The Executive Chef, DE 46, Purchase Coordinator, and the Food Service Director (FSD) were unable to state how long the chicken had been in the refrigerator for thawing.
DE 46 was asked how long the poultry was allowed to stay in its thawed state before it would be cooked, and he said, "6 days."
According to the Executive Chef the hospital's policy was to allow up to 3 days for thawing before the food would need to be cooked. Inside the same "thaw box," were boxes of meat that were thawing. The box contained a sticker label of "5/6/13," and "5/10/13." The Executive Chef stated that the first sticker indicated the date the item was placed into the thaw box, and the 5/10/13, date was the date it needed to be cooked or discarded. The Food Service Director who was present for the observation verified that the thawing meat was dated incorrectly as it allowed more than 3 days of thawing.
The hospital's policy entitled "Storage and Defrosting of Meats, Fish and Poultry (Policy 4.9, Reviewed 2/11)" lacked guidance to dietary staff on the amount of days for thawing in the thaw box.
2. 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 (food service director) 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 that the cook 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 [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."
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 hospital lacked an effective system to ensure that PHFs were cooled down safely.
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.


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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 therapeutic diet orders met the nutritional needs, for 2 of 43 sampled patients (Patients 54 and 55) who were identified as being at risk nutritionally and lacked an assessment of nutritional needs by the Registered Dietitian. Failure to ensure patients nutritional needs are met in a timely manner could impede healing and could negatively impact the health status of medically fragile patients.

Findings:

1. 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), organ transplant candidate, and acute kidney injury according to the Facesheet.
On 5/7/13, a patient data base form was completed by a nurse for Patient 54. Under the Nutritional Status/Functional Status nutrition screening questions, Patient 54 was identified as having unplanned weight loss, and impaired skin integrity.
On 5/7/13, a clinical nutrition screen was completed by a Dietetic Technician, Registered (DTR). According to the Clinical Nutrition Manager (CNM), Patient 54 should have been seen by a Registered Dietitian (RD) based on the hospital's nutrition screening system that had already picked up a nutritional risk trigger of the "unplanned weight loss," and due to medical history.
On 5/8/13 at 2:14 P.M., RD 51 said that she asked the DTR to visit the patient to address the nutrition issues, and acknowledged that she had not completed an individualized assessment of Patient 54's nutritional needs.
The hospital's policy and procedure entitled Nutritional Assessment (Policy 14.10, reviewed 4/2011) indicated, "Policy: A Nutritional Assessment will be documented by the clinical staff in the medical record for patients found to be at Nutritional Risk. Purpose: To define the process for the documentation of a Nutritional Assessment in the medical record ..., ...review diet order for appropriateness to diagnosis, tolerance, adherence, and current medical status ...,The following methods are used to assess patients' weight status and determine calorie, protein, and fluid requirements ..."
2. On 5/8/13 at 2:20 P.M., Patient 55's medical record was reviewed. Patient 55 was admitted to Hospital B on 5/6/13, with diagnoses that included exacerbation of cystic fibrosis (a hereditary disorder that causes thick mucous to build up in the lungs) pulmonary disease and protein calorie malnutrition, per the History and Physical, dated 5/6/13.
According to the CNM, RD's in the hospital had a daily screening practice in which patient's electronic medical record (EMR) was reviewed for the RD's assigned floor in order to help prioritize and delineate workload appropriate for the RD, and those appropriate for the DTR. The CNM stated that an RD must have assigned Patient 54 to have been seen by a DTR as Patient 54 had not had a comprehensive individualized nutrition assessment completed by an RD, despite MD documentation of protein calorie malnutrition. The CNM verified that Patient 55 should have had a comprehensive nutrition assessment completed by an RD as the patient was a level 3 at high nutrition risk at time of admission.
According to the EMR, Patient 54 was visited by a DTR who had the ability to conduct a limited nutrition screening. The nutrition screening note, dated 5/7/13, included the protein calorie malnutrition, and %IBW [percent ideal body weight] of 81.6%. In addition, Patient 54 stated that her goal for "this hospitalization was an evaluation for a lung transplant," per the patient data base form completed by a nurse upon admission. The nutrition screening note completed by the DTR categorized Patient 54 as a level 1 low nutrition risk care level patient which would determine that the patient would have had a follow-up nutrition visit by a DTR in 6 - 8 days per the hospital policy for a Level 1.
The hospital's policy and procedure entitled Nutritional Assessment (Policy 14.10, reviewed 4/2011) indicated, "Policy: A Nutritional Assessment will be documented by the clinical staff in the medical record for patients found to be at Nutritional Risk. Purpose: To define the process for the documentation of a Nutritional Assessment in the medical record, Procedure: Dietitian responsibilities ...review diet order for appropriateness to diagnosis, tolerance, adherence, and current medical status ..., The following methods are used to assess patients' weight status and determine calorie, protein, and fluid requirements ... "


17065

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, the hospital failed to ensure that 2 of 43 sampled patients (Patient 49 at Hospital A, Patient 25 at Hospital B) had documented evidence in their electronic medical records (EMR) that Beneprotein supplements were given to the patients, as ordered by the physician. In addition, Hospital A failed to ensure that Ensure Plus supplements were given in accordance with the physician's order, for 1 of 43 sampled patients (Patient 53). There was no documented evidence to show that Patient 53 had been given his Ensure Plus supplements three times a day.

Findings:

1. Patient 25 was admitted to Hospital B on 4/30/13, for chemotherapy treatment for his diagnosis of Ewing's Sarcoma (a malignant bone tumor) of the frontal calvarium (frontal bone of the skull) according to the admission History and Physical, dated 4/30/13. A review of Patient 25's medical record was conducted on 5/8/13 at 11:00 A.M. According to a physician's order, dated 5/2/13, Patient 25 was to be given a Glucerna Shake (ready to drink diabetic shake with no added sugar) tid (three times a day) with meals and Beneprotein (instant protein powder) three scoops with meals three times a day. However, a review of the intake and output section of Patient 25's EMR indicated that Patient 25 was receiving the Glucerna Shake three times a day with meals but, there was no documented evidence that Patient 25 had been given three scoops of Beneprotein powder in a liquid drink three times a day with meals since the physician's order was written on 5/2/13.

An interview was conducted with the Director of Nursing Quality (DONQ) on 5/9/13 at 10:40 A.M. The DONQ stated that it is the expectation of the nursing staff to document that Patient 25 had taken his Beneprotein powder and the amount of liquid the powder was mixed with on his intake and output record under dietary supplements.


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2. A review of Patient 53's medical record was conducted on 5/7/13 beginning at 1:58 P.M. with a 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. According to the Physician's Orders dated 5/3/13 at 4:33 P.M., Ensure Plus supplements three times daily were to be given to Patient 53. There was no documented evidence to show that Patient 53 was given his Ensure Plus supplements on 5/4/13, 5/5/13 and 5/6/13 from 7:00 A.M. to 4:00 P.M.

An interview and joint record review with RN 35 was conducted on 5/7/13, beginning at 2:55 P.M. RN 35 stated that Patient 53 was receiving Ensure Plus supplements three times a day per his physician's orders. She stated that it was the nursing staff's responsibility to document that patient's intake of the supplement in the "Intake/Output" section of the medical record. She acknowledged that there should have been documentation of Patient 53's Ensure Plus supplement intake on 5/4/13, 5/5/13 and 5/6/13 from 7:00 A.M. to 4:00 P.M.

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 "Implementation of interventions identified in the Plan of Care will be documented in the designated flow sheet section of the patient's record." Per the same Practice Guidelines, it stipulated that time frames for documentation were dependent on the patient's condition and physician's orders. It also indicated that "Specific interventions and assessment data at this interval will be entered into the electronic health record."

An interview with the Nursing Director of Critical Care (NDCC) was conducted on 5/7/13 at 3:30 P.M. The NDCC agreed that there was no documented evidence in Patient 53's medical record to show that he had been given his Ensure Plus supplements on 5/4/13, 5/5/13 and 5/6/13 from 7:00 A.M. and 4:00 P.M., as ordered by the physician. She stated that the nursing staff should have been documenting the supplemental intakes in Patient 53's medical record in accordance with the hospital's practice.


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3. 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.
On 5/9/13 at 11:00 A.M., the CNM reviewed Patient 49's intake and output section of the EMR and acknowledged that there had been no documented evidence that Patient 49 had been given beneprotein three times a day.
On 5/9/13 at 11:15 A.M., LN 52, and charge nurse 53 verified that Patient 49 had been receiving Beneprotein. Licensed Nurse (LN 52) and charge nurse 53 reviewed Patient 49's electronic medical record (EMR) and verified that there was no documented evidence that Patient 49 had been receiving the Beneprotein supplement since it was ordered on 4/30/13 through 5/8/13.
On 5/9/13, at 11:30 A.M., Patient 49 was asked if he knew what beneprotein was. He showed a packet of beneprotein he had at the bedside and stated he would mix it in with his Glucerna supplement, and he knew beneprotein was an additional protein source.
The hospital failed to ensure that the healthcare team members documented a therapeutic nutritional intervention that had been provided to Patient 49 since 4/30/13. The hospital failed to ensure that a registered nurse clarified the beneprotein order when it was entered as an order by the RD, who had not been granted the authority to order beneprotein, as the RD was not the practitioner responsible for the care of the patient.

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Based on observation, interview, record and document review, Hospital A failed to ensure that Registered Nurses (RNs) in the Neonatal Intensive Care Nursery (NICU) implemented infection control practices related to contact precautions. Hospital A failed to ensure that a parent followed the hospital's infection control practices, for 1 of 43 sampled patients (Patient 32) who was on contact precautions. Patient 32's parent did not have a gown and gloves on while assisting with the care of the patient. In addition, the hospital failed to ensure that a contact precaution stop sign was posted at a bedside in the NICU, for 1 of 43 sampled patients (Patient 32).

Findings:

1. 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).

An interview with Registered Nurse (RN 32) was conducted on 5/8/13, at 2:23 P.M. During a discussion about silencing alarms for patients in the NICU that were placed on contact isolation, RN 32 stated that nurses often used the hand sanitizer, placed gloves on, assessed if patient required any interventions and then proceeded to silence the alarms without wearing a gown, as there was no patient contact involved. However, she confirmed that in order to silence the patients' alarms, the nursing staff were required to enter the patients' environment, more often than not.

An interview and joint observation with the Director of Infection Prevention and Clinical Epidemiology (DPCE) was conducted on 5/8/13 at 2:50 P.M. An observation of a patient's bedside who was on contact precautions was conducted. The DPCE stated that the nursing staff, hospital staff, family and visitors were required to follow the instructions on the contact precaution signs and follow the infection control practices that instruct all to wash their hands, use hand sanitizer, wear the gown and gloves when touching the patient or the patient's environment.

A review of the hospital's document entitled "Contact Precautions In the Infant Special Care Nursery For Multi Drug Resistant Organisms " dated April 2006 was conducted on 5/8/13. The document indicated that "Transmission is from hand/fomite (Inanimate Objects) contact; therefore good Handwashing and Contact Precautions are REQUIRED." Per the same document, it instructed that "Contact Precaution and STOP sign on the isolette" and "ALL persons (including parents, physicians, nurses, respiratory, occupational and physical therapists, etc.) must gown and glove if touching the patient or the patient's environment.

An interview with RN 33 was conducted on 5/8/13 at 3:05 P.M. During a discussion of infection control practices in the NICU, RN 33 was asked to describe how she silenced alarms for patients that were placed on contact precautions. RN 33 stated that she would wash her hands or use the hand sanitizer that was at the bedside, applied gloves, assessed if the patient required an intervention and then proceed to silence the alarm without wearing a gown. She acknowledged that silencing the alarm would require her to enter the patient's environment. However, she stated that if she had to touch the patient, she would be wearing a gown for all patient care related interventions.

An interview with the NICU Nurse Manager (NNM) was conducted on 5/8/13 at 3:20 P.M. The NNM acknowledged that the NICU nursing staffs' practice was to wash their hands or use the hand sanitizer at the patients' bedside, wear the gloves, assess the patients' need for an intervention or the need to silence the alarm, and then proceed to silence alarm without wearing gloves since there was no patient contact involved. She stated that the nursing staff may or may not be entering the patients' environment however, the patients' monitor will be touched. She acknowledged that the NICU staffs infection control practices related to silencing alarms for patients' on contact precautions did not follow the hospital's contact precaution policy in the NICU.

2. 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."

The hospital's Contact Precaution Stop Sign was observed and reviewed on 5/8/13 at 2:15 P.M. It was a green sign that read "Stop Contact Precautions." It also indicated that gown and gloves were required for all persons entering room. Per the sign, it stipulated that no shared equipment and limit traffic to essential staff.

An interview and joint record review was conducted with Registered Nurse (RN 32) on 5/8/13 at 2:23 P.M. RN 32 stated that when neonates (patients) were placed on contact precaution, a green sign was posted at the patient's bedside and the personal protective equipment (the gloves, yellow gown and hand sanitizer) were placed on the patient's bedside tray.

A review of the hospital's document entitled "Contact Precautions In the Infant Special Care Nursery For Multi Drug Resistant Organisms " dated April 2006 was conducted on 5/8/13. The document indicated that "Transmission is from hand/fomite (Inanimate Objects) contact; therefore good Handwashing and Contact Precautions are REQUIRED." Per the same document, it instructed that "Contact Precaution and STOP sign on the isolette" and "ALL persons (including parents, physicians, nurses, respiratory, occupational and physical therapists, etc.) must gown and glove if touching the patient or the patient's environment.

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 Patient 32's parent should have been following the hospital's infection control practices since Patient 32 was placed on contact precautions by the physician. They both agreed that she should have been wearing the gloves and gown when she was assisting in the care of Patient 32.

3. 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 stated that Patient 32 was on contact precautions. She acknowledged that a contact precaution sign had not been posted in accordance with the hospital's policy.

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."

The hospital's Contact Precaution Stop Sign was observed and reviewed on 5/8/13 at 2:15 P.M. It was a green sign that read "Stop Contact Precautions." It also indicated that gown and gloves were required for all persons entering room. Per the sign, it stipulated that no shared equipment and limit traffic to essential staff.

A review of the hospital's document entitled "Contact Precautions In the Infant Special Care Nursery For Multi Drug Resistant Organisms" dated April 2006 was conducted on 5/8/13. The document indicated that "Transmission is from hand/fomite (Inanimate Objects) contact; therefore good Handwashing and Contact Precautions are REQUIRED." Per the same document, it instructed that "Contact Precaution and STOP sign on the isolette" and "ALL persons (including parents, physicians, nurses, respiratory, occupational and physical therapists, etc.) must gown and glove if touching the patient or the patient's environment.

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 a contact precaution sign should have been posted at Patient 32's bedside in accordance with the hospital's policy.