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Based on patient interview, staff interview, record review and policy review, the hospital failed to ensure an effective process for responding to dietary complaints and grievances for 6 of 6 dietary complaints reviewed (Patient #3, 21, 22, 23, 24 and 25).

The findings include:

On 1/20/16 at 8:30am an observation of stretch and community group therapy was conducted. Staff in attendance included direct care staff C, E, F and H. During the group, patient #3 was heard to voice complaints about breakfast. Patient #3 stated that the only thing on the breakfast tray was 2 slices of bread, peanut butter and jelly. Patient #3 stated that he received 4 PB&J's (peanut butter and jelly) yesterday and another PB&J for breakfast today, and he was sick of it. Staff were observed to assist patient #3 in completing a grievance.

Immediately after group on 1/20/16 beginning at about 9:00am, an interview was conducted with direct care staff C, E, F and H. The staff were asked what would happen to the grievance. Staff stated they would give it to the Unit Supervisor, Staff B.

The Grievance completed by patient #3 was reviewed. Patient #3 wrote that on 1/20/16 he did not receive enough food at breakfast to hold him until lunch. I am on a healthy heart diet, and I received peanut butter and 2 slices of bread. Since I have been here all I get is PB&J.

On 1/21/16 at 10:45am, an interview was conducted with the Unit Supervisor, Staff B. Staff B stated that lately we have had several complaints regarding dietary, cold food, warm milk, and not enough food. Patient #3 wrote a grievance yesterday stating that he felt that he was not getting enough food. I notified the dietitian, and she came up this morning and addressed the morning group. The dietitian explained how their nutritional needs were met. Patient #3 did not agree. Since he did not agree, the next step in our process is to complete an incident report. Staff B stated that the floor staff have been bringing food concerns to her, and she has been contacting the dietitian. She also sends and food related complaints to both the Director of Nursing and the dietitian. The dietitian did not do any 1:1 counseling with patient #3, nor did she make any diet change recommendations.

A record review of complaints which had been completed and submitted to Performance Improvement was conducted.

A grievance dated 9/22/15 from Patient #25 was reviewed. Patient #25 wrote, "This morning in breakfast I received cold food so I asked a staff member that my food was cold he just looked at me and shrug his shoulders like what you want me to do about it". The Action taken section was completed by the Unit Supervisor who wrote, "patient reports staff being insensitive this morning during breakfast. Will follow up with night shift staff and address issue." The action taken does not address the cold food. There was nothing documented by the dietitian.

On 1/5/16, patient #23 wrote, "The cafeteria didn't give me enough food". On 1/5/16 at 4:05am, the Unit Supervisor completed the 'Action Section' taken. The Supervisor wrote that patient #23 reported not having enough food for breakfast or lunch. Is continuously hungry and afraid of becoming thin. Will refer to dietitian to follow-up. There was nothing documented by the dietitian.

On 1/6/16, patient #24 wrote, "This morning at breakfast I received hot milk". On 1/6/16 at 9:45am, the Unit Supervisor completed the 'Action Section' taken. The Unit Supervisor wrote "Will refer to Dietitian for follow-up." There was nothing documented by the dietitian.

On 1/6/16, patient #22 wrote that the milk was hot and breakfast was cold. On 1/6/16 at 9:50am, the Unit Supervisor completed the 'Action Section' taken. The Unit Supervisor wrote, "will refer to dietitian for follow up." There was nothing documented by the dietitian.

On 1/13/16, patient #21 wrote, "I need to let you guys know that the food is not good. Change the food please." On 1/13/16 at 1:35pm, the Unit Supervisor completed the 'Action Taken' section. The Unit Supervisor wrote that patient #21 reports the taste of the food is bad and wants more options to choose from and that patient #21 does not drink tea. The Unit Supervisor wrote, "Will forward complaint to the Dietary Department." There was nothing documented by the dietitian.

A clinical record review was conducted for patient #3, 21, 22, 23 and 24. There were no dietitian notes in any of the 5 records reviewed.

On 1/20/16 at 1:00pm, an interview was conducted with the Inpatient Services Director about the grievance process. The Director stated that staff try to resolve grievances, but if they are unable, typically the grievance form first goes to the Unit Supervisor, then to the DON and then to me. When I am done, I forward it to the Performance Improvement director.

On 1/20/16 at 2:00pm, an interview was conducted with the Performance Improvement director. The director stated that the dietitian gets all food related complaints.

On 1/21/16 at about 12:00pm, an interview was conducted with the dietitian. The dietitian was asked about the morning meeting and patient #3. The dietitian stated that she addressed the patients this morning during group, and advised them that the menu was nutritionally adequate. The dietitian confirmed that she had not reviewed patient #3's record to date. The dietitian was shown the grievances completed by patients #21, #22, #23 and #24. The dietitian stated that she had not seen any of these dietary grievances previously.

Based on patient interview, staff interview, clinical record review and policy review, the facility failed to implement their policies on the right to refuse treatments for 2 of 20 sampled patients, #3 and 4. There was no process for patients to refuse a specialty diet.

The findings include:

An initial interview was conducted with Patient #3 on 1/19/16 at 3:00pm. Patient #3 stated, the food is lousy and the portions are small. The medications make me extra hungry.

On 1/20/16 at 8:30am an observation of stretch and community group therapy was conducted. Staff in attendance included direct care staff C, E, F and H. The staff went over the lunch and dinner menu for today and breakfast tomorrow. Staff only read the regular diet, they did not read the menu for other diets, nor did they read any alternatives. Two patients on a "Healthy Heart" diet (#3 and #4) began to complain about their breakfast. They stated that they only thing on their trays were 2 slices of bread, peanut butter and jelly. patient #3 stated that he received 4 PB&J's (peanut butter and jelly sandwiches) yesterday and then again for breakfast, and he was sick of it. Staff were observed to assist patient #3 in completing a grievance.

Immediately after group on 1/20/16 beginning at about 8:45am, an interview was conducted with patients #3, #4 and direct care staff C, E, F and H. The patients and staff were asked about the meal complaints voiced during group. Patient #3 stated that he does not want to be on a healthy heart diet. He wants to be on a regular diet. He is not allowed to refuse the special diet. Patient #3 stated that he was not getting enough to eat, and he stayed hungry. Patient #4 stated that she was on a healthy heart diet. Patient #4 stated that she has to fight with the hospital every time she is admitted about her diet. She does not need a healthy heart diet. She wants a regular diet, but the hospital will not change her diet nor will they allow her to refuse the healthy heart diet. The staff stated that patients often complain of being hungry during the day. Patients complain of being hungry even after eating everything on their trays. This is especially prevalent for the patients on the Healthy Heart diet. The diet order can only be changed by the physician. The staff were unable to verbalize a diet order refusal process.

On 1/21/16 at about 10:15am, an interview was conducted with nurse D about diets. Nurse D stated that upon admission, nursing does an initial nutritional screen and nursing picks a diet order. Typically, the nurse chooses a "healthy heart" diet if it was a known previous diet or if the patient appears overweight. The doctor will then either co-sign the diet order or change the diet. When asked if a patient can refuse a diet, nurse D thought about it and then stated that he thought patients could refuse, but he would have to call the dietitian to verify. Nurse D commented that typically, the ordered diet is not changed, even though patients complain.

A clinical record review was conducted for patient #3. The 'Nutrition Screening / Diet Order Form' was completed on 1/16/16 by a nurse. The nurse noted that Patient #3 was 5'9'' tall and weighed 179 pounds. The nurse selected a "Healthy Heart" diet. The admission physician orders on 1/16/16 also had the box for Healthy Heart diet marked. The form, "Diet Changes / Requests / Additions" was completed on 1/18/16. The form notes that patient #3 was currently on a Healthy Heart diet. Additions of Ensure, 1 can twice a day and an uncrustable PB&J three times a day were added. The patient's diet was not changed to regular. The form was signed by a Licensed Practical Nurse.

A clinical record review was conducted for patient #4. The 'Nutrition Screening / Diet Order Form' was completed on 1/15/16 by a nurse. The only documentation noted on the form was "no added salt" and "Healthy Heart" diet. There was no diet specified on the physician order sheet dated 1/15/16.

An observation of the breakfast and lunch meal was conducted on 1/20/16. Both residents #3 and #4 were observed to receive a Healthy Heart diet.

On 1/20/15 beginning at 2:40pm, an interview was conducted with the Dietitian. The Dietitian indicated that she would not recommend that patients refuse their Healthy Heart diets. They were ordered for a reason. The dietitian did not identify any specific process for how a patient can refuse a diet order.

The policy entitled, "Client Rights, Responsibilities and Ethics" last revised September 2015, was reviewed. The Policy stated, "It is the policy of Apalachee Center, Inc that services shall be provided in such a manner as to respect and foster the client's sense of dignity, autonomy, positive self-regard, civil rights and empowerment to be an active participant in his/her treatment, care and services. Under the section entitled, 'Procedure', part b states, "Individuals served shall be treated with personal dignity and be involved in all aspects of treatment, care and service ..." Part d stated that clients shall be invited to be active participants in their treatment process and have the right to ongoing informed participation in decisions regarding treatment, care and services. Individuals have the right, to the extent permitted by law, to refuse treatment or medications.

Based on observation, interview and facility record review, the facility failed to ensure that medications were not expired, medication were stored and labeled appropriately and that medications past their Beyond Use Date (BUD) were removed from patient use. (Medication Room)

The findings include:

On 01/20/2016 beginning at approximately 09:35am an inspection of the Unit's Medication Room was conducted in the presence of the medication nurse, the LPN on duty, Staff Member A. The facility's stock medications and medications stored in the refrigerator were inspected and revealed the following medications to be outdated, improperly stored or improperly labeled:

- One opened bottle of Naproxen 500mg tablets - with an expiration date of 11/2015
- (17) Trilafon 16mg tablets with a discard date of 04/17/2015 - stored in a blue pill box cartridge.
- Five Mirtazapine 15mg tablets - with an expiration date of 12/15
- One 30g tube of Nystatin cream with an expiration date of 12/15

The medication cabinets contained various multidose medication. An inspection of the cabinet contents revealed the followed outdated, unlabeled medications:
- One opened bottle of Fluphenazine Hydrochloride 2.5mg/ml 10ML multidose vial box indicates opened on 10/26/2015 .
- One bottles of sterile water opened - and not labeled as to when it was opened.
- (10) Albuterol inhalation solutions - with an exp. date of 08/15 and one with an exp date of 08/2014
- A box containing (19) Promethazine 25mg/ml injection - with an expiration date of 05/2015. Noted on the outside box was a sticker to indicate date of expiration on outside of box, but not removed. - Susan nurse indicates that it should be discarded 30 days after opened. Susan indicates they have stickers they are suppose to put on the bottle as to when expired. She confirmed the medication was past the BUD (Beyond Use Date).
There was also an opened box of "Lice Treatment" with a partial client label that had been removed. Staff A indicated she was not sure if this had been for a client or not. The expiration date of the Permethrin Lotion (2 bottles) was 08/15.

The Medication refrigerator was inspected which contained several vaccines, locked injectables and normally stores insulin (insulin bin was empty). The refrigerator also contained pre-packaged peanut butter & jelly sandwiches, applesauce, pudding and Ensure / Glucerna.
Staff Nurse A indicated that these were prescribed dietary supplies and allowed in the same refrigerator. She also stated that the night nurse is suppose to check medications for outdates and proper labeling. There was no mention of a "Monthly Inspection Checklist" as per the facility's policy and procedure.
The medication cabinets contained various multidose medication. An inspection of the cabinet contents revealed the followed outdated, unlabeled medications:
- One opened bottle of Fluphenazine Hydrochloride 2.5mg/ml 10ML multidose vial box indicates opened on 10/26/2015 .
- One bottles of sterile water opened - and not labeled as to when it was opened.
- Ten Albuterol inhalation solution - with an exp. date of 08/15 and one with an exp date of 08/2014
- A box containing (19) Promethazine 25mg/ml injection - with an expiration date of 05/2015. Noted on the outside box was a sticker to indicate date of expiration on outside of box, but not removed. - Susan nurse indicates that it should be discarded 30 days after opened. Susan indicates they have stickers they are suppose to put on the bottle as to when expired. She confirmed the medication was past the BUD (Beyond Use Date).
There was also an opened box of "Lice Treatment" with a partial client label that had been removed. Staff A indicates was not sure if this had been for a client or not. The expiration date of the Permethrin Lotion (2 bottles) was 08/15.

On 01/21/2016 beginning at approximately 08:45am an interview was conducted with the Infection Control Nurse regarding the facility's Infection Control Program. She stated that multi-dose medications should have an expiration sticker applied to the bottle to indicate to discard 28 days from the date of open. She stated she didn't think the facility had a policy to prohibit multidose medication from being drawn up in a immediate patient care area, but didn't think this had been a practice problem. She was asked about food being stored in the medication refrigerator. She stated there should be no food in the medication refrigerator, Ensure was okay, but the other items should be kept in the client kitchen refrigerator.


On 01/21/2016 at approximately 11:45 am an interview was conducted with the Unit Manager, she was asked about multi-dose medication, the storage and labeling of bottles should be dated to expire 28 days from time opened. The expiration date would be noted on the bottle. The night nurse is responsible for checking medication labels and removing any outdated medication from the medication room. She stated that only medications should be stored in the refrigerator and any food items are suppose to be in the client kitchen. She returned approximately 15 minutes later and indicated that the reason snacks were being kept in the medication refrigerator was because staff were taking the snacks.

A review of the facility's policy and procedure entitled "Medication Storage", #510-8, last revised August 2014, indicates "a. ....(8) Outdated drugs shall not be stocked. (9) Multi-dose medications shall be labeled with an expiration date of 28 days after opening. b. Monthly inspections of all drug storage units shall be performed by designated staff using the Monthly Inspection Checklist (attachment 2 ) to assess and ensure adherence to the above standards. See Attachment 1 for 'Calculation of Expiration Date' table." The facility's policy and procedure failed to be followed.

Based on observation, patient interview, staff interview, clinical record review and policy review, the hospital failed to ensure the dietetic services were directed in a manner to ensure the nutritional needs of the patients. The dietary director failed to ensure food service complaints were addressed to include complaints of cold food, portion size, snacks, preferences and diet choice. The dietary director failed to ensure that food items were discarded upon reaching their marked expiration date. The dietary director failed to ensure that appropriate dietary substitutions were available. The culmination of these failures resulted in a determination of non-compliance with the Condition of Participation of Food and Dietetic Services.

The findings:

Refer to A0619: Based on observation, patient interview, staff interview, clinical record review and policy review, the hospital failed to ensure the kitchen was organized to ensure quality control of dietetic services. The kitchen failed to ensure food was consistently served at the proper serving temperature, that concerns regarding portion sizes were addressed, that snacks were available, that food preferences were respected, that appropriate dietary substitutions were available and that expired food items were discarded. This had the potential to effect all 14 current patients including 6 of 25 sampled patients (#3, 4, 8, 22, 24 and 25).

Refer to A0620: Based on observation, patient interview, staff interview, clinical record review and policy review, the hospital failed to ensure that the dietary director was responsible for addressing food related complaints for 6 of 7 sampled patients (#3, 4, 21, 22, 23, 24).

Refer to A0629: Based on observation, patient interview, staff interview, clinical record review, and policy review, the hospital failed to ensure the menu met the needs of the patients served. The kitchen failed to address complaints of hunger and wanting more food and /or snacks. This issue had been brought to the attention of the kitchen by both patients and staff. The staff stated that hunger can lead to increased agitation and behaviors which in turn can lead to safety issues for both patients and staff. This had the potential to effect all 14 current patients, including sampled patients #3 and #4.

Based on observation, patient interview, staff interview, clinical record review and policy review, the hospital failed to ensure the kitchen was organized to ensure quality control of dietetic services. The kitchen failed to ensure food was consistently served at the proper serving temperature, that concerns regarding portion sizes were addressed, that snacks were available, that food preferences were respected, that appropriate dietary substitutions were available and that expired food items were discarded. This had the potential to effect all 14 current patients including 6 of 25 sampled patients (#3, 4, 8, 22, 24 and 25).

The findings:


FOOD PREFERENCES AND CHOICES:

The Food and Nutrition Services policy entitled, "Menu Substitutions", last revised 10/16/15, was reviewed. The purpose stated, "It is the purpose of this procedure to provide guidelines for meal substitution when a client does not want the regularly served meal." Procedure: "The written menu meets the Daily Reference Intake requirements for all vitamins and minerals. When the written menu is not followed, the client may not receive proper nutrition. Due to this fact, the peanut butter and jelly substitution will occur as follows: Inpatient Clients: In the morning, clients will review the menu for the day. At this time, they can decide (if wanted) to substitute an entree for 1 Uncrustable Peanut Butter and Jelly Sandwich. All sides will remain the same.

The policy entitled, Diet Orders: Initial, Changes, Transfers and Discharges , last revised 6/3/14, was reviewed. The purpose stated, "It is the purpose of the procedure to ensure that diet orders and dietary recommendations are processed appropriately and efficiently." 1. Within 24 hours of admission, the physician will order and sign off on all diets. 4. Any changes from the prescribed / non-select diet needs to be medically or nutritionally needed. "Preferences are not considered" was the next sentence, but it had been crossed off with a note to see the above policy "Menu Substitutions."

On 1/20/16 at 8:30am an observation of stretch and community group therapy was conducted. Staff in attendance included direct care staff C, E, F and H. The staff went over the regular lunch and dinner menu for today and breakfast tomorrow. Staff only read the regular diet, they did not read the menu for other diets, nor did they read any alternatives. Two patients on a "Healthy Heart" diet (#3 and #4) began to complain about their breakfast. They stated that they only thing on their tray was 2 slices of bread, peanut butter and jelly. The patients on a regular diet all received biscuits and gravy.

Immediately after group on 1/20/16 beginning at about 8:45am, an interview was conducted with patients #3 and #4 and direct care staff C, E, F and H. The staff provided a copy of the weekly menu from which they read during the meeting. The weekly menu only listed the regular diet. No alternate diets, such as Healthy Heart, were listed on the weekly menu. The staff confirmed that the kitchen has only provided the regular menu to read. The kitchen has not provided the menu for the specialty diets. The staff stated that they are to read the menu during morning meeting. If a patient doesn't like something, they have to tell staff during group so that staff can notify the kitchen. The kitchen requires a 2 hour notice for a substitution. The only substitution is a PB&J (peanut butter and jelly sandwich). The staff further stated that there were no alternates and no substitutes. Preferences were not honored. If a patient doesn't like an item at the time of service, we can't get them anything else. They just have to wait until the next meal. Patient #3 stated that he does not want to be on a healthy heart diet. He wants to be on a regular diet. He is not allowed to refuse the special diet. Patient #3 stated that he was not getting enough to eat, and he stayed hungry. Patient #3 stated that he received 4 PB&J's yesterday and then again for breakfast today, and he was sick of it. Patient #4 stated that she was on a healthy heart diet. Patient #4 stated that she has to fight with the hospital every time she is admitted about her diet. She does not need a healthy heart diet. She wants a regular diet, but the hospital will not change her diet nor will they allow her to refuse the healthy heart diet. The staff confirmed that Patient #3 did, in fact, receive 4 uncrustable PB&J sandwiches yesterday, one for lunch and 3 on the unit for snacks. The PB&Js and Ensure were ordered by the doctor for complaints of hunger.

An observation of the lunch meal was conducted on 1/20/16 beginning at 11:45am. Twelve patients were observed eating in the lunch room. Each patient received only 1 beverage, a small cup of tea (about 8 ounces). No pitcher of tea was observed for refills. There were no other beverage choices available. As patients finished their cup of tea, staff asked if they would like some water. Eleven of the patients requested a glass of water. An interview was conducted staff C. Staff C stated that the kitchen does not send a pitcher of tea, nor does the kitchen send additional beverages. Staff must provide further hydration. Only water is available.

A review of the menus for all diets was conducted for the week. There were no alternate items listed, and no patient choice was built into the menu.

On 1/21/16 at about 10:15am, an interview was conducted with nurse D about diets and snacks. Nurse D stated that the only snacks available were PB&Js and Ensure (Glucerna for diabetics). Upon admission, nursing does an initial nutritional screen and nursing picks a diet order. Typically, the nurse chooses a "healthy heart" diet if it was a known previous diet or if the patient appears overweight. The doctor will then either co-sign the diet order or change the diet. When asked if a patient can refuse a diet, nurse D thought about it and then stated, "I think they can. I would call the dietitian." Typically, the diet is not changed, even though patients complain.

On 1/21/16 at 10:30am, a follow-up interview was conducted with staff C, E and H about meal refusals. All 3 staff stated that they have to notify the kitchen 2 hours in advance of meal service if a patient does not want what is on the menu. If the patient waits until the meal is served, no substitute is typically offered. They just go hungry. The only substitute ever offered is a peanut butter and jelly sandwich. Most of the time it is a pre-packaged uncrustable.

On 1/20/15 beginning at 2:40pm, an interview was conducted with the Dietitian. If a patient does not like the entree, they can tell staff in community group when the menu is read. We will substitute the entree with a PB&J. Quantity wise, a PB&J is a small portion, but it is a nutrient dense food. We will substitute a side item or a vegetable for allergies, but if they just don't like it, we won't substitute. Only the entree is substituted. We have a non-select menu. The dietitian was asked about patients refusing food at the time of service. The dietitian stated that their has to be a legitimate reason, not just that they don't like it. The kitchen cannot meet everybody's likes and dislikes. We have a non-select menu. The dietitian was asked about beverage refills and patients receiving only one 8 ounce cup. The dietitian stated that the kitchen serves tea. The tea is caffinated and is sweetened, so we don't send another beverage. Being a dietitian, I want to promote healthiness, so water is the best choice. I do not send any pitchers of tea, or extra tea for refills.


PORTION SIZE & SNACKS:

An observation of the breakfast meal was conducted on 1/20/16 at about 7:45am. Both patients #3 and #4 were observed to receive a Healthy Heart diet. For breakfast, the meal consisted of 2 slices of untoasted bread, 2 tablespoons of peanut butter and 2 packets of diet jelly.

Interview with patient #8 on 1/20/16 at 9:00am. Patient #8 stated that the food is not balanced. sometimes you have too much protein and sometimes not enough. I never feel satisfied.

An initial interview was conducted with Patient #3 on 1/19/16 at 3:00pm. Patient #3 stated, the food is lousy and the portions are small. The medications make me extra hungry.

On 1/20/16 at 8:30am an observation of stretch and community group therapy was conducted. Staff in attendance included direct care staff C, E, F and H. During the group, patients #3 and #4 began to complain about their breakfast. They stated that the only thing on this morning's breakfast tray were 2 slices of bread, peanut butter and jelly. Both stated they were still hungry.

After group on 1/20/16 beginning at about 8:45am, an interview was conducted with patients #3, #4 and direct care staff C, E, F and H. The staff stated that patients often complain of being hungry during the day. Patients complain of being hungry even after eating everything on their trays. The meal trays typically have small portions. The kitchen will not send large portions or double portion trays. The staff stated that there were no snacks available on the unit for them to distribute. If a patient doesn't eat their meal, we cannot offer them anything else. The kitchen won't send anything, and we have nothing to offer on the unit. They just have to wait to the next meal. The patients have no access to snacks. There is no pantry and no vending machines. The kitchen does not send a morning snack. The only snack they get during the day is at 2:00pm. The snack consists of a cup of coffee and 1 piece of fruit. Patients complaint of being hungry even after eating everything on their trays. This is especially prevalent for the patients on heart healthy diets. Our patients are hungry. Many come off the streets where they not have eaten for days, or at least very little. Many are homeless. They take psychiatric medications which have the side effect of increasing hunger. Patients who are hungry can be a safety issue on this unit. Patients have increased behaviors. They will sometimes take a look at their lunch tray and throw it across the room. People who are hungry are not paying attention in therapy, and are agitated more easily. If there is a patient who doesn't each much, the hungry patients will sit next to them during meals to get extra food. This is not allowed. We are supposed to stop any food sharing, but at the same time we are not supposed to be instigating aggressive behavioral episodes, it is our job to try and reduce them.

An observation of the lunch meal was conducted on 1/20/16 beginning at 11:45am. The lunch trays were delivered to the lunch room at about 11:45am. Patient's #3 and #4 were served 3/4 cup of "creamy chicken tomato alfredo" pasta, 1 small side salad and a 4 ounce cup of applesauce. An interview was conducted with staff C and E during the lunch meal. The staff stated that the meal served at lunch today was the largest portion they have seen in a long time at any one meal. Yesterday they got 1 uncrustable PB&J and a cup of chicken noodle soup. Rarely do the patients say they are full after a meal. They often complain that they are still hungry. The only thing we can do is tell a nurse. We can't give them a double portion, or let them have a tray that someone refused or was discharged. The only thing the nurse can do is give the patient a PB&J if she has an order.

An interview was conducted with staff C, E and H about breakfast today on 1/21/16 at 10:30am. The staff stated that the healthy heart diets received raisin toast, a small scoop of eggs (less than the regular diets) and 1 tiny sausage link. No seconds were available. This was confirmed in interview with patient #3 at 10:45am. Patient #3 stated that he was still hungry.

On 1/21/16 at about 10:15am, an interview was conducted with nurse D about diets and snacks. Nurse D stated that the only snacks available were PB&Js and Ensure (Glucerna for diabetics). Upon admission, nursing does an initial nutritional screen and nursing picks a diet order. Typically, the nurse chooses a "healthy heart" diet if it was a known previous diet or if the patient appears overweight. The doctor will then either co-sign the diet order or change the diet. When asked if a patient can refuse a diet, nurse D thought about it and then stated, "I think they can. I would call the dietitian." Typically, the diet is not changed, even though patients complain.

On 1/20/15 beginning at 2:40pm, an interview was conducted with the Dietitian. The Dietitian stated that unfortunately food complaints occurs more often than I would like. The complaints mostly occur on exit surveys. 'More food' is the food complaint most often seen on exit surveys. I feel confident that what the patients are receiving is nutritionally sufficient. Certain psychotropic medications can increase appetite as a side effect. A meal is something that the patients can look forward to. The average daily regular diet provides 2700 to 3000. I just know this from years of being a dietitian. I feel confident that the menu is nutritionally adequate.

A follow-up interview was conducted with the dietitian on 1/21/16 at about 9:50am. The dietitian was asked about portion sizes and snacks available on the inpatient unit. The dietitian stated that she determined what snacks the nurses can have for the patients. The snacks had to be medically needed. Only the nurse can give out a snack. The only snacks kept on the inpatient unit were uncrustable PB&Js. The nurses needed authorization from her or the doctor to give the sandwiches to the patients. There was also Ensure available with a physician order. The kitchen did not offer large portion diets or double portion diets. The dietitian again reiterated that the diets were nutritionally sufficient.


FOOD IS SERVED AT THE PROPER TEMPERATURE:

The dietary policy on 'Procurement of Food Stock and Transportation of Meals', revised 4/1/02 was reviewed. The purpose of the policy is describe as, "It is the purpose of this procedure to assure that the distribution of meals is appropriate and efficient and is in compliance with all applicable rules and standards." "2. Prepared meals shall arrive at the site of distribution well protected, and at the appropriate temperature." "Receipt of read to serve prepared meals should not be accepted by facility staff if the temperature of hot foods is less than 140 degrees or if the temperature of cold foods is not at 41 degrees or below." 3. In order to maintain the appropriate and required temperatures, pre-plated meals must be served as soon as possible after receipt at the inpatient units.

On 1/20/16 beginning at about 8:45am, an interview was conducted with direct care staff C, E, F and H about food complaints. The staff stated that they get patient complaints about cold food. We are not allowed to reheat the food. We have no way of testing the food temperature upon service. If we tell the kitchen that the food is cold, we just get attitude. They don't do anything about it. The staff stated that the food was not served on heated plates so it cools more quickly. The kitchen plates food for all the patients, then brings it up in a cart. They don't notify us when they are on the way. Staff was asked how they know the food was cold since they can't test it? For example, if they put the butter on the grits, does it not melt? The staff responded, "what butter?"

A record review of food service grievances was conducted.

A grievance dated 9/22/15 from Patient #25 was reviewed. Patient #25 wrote, "This morning in breakfast I received cold food so I asked a staff member that my food was cold he just looked at me and shrug his shoulders like what you want me to do about it".

On 1/6/16, patient #24 wrote, "This morning at breakfast I received hot milk". The Unit Supervisor wrote that the dietitian was informed.

On 1/6/16, patient #22 wrote that the milk was hot and breakfast was cold. The Unit Supervisor wrote that the dietitian was informed.

An observation of the lunch meal was conducted on 1/20/16 beginning at 11:45am. The lunch trays were delivered to the lunch room at about 11:45am, but there were no staff and no patients in the room. At 11:50am, staff member C arrived, saw that the trays were there and notified the unit to send the patients. As soon as the patients began arriving, staff was observed to distribute the pre-plated food. An interview was conducted with the staff member C and E during the lunch observation. Staff stated that the kitchen staff does not communicate with the floor staff that trays have arrived. Trays may sit here 15 minutes before we know it. We need to just keep coming to the unit kitchen to check. There is a phone available in the main kitchen area beside the door that the kitchen staff could use for notification. Staff was asked what they did if the patients' complained of cold food. The staff stated that there is not much they can do. They are not allowed to re-heat the food. They can notify the kitchen, but they do not send up replacement trays.

On 1/20/15 beginning at 2:40pm, an interview was conducted with the dietitian. The dietitian was asked about the process to ensure food is hot when it arrives on the unit. The dietitian stated that they cook all foods to 165 degrees, so we feel confident it is getting to them at least 140 degrees. The dietitian did not identify any official type of food temperature monitoring process. The dietitian was specifically asked about test trays, and stated that she has done a test tray unofficially. The unit supervisor called me to say that the milk was hot one day. I held a kitchen staff meeting and addressed the warm milk with staff.


FOOD STORAGE:

On 1/19/16 beginning at about 3:20pm, an observation was conducted of the kitchen. The external thermometer on the walk-in refrigerator said 45-46 degrees (should be 41 or less) and the internal thermometer was broken. In the walk-in refrigerator several items past their best-by or use-by dates were observed stored on shelves ready-to-use. There were 4 multi-use containers of sour cream, best-by 1/11/16, and a box of individual portions of sour cream with a use-by date of 12/28/15. There were 2 containers of 4% cottage cheese with a best-by date of 1/18/16 and 12/8/15. There were 3 boxes of individual cream cheese packets, 1 box with a use-by date of 12/18/15 and 2 more with a use-by date of 1/8/16.

In the dry storage area, there was a box of individual packets of Newman's Own Italian Dressing with a use-by date of 1/3/16.

An interview was conducted with the Dietitian during the observations. The dietitian stated that the kitchen treats 'best-by' dates and 'use-by' dates in the same manner. They are all discarded by the date on the container. When asked about all the expired items, the dietitian stated that her staff make it a point to check the dates before the products are actually used.

A follow-up kitchen observation was conducted on 1/21/16 at about 9:30am. The box of Italian dressing packets which expired on 1/3/16 remained ready-to-use in the dry storage room. Also observed ready-to-use in the dry storage room, were 3 boxes of assorted jelly, 200 packets per box, with a best-by date of 12/16/15. In the walk-in refrigerator, 2 boxes of individual orange juice cups, 72 cups per box, were observed with a use-by date of 1/16/16.

A review of the Food Service Inspection conducted by the Florida Department of Health on 9/2/15 was conducted. The report stated that there was outdated buttermilk and reduced fat milk in the walk-in cooler.

Food service policies which address food storage, 'best-by' and 'use-by' dates were requested. The facility provided 2 policies which addressed food storage.

The Dry Food Storage Policy, last revised 4/1/02, was reviewed. The policy did not address the shelf life of foods.

The 'Food Handling Guidelines' policy, last revised 7/23/12, was reviewed. Under the section for 'Food Storage', the policy stated, "All dry goods shall be stored and used on a first in first out basis. This will reduce the risk of foods not being used before their expiration date." The policy did not address how the process by which the facility would ensure all stored foods were within date.

Based on observation, patient interview, staff interview, clinical record review and policy review, the hospital failed to ensure that the dietary director was responsible for addressing food related complaints for 6 of 7 sampled patients (#3, 4, 21, 22, 23, 24).

The findings:

On 1/20/16 at 8:30am an observation of stretch and community group therapy was conducted. Staff in attendance included direct care staff C, E, F and H. The staff went over the lunch and dinner menu for today and breakfast tomorrow. Staff only read the regular diet, they did not read the menu for other diets, nor did they read any alternatives. Two patients on a "Healthy Heart" diet (#3 and #4) began to complain about their breakfast. They stated that the only thing on their trays were 2 slices of bread, peanut butter and jelly. Client #3 stated that he received 4 PB&J's (peanut butter and jelly sandwiches) yesterday and another PB&J for breakfast today, and he was sick of it. Staff were observed to assist client #3 in completing a grievance.

Immediately after group on 1/20/16 beginning at about 8:45am, an interview was conducted with clients #3, #4 and direct care staff C, E, F and H. The patients and staff were asked about the meal complaints voiced during group. Patient #3 stated that he does not want to be on a healthy heart diet. He wants to be on a regular diet. He is not allowed to refuse the special diet. Patient #3 stated that he was not getting enough to eat, and he stayed hungry. Patient #4 stated that she was on a healthy heart diet. Patient #4 stated that she has to fight with the hospital every time she is admitted about her diet. She does not need a healthy heart diet. She wants a regular diet, but the hospital will not change her diet nor will they allow her to refuse the healthy heart diet. The staff confirmed that Patient #3 did, in fact, receive 4 uncrustable PB&J sandwiches yesterday, one for lunch and 3 on the unit for snacks. The PB&Js and Ensure were ordered by the doctor for complaints of hunger. At breakfast today, patient #3 received 2 slices of bread, 2 tablespoons of peanut butter and jelly.

The Grievance completed by patient #3 was reviewed. Patient #3 wrote that on 1/20/16 he did not receive enough food at breakfast to hold him until lunch. I am on a healthy heart diet, and I received peanut butter and 2 slices of bread. Since I have been here all I get is PB&J.

On 1/20/16 at 2:00pm, an interview was conducted with the Performance Improvement director. The director stated that the dietitian gets all food related complaints.

A record review of grievances to date in January 2016 was conducted. Four more dietary complaints were found.

On 1/5/16, patient #23 wrote, "The cafeteria didn't give me enough food". Action Taken was documented as, "Client reported not having enough food for breakfast or lunch. Is continuously hungry and afraid of becoming thin". Will refer to dietitian to follow-up. The form was signed by the Unit Supervisor.

On 1/6/16, patient #24 wrote, "This morning at breakfast I received hot milk". The Unit Supervisor wrote "Will refer to Dietitian for follow-up."

On 1/6/16, patient #22 wrote that the milk was hot and breakfast was cold. The Unit Supervisor wrote, "will refer to dietitian for follow up."

On 1/13/16, patient #21 wrote, "I need to let you guys know that the food is not good. Change the food please." The Unit Supervisor wrote that patient #21 reports the taste of the food is bad and wants more options to choose from and that patient #21 does not drink tea. The Unit Supervisor wrote, "Will forward complaint to the Dietary Department."

On 1/21/16 at 10:45am, an interview was conducted with the Unit Supervisor, Staff B. Staff B stated that lately we have had several complaints regarding dietary, cold food, warm milk, and not enough food. Patient #3 wrote a grievance yesterday stating that he felt that he was not getting enough food. I notified the dietitian, and she came up this morning and addressed the morning group. The dietitian explained how their nutritional needs were met. Patient #3 did not agree. Staff B stated that the floor staff have been bringing food concerns to her, and she has been contacting the dietitian. She also sends and food related complaints to both the Director of Nursing and the dietitian. The dietitian did not do any 1:1 counseling with patient #3, nor did she make any diet change recommendations.

A clinical record review was conducted for patients #3, 4, 21, 22, 23 and 24. Patients #3, 4, and 22 were on a 'Healthy Heart' diet, and the other three were on a regular diet. There were no dietitian notes in any of the 6 records.

On 1/20/15 beginning at 2:40pm, an interview was conducted with the Dietitian. The Dietitian stated that unfortunately food complaints occur more often than I would like. The complaints mostly occur on exit surveys. 'More food' is the food complaint most often seen on exit surveys. I feel confident that what they are receiving is nutritionally sufficient. I feel confident that the menu is nutritionally adequate. The PB&J might be the bane of my existence. Quantity wise it is a small portion, but it is a nutrient dense food. We have a non-select menu.

On 1/21/16 at about 12:00pm, a follow-up interview was conducted with the dietitian. The dietitian was asked about the morning meeting and patient #3. The dietitian stated that she addressed the patients this morning during group, and advised them that the menu was nutritionally adequate. The dietitian was asked about an apparent order discrepancy for patient #3. Patient #3 had current orders for both the 'Healthy Heart' diet and orders for Ensure twice a day and a PB&J three times a day. The dietitian stated that this did not seem right, but she would have to review the record. The dietitian confirmed that she had not reviewed patient #3's record to date.

Based on observation, patient interview, staff interview, clinical record review, and policy review, the hospital failed to ensure the menu met the needs of the patients served. The kitchen failed to address complaints of hunger and wanting more food and /or snacks. This issue had been brought to the attention of the kitchen by both patients and staff. The staff stated that hunger can lead to increased agitation and behaviors which in turn can lead to safety issues for both patients and staff. This had the potential to effect all 14 current patients, including sampled patients #3 and #4.

The findings are:

On 1/20/16 at 8:30am an observation of stretch and community group therapy was conducted. Staff in attendance included direct care staff C, E, F and H. During the group, patients #3 and #4 began to complain about their breakfast. They stated that the only thing on this mornings breakfast tray was 2 slices of bread, peanut butter and jelly. Both stated they were still hungry.

After group on 1/20/16 beginning at about 8:45am, an interview was conducted with patients #3, #4 and direct care staff C, E, F and H. The staff stated that patients often complain of being hungry during the day. The meal trays typically have small portions. The kitchen will not send large portions or double portion trays. The staff stated that there were no snacks available on the unit for them to distribute. If a patient doesn't eat their meal, we cannot offer them anything else. The kitchen won't send anything, and we have nothing to offer on the unit. They just have to wait to the next meal. The patients have no access to snacks. There is no pantry and no vending machines. The kitchen does not send a morning snack. The only snack they get during the day is at 2:00pm. The snack consists of a cup of coffee and 1 piece of fruit. Patients complain of being hungry even after eating everything on their trays. This is especially prevalent for the patients on heart healthy diets. Our patients are hungry. Many come off the streets where they not have eaten for days, or at least very little. Many are homeless. They take psychiatric medications which have the side effect of increasing hunger. Patients who are hungry can be a safety issue on this unit. Patients have increased behaviors. They will sometimes take a look at their lunch tray and throw it across the room. People who are hungry are not paying attention in therapy, and are agitated more easily. If there is a patient who doesn't eat much, the hungry clients will sit next to them during meals to get extra food. This is not allowed. We are supposed to stop any food sharing, but at the same time we are not supposed to be instigating aggressive behavioral episodes, it is our job to try and reduce them.

On 1/20/16, patient #3 wrote a grievance which stated, "I feel that breakfast was not enough to hold me to lunch. I am on a healthy heart and I received a PB&J and 2 slices of bread. Since I have been here all I get is PB&J." (The regular diets received biscuits and gravy that morning).

The menus for all diets were requested for the week of survey. It was a non-select menu. This means there were no patient choices. There were 4 different diets listed on the master menu: Regular, Healthy Heart, 1800 calorie and mechanical soft. The regular diet had the largest portions. The menus were reviewed for portion sizes. The menus with portion sizes for the regular diet (largest portions) are listed below for 1/17/16, 1/18/16 and 1/19/16.

1/17/16
Breakfast: 1 chicken biscuit and 1 box cereal Lunch: 1 cup chili, 4 corn nuggets, 1 roll
Dinner: 1 cup ravioli, 1/2 steamed broccoli, 1 slice garlic toast

1/18/16
Breakfast: 2 pancakes and 2 sausage slices
Lunch: 1 Italian baked chicken, 1/2 cup green beans and 1/2 cup pasta salad, and garlic toast.
Dinner: 1 slice porkloin with brown sugar, 1/2 cup rice and 1/2 cup zucchini fries and peach cobbler.

1/19/16
Breakfast: 1/2 cup creamy grits, 1/2 cup eggs and 2 slices bacon
Lunch: 1 cup chicken noodle soup, 1 uncrustable PB&J, 1 slice chocolate cake.
Dinner: 1 sausage dog, 1/2 cup potato salad and 1/2 cup green beans.

An observation of the lunch meal was conducted on 1/20/16 beginning at 11:45am. An interview was conducted with the staff member C and E during the lunch observation. The staff stated that the meal served at lunch today was the largest portion they have seen in a long time at any one meal. (The menu for lunch today for the regular diet was 1 cup of creamy chicken tomato alfredo, 1 Caesar salad and 1 slice of apple pie.) Rarely do the patients say they are full after a meal. They often complain that they are still hungry. The only thing we can do is tell a nurse. We can't give them a double portion, or let them have a tray that someone refused or was discharged. The only thing the nurse can do is give the patient a PB&J if she has an order.

On 1/20/15 beginning at 2:40pm, an interview was conducted with the Dietitian. The Dietitian stated that unfortunately food complaints occurs more often than I would like. The complaints mostly occur on exit surveys. More food is the food complaint most often seen on exit surveys. I feel confident that what they are receiving is nutritionally sufficient. Certain psychotropic medications can increase appetite as a side effect. A meal is something that the patients can look forward to. The average daily regular diet provides 2700 to 3000. The dietitian was asked how she determined the calorie count. The dietitian stated that she knew this from years of being a dietitian. I feel confident that the menu is nutritionally adequate. We have a non-select menu.

On 1/21/16 at about 10:15am, an interview was conducted with nurse D about diets and snacks. Nurse D stated that there were no readily available snacks. Snacks required an order. Even with an order, the only snacks available were PB&Js and Ensure (Glucerna for diabetics). dietitian." The PB&Js and Ensure are kept in a refrigerator in the medication room.

An interview was conducted with staff C, E and H about breakfast today on 1/21/16 at 10:30am. The staff stated that the healthy heart diets received 1 slice of raisin toast, a small scoop of eggs (less than the regular diets) and 1 tiny sausage link. No seconds were available. This was confirmed in interview with patient #3 at 10:45am. Patient #3 stated that he was still hungry.

On 1/21/16 at 10:45am, an interview was conducted with the Unit Supervisor, Staff B. Staff B stated that lately we have had several complaints regarding dietary, cold food, warm milk, and not enough food. Patient #3 wrote a grievance yesterday stating that he felt that he was not getting enough food. I notified the dietitian, and she came up this morning and addressed the morning group. The dietitian explained how their nutritional needs were met. Patient #3 did not agree. Staff B stated that the floor staff have been bringing food concerns to her, and she has been contacting the dietitian. She also sends any food related complaints to both the DON and the dietitian. The Unit Supervisor was informed of staff concerns regarding hunger being a safety issue as it can cause increased agitation and behavioral episodes. The Unit Supervisor stated that the staff was absolutely right, we do have behaviors that will increase. If a patient is hungry or if they don't receive what the person sitting next to them gets, they can become agitated, behaviors escalate, and trays fall. Mental health staff are in a difficult position. They are supposed to stop food swapping, but they also don't want to be the instigator of a behavior. Food complaints have been a common occurrence, but they have only been filling out the grievances for the past couple of weeks. The Unit Supervisor confirmed that their was no snack between breakfast and lunch. Dietary staff are not with the patients, they are down in the kitchen. As floor staff, we hear the frequent complaints, dietary does not. It puts us in the middle between the patients and the kitchen.

A follow-up interview was conducted with the dietitian on 1/21/16 at about 9:50am. The dietitian was asked about portion sizes and snacks available on the inpatient unit. The dietitian confirmed that there are no readily available snacks on the unit. Only the nurse can give out a snack. The nurses needed authorization from her or the doctor to give the sandwiches to the patients. The snack had to be medically needed. The only snacks kept on the inpatient unit were uncrustable PB&Js. The kitchen did not offer large portion diets or double portion diets. The dietitian stated that the diets were nutritionally sufficient.

The policy entitled, "Snacks and Nourishments", last revised 6/3/14, was reviewed. 1. Nourishments for special diets shall be provided as required by the diet order or by identified problems in the nutritional screening and assessment of the client / resident. Clients are not to receive extra snacks or food items unless approved by the Registered Dietitian or written as a medical order. 2. Foods may be served as between-meal nourishment to increase the daily protein and/or caloric intake when nutritionally needed. Foods to be served include liquid nutritional supplements, milk, sandwiches, fruit / fruit juices, and cookies / crackers. The need for these nourishments will be determined by nutritional assessment or ordered by the medical doctor.