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Based on interview and record review, the facility failed to ensure there was documented evidence of:

1.Reappointment to the medical staff for one (MD 1) of five physician credential files (employee file) reviewed.

2.Current competencies/ experience for one (MD 1) of five physician credential files reviewed.

3.PALS (Pediatric Advanced Life Support) Training for one medical staff member (MD 1) and one Allied Health Professional (AHP 1) of six Medical Provider files reviewed.

4.An unrestricted license for one Allied Health Professional (AHP 1).

These deficient practices had the potential to affect the health and safety of patients.

Findings:

1. During an interview with Staff 1, on November 13, 2014, at 10:30 AM, she reviewed the physician credential file for MD 1 and was unable to find documentation of MD 1's reappointment to the medical staff which had expired on July 20, 2014, by the Governing Body.

The facility Medical Staff Bylaws, adopted June 2014, indicated "4.3.4 Board Action. At its next regular meeting after receipt of the report and recommendation of the Medical Executive Committee regarding an initial application for membership, the Governing Board shall consider and act on the recommendation of the Medical Executive Committee ...On Favorable Medical Executive Committee Recommendation: The Governing Board shall, in whole or part, adopt, modify or reject a favorable recommendation of the Medical Executive Committee." And ".4.6. Final Processing and Board Action. Following the report of the Medical Executive Committee to the Governing Board, the procedure provided in Section 4.3 relating to initial applications shall be followed. For purposes of reappointment, the terms "applicant" and "appointment" as utilized in this Section shall be read to mean "medical staff member" and "reappointment." The Governing Board shall render a proposed decision prior to the expiration date (required every 2 years) of the current appointment to medical staff membership of the member being considered for reappointment."

2. During an interview with Staff 1, on November 13, 2014, at 10:30 AM, she reviewed the physician credential file for MD 1 and was unable to find documentation of MD 1's current competency/experience as a basis for reappointment to the medical staff.

The facility Medical Staff Bylaws, adopted June 2014, indicated "4.4.3. The application for reappointment shall be in a prescribed form setting forth, without limitation, the following information: Continuing training, education, and experience that qualified the staff member for the privileges sought on reappointment."

3. During an interview with Staff 1, on November 13, 2014, at 10:30 AM, she reviewed the physician credential file for MD 1 (Chief of Anesthesia) and was unable to find documentation of current PALS (Pediatric Advanced Life Support) Training. She also reviewed the Allied Health Professional credential file for AHP 1, and was unable to find documentation of current PALS (Pediatric Advanced Life Support) Training.

During an interview with MD 1, on November 14, 2014, at 11:15 AM, she stated that the facility provides care for two to three pediatric patients per year and that she expects all of the Anesthesia providers to have current PALS training. MD 1 was surprised to hear that there was no documentation of current PALS training in two provider charts (MD 1 and AHP 1-Certified Nurse Anesthetist).

The facility policy and procedure titled "Anesthesia and Analgesia" (Anesthesiologist CRNAs and non-Anesthesiologist Personnel), dated 6, 2013, indicated "Practitioner Qualifications ...PALS, if treating patient 14 years and younger."

The facility Medical Staff Bylaws, adopted June 2014, indicated "Article II. Purposes and Responsibilities of the Medical Staff ...2.2.6. To develop, administer, and seek compliance with these Bylaws, the Rules and Regulations of the Medical Staff, the Rules and Regulations of the Services and sections, and all other relevant and lawful standards and policies of the medical staff of the hospital."

4. During an interview with Staff 1, on November 13, 2014, at 10:30 AM, she reviewed the Allied Health Professional credential file for AHP 1 and found a letter from the Board of Nursing, which placed AHP 1 on probation until 2015.

During a follow up interview with MD 1, on November 14, 2014, at 12:20 PM, when asked if AHP1 had an unrestricted license, she answered "no, it is restricted."

The facility policy and procedure titled "Organization and Regulation of The Department of Anesthesia", dated 9/2009, indicated "Staff Nurse Anesthetist ...Must be a licensed registered nurse and maintain an active and unrestricted nurse anesthetist (CRNA) certification through the California Board of Registered Nursing."

The facility Medical Staff Bylaws, adopted June 2014, indicated "Article II. Purposes and Responsibilities of the Medical Staff ...2.2.6. To develop, administer, and seek compliance with these Bylaws, the Rules and Regulations of the Medical Staff, the Rules and Regulations of the Services and sections, and all other relevant and lawful standards and policies of the medical staff of the hospital."

Based on observations and interviews, the hospital failed to ensure patients medical records were stored in a manner that protected the confidentiality of the patient's personal and medical information from unauthorized individuals. This failure had the potential to result in the medical breaches of patients confidential information, and the unauthorized use of the patients personal information, in a universe of 18 patients.

Findings:

During a tour of the rural clinic, on November 13, 2014, at 3:00 PM, it was observed that the medical records storage area was open and accessible to both the medical staff and unauthorized individuals. The clinic's medical records storage, was located in a small narrow room behind the receptionist desk. The medical records were observed to be left unattended, with both doors in the room to open. One of the doors open to receptionist area, with the receptionists backs to the door, and the other door was opened to the hallway leading to the examination rooms.

During an interview, on November 13, 2014, at 3:10 PM, LVN 10 (license vocational nurse) stated that the door to the medical records should be closed. LVN 10 further stated when the clinic was open, the doors to the medical records were usually left open, because staff didn't like having to open and close the door each time they needed to get another medical record.

During a tour, of the medical records stored at the hospital, on November 14, 2014, at 11:25 AM, the medical records were observed to be stored in a large warehouse located behind the hospital. The warehouse had been divided into different sections for multiple uses. The section for the medical records had a locked door entering a storage area used to store patients medical record from the radiology department, and extra medical supplies for the hospital.

During an interview on November 14, at 11:35 AM, the Medical Records Director stated, that most of the different departments in the hospital have a key and access to the area where the medical records for the radiology department were stored. The storage area used for the radiology medical records is also where the hospital stores extra medical supplies.

During the same tour of the hospital's medical record storage on November 14, 2014, at 11:40 AM, an area used for medical records storage referred to as "the cage" by the Medical Records Director was observed. The cage area consisted of an area enclosed with a chain link fenced around it. The fencing did not go up to the ceiling and the medical records were stacked on shelves in boxes that went up higher then the fencing. There was an unlocked gate that opened into the cage area making the medical records stored in this area easily accessible to anyone entering the locked door leading to the area where the radiology medical records and extra hospital supplies were stored. The cage area also had the potential of being breached and accessible by climbing over the top of the fencing from the side where the medical supplies and radiology records were stored, as well as, from the other side of the cage that was observed to be a large open area on the other side of the warehouse.

During the tour of medical records, on November 14, 2014 at 11:40 AM, medical records were also observed to be store in a separate storage area that was across from the area where the radiology medical records storage and the area referred to as the cage. The medical records stored in this area were behind a wall built inside the warehouse space, the wall created a partial room. The room consisted of three solid walls and a chain linked fence, made up the fourth wall. The side where the chain link fence was divided the medical storage area from a large open area inside another part of the warehouse. The chain link fencing used to enclose the area for the medical storage did not go up to the ceiling, and the medical records stored on the shelves next to the fencing were stacked up above the height of the fencing. The medical records storage for this area had a locked door between the room with the medical records and the area where the radiology record storage/ medical supplies were kept. The storage of the medical records in this room had the potential to be accessible to unauthorized individual from the open warehouse side.

During an interview on November 14, 2014, at 11:50 AM, the Medical Records Director acknowledged that the medical records storage is not totally secured from unauthorized individuals and the areas enclosed by the chain link fencing had the potential to be breached.

Based on observation, interview, and document review, the facility failed to control drugs in a safe and effective manner to protect the patient safety by failing to:

1. Implement the facility's policy and procedures on the timely availability of non-formulary (hospital medications not in stock) medications by requesting the patient or the patient's family member(s) to provide their own medications instead of contacting the physician resulting in the patient not receiving the medications for 2 days.

2. Make immediately available a medication used to treat an emergency in sufficient quantity as indicated in the facility's policy and procedure and in accordance with Malignant Hyperthermia Association of the United States (MHAUS).

These findings had the potential to affect the health and safety of all patients admitted to the hospital.

Findings:

1. During a medication pass observation conducted on November 13, 2014 at 9:40 AM and concurrent review of Patient 21's medical record, it was noted that there were following medications the patient was taking from home that the physician, on November 11, 2014, authorized to continue during the patient's stay at the hospital:

Co-Q-10 (supplement) 200 mg tablet by mouth once a day.
Depacon (medication used for seizure or neuropathic pain) 1000 mg by mouth twice a day.
Lumigan 1% (eye drop used for glaucoma) 1 drop to left eye daily.
Combigan (eye drop used for glaucoma) 2 drops to left eye daily.
Luteine/Zexanthin (supplement for eye) 20 mg by mouth twice a day.

The facility form titled, "[Hospital] Pharmacy Services Communication/Drug Therapy Inquiry" completed by a pharmacist on November 12, 2014 in the patient's medical record indicated that the above medications were "not on Hospital's Formulary" and that "Pt (patient) may use own meds."

During an interview on November 13, 2014 at 2:00 PM, RPH 1 stated that non-formulary medications that the Pharmacy did not routinely provide for the hospital patients were asked to be brought from home if they were to be continued at the hospital. RPH 1 also stated that he spoke to the nurse taking care of the patient for the medications to be brought from home on November 11, 2014 when he received the above medication orders.

During an interview on November 13, 2014 at 12:10 PM, both Patient 21 and his wife at the bedside did not indicate there was communication made to them by the nursing staff for medications to be brought from home.

During an interview on November 13, 2014 at 12 PM, RN 30 was not aware of any medications for the patient to be brought from home to the facility.

During an interview on November 13, 2014 at 2 PM, the Director of Pharmacy (DOP) indicated it was his expectation that the verifying pharmacist would contact the ordering physician for clarification of medication orders or alternate medications for non-formulary medications.

Review of the facility's policy and procedure titled, "Hospital Formulary" (medications provided by the hospital) indicated the following:

"Commonly ordered medications will be stocked in the Pharmacy, based on previous usage. If ordered drug will not be available when the first dose is due, the physician must be initially notified within two hours of receiving the medication order. When this occurs, an alternative agent may be suggested, or the physician may choose to delay therapy until the requested drug is available, etc. Any medication order the physician wishes to continue will be purchased and will usually be available the following morning. Medications will be ordered before closing if the physician is not successfully contacted."


2. During inspection of the emergency Malignant Hypertermia (MH) Cart located in OR 2 of the Airway Outpatient Center on November 14, 2014 at 8:30 AM, it was noted that there was only two 1000-ml IV bag of 0.9% Normal Saline (a solution given through the veins) in the medication refrigerator attached to the cart.

During a concurrent interview, DOP stated that the facility stocked the cart based on the recommendations by MHAUS and acknowledged that the medication refrigerator had only two chilled 0.9% Normal Saline bags.

MHAUS is a leading national organization for prevention and treatment of Malignant Hyperthermia (a condition where the individual's body temperature increases to over 106 degrees Fahrenheit when exposed to the use of muscle relaxants and inhalation anesthesia gases, is often fatal if not treated immediately).

According to MHAUS, it was recommended that the facility needed to stock three 1000-ml IV bags of 0.9% Normal Saline to help decrease body temperature of a patient with MH, a life-threatening condition in response to a triggering anesthetic drug causing uncontrollable increase in body temperature.

Review of the facility's policy and procedure titled, "Malignant Hyperthermia Kit Contents and Monitoring" indicated,

"The medication content of the Malignant Hyperthermia kit will be determined by the Pharmacy Dept., following the recommendations of the Malignant Hyperthermia Association of the United States."

Based on observation, record review, and staff interview, the hospital failed to ensure that the food and dietetic department was organized in a manner appropriate to the scope and complexity of the food service operations.

Findings:

As a result of the deficient practices identified during November 12-14, 2014 inspection, the hospital failed to ensure that the department was organized in a manner to ensure that dietary services met the needs of all patients as evidenced by failure to:

1. Provide organized dietetic services as evidenced by failure to develop policies for food storage and nutrition assessment (Refer to A-0620, A-0621, A-0630).

2. Ensure the registered dietitian provided nutrition care according to recognized nutritional standards. (Refer to A-0630).

3. Provide menu as ordered by the physician. (Refer to A-0630).

4. Practice safe and effective equipment sanitation practices (Refer to A-0620).

5. Ensure equipment was maintained in a manner that was safe for staff. (Refer to A-0724).

6. Failure to have an ongoing quality appraisal and performance improvement program that addressed the complexity and scope of Nutrition and Dietetic Services. (Refer to A-0267).

The cumulative effect of these systemic problems resulted in the inability of the hospitals' food and nutrition services to direct and provide staff in such a manner to ensure that the nutritional needs of the patients' were met in accordance with practitioners' orders and acceptable standards of practice.

Based on observation, review of hospital documents and staff interviews, the hospital failed to ensure that the food service director (FSD) organized the department in a manner that would ensure that the dietary needs of the patients were met. The FSD failed to ensure the department had developed effective policies to direct staff in the operation of food service and nutrition therapies. There was inadequate staff to ensure that food served was in compliance with the orders of the physician. The FSD accepted supervisory responsibilities for staff he could not effectively supervise due to lack of expertise. This deficient practice had the potential to affect the nutritional health and safety of all patients admitted to the hospital.

Findings:

During the tour of the kitchen on 11/12/14 at 8:50 AM, the food service director stated that he was responsible for the day to day operation of the hospital food services department including the hospital's skilled nursing facility.

1. At 8:45 AM, there were boxes of green leaf, romaine and iceberg lettuce in the walk-in refrigerator. There was a 10 pound unopened box of green leaf lettuce with a date of 10/31/14 and a second box with a date of 11/11/14. Inspection revealed green leaves but end of stalk was reddish brown, indicating early signs of deterioration.

There was also an opened bag of lettuce with a 10/20 " date on it. The leaves in the bag were not all green, some were brown others were starting to turn brown. The Food Service Director (FSD) was asked in a concurrent interview about the expiration dates of the items, he stated he was unsure because they followed manufacturer's recommendations and the Food Code. The hospital produced information from the distributor on storage times based on the date that the vegetables were harvested and shipped from the distributor. This information was not readily available and did not help staff in making a consistent and easy decision on how long food could be stored and when food should be discarded. There was no information from the Food Code provided on the storage of vegetables.

The hospital did not have in place specific policy on the storage of vegetables. Review of the job description for the position of Director shows that the position has responsibility for development of policies and storage of food. The job description states "oversees the storage and preparation of patients, employees and visitors food and the procurement of supplies and food vendors and suppliers". Also "establishes policy, plans and directs the activities for patients, employees and visitors to ensure delivery of quality nutrition and food service."

2. Review of clinical records showed that the nutrition assessments were not conducted according to recognized nutritional practices. Three of three sampled records (Patients 31, 32 and 33) did not have calculations of estimated needs to determine adequacy or appropriateness of diet. Review of hospital policy titled "Patient Nutritional Assessment and Plan" with revision dated of 5/14, "Assessment calculations will be based on "Nutritional Needs by the American Dietetic Association". None of the assessments reviewed had assessment calculations. The policy did not define or specify what these assessment qualifications were. This lack of clarity may have contributed to the inability of hospital staff to effective assess the competency of Dietary Staff 2 by a non-nutrition professional. (Refer to A-0 621 and A-0630).

In an interview with the FSD on 11/12/14 at 12:05 PM, the FSD produced an organizational chart for the hospital but stated there was no organizational chart for the department. Review of job descriptions of the FSD showed that his responsibilities to "supervise the registered dietitian and diet aides in performance of therapeutic and other dietary duties". Review of personnel record showed that the person in the position did not have an educational background in clinical or therapeutic nutrition. The minimum requirements for the position are a DSS (Dietary Service Supervisor), a state program of 90 or more hours of instruction, high school diploma, sufficient previous managerial experience in food service administration or previous food and nutrition experience. (Refer to A-0621)

3. During a kitchen observation on 11/12/14, the ice and soda machines were not being cleaned and sanitized according to manufacturer's instruction. The FSD was not aware that the Engineering department who had been assigned the responsibility of cleaning the machines sanitized the machines. The FSD had also not been aware of the weekly cleaning instructions of the soda machine. He had believed it was the responsibility of the vendor to perform the maintenance of the equipment.

4. A sampled patient (Patient 32) was sent a wrong diet. The physician ordered diet for the patient was a Mechanical soft diet (diet that is easier to chew). During tray line (process where dietary staff prepares diet trays for the patients) observation on 11/12/14, the patient was served 2 half sandwiches. Review of the menu showed that Patient 32' sandwich should have been minced. The food tray had to be retrieved from the cart after it had been sent to the nursing unit. The error posed a choking risk and/or patient inability to consume the meal.

It was observed, on 11/12/14, that dietetic department had food workers that placed items on the cart. There was no staff assigned to ensure that patient received the correct items according to the menu or preferences. The department did not have a system in place to ensure that meals were checked for accuracy and in compliance with diet ordered by the physician. (Refer to A-0630)

Based on observation, review of clinical records, hospital documents and staff interviews, the hospital failed to ensure that the person in the position of dietitian adequately supervised the nutritional aspects of patient care. Three of three records (Patients 31, 32 and 33) reviewed showed incorrect, incomplete assessments and/or dietary interventions. The hospital dietitian failed to provide adequate oversight of a dietetic intern who had been allowed to provide assessments and dietary interventions.

Findings:

1. Patient 31 was admitted to the hospital with diagnoses including asthma and pancreatitis. Pancreatitis (acute) is a disease of the pancreas characterized by sudden and severe abdominal pain, nausea, vomiting and diarrhea. Review of physician orders dated 11/10/14 showed a diet order was "Clear Liquid" with modifications of diabetic fluids (liquids without sugar).

Review of clinical record showed that Patient 31 was interviewed by Dietary staff 1 (a dietetic intern) on 11/11/14. Her admission height was 5' 8" and documented weight of 258 lbs. Her diet order changed during the hospital stay from NPO on day of admission to clear liquids with diabetic liquids by the second day of admission.

Dietary Staff 1 documented in the Patient Assessment: Nutrition Screening Assessment a nutrition diagnosis of "inadequate po (oral) intake r/t (related) to pancreatitis aeb ( as evidenced by)po intake of 0%". Additional information on the document indicated that she was not on tube feeding or TPN (Total Parenteral Nutrition).The diet order recommendation was "continue diet as ordered-receiving supplement with clear liquid diet". There was no assessment of her nutritional needs including calories, protein and fluids. Documentation did not include whether the diet ordered would meet her nutritional needs if she consumed 100% of the diet ordered.

A review of the hospital's diet manual provided during the entrance conference showed that a Clear Liquid Diet would provide would provide approximately 800 to 1000 calories and was "inadequate in all nutrients". However, with modifications of diabetic liquid, the diet would provide less than 700 calories per day. This low intake of calories would not be sufficient to meet the daily caloric needs of a patient who is 5' 8" tall. The estimated needs of a female 5' 8" tall using the Ireton-Jones calculation (a nutritional calculation that shows calorie requirments based on a persons weight and height) is approximately 1900 calories per day. No recommendation was made to the physician by the dietitian regarding the non-necessity of an additional diabetic restriction with such a diet that was low in calories and that total carbohydrate in was more important.

The current treatment for diabetes according to the American Diabetes Association (ADA) 2014 Standards of Medical Care in Diabetes is that total carbohydrate was more important than low or same calorie items. The ADA states "While substituting sucrose (sugar)-containing foods for isocaloric (similar caloric value) amounts of other carbohydrates, (it) may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices."

Patient 31's diet was changed to NPO (nothing by mouth) on 11/12/14 and was transferred to the Intensive Care Unit. On 11/13/14, five days after admission, a new order for intravenous solution that included dextrose (a form of sugar found in fruits and plants) was added. This order provided approximately 510 calories in 24 hours. "Solutions containing carbohydrate in the form of dextrose restore blood glucose levels and provide calories. Carbohydrate in the form of dextrose may aid in minimizing liver glycogen (main form in which glucose is stored in tissues and liver) depletion and exerts a protein-sparing action".

According to review of medical literature and nutrition text books, prolonged fasting or failure to use the gastrointestinal tract can exacerbate (worsen) metabolic changes that may complicate recovery. The guidelines from ASPEN (American Society for Enteral and Parenteral Nutrition) and ACG (American College of Gastroenterology) for severe pancreatitis are the use of enteral feeding after five days of NPO. No recommendation for progression towards use of enteral feeding was made in the record.

2. Patient 32 was admitted with diagnoses including seizures (abnormal state in which the body moves in an uncontrollable and violent way) and urinary tract infection. His admission height was 65 inches and weight was 115 pounds. He was placed on a mechanical soft diet on admission. Review of the Patient Assessment Form under the heading Nutrition, indicated Patient 32 did not have difficulties with Chewing/swallowing.

Further review of clinical record showed Patient 32 had a BMI (Body Mass Index) of 15.8 (Normal/healthy range is 18.5 to 24.99.) and was underweight, consuming 0% of his meals per nurse (RN 30). Body Mass Index, is an evaluation of how an individual body departs from what is normal for a person his or her height.) Patient 32 had triggered (for nutrition assessment) according to the hospital policy for nutritional risk for BMI less than 19, low albumin (blood protein) and poor intake result. Patient 32 had met the threshold of high nutritional risk with three areas of concern with a referral to the registered dietitian for consultation. There was no calculation of nutrient needs or indication that the current nutrition plan would meet Patient 32's needs. Dietary Staff 1 recommended Boost Glucose control for Patient 32.

The manufacturer's information for Boost Glucose Control describes it as "a balanced nutritional drink formulated for people with diabetes. "There was no documented evidence that Patient 32 had diabetes or had elevated blood sugars to justify the diabetic nutritional supplement. There was no documented justification for the selection of this product such as patient preference.

Documentation by Dietary Staff 1 included an error in the description of Patient 32. He was listed as a 55 year old, Patient 32 was younger than 55 years of age. The significance of this error is that according to the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council, the recommended caloric needs for the 51 to 70 year old male is lower for this age group than the 23 to 50 year old; the age group Patient 32 belongs to.

All of the assessments completed by Dietary Staff 1 had been cosigned by Dietary Staff2 attesting to its accuracy and appropriateness.

3. A review of clinical record for Patient 33 conducted by Dietary staff 2 showed the same lack of complete nutrition assessment for the patient who was receiving TPN (Total Parenteral Nutrition-feeding the patient through the vein). The 2011 ASPEN (American Society for Enteral and Parenteral Nutrition) clinical guidelines for nutrition screening, assessment, and intervention in adults are listed as follows: "Screening for nutrition risk is suggested for hospitalized patients. Nutrition assessment is suggested for all patients who are identified to be at nutrition risk by nutrition screening. Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished" The assessments conducted by the Dietary Staff 2 did not meet recognized dietary practices.

In an interview with hospital dietitian, Dietary Staff 2 (DS 2) on 11/12/14 at 3:50 pm, in response to the lack of nutrition assessment calculation on nutrient needs, DS 2 stated that based on the training that had been provided to her by the previous RD (registered dietitian, nutrient assessments are only completed on high risk patients such as those on " tube feeding, TPN and high risk (malnutrition) " . According to the hospital policy and procedure titled " Patient Nutritional Assessment and Plan " with revision dated of 5/14, " Assessment calculations will be based on " Nutritional Needs by the American Dietetic Association " . None of the assessments reviewed had assessment calculations.

A review of personnel records for Dietary Staff 2 indicated that she was hired in 2013, and was evaluated for competency by the former director of nursing (Nursing Staff 10). In an interview with Nursing Staff 10 on 11/13/14 at 5:45 PM, she indicated that she performed many different tasks at the time and was assigned to evaluate the competency of Dietary Staff 2. She explained that she asked Dietary Staff 2 what areas she needed to meet in terms of assessment and " checked her notes against those " . She acknowledged that she was not a nutrition expert. Nursing Staff10 stated that she was not aware that the calculations needed to have completed.

Review of the job description for the Registered Dietitian showed the primary responsibilities for the position included " documents all aspects of nutritional care for patients in accordance with departmental standards. Key quality responsibilities included " demonstrates accuracy and reliability for the quality of work performed " . These duties and responsibilities were not effectively demonstrated in the three patient records reviewed.

In an interview with the current director of nursing on 11/14/14 at 3:00 PM, she stated that the hospital management had not been aware that the pertinent nutrition assessments and calculations had not been completed on high risk patients.

Dietary Staff 2 indicated in the concurrent interview that she worked five days a week and was the only dietitian for the hospital. In response to a question regarding completion of assessments on weekends, she stated that the hospital policy was revised to include completion of nutrition assessments within 48 hours of referral, although she attempted to see all consults within 24 hours. According to ASPEN "The goal of nutrition assessment is to identify any specific nutrition risk(s) or clear existence of malnutrition. Nutrition assessments may lead to recommendations for improving nutrition status".
Based on the hospital's average length of stay of 4 days, it conceivable that a patient who is admitted late on a Friday may not be assessed until Monday and nutrition interventions based on Registered Dietitian (RD) recommendations may not be instituted until a day before or day of discharge. This late intervention would prevent the demonstration of the effectiveness of the nutrition treatment immeasurably and could result in some patients being discharged without the appropriate nutritional intervention. The 2014 PI (Performance Improvement) for Nutrition Services validates this assertion.

Review of the hospital's Performance Improvement Plan for 2014 for nutrition services was conducted. The goal of 100% was not met when patient education was measured for Coumadin. The conclusion was "patients not seen due to being discharged early".

Based on review of clinical records, facility documents and staff interviews, the hospital failed to ensure that the nutritional needs of three of three sampled patients (Patients 31, 32 and 33) were in accordance with recognized dietary practices. All three patients were either not assessed, improperly assessed or executed dietary interventions that were flawed.

Findings:

Patient 31 was admitted to the hospital with diagnoses including asthma and pancreatitis. Pancreatitis (acute) is a disease of the pancreas characterized by sudden and severe abdominal pain, nausea, vomiting and diarrhea. Review of physician orders dated 11/10/14 showed the diet order was "Clear Liquid" with modifications of diabetic fluids (liquids without sugar).

In a review of the clinical record showed that Patient 31 was interviewed by Dietary staff 1 on 11/11/14 in which she stated that she had no appetite and was unsure of her usual body weight. Dietary Staff 1 documented in the Patient Assessment: Nutrition Screening Assessment a nutrition diagnosis of "inadequate po (oral) intake r/t (related) to pancreatitis ... and po intake of 0%". Additional information the document indicated that she was not on tube feeding (nutritional feeding through a tube passing through the nose) or TPN (Total Parenteral Nutrition). The diet order recommendation was "continue diet as ordered-receiving supplement with clear liquid diet". There was no assessment of her nutritional needs including calories, protein and fluids. Documentation did not include whether the diet ordered would meet her nutritional needs if she consumed 100% of the diet ordered.

In a review of the hospital's diet manual provided during the entrance conference showed that a Clear Liquid Diet would provide the following items three meals a day: Broth, Jello-O, Popsicle, Orange, Cranberry, Apple or Orange Juice, Sugar (2 (tsp)) Boost Breeze, coffee or tea. This diet would provide approximately 800 to 1000 calories and inadequate in all nutrients. However, with modifications of diabetic liquid, the diet would provide less than 700 calories per day. This low intake of calories would not be sufficient to meet the daily caloric needs of a patient who is 5' 8" tall. The estimated needs of a female 5' 8" tall using the Ireton-Jones Calculation (a nutritional calculation or required calories according to ones weight and height) is approximately 1900 calories per day.

Some of the many complications from acute pancreatitis are high blood sugar or diabetes, malnutrition, kidney failure etc. There was no evidence of the risk -benefit analysis in the choice to provide Patient 31 with a diabetic modification in the presence of inadequate calories. No recommendation was made to the physician regarding the possible risk and inadequacy of calories with the diet as ordered.

Patient 31's diet was changed to NPO (nothing by mouth) on 11/12/14 and was transferred to the Intensive Care Unit. On 11/13/14, five days after admission, a new order for intravenous solution that included dextrose (sugar) was added. This order provided approximately 510 calories in 24 hours. "Solutions containing carbohydrate (starch and sugar in food) in the form of dextrose restore blood glucose levels (blood sugar levels) and provide calories. Carbohydrate in the form of dextrose may aid in minimizing liver glycogen (stored sugar in the liver) depletion and exerts a protein-sparing action (makes the body save protein)".

According to review of medical literature and nutrition text books, prolonged fasting or failure to use the gastrointestinal tract (digestive tract) can exacerbate (worsen) metabolic (how the body uses fuel for energy) changes that may complicate recovery. The guidelines from ASPEN (American Society for Enteral and Parenteral Nutrition) and ACG (American College of Gastroenterology) for severe pancreatitis are the use of enteral feeding after five days of NPO. No recommendation for progression towards use of enteral feeding (feeding through a tube) .

2. Patient 32 was admitted with diagnoses including seizures and urinary tract infection. His admission height was 65 inches and weight was 115 pounds. He was placed on a mechanical soft diet (diet that is easy to chew) on admission. Review of the Patient Assessment Form under the heading Nutrition, indicated Patient 32 did not have difficulties with Chewing/swallowing.

Further review of the clinical record showed Dietary Staff 1 documented in the Patient Assessment that his BMI (Body Mass Index) was 15.8 (Normal/healthy range is 18.5 to 24.99.) Body Mass Index, is an evaluation of how an individual body departs from what is normal for a person his or her height.) Patient 32 had triggered (for nutrition assessment) according to the hospital policy for nutritional risk for BMI less than 19. Documentation also showed that Patient 32's usual weight was 130 pounds indicating a 15 pound weight loss. (Review of closed record indicated this was within two weeks.) He also had a Blood Albumin of 1.5 (Normal value 3.5 to 5.5), albumin is an indicator of malnutrition.

Dietary Staff 1 documented in her comments that Patient 32 was underweight and consuming 0% per nurse (RN 30). She recommended nutrition supplement three times per day "per patient request". There was no calculation of nutrient needs or indication that the current nutrition plan would meet Patient 32's needs. Further review showed that she recommended Boost Glucose control for Patient 32.

The manufacturer's information for Boost Glucose Control describes it as "a balanced nutritional drink formulated for people with diabetes." There was no documented evidence that Patient 32 had diabetes or had elevated blood sugars to justify the diabetic nutritional supplement. The manufacturer had other products that were formulated for people with variety of health and nutrition needs: Boost Original, Boost High Protein and Boost Plus. These products provide 240 calories 10 grams (g) of protein, 240 calories 15 g protein and 360 calories, 14 g protein respectively while Boost Glucose control provides 190 calories and 16 grams of protein. None of these products was recommended.

There was no documented justification for the selection of this product such as patient preference. Dietary Staff 1 failed to formulate an effective plan to encourage weight gain in the presence of poor intake. There were items listed as preferences/likes. There was no indication to provide these items when intake was poor. Dietary Staff 2 who provided oversight to Dietary Staff 1 was interviewed on the rationale behind the choice of supplements.

Documentation by Dietary Staff 1 included an error in the description of Patient 32. He was listed as a 55 year old, Patient 32 was younger than 55 years of age. The significance of this error is that according to the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council, the recommended caloric needs for the 51 to 70 year old male is lower for this age group than the 23 to 50 year old, the age group Patient 32 belongs to.

Although it was unclear why Patient 32 was placed on a Mechanical Soft diet, during trayline observation (a process where dietary staff prepares patient diet trays) on 11/12/14 at 12:05 PM, a tray with his name and room number was observed to have a ham and cheese sandwich cut in half. None of the staff in the kitchen including those who participated in tray line activities noticed that the tray labeled "chopped" had two half sandwiches. The FSD (Food service director) was interviewed on 11/12/14 at 12:15 PM on the appropriateness of a half sandwich on a chopped diet. He stated it was not appropriate and the sandwich should have been cut into smaller pieces.

The cart containing the food tray for Patient 32 had been sent to the patient floor. The cart with his tray was found in the hallway, the tray was retrieved before it could be passed to him. This error could have been a potential choking risk.

In an interview with hospital dietitian (RD 2) on 11/12/14 at 3:50 PM, in response to the lack of nutrition assessment calculation on nutrient needs, she stated that based on the training that had been provided to her by the previous RD, nutrient assessments are only completed on high risk patients such as those on tube feeding and TPN. According to the hospital policy and procedure titled "Patient Nutritional Assessment and Plan" with revision dated of 5/14, "Assessment calculations will be based on" Nutritional Needs by the American Dietetic Association. Review of a closed clinical record (Patient 33) did not support this assertion.

3. A closed record review showed Patient 33 was admitted with diagnoses including perforated viscus (abnormal opening in internal organ located in the large cavity of the trunk) which resulted in the removal of the colon (intestines) . His admitting order included TPN. Nursing assessment classified him as a "2" also had a Braden Score of 10 (high risk to develop pressure ulcer). A score of 2 or higher on the nutrition screening tool, Braden score of less than 16 were referred to the dietitian for nutrition consult.

Nutrition Screening and Assessment conducted by Dietary Staff 2 on 07/28/14 showed comments and no complete nutrition assessments with calculation of needs. Follow up notes by Dietary Staff 2 on 8/1/14 showed comments and no calculations to determine the adequacy of TPN order. Documented in the record was "will monitor for diet advancement" for both entries.

The 2011 ASPEN (American Society for Enteral and Parenteral Nutrition) clinical guidelines for nutrition screening, assessment, and intervention in adults are listed as follows: "Screening for nutrition risk is suggested for hospitalized patients. Nutrition assessment is suggested for all patients who are identified to be at nutrition risk by nutrition screening. Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished" The assessments conducted by the Dietary Staff 2 did not meet recognized dietary practices.

Interview with Dietary Staff 2 could not be conducted to determine why the nutritional calculations were not completed in the case of Patient 33. Dietary staff 2 failed to effectively assess the nutritional need of 3 of 3 patients.

Based on observation, review of hospital documents and staff interviews, the hospital failed to safely installed the eye wash station in the kitchen to prevent risk of scalding eyes during use by its staff. The eye wash station was installed in a manner that could result in the dispensing of hot water. This finding had the potential to result affect the safety of the dietary staff in need of using the eye wash station due to an emergency.

Finding:

During the tour of the kitchen on 11/12/14 at 8: 50 AM, two plastic caps were observed attached to the faucet of the hand wash sink. During hand washing, the faucet delivered hot water when the hot water foot lever was turned on.

The Food Service Director (FDS) stated on 11/12/14 at 8:52 AM, the mechanism was for the eye wash station was installed by Engineering. A test was conducted to determine whether the eye wash station would deliver hot water to eyes when activated. When the pin was pulled to activate the eye wash station, the hot water flowed when only the hot water foot pedal was pressed. The FSD stated cold water was better on the eyes and would hope the staff would use cold water. In response to whether dietary staff had been trained to ensure that the proper foot pedal was stepped on, he stated that he had not done any training and assumed that Engineering conducted a raining after installation. Interview with the Engineer on 11/14/14 at 10:00 AM revealed no training had been provided on the use of the eye wash station..

In a review of manufacturer's instructions of Faucet Mount Eyewash Station similar to the one observed at the facility states "To eliminate the risk of scalding eyes during use, it is recommended that hot water supply to the faucet be disconnected."

In the event, that facility staff turned on the hot water in an emergency, possibility exists that further eye damage could result. The facility failed to ensure that the eye wash station was correctly plumbed to ensure that water delivered to the eye wash station mechanism was safe for dietary staff.

Based on observation, interview and record review, the hospital failed to ensure that their system for Identifying Infection Control issues included:

1.Sterile supplies were stored in areas where it was difficult to assure sterility.

2.An anesthesia provider ' s personal bag was observed in O.R 2.

3.The circulator desk in O.R. 2 had a 4" by 5" area of corrosion.

4. Written policies that addressed steps to be taken when there are discrepancies between the manufacturer's instructions for items to be disinfected/sterilized and the disinfection/sterilization equipment.

5. Sanitizing its ice and soda machines per manufacturer's recommendations. The hospital did not have as part of the cleaning and equipment maintenance, the sanitizing step. Ice machines and improperly sanitized food contact surfaces could potentially harbor microorganisms that could result in food borne illness. Food borne illness in people with compromised immune system could result in longer hospital stays and even death.

These failures increased the risk of a poor health outcome for all facility patients.

Findings:

1. During an observation on November 10, 2014, at 9:45 AM, between O.R. 1 and O.R. 2, multiple sterile supplies were stored in open shelves near the surgical scrub sinks. During a concurrent interview, Staff 2 acknowledged the presence of the supplies and Staff 4 stated that the facility was in the process of moving the supplies to another location where sterility of the supplies can be assured.

During an observation on November 10, 2014, at 10:15 AM, in a surgical storage room, sterile supplies were seen stored next to clean non-sterile supplies. During a concurrent interview with Staff 2 and Staff 4, they both acknowledged this observation and agreed that the sterile supplies should be relocated to assure sterility.

The facility policy and procedure titled "Central Processing Surgery Services," dated 9/2014, indicated "Purpose: To outline proper storage of sterile supplies ...All storage areas will be clean, dry, protected from moisture, vermin or insect, etc ...All sterile wrapped items will be stored in the Central Processing sterile area, closed shelf/cabinet's in OR, or in draws as designated." "Sterile supplies will be separated from clean supplies: A clean non-sterile storage area shall be designated for this purpose ...Storage of sterile supplies will be done under conditions which tend to preserve, not threaten the integrity of the packaging. Traffic in storage areas will be kept to a minimum ...Sterile packages will not be placed next to or below any sink to avoid contamination."

The AORN (Association of peri-Operative Registered Nurses) Recommended Practices for Sterilization, 2013, Recommendation XV: "Sterilized materials should be labeled and stored in a manner to ensure sterility, and each item should be marked with the sterilization date. Limiting exposure to moisture, dust, excessive light or handling, and temperature and humidity extremes decreases potential contamination of sterilized items. Factors that contribute to contamination include air movement, humidity, temperature, location of storage, presence of vermin, whether shelving is open or closed, and properties of the packaging material."

2. During an observation on November 10, 2014, at 10:35 AM, in O.R. 2, a personal bag was observed next to the Anesthesia machine. During a concurrent interview with Staff 5, she stated that the Anesthesia provider brought the bag into the O.R. earlier that day.

The facility policy and procedure titled "Operating Room Attire," reviewed 4/2013, indicated "Fanny packs, briefcases, and backpacks that cannot be cleaned or laundered daily will not be brought into the peri-operative area."

3. During an observation on November 10, 2014, at 10:45 AM, in O.R. 2, the circulator fold-up desk was noted to have a four- inch by five- inch area of corrosion on the horizontal surface of the desk. During a concurrent interview, Staff 4 and Staff 5 confirmed the observation and agreed that the desk would be difficult to clean and should be repaired. During this interview Staff 5 stated that the facility follows AORN (Association of peri-Operative Registered Nurses) guidelines.

The AORN (Association of peri-Operative Registered Nurses) Standards and Recommended Practices, 2014, "Recommendation V. The integrity of structural surfaces (eg, doors, floors, walls, ceilings, cabinets) should be maintained, and surfaces can lead to an inability to clean ...V.a. Personnel should report damage to floors, walls, ceilings, cabinets and other structural surfaces according to the health care organization ' s policy. Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning."

4. During an interview with Staff 1, on November 14, 2014, at 1:20 PM, she stated that the facility did not have written policies and procedures that address steps to take when there are discrepancies between a device manufacturer's instructions and automated high-level disinfection equipment manufacturer's instruction for completing high-level disinfection. She also acknowledged that the facility did not have written policies and procedures to address steps to take when there are discrepancies between a device manufacturer's instructions and the sterilizer's manufacturer's instruction for completing sterilization.



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5. During an observation on November 13, 2014 at 9:53 AM, RN 1 was wiping a medication and patient identification barcode checking device with disinfectant wipes. The disinfectant was observed to begin drying within 30 seconds of being applied to the patient care device.


In a concurrent interview with RN 1, RN 1 was unable to state what the dwell time (the amount of time the disinfectant must stay wet on a device or surface to kill the germs) was for the disinfectant wipes she was using.


During a concurrent review of the disinfectant wipe manufacturer's label instructions, the instructions showed that the item to be disinfected must remain wet for 2 minutes.


6. During an observation of LVN 1 on November 13, 2014 at 3:05 PM, LVN 1 was wiping down a glucometer (a device for checking blood sugar levels) and the disinfectant was observed to begin drying within 30 seconds.


In a concurrent interview with LVN 1, LVN 1 stated that the dwell time for the disinfectant wipes she was using was 2 minutes. LVN 1 stated that she let the device dry for 2 minutes before she used it on another patient. The LVN indicated that she thought the 2 minutes meant that the disinfectant should dry for 2 minutes, instead of staying wet with the disinfectant for 2 minutes as indicated on the manufacturer's label instructions.



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7. An interview conducted on 11/14/14 at 9:45 AM, with the FSD (Food service director) on the maintenance of the ice machine. According to him, there were two ice machines in the dietary department and there was shared responsibility between dietary and engineering. He stated that dietary staff cleaned the exterior while engineering cleaned the interior components.

In an interview with the Engineering staff 1 (ES 1) on 11/14/14 at 10:30 AM, he explained the cleaning process for both machines but did not mention the sanitizing process recommended by the ice machine manufacturer. When asked about sanitizing process, he stated that they do not sanitize the machine. ES 1 stated that the ice machines were slightly over a year implying that the machines had not been sanitized in over a year.

Review of manufacturer's instructions for the ice machines showed that the ice machines should be cleaned and sanitized at a minimum of every six months, with a chlorine- based sanitizer. ES 1 indicated that the use of the chlorine -based sanitizer was a problem because as of two years earlier, the use of chlorine was no longer permitted with the hospital's waste management plant.

Observation of another ice machine located in a nourishment room showed that the ice machine was an older model possibly installed when the hospital was built about 38 years ago. He stated that he had never sanitized the machine and did not know where he would sanitize. He was unsure whether the manufacturer's instruction booklet for the ice machine was available. The hospital had a total of eight ice machines.

In a concurrent interview with the FSD, on the soda machine on cleaning and sanitizing of the machines, he stated that the hospital had a contract with the distributor of the product. He explained the cleaning of the exterior of the soda machines. Review of the manufacturer's cleaning instructions online document revealed that the plastic tubing that attaches to the syrup (syrup connectors) should be sanitized with a chlorine- based sanitizer weekly.

The hospital had failed to follow manufacturer's instructions on the cleaning of the ice machine and did not have a plan in place to ensure that the ice machines were properly sanitized. Ice machines and improperly sanitized food contact surfaces could potentially harbor microorganisms that could result in food borne illness. Food borne illness in people with compromised immune system could result in longer hospital stays and even death.

Based on interview and record review, the hospital failed to ensure, for 1 of 34 patients, (Patient 33) that a discharge planning evaluation and plan was present in the patient's medical record. This failure had the potential for the patient's care staff to be unaware of the need for a discharge plan for the patient's discharge that could result in the patient not receiving the care and services needed after discharge.

Findings:

A review of Patient 33's medical record was conducted on November 13, 2014. The face sheet shows that Patient 33 was admitted to the hospital on July 26, 2014 with a diagnosis of perforated viscus (a hole in the stomach or intestines).

A review of a document titled "ICU Reassessment" dated July 28, 2014, showed that the family was at the patient's bedside and "They als (all) spoke with (name of HMO case manager)."

There was no other documentation of a discharge evaluation in the patient's record.

In an interview with the Case Management Director (CM) on November 13, 2014 at 11:00 AM, CM stated that all patients get a discharge evaluation by the case management department. The (name of company) HMO (Health Maintenance Organization) has their own case managers that do their patients' evaluation. They cannot document in our medical records. They verbally tell the patient's nurse the result of the evaluation and the discharge plan.

A review of a policy and procedure titled "Interdisciplinary Discharge Planning" with a review date of March 2013, showed the following:

"Discharge Planning is a process by which a discharge planning assessment is made on the patient...There is communication with the patient, family, medical staff, nursing and other staff. The plan is implemented and there is follow up as necessary. Evidence for meeting the Criteria of this process will be documented in the medical record.

Communication of information about discharge planning arrangements either can be done verbally between team members or in writing, but permanent communication about the plan will be documented in the patient's medical record."

Based on interview and record review, 1.the final sponge and sharp counts were not documented in one of two open surgical charts reviewed and 2. Surgical procedures were performed while the O.R. humidity was out of range. These failures increased the risk of fire danger and a poor health outcome for all facility patients.

Findings:

1. During a review of the clinical record for Patient 5, the "Surgical Case Record," dated November 10, 2014, indicated "Count Type: "Sponges" and "Sharps" both were followed by a blank space where the count should have been recorded.

During an interview with Staff 2 and Staff 3, Staff 3 confirmed that the Sponges and Sharps counts were not performed for Patient 5's surgical procedure.

The facility policy and procedure titled "Surgical Counts," reviewed 4/2013, indicated "The items to be counted include: All radiopaque sponges ...All needles, regardless of size, All sharps ..."

2. During an interview with Staff 3, on November 17, 2014, at 2:25 PM, she reviewed the "Hi-Desert Medical Center SCH**LIVE**Daily Log," dated 11/17/2014, which indicated that three surgeries were performed in the O.R. on November 5, 2014. She also reviewed the "TempTrak Sensor History" graph for 11/5/2014, which indicated that the humidity fell below the recommended AORN (Association of peri-Operative Registered Nurses) guideline of 20-60% and remained below this range for the entire day. Review of the "TempTrak Sensor History" tabulation of humidity readings for 11/5/2014, during the times surgery was performed in the O.R., confirmed that the O.R. humidity ranged between 14.4 and 17.9%. Staff 3 acknowledged the increased fire danger while the O.R. humidity was below 20%.

The facility policy and procedure titled "Temperature and Humidity," revised 4/2013, indicated "Humidity and temperature in the operating room is important for the comfort and safety of the surgical patient and staff ...The purpose of this policy is to ensure the proper response to temperature and humidity outside the parameters addressed in "Temperature & Humidity in the Surgical Environment Policy." "In the event of a Humidity reading which does not fall between the acceptable levels of 20% to 60%, Temp trak will alarm at appropriate computers ...Out of range readings for humidity or temperature will be addressed accessing the temperature track notification system. RN will document the acknowledgment and action taken ...The Director of Surgical Services & Surgical team will take appropriate action that may include canceling or delaying surgical procedures."

Based on observation, review of clinical records, hospital documents and staff interviews, the hospital failed to ensure that the person in the position of dietitian adequately supervised the nutritional aspects of patient care. Three of three records (Patients 31, 32 and 33) reviewed showed incorrect, incomplete assessments and/or dietary interventions. The hospital dietitian failed to provide adequate oversight of a dietetic intern who had been allowed to provide assessments and dietary interventions.

Findings:

1. Patient 31 was admitted to the hospital with diagnoses including asthma and pancreatitis. Pancreatitis (acute) is a disease of the pancreas characterized by sudden and severe abdominal pain, nausea, vomiting and diarrhea. Review of physician orders dated 11/10/14 showed a diet order was "Clear Liquid" with modifications of diabetic fluids (liquids without sugar).

Review of clinical record showed that Patient 31 was interviewed by Dietary staff 1 (a dietetic intern) on 11/11/14. Her admission height was 5' 8" and documented weight of 258 lbs. Her diet order changed during the hospital stay from NPO on day of admission to clear liquids with diabetic liquids by the second day of admission.

Dietary Staff 1 documented in the Patient Assessment: Nutrition Screening Assessment a nutrition diagnosis of "inadequate po (oral) intake r/t (related) to pancreatitis aeb ( as evidenced by)po intake of 0%". Additional information on the document indicated that she was not on tube feeding or TPN (Total Parenteral Nutrition).The diet order recommendation was "continue diet as ordered-receiving supplement with clear liquid diet". There was no assessment of her nutritional needs including calories, protein and fluids. Documentation did not include whether the diet ordered would meet her nutritional needs if she consumed 100% of the diet ordered.

A review of the hospital's diet manual provided during the entrance conference showed that a Clear Liquid Diet would provide would provide approximately 800 to 1000 calories and was "inadequate in all nutrients". However, with modifications of diabetic liquid, the diet would provide less than 700 calories per day. This low intake of calories would not be sufficient to meet the daily caloric needs of a patient who is 5' 8" tall. The estimated needs of a female 5' 8" tall using the Ireton-Jones calculation (a nutritional calculation that shows calorie requirments based on a persons weight and height) is approximately 1900 calories per day. No recommendation was made to the physician by the dietitian regarding the non-necessity of an additional diabetic restriction with such a diet that was low in calories and that total carbohydrate in was more important.

The current treatment for diabetes according to the American Diabetes Association (ADA) 2014 Standards of Medical Care in Diabetes is that total carbohydrate was more important than low or same calorie items. The ADA states "While substituting sucrose (sugar)-containing foods for isocaloric (similar caloric value) amounts of other carbohydrates, (it) may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices."

Patient 31's diet was changed to NPO (nothing by mouth) on 11/12/14 and was transferred to the Intensive Care Unit. On 11/13/14, five days after admission, a new order for intravenous solution that included dextrose (a form of sugar found in fruits and plants) was added. This order provided approximately 510 calories in 24 hours. "Solutions containing carbohydrate in the form of dextrose restore blood glucose levels and provide calories. Carbohydrate in the form of dextrose may aid in minimizing liver glycogen (main form in which glucose is stored in tissues and liver) depletion and exerts a protein-sparing action".

According to review of medical literature and nutrition text books, prolonged fasting or failure to use the gastrointestinal tract can exacerbate (worsen) metabolic changes that may complicate recovery. The guidelines from ASPEN (American Society for Enteral and Parenteral Nutrition) and ACG (American College of Gastroenterology) for severe pancreatitis are the use of enteral feeding after five days of NPO. No recommendation for progression towards use of enteral feeding was made in the record.

2. Patient 32 was admitted with diagnoses including seizures (abnormal state in which the body moves in an uncontrollable and violent way) and urinary tract infection. His admission height was 65 inches and weight was 115 pounds. He was placed on a mechanical soft diet on admission. Review of the Patient Assessment Form under the heading Nutrition, indicated Patient 32 did not have difficulties with Chewing/swallowing.

Further review of clinical record showed Patient 32 had a BMI (Body Mass Index) of 15.8 (Normal/healthy range is 18.5 to 24.99.) and was underweight, consuming 0% of his meals per nurse (RN 30). Body Mass Index, is an evaluation of how an individual body departs from what is normal for a person his or her height.) Patient 32 had triggered (for nutrition assessment) according to the hospital policy for nutritional risk for BMI less than 19, low albumin (blood protein) and poor intake result. Patient 32 had met the threshold of high nutritional risk with three areas of concern with a referral to the registered dietitian for consultation. There was no calculation of nutrient needs or indication that the current nutrition plan would meet Patient 32's needs. Dietary Staff 1 recommended Boost Glucose control for Patient 32.

The manufacturer's information for Boost Glucose Control describes it as "a balanced nutritional drink formulated for people with diabetes. "There was no documented evidence that Patient 32 had diabetes or had elevated blood sugars to justify the diabetic nutritional supplement. There was no documented justification for the selection of this product such as patient preference.

Documentation by Dietary Staff 1 included an error in the description of Patient 32. He was listed as a 55 year old, Patient 32 was younger than 55 years of age. The significance of this error is that according to the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council, the recommended caloric needs for the 51 to 70 year old male is lower for this age group than the 23 to 50 year old; the age group Patient 32 belongs to.

All of the assessments completed by Dietary Staff 1 had been cosigned by Dietary Staff2 attesting to its accuracy and appropriateness.

3. A review of clinical record for Patient 33 conducted by Dietary staff 2 showed the same lack of complete nutrition assessment for the patient who was receiving TPN (Total Parenteral Nutrition-feeding the patient through the vein). The 2011 ASPEN (American Society for Enteral and Parenteral Nutrition) clinical guidelines for nutrition screening, assessment, and intervention in adults are listed as follows: "Screening for nutrition risk is suggested for hospitalized patients. Nutrition assessment is suggested for all patients who are identified to be at nutrition risk by nutrition screening. Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished" The assessments conducted by the Dietary Staff 2 did not meet recognized dietary practices.

In an interview with hospital dietitian, Dietary Staff 2 (DS 2) on 11/12/14 at 3:50 pm, in response to the lack of nutrition assessment calculation on nutrient needs, DS 2 stated that based on the training that had been provided to her by the previous RD (registered dietitian, nutrient assessments are only completed on high risk patients such as those on " tube feeding, TPN and high risk (malnutrition) " . According to the hospital policy and procedure titled " Patient Nutritional Assessment and Plan " with revision dated of 5/14, " Assessment calculations will be based on " Nutritional Needs by the American Dietetic Association " . None of the assessments reviewed had assessment calculations.

A review of personnel records for Dietary Staf

Based on review of clinical records, facility documents and staff interviews, the hospital failed to ensure that the nutritional needs of three of three sampled patients (Patients 31, 32 and 33) were in accordance with recognized dietary practices. All three patients were either not assessed, improperly assessed or executed dietary interventions that were flawed.

Findings:

Patient 31 was admitted to the hospital with diagnoses including asthma and pancreatitis. Pancreatitis (acute) is a disease of the pancreas characterized by sudden and severe abdominal pain, nausea, vomiting and diarrhea. Review of physician orders dated 11/10/14 showed the diet order was "Clear Liquid" with modifications of diabetic fluids (liquids without sugar).

In a review of the clinical record showed that Patient 31 was interviewed by Dietary staff 1 on 11/11/14 in which she stated that she had no appetite and was unsure of her usual body weight. Dietary Staff 1 documented in the Patient Assessment: Nutrition Screening Assessment a nutrition diagnosis of "inadequate po (oral) intake r/t (related) to pancreatitis ... and po intake of 0%". Additional information the document indicated that she was not on tube feeding (nutritional feeding through a tube passing through the nose) or TPN (Total Parenteral Nutrition). The diet order recommendation was "continue diet as ordered-receiving supplement with clear liquid diet". There was no assessment of her nutritional needs including calories, protein and fluids. Documentation did not include whether the diet ordered would meet her nutritional needs if she consumed 100% of the diet ordered.

In a review of the hospital's diet manual provided during the entrance conference showed that a Clear Liquid Diet would provide the following items three meals a day: Broth, Jello-O, Popsicle, Orange, Cranberry, Apple or Orange Juice, Sugar (2 (tsp)) Boost Breeze, coffee or tea. This diet would provide approximately 800 to 1000 calories and inadequate in all nutrients. However, with modifications of diabetic liquid, the diet would provide less than 700 calories per day. This low intake of calories would not be sufficient to meet the daily caloric needs of a patient who is 5' 8" tall. The estimated needs of a female 5' 8" tall using the Ireton-Jones Calculation (a nutritional calculation or required calories according to ones weight and height) is approximately 1900 calories per day.

Some of the many complications from acute pancreatitis are high blood sugar or diabetes, malnutrition, kidney failure etc. There was no evidence of the risk -benefit analysis in the choice to provide Patient 31 with a diabetic modification in the presence of inadequate calories. No recommendation was made to the physician regarding the possible risk and inadequacy of calories with the diet as ordered.

Patient 31's diet was changed to NPO (nothing by mouth) on 11/12/14 and was transferred to the Intensive Care Unit. On 11/13/14, five days after admission, a new order for intravenous solution that included dextrose (sugar) was added. This order provided approximately 510 calories in 24 hours. "Solutions containing carbohydrate (starch and sugar in food) in the form of dextrose restore blood glucose levels (blood sugar levels) and provide calories. Carbohydrate in the form of dextrose may aid in minimizing liver glycogen (stored sugar in the liver) depletion and exerts a protein-sparing action (makes the body save protein)".

According to review of medical literature and nutrition text books, prolonged fasting or failure to use the gastrointestinal tract (digestive tract) can exacerbate (worsen) metabolic (how the body uses fuel for energy) changes that may complicate recovery. The guidelines from ASPEN (American Society for Enteral and Parenteral Nutrition) and ACG (American College of Gastroenterology) for severe pancreatitis are the use of enteral feeding after five days of NPO. No recommendation for progression towards use of enteral feeding (feeding through a tube) .

2. Patient 32 was admitted with diagnoses including seizures and urinary tract infection. His admission height was 65 inches and weight was 115 pounds. He was placed on a mechanical soft diet (diet that is easy to chew) on admission. Review of the Patient Assessment Form under the heading Nutrition, indicated Patient 32 did not have difficulties with Chewing/swallowing.

Further review of the clinical record showed Dietary Staff 1 documented in the Patient Assessment that his BMI (Body Mass Index) was 15.8 (Normal/healthy range is 18.5 to 24.99.) Body Mass Index, is an evaluation of how an individual body departs from what is normal for a person his or her height.) Patient 32 had triggered (for nutrition assessment) according to the hospital policy for nutritional risk for BMI less than 19. Documentation also showed that Patient 32's usual weight was 130 pounds indicating a 15 pound weight loss. (Review of closed record indicated this was within two weeks.) He also had a Blood Albumin of 1.5 (Normal value 3.5 to 5.5), albumin is an indicator of malnutrition.

Dietary Staff 1 documented in her comments that Patient 32 was underweight and consuming 0% per nurse (RN 30). She recommended nutrition supplement three times per day "per patient request". There was no calculation of nutrient needs or indication that the current nutrition plan would meet Patient 32's needs. Further review showed that she recommended Boost Glucose control for Patient 32.

The manufacturer's information for Boost Glucose Control describes it as "a balanced nutritional drink formulated for people with diabetes." There was no documented evidence that Patient 32 had diabetes or had elevated blood sugars to justify the diabetic nutritional supplement. The manufacturer had other products that were formulated for people with variety of health and nutrition needs: Boost Original, Boost High Protein and Boost Plus. These products provide 240 calories 10 grams (g) of protein, 240 calories 15 g protein and 360 calories, 14 g protein respectively while Boost Glucose control provides 190 calories and 16 grams of protein. None of these products was recommended.

There was no documented justification for the selection of this product such as patient preference. Dietary Staff 1 failed to formulate an effective plan to encourage weight gain in the presence of poor intake. There were items listed as preferences/likes. There was no indication to provide these items when intake was poor. Dietary Staff 2 who provided oversight to Dietary Staff 1 was interviewed on the rationale behind the choice of supplements.

Documentation by Dietary Staff 1 included an error in the description of Patient 32. He was listed as a 55 year old, Patient 32 was younger than 55 years of age. The significance of this error is that according to the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council, the recommended caloric needs for the 51 to 70 year old male is lower for this age group than the 23 to 50 year old, the age group Patient 32 belongs to.

Although it was unclear why Patient 32 was placed on a Mechanical Soft diet, during trayline observation (a process where dietary staff prepares patient diet trays) on 11/12/14 at 12:05 PM, a tray with his name and room number was observed to have a ham and cheese sandwich cut in half. None of the staff in the kitchen including those who participated in tray line activities noticed that the tray labeled "chopped" had two half sandwiches. The FSD (Food service director) was interviewed on 11/12/14 at 12:15 PM on the appropriateness of a half sandwich on a chopped diet. He stated it was not appropriate and the sandwich should have been cut into smaller pieces.

The cart containing the food tray for Patient 32 had been sent to the patient floor. The cart with his tray was found in the hallway, the tray was retrieved before it could be passed to him. This error could have been a potential choking risk.

In an interview with hospital dietitian (RD 2) on 11/12/14 at 3:50 PM, in response to the lack of nutrition assessment calculation on nutrient needs, she sta

Based on observation, interview and record review, the hospital failed to ensure that their system for Identifying Infection Control issues included:

1.Sterile supplies were stored in areas where it was difficult to assure sterility.

2.An anesthesia provider ' s personal bag was observed in O.R 2.

3.The circulator desk in O.R. 2 had a 4" by 5" area of corrosion.

4. Written policies that addressed steps to be taken when there are discrepancies between the manufacturer's instructions for items to be disinfected/sterilized and the disinfection/sterilization equipment.

5. Sanitizing its ice and soda machines per manufacturer's recommendations. The hospital did not have as part of the cleaning and equipment maintenance, the sanitizing step. Ice machines and improperly sanitized food contact surfaces could potentially harbor microorganisms that could result in food borne illness. Food borne illness in people with compromised immune system could result in longer hospital stays and even death.

These failures increased the risk of a poor health outcome for all facility patients.

Findings:

1. During an observation on November 10, 2014, at 9:45 AM, between O.R. 1 and O.R. 2, multiple sterile supplies were stored in open shelves near the surgical scrub sinks. During a concurrent interview, Staff 2 acknowledged the presence of the supplies and Staff 4 stated that the facility was in the process of moving the supplies to another location where sterility of the supplies can be assured.

During an observation on November 10, 2014, at 10:15 AM, in a surgical storage room, sterile supplies were seen stored next to clean non-sterile supplies. During a concurrent interview with Staff 2 and Staff 4, they both acknowledged this observation and agreed that the sterile supplies should be relocated to assure sterility.

The facility policy and procedure titled "Central Processing Surgery Services," dated 9/2014, indicated "Purpose: To outline proper storage of sterile supplies ...All storage areas will be clean, dry, protected from moisture, vermin or insect, etc ...All sterile wrapped items will be stored in the Central Processing sterile area, closed shelf/cabinet's in OR, or in draws as designated." "Sterile supplies will be separated from clean supplies: A clean non-sterile storage area shall be designated for this purpose ...Storage of sterile supplies will be done under conditions which tend to preserve, not threaten the integrity of the packaging. Traffic in storage areas will be kept to a minimum ...Sterile packages will not be placed next to or below any sink to avoid contamination."

The AORN (Association of peri-Operative Registered Nurses) Recommended Practices for Sterilization, 2013, Recommendation XV: "Sterilized materials should be labeled and stored in a manner to ensure sterility, and each item should be marked with the sterilization date. Limiting exposure to moisture, dust, excessive light or handling, and temperature and humidity extremes decreases potential contamination of sterilized items. Factors that contribute to contamination include air movement, humidity, temperature, location of storage, presence of vermin, whether shelving is open or closed, and properties of the packaging material."

2. During an observation on November 10, 2014, at 10:35 AM, in O.R. 2, a personal bag was observed next to the Anesthesia machine. During a concurrent interview with Staff 5, she stated that the Anesthesia provider brought the bag into the O.R. earlier that day.

The facility policy and procedure titled "Operating Room Attire," reviewed 4/2013, indicated "Fanny packs, briefcases, and backpacks that cannot be cleaned or laundered daily will not be brought into the peri-operative area."

3. During an observation on November 10, 2014, at 10:45 AM, in O.R. 2, the circulator fold-up desk was noted to have a four- inch by five- inch area of corrosion on the horizontal surface of the desk. During a concurrent interview, Staff 4 and Staff 5 confirmed the observation and agreed that the desk would be difficult to clean and should be repaired. During this interview Staff 5 stated that the facility follows AORN (Association of peri-Operative Registered Nurses) guidelines.

The AORN (Association of peri-Operative Registered Nurses) Standards and Recommended Practices, 2014, "Recommendation V. The integrity of structural surfaces (eg, doors, floors, walls, ceilings, cabinets) should be maintained, and surfaces can lead to an inability to clean ...V.a. Personnel should report damage to floors, walls, ceilings, cabinets and other structural surfaces according to the health care organization ' s policy. Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning."

4. During an interview with Staff 1, on November 14, 2014, at 1:20 PM, she stated that the facility did not have written policies and procedures that address steps to take when there are discrepancies between a device manufacturer's instructions and automated high-level disinfection equipment manufacturer's instruction for completing high-level disinfection. She also acknowledged that the facility did not have written policies and procedures to address steps to take when there are discrepancies between a device manufacturer's instructions and the sterilizer's manufacturer's instruction for completing sterilization.



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5. During an observation on November 13, 2014 at 9:53 AM, RN 1 was wiping a medication and patient identification barcode checking device with disinfectant wipes. The disinfectant was observed to begin drying within 30 seconds of being applied to the patient care device.


In a concurrent interview with RN 1, RN 1 was unable to state what the dwell time (the amount of time the disinfectant must stay wet on a device or surface to kill the germs) was for the disinfectant wipes she was using.


During a concurrent review of the disinfectant wipe manufacturer's label instructions, the instructions showed that the item to be disinfected must remain wet for 2 minutes.


6. During an observation of LVN 1 on November 13, 2014 at 3:05 PM, LVN 1 was wiping down a glucometer (a device for checking blood sugar levels) and the disinfectant was observed to begin drying within 30 seconds.


In a concurrent interview with LVN 1, LVN 1 stated that the dwell time for the disinfectant wipes she was using was 2 minutes. LVN 1 stated that she let the device dry for 2 minutes before she used it on another patient. The LVN indicated that she thought the 2 minutes meant that the disinfectant should dry for 2 minutes, instead of staying wet with the disinfectant for 2 minutes as indicated on the manufacturer's label instructions.



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7. An interview conducted on 11/14/14 at 9:45 AM, with the FSD (Food service director) on the maintenance of the ice machine. According to him, there were two ice machines in the dietary department and there was shared responsibility between dietary and engineering. He stated that dietary staff cleaned the exterior while engineering cleaned the interior components.

In an interview with the Engineering staff 1 (ES 1) on 11/14/14 at 10:30 AM, he explained the cleaning process for both machines but did not mention the sanitizing process recommended by the ice machine manufacturer. When asked about sanitizing process, he stated that they do not sanitize the machine. ES 1 stated that the ice machines were slightly over a year implying that the machines had not been sanitized in over a year.

Review of manufacturer's instructions for the ice machines showed that the ice machines should be cleaned and sanitized at a minimum of every six months, with a chlorine- based sanitizer. ES 1 indicated that the use of the chlorine -based sanitizer was a problem because as of two years earlier, the use of chlorine was no longer permitted with the hospital's waste management plant.

Observation of another ice machine located in a nourishment room showed that the ice machine was an older model possibly installed when the hospital was built about 38 years ago. He stated that he had never sanitiz