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Based on medical record review and interview with nursing and dietary staff, the facility failed to ensure that documentation of fluid intake and protein supplement intake reflected following physician's orders for two (#12, 28) of thirty sampled patients, putting those patients at risk for negative outcomes when either fluid or protein intake wasn't monitored.
Findings include:
1. Patient # 12 was admitted to the facility on 02/24/11 with Hepatic Encephalopathy per the admitting notes located in the patient's medical record. A physician's order, dated 02/25/11 with the time at 1530 (3:30 p.m.), was noted for "1 liter day po (by mouth) fluid restriction."
Review of the Vital Signs and I & O (Intake & Output) Worksheet for 02/25/11 revealed entries documenting the "Oral/PO" input which had been totaled for the first twelve hours equaling 375 (mls). The next twelve hours intake, not totaled per the Worksheet directions "Please total every 4 hours," but documented a total of 1135 mls. The 24 hour total for 02/25/11 was 1510 cc, 510 cc more than the physician's order for 1000 mls.
Review of the same worksheet for 02/26/11 revealed the patient had a total intake of 870 mls. Review of the same worksheet for 02/27/11 revealed the patient had a total intake of 1320 mls, 320 mls more than the physician's order for 1000 mls.
Interview with the patient's nurse, on 02/28/11 at 1:30 p.m. confirmed that the physician's order for one liter a day had not been followed.
2. Patient #28 had been admitted on 02/16/11 with multiple decubitus ulcers, per the Emergency Department admitting documents located in the patient's medical record. Review of the History and Physical, dated 02/17/11 , revealed discussion of the multiple decubitus and an albumin at 1.9 mg ( normal = 3.5 - 5.0 mg). The plan included "enhance protein in the diet." A physician's order was noted, dated 02/18/11, for promod powder BID (protein powder twice a day). Interview with the Registered Dietitian(RD), on 03/02/11 beginning at 1:30 p.m. revealed that orders for protein powder supplements were filled by the dietary department. The RD reported that the powder would be mixed into a food, such as applesauce, and delivered to the patient on the meal tray. The patient's intake of the supplement would be documented by the nurse.

Review of the documentation of the percentage of meals eaten revealed three columns - breakfast, lunch, dinner, and snack. Only a number was documented in the columns and there was no specific listing of the physician's ordered protein powder. The RD reported during the interview and while looking at the document, that the intake of the protein powder was probably the number listed in the snack column, even though the order for the protein powder was for twice daily.

Documentation for the period from 02/19/11 through 02/28/11 revealed only 24 entries out of the 40 opportunities to document percentage eaten of three meals and a snack had occurred. The 'snack' column, identified as the documentation of the protein powder contained four entries for the 10 day period.
Review of the Medication Administration Record did not reveal a listing for the physician ordered protein powder allowing documentation by the nurse that the patient had taken the protein supplement.

Based on clinical record review, review of facility policy and staff interview it was determined the facility failed to obtain a properly executed informed surgical consent for 1 (#29) of 30 sampled patients, prior to the patient receiving surgery.
Findings include:
A review of the clinical record for patient #29 revealed a surgical consent for "Bilateral total knee replacement" was signed and witnessed on 12/21/10. A review of the Physician's admission orders dated for 2/8/11 at 2:30 p.m. revealed an order to obtain an Operative permit for "Bilateral total Knee Replacement." Further review of the Physician's orders revealed the date of admission listed as 3/1/11 and the date of surgery was listed for 3/1/11. A review of the electronic surgical checklist revealed the surgical consent was written, signed and completed.
A telephone interview was conducted with the surgical director 3/2/11 at approximately 1:30 p.m. to verify when the surgery consent is obtained. The Director responded that surgery usually gets the consent signed the day of surgery and sometimes the patients will sign consent at the Physicians office prior to arrival.
An interview was conducted with the Director of the Surgery Intensive Care Unit (SICU) on 3/2/11. After she reviewed the clinical record, she confirmed the findings.
A review of the facility policy, "Informed Consent Policy", policy # ADMIN.09/RI-7, approved 4/28/09 revealed on page 8 of 9, section VII. (A.) Informed consent should be discussed sufficiently prior to proposed treatment of procedure to provide the patient with adequate time to deliberate, but not more than 30 days. (D) A new consent is required in all circumstances in which the consent is more than 30 days old. On page 9 of 9, section VIIII, (B) Nursing Personnel- Prior to the beginning of any procedure where written informed consent is required, the nurse must verify that the consent form has been appropriately completed, signed and witnessed.

Based on observation, review of facility policies, and interview with Dietary staff, the facility failed to ensure that facility policies were followed, putting patients at risk for possible food borne illness, physical contamination , and potentially receiving the wrong meal tray.
Findings include:
1. During the tour of the main kitchen, beginning on 02/28/11 at 10:00 a.m., the following concerns were noted:
a-Dishwashing /Warewashing Machine Temperature Logs, one for each meal, were posted on the outside wall of the dish machine room. There were no temperatures documented for the dish machine on 02/28/11, even though dishes from breakfast were being washed.
The log for documenting temperatures for washing the lunch dishes, documented throughout February at 1:00 p.m., had as the last entry on the log the pre wash temperature on 02/27/11. The other two temperatures that were to be logged were the wash and final rinse temperature which had not been logged on 02/27/11.
The log for documenting temperatures for washing the dinner dishes had as the last entry temperatures logged on 02/25/11. There had been no temperatures logged at 6:00 p.m. for the 26th or the 27th of February.
Review of the policy entitled, "Dishmachine Temperature Checks" (Policy # 800.11/F-20 effective 1/11), revealed the statement: "Dishmachine temperature is monitored to assure that dishes are cleaned and sanitized." The procedure included: "Temperature checks on the dishmachine are completed twice daily - A.M. and P.M. - and documented on log by supervisor on duty." The temperature log attached to the policy indicated areas for three documentation times - Breakfast, Lunch, and Dinner - which was a different log than the one that was currently in use and did not represent the procedure outlined in the policy.
Interview with the Dietary Director on 02/28/11 beginning at 10:15 a.m. confirmed that temperatures were to be logged prior to running the dish machine after each meal.
b- Observation of the shelving racks inside the reach in refrigerator located in the cold preparation area , on 02/28/11 at 10:15 a.m., revealed the plastic coating had worn off of the edges of the racks, potentially allowing plastic bits to break off into food items. Without the plastic coating, the rack edges presented with a surface that was difficult to keep clean and provided a rusty surface, also a potential contaminant.
The shelving in the walk in produce refrigerator, observed on 02/28/11 at 10:25 a.m., was observed to be soiled with a wet, black substance on the edges of the racks, which was easily wiped away.
Both refrigerator shelving racks were observed with the Department Director.
c-A dietary aide was observed, on 02/28/11 beginning at 10:15 a.m., finishing the task of cutting and plating slices of cheesecake in the nourishment/catering area. This aide had on plastic gloves (with a knife glove under the plastic glove on the right hand) and was observed placing a knife into a pitcher filled with water. This aide was then observed to walk away from her station and within a few minutes returned to the area, still with gloves on, go into the produce cooler, exit with a plastic container of strawberries, obtain a metal sieve from a rack of clean equipment, and go to the sink to rinse the strawberries. This aide was questioned about what she was doing and when it would be appropriate to change her gloves. She reported that she was going to change her gloves after she rinsed the strawberries. The Department Director, at that same time, asked the aide to remove the gloves and wash her hands. The Director then reported that dietary staff are trained to change gloves after finishing a task and when they leave their preparation area to obtain other food items or equipment.
2- Observation of the nonperishable food supply adequate for seven days, with the Department Director and Clinical Nutrition Manager on 03/02/11 beginning at 11:10 a.m., revealed the supply was based on the average hospital census. The average census was reported to be 220, which would indicate 21 cases of #10 cans of protein foods should be available. There were 12.5 cases of #10 cans, plus one case of tuna, two cases of pc (personal consumption) peanut butter and 5 cases of dried beans available as nonperishable protein sources, which would not equal the 21 cases required. Review of the planned menu did not reveal several items included on the menu that were available in the dry storage area.
Fruits and vegetables required for the seven day non perishable food supply were calculated at 42 cases of #10 cans for the average census. Approximately 20 cases were observed in the nonperishable food supply.
The only dairy products in the nonperishable food supply were cases of thickened milk.
Review of the department's policy for service during emergency listed the state requirement to maintain a 7-day supply of nonperishable foods.
3- Observation of the procedure of passing meal trays, on the Oncology unit, on 03/01/11 beginning at 11:30 a.m., revealed out of the five meal trays passed by a dietary aide to five patients, neither of the two identifiers (patient's name and date of birth) were requested from the patient prior to the presentation of the meal tray. Review of the policy for passing meal trays (Tray Distribution and Retrieval, policy # 800.11/B-9, effective 1/11) revealed point # 4 "The aide delivering the tray should hold it so the entrée side will face the patient, and assure the patient's name is the same as that on the menu card. The second identifier check patients date of birth."
Interview with the aide passing the meal trays, on 03/01/11 at approximately 12:00 p.m., confirmed that the aide was aware of the procedure to ask for the two identifiers, said that she knew the patients, and confirmed that she had forgotten to ask the birth dates.

Based on clinical record review, facility document review and staff interviews, it was determined the facility failed to obtain a properly executed informed consent form prior to the operation of 1 (#29) of 30 sampled patients reviewed.
Evidenced by:
A review of the clinical record for patient #29 revealed a surgical consent for "Bilateral total knee replacement" was signed and witnessed on 12/21/10. A review of the Physician's admission orders dated for 2/8/11 at 2:30 p.m. revealed an order to obtain an Operative permit for "Bilateral total Knee Replacement." Further review of the Physician's orders revealed the date of admission listed as 3/1/11 and the date of surgery was listed for 3/1/11. A review of the electronic surgical checklist revealed the surgical consent was written, signed and completed.
A telephone interview was conducted with the surgical director 3/2/11 at approximately 1:30 p.m. to verify when the surgery consent is obtained. The Director responded that surgery usually gets the consent signed the day of surgery and sometimes the patients will sign consent at the Physicians office prior to arrival.
An interview was conducted with the Director of the Surgery Intensive Care Unit (SICU) on 3/2/11. After she reviewed the clinical record, she confirmed the findings.
A review of the facility policy, "Informed Consent Policy", policy # ADMIN.09/RI-7, approved 4/28/09 revealed on page 8 of 9, section VII. (A.) Informed consent should be discussed sufficiently prior to proposed treatment of procedure to provide the patient with adequate time to deliberate, but not more than 30 days. (D) A new consent is required in all circumstances in which the consent is more than 30 days old. On page 9 of 9, section VIIII, (B) Nursing Personnel- Prior to the beginning of any procedure where written informed consent is required, the nurse must verify that the consent form has been appropriately completed, signed and witnessed.

Based on observations and staff interview it was determined the facility did not have the minimum required equipment (Cardiac defibrillators with synchronization capability) in each of the facility's operating room suites.
Findings include:
A tour was conducted on 3/1/11 at 10:30 a.m. of the Surgical Areas, accompanied by the Director of Surgery. During the Tour of the (7) Operating Room (OR) suites it was observed there were no Cardiac Defibrillators kept in the OR suites. When the Director of Surgery was asked where the "Code Carts" were kept at, she pointed out the (3) Code carts kept on the unit. This surveyor questioned the Director how the defibrillators are obtained when the patient codes in the OR. The Director responded the staff would have to retrieve it from the hall or just call out to have it brought into the room.