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Based on observation, staff interview and review of dietary policy and procedures, the Food Service Director did not ensure that the daily operation of the food service department is maintained in a sanitary manner.

Findings include:

A tour of the hospital kitchen was conducted on 1/27/14 at approximately 11:00 AM. The surveyor was accompanied by staff #2. The following issues observed included, but are not limited to, the following:

A. Unsanitary Environment/ Food Safety

1- Garbage cans in the kitchen were uncovered.
2- Plastic container with condiment had been open yet not labeled when they were opened and when they would expire.
3- Small freezer in the back of the kitchen had food items wrapped in saran wrap which were not dated as to the date they were wrapped in the saran wrap. These food items were waffles, 2- packages of cheese pizza, veggie burgers etc.
4- Four large ceiling tiles above the door entering the cafeteria were detached one from the other and held with tape.
5- Plastic wrap was observed to be taped to the top of the door leading to the cafeteria.
6- Seven infant dry formula containers had been open yet not dated.
7- Eye washing sink was dusty and did not have a sign as to how to use this sink.
8- Vegetable freezer had open bags of peas and carrots and string beans with no label.
9- A chunk of Swiss cheese was wrapped in saran wrap yet had not been labeled.
10- Meat freezer had four beef roast that had been cut in half and wrapped in saran wrap but were not labeled.
11- Twenty seven brown floor tiles were missing in front of the freezer.
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Based on medical record review, staff interview and other documents, it was determined that the facility 's policy failed to promote the health and safety of patients to ensure positive outcomes.

This was noted in 7 of 12 concurrent medical records reviewed.

MR#6, MR#20, MR#51, MR#52, MR#53, MR#54, NR#55

Findings include:

1. An interview was conducted with Staff #3 on 1/28/14 at approximately 11 a.m. to discuss Clinical Nutrition Policies on Nutrition Assessment, Reassessment and Calorie Count. Staff #3 informed the surveyor that patients identified at high nutritional risk are reassessed every 14 days. The patients identified moderate nutritional risk, are reassessed every 28 days.

On 1/28/14 at 1 p.m., an interview was conducted with Staff #4. During the interview, patients with pressure ulcers and lengthy timeframe's for nutritional reassessments was discussed. Staff #4 informed the surveyor that he and the facility's wound team are "Nutritionists" and can perform calorie counts without the need of a dietitian.

2. The Hospital's Policy on Nutrition Screen and Nutrition Assessment were reviewed on 1/27/14. The policy titled PE802 Nutrition Care Process, Nutrition Assessment and Reassessment Inpatients did not mention or address the issue of patients with Pressure Ulcers.

3. Based on medical record reviews the following issues were noted: weight loss and pressure ulcers and a lack of nutritional intervention.

Patients who that had weight loss during their hospital stay:

A review of MR#51 revealed that this 13 year old male was admitted on 12/23/13 with a diagnosis of autistic disorder. The patient was admitted for comprehensive rehabilitation. At the time of admission the patient weighed 72.6 kg and order for a Regular diet. An initial nutritional assessment was done on 12/24/13 and the patient was identified at moderate nutritional risk. A nutritional reassessment was done on 1/21/14,
and this patient was classified at moderate nutritional risk. On 1/21/14 the patient's weight was 65.7 kg. This reflected a weight loss of 6.9 kg. This was reweighed on 1/24/14, and the recorded weight was 66.8 kg. (positive for weight loss).

According to the facility's policy on nutritional reassessment, reassessment occurs every 28 days.

A review of MR#20 was a 10 month old male admitted on 12/6/13 with perinatal respiratory distress and failure to thrive. On admission, the patient's weight was 5.075 kg and height was 63 cm. At the time of admission, the diet orders were Neosure 22 calories/per ounce nectar thickened feed P.O. at lib. 12/6/13 the physicians goal is the patient will gain 15-20 gms per day.

On 12/7/13 a calorie count was ordered and the diet was changed to 22 calories per ounce nectar thick liquids P.O. feed ad lib...1 tbs. rice cereal with 60 ml. of formula. Clear for spoon feeds--baby foods t.i.d. On 12/2/13 an initial nutrition assessment was done which identified the patient at moderate nutritional risk.

On 12/13/13, the diet was changed to 27 calories per ounce nectar thick liquids P.O. feeds ad lib..one tbs. rice cereal/60 ml of formula. Clear for spoon feeds/baby foods t.i.d.

Calorie counts for meals were recorded for food intake by the nursing staff, however, calories and protein calculation for the intake was not recorded by the dietician as per the facility's policy requirement.

12/7/13 at 12:47 Intake recorded by nursing; no calorie or protein recorded by the dietician.

12/11/13 at 4:34 p.m. Intake recorded. No calories or protein recorded.

12/12/13 at 5:17 p.m. Intake noted. No calories or protein recorded.

12/13/13 at 4:37 p.m. Intake noted. No calories or protein recorded.

12/16/13 at 3:36 p.m. Same as above

12/17/13 same above.

12/20/13 at 12:41 p.m. same as above.

The calorie counts were not calculated for calories or protein on any days, therefore, an assessment of this patient's intake was not done.

12/6/13 at 6:68 p.m. 5.75 kg

12/9/13 at 4:59 p.m. 5.235 kg

12/14/13 at 5:00 a.m. 5.81 kg

12/16/13 at 8:30 a.m. 5.635 kg

12/20/13 at 5 a.m. 5.565 (reflects a weight loss of .070 kg.)

The patient's weight was not monitored on a timely basis by the dietician, nor was the patient's food intake was not calculated by the dietitian to prevent weight loss.

This patient identified at moderate nutritional risk despite a diagnosis of a failure to thrive.

MR#53 This two year old male was admitted on 1/17/14 with diagnosis of pulmonary hypertension and a history of chronic small bowel obstruction. The patient had a J tube inserted prior to admission. The physician's admitting diet order was Pediasure peptide via the J tube at 50 ml/hr for 20 hours. The patient's recorded weight on 1/17/14 5:44 p.m. was 9.08 kg. An initial nutritional assessment was done on 1/20/14 at 1:54 p.m. The patient was identified at high nutritional risk. The patient's weight/age was < the 5th percentile.

On 1/12/14 at 10:59 p.m. the patient weighed 8.945 kg.
On 1/27/14 at 6:21 p.m. the patient weighed 8.75 kg.

The above represents a weight loss of .33 kg.

This patient will not be scheduled for a nutritional reassessment for 14 days after 1/20/14.

Examples of Pressure Ulcers:

MR#55 Was a 13 year old male admitted on 12/20/13 with a diagnosis of spina bifida. The patient was admitted to the Hospital for comprehensive rehabilitation and wound care. On 12/20/13, the record (a Physician's note) reflected that the patient had a stage IV sacral decubitus ulcer tunneling to the bone. The patient's weight on admission was 34.4 kg. and his height was 125 cm. The admission diet orders were pureed diet with ensure q.i.d. On 12/22/13 a weight loss was noted. The weight went from 34.4 kg to 32.8 kg.

On 12/23/13 the blood albumin was 1.2. A initial nutrition assessment was done on 12/23/13 at 8:43 a.m. and the patient identified at high nutritional risk. On 12/23/13, the registered nurse (RN) reports that the patient has a poor appetite. The patient's mother informs the dietician of the patient's food preferences. On 1/5/14 the patient's weight was recorded as 38.0 kg. On 1/6/14 at 3:03 p.m. the dietary reassessment classifies this patient at moderate nutritional risk due to weight gain. This patient was reclassified as a moderate risk, despite the presence of a stage III and IV sacral decubitus ulcer. The nurse also informed the dietician of the patient's poor appetite.

On 1/26/14 the patient's weight was recorded as 35.4 kg. This represents a weight loss of 2.6 kg. from the 1/5/14 to 1/26/14.

Due to the reclassification of this patient from high risk to moderate risk, the next scheduled nutrition reassessment would occur in 28 days.

MR#6 This 15 year old male was admitted on 12/16/13 with a diagnosis systemic sclerosis and multiple pressure ulcers. On admission stage IV sacral pressure ulcer, a stage IV pressure ulcer on the right posterior elbow, the right had black eschar on the toe and the left forefoot had black eschar. The patient's weight on admission was 50 kg.

The patient had a G tube placed prior to admission. At the time of admission the diet order order was Vital 1.5 one tbs of rice per 150 ml feed to run at 80 ml per hour.

A dietary assessment was completed on 12/18/13 and patient was classified at high nutritional risk. The dietician noted that this patient had a history of severe weight loss due to a prolonged illness. This initial assessment did not address this patient's stage IV pressure ulcers.

A nutritional reassessment was completed on 1/2/14, however no mention was made of the status of the pressure ulcers or of the weight gain of 3 kg. Patient's weight was recorded as 53.0 kg. on 1/2/14.

Another nutritional reassessment was done 1/16/14. The nutritional plan was to continue current feeding as tolerated to promote weight gain. However, if the weight gain continues, consider 1.0 calorie formula.

However on 1/16/14, this patient stage IV pressure ulcer remained the same and he should not a candidate for weight loss as recommended by the dietician.

MR#52 was a 13 year old female who was admitted on 7/26/13 with a diagnosis of acute osteomyelitis. The patient's history included: spina bifida, and a colostomy. At the time of a admission, a large sacral wound at buttocks tunneling to the vulva (5 cm by 5 cm.) a left medial heel decubitus. On admission the patient's weight was recorded as 54.8 kg and the height 132 cm. A regular diet was ordered on admission.

A initial nutrition assessment was done on 7/30/13 and this patient was classified at moderate nutritional risk. The dietician noted an increase in protein needs for wound healing, however the dietitian makes no mention of how the increase in portion needs would be met.

On 8/27/13 a dietary reassessment was done. The patient's recorded weight was 52.8 kg. The dietician did not mention the patient's weight status nor the condition of the pressure ulcers.

On 9/24/13 a dietary reassessment is completed. The patient's weight is recorded as 52.1 kg. The dietitian recommends, continue present diet.

On 10/22/13 the patient's weight is recorded as 56.0 which reflects a weight gain of 3.9 kg. The dietary reassessment completed on 10/22/13 at 11:38 a.m. did not mention the weight gain, nor how the weight gain occurred. The patient's diet orders remained the same.

On 11/18/13 a dietary reassessment is completed. The patient's weight is recorded as 56.2 kg. Diet unchanged. Again the status of the patient's decubiti were not mentioned.

On 12/13/13 a dietary reassessment was completed. The patient reports ordering double portions of food. However, the dietician makes no mention of the need for a possible change in this patient's diet order to high calorie, high protein. There was no documentation that the dietician informed the physician of the patient's food intake.

On 1/7/14 the wound care team noted that a wound on the right buttock measured at least 8 cm by 10 cm with tunneling.

On 1/10/14 the patient's weight is recorded as 60.7 kgs., reflecting a weight gain of 4.5 kg. A dietary reassessment was completed on 1/10/14. The dietician noted an excessive weight gain, despite the dietician's knowledge of the patient's ordering double portions of food.

Given the clinical outcomes cited above, facility's protocol (policy and procedure) does not address the issue of patients with pressure ulcers and the patients with a diagnosis of failure to thrive.

The facility's nutritional reassessment policy for patients identified at high and moderate nutritional risk increases the probability for negative clinical outcomes. This protocol's timeframe is too long and it does not promote patients' health and well being.
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Based on staff interview, review of master menus and nutrient analysis of menus, it was determined that that the Food and Nutrition Department failed to ensure that physician prescribed diets met the therapeutic nutritional needs of patients. This finding was noted in 20 of 30 diets.

Findings include:

A review of hospital menus and nutrient analysis was conducted on 1/27/14 at approximately 1: 00 PM in the presence of staff # 3. The hospital has a three week cycle menu and a diet formulary consisting of 30 different diets available to the physician for diet ordering.

Listed below are the findings identified in the menus and the nutrient analysis of prescribed diets:

1- Physician diet formulary to select prescribed diets was not specific as to the amount of nutrient the diet provides. Example of this finding:
a) Calorie Controlled diet did not specify calories
b) Pediatric Diabetic Diet did not specify calories
c) Carbohydrate Controlled diet did not specify grams of carbohydrate per day
d) High Fiber diet did not specify the amount of fiber
e) High Protein diet did not specify the grams of protein
f) The diet Low Cholesterol, Low Fat and Low Sodium also does not specify the amount of the restrictions.
2-There was no menu nutrient analysis for 20 diets of the physician diet formulary.
3- There was no evidence of age specific menu for this pediatric population.
4- Review of menus show there was no portions specific to the food items listed on the menu.
In addition, the lack of food portions on the menu does not validate the nutrient analysis.
5- It was noted on all dinner menus a statement noting " All food types may not be appropriate for all diets " . It is confusing and unknown to the reader as to the purpose of this statement.
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Based on staff interview, review of hospital's menus and physician diet prescription formulary, it was determined that the prescribed physician diet orders were not being accurately transcribed on patients menus.

Findings include:

1- Menus were reviewed with staff #3. It was observed that the Physicians' diet orders were abbreviated on menus and did not match the physician ' s prescribed diet orders. Consequently diet orders do not correspond or match with menus. The menu must correspond with the prescribed diet. The menu is placed on the patient tray to identify the diet, portion allowed and food item. The menu is also an education tool for parents, staff and patients concerning the prescribed diet by the physician.

Physician prescribed diets were abbreviated on the menu so that the diet was not legible. Diet on menu should be identical to the physician prescribed diet. An example of this was noted for the diet " Calorie Controlled diet - menu read " HC- CCD " . The amount of calories was not listed on the menu. The Pediatric Diabetic diet menu read " WK 1 Diabetic " The amount of calories was not noted on the menu.
Another example of an abbreviated diet on the menu was a diet abbreviated as " CC15D " on the menu. Upon interviewing staff # 3, the surveyor was informed that this abbreviation means " Calorie Controlled 1500 calories Diabetic. The abbreviated diet titled " CC15D " on the menu was not the diet the physician prescribed from the physician diet formulary.
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Based on observation, staff interview, review of diet formulary and patient menus, it was determined that the facility failed to ensure that physician diet formulary and menus coincide with the facility diet manual by the American Academy of Nutrition titled : Pediatric Diet Manual

Findings include:

There was no evidence that age specific food portion in menus was followed for the population of infants, toddler, school age child and adolescent. There were no age specific menus and none of the hospital ' s menus had food portions documented next to the food item. Food portions provided on tray is unknown since the menu was blank for food portions.
The findings were discussed with staff #3. It is evident that the Pediatric Diet Manual was not used as guidance for the physican diet formulary or for the ordering and preparing of patient diets.
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1. During the tour of the facility from 01/27/14 to 01/28/14 between 11:00 AM to 4:00 PM following issues were noted in the facility:
i. There was open Asbestos on the ceiling of electrical room/ATS switch room. This Asbestos was not confined/closed out to prevent environmental hazard to the staff using the room for maintenance and testing purposes of the electrical panel/ATS switches.
ii. The Outpatient (OPD) exam room #2 on the first floor was noted having stain ceiling tiles. Furthermore the walls were noted dirty and stained.
iii. OPD Exam room #3 was noted having stained ceiling tiles plus the perimeters of the room were dusty and dirty
iv. In room #1556 the above door sign for X-ray was noted ON for being in-use, however there was no one in the room and the door was open. It was not clear why the light was ON and if the X-ray machine was indeed on indicating the in-use sign.
v. There were 4 to 5 ceiling tiles that were noted stained in the cafeteria.
vi. The House keeping closet opposite cafeteria did not exhibit negative air-pressure and did not have any self closure installed at the door.
vii. During the tour of the infant/child in-patient unit on 01/27/14 at 12:00 PM, when a call bell was elicited from a patient room, it did not register in the clean utility room and soiled utility room and subsequent rooms as required by code.
As per AIDA 1996-97 7.32.1/FGI 2010 2.1-8.3.7.2(3)(b):
In patient areas, each patient room shall be served by at least one calling station for two-way voice communication. Each bed shall be provided with a call device. Calls shall activate a visible signal in the corridor at the patient's door, in the clean workroom, in the soiled workroom, Medication, Charting, clean linen storage, nourishment, equipment storage and examination/treatment room and at the nursing station of the nursing unit.
viii. In the Day Hospital, there was no nurse call bell console installed in the Clean utility room and other subsequent rooms so that it can register the nurse call bell as required by FGI 2010 2.1-8.3.7.2(3)(b).
ix. Temperature of the formula room #1206 on first floor was noted very hot. Director of Facilities stated that the temperature was approximately 80*F.
x. The bays of the Day hospital were not labeled.
xi. Open clean supplies such as toilet rolls and hand towel rolls were noted stored in the house keeping closet room #2103.

All above findings were verified with Staff #5 and Staff #6 at the time of observation.

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Based on record review and staff interview, the facility did not have a method in place to ensure that ventilators have all aspects of their preventive maintenance conducted in the frequency prescribed by the manufacturer.

Findings Include:

1. On 01/30/14 at 10:30 AM during the review of the preventive maintenance(PM) records of the ventilators it was noted that many of the ventilators were running between 27,000 to 55,000 hours. When asked about the information for the last 10, 000 hours major preventive maintenance (which is separate from annual and semi-annual PMs)as required by the manufacturer, the Bio-Med vendor did not have the information on all the ventilators. The PM work orders printed also did not have any information on each individual ventilator's last 10K check also did not have the current hours of the equipment to ensure that as soon as 10K hours are reached the PMs are done in a timely manner.

For example:
Work order # 0006072666 for ventilator #647968 on its last PM of 10/7/13 indicates that 'Checked unit to find, accumulated hours does not qualify for a PA at this time. PA not needed'.
This ventilator in its 4/26/13 indicated that 'Major PM due at 59, 206 hours, current hours 52,121'.

The current PM of 10/13 of this ventilator does not show the hours therefore it could not be verified by looking at these reports if major PM was due for the ventilator if the required 7, 000 hours were acquired in 6 months.

Similar issue was noted in other reports of the ventilators.

2. The Director of respiratory provided a spread sheet that she keeps for the current hours of the ventilator in the units. This spread sheet is not a part of vendor's preventive maintenance record and is for facility's/Respiratory Department's internal use only.

Although the information on the spread sheet did show that some of the units were not due for 10K PM, however it was also not accurate for all cases.

For Example
For ventilator #648797, the last major 10K PM was done in 03/14/12 at 28, 988 hrs. Therefore the next 10K should be at 38, 988 hrs. This vent is running currently at 33, 884 hours and as per the spreadsheet the next PM is due at 40,000 hours which is more than the required hours for 10K PM.

Therefore, the facility did not have any consistent manner and method to ensure that the hours are monitored accurately for a timely 10 K PM on ventilators..

3. Facility did not have any policy and procedure regarding how to perform preventive maintenance on any equipment in the facility. Facility relies on the vendor to perform whatever the preventive maintenance is required on the equipment and whatever frequency is deemed acceptable to them. Facility does not have a program in place that dictates what an outside vendor/contractor needs to follow and do more if required.

Findings were verified with Director of Facilities, Director of Respiratory Services and the Bio-Medical PM Vendor.

Based on review of the Organ, Tissue and Eye Procurement Program (OPO) Manual and staff interview, it was determined that the facility failed to ensure that this program was integrated into the Hospital Wide Quality Assurance Performance Improvement Program (QAPI).

Findings include:

1- A review of the hospital ' s Organ, Tissue and Eye Procurement Program Manual was conducted on 1/29/14 at approximately 1:00 PM. Present during the review of the contract was staff # 1. The surveyor requested the facility ' s tracking data and quality assurance program concerning compliance with Time Notification. Staff # 1 informed the surveyor that she had no formal document from OPO as evidence of any tracking. She informed the surveyor that in 2012 she notified OPO of a few deaths (a few was the count of 4) however " they did not want them " . There was no formal documentation of this notification beside a paragraph handwritten in a " Contract Assessment " dated 2012.
The facility had no formal report from OPO . There was no evidence by means of an OPO report that the facility called in 4 organ donation to OPO in 2012.
There was no documentation on the Time Notification called in within one hour to OPO.
2- Staff # 1 informs the surveyor that there was no hospital quality assurance program for the program of Organ, Tissue and Eye Procurement.
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