HospitalInspections.org

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4. Record review, on 9/24/12, showed the facility admitted Patient 20 to remove an infected left total hip replacement prosthesis on 9/21/12. The post-operative physician's orders showed two IV antibiotics; Vancomycin 1.5 grams every 12 hours and Ancef 1 gram every eight hours.

Review of the "Operative Report", dated 9/21/12, showed the "Postoperative Plan" was to keep Patient 20 on IV antibiotics for at least six weeks in order to clear the left hip infection.

The physician's orders, dated 9/22/12 at 10:05 a.m., showed an order for a peripherally inserted central catheter (PICC) placement.

A intravenous catheter is inserted peripherally, usually via a upper arm vein, with the tip terminating in a large vessel near the heart, the vessel can be subclavian vein or superior vena cava. Specially trained nurses insert PICC lines. PICC lines are placed for long term IV therapy, such as long term antibiotic therapy, in patients with poor veins or who have repeated vein punctures. (Lippincott's Nursing Procedure, 5th ed., 2009, pg. 375)

Review of the hospital policy and procedure, titled, "Central Venous Catheters (Central Lines)", dated 10/2010, showed, "Blood specimens may be drawn from all central lines, ..."

During an interview, on 9/24/12 at 10:46 a.m., RN 4 (7 West nursing unit dayshift charge nurse) stated Patient 20's PICC line had not been inserted yet, two days l after the order was written. RN 4 stated once the PICC line order was written the unit secretary would call the PICC line insertion nurse and inform them of the order. RN 4 was not aware no one had followed up and confirmed the PICC line nurse had received the order and then placed the PICC line.

During an observation, on 9/24/12 at 11:05 a.m., Patient 20 had an intermittent infusion device (intermittent IV use) on the back of each hand. Intermittent infusion devices maintain venous access in patients who are receiving IV medication regularly or intermittently but who do not require continuous infusion. The IV catheter has an injection cap attached to it. RN 2 attached Ancef solution bag and IV tubing to Patient 20's right hand intermittent infusion device, the site leaked. RN 2 then transferred the Ancef IV tubing to Patient 20's left hand, it too leaked. Both sites could not be used for the antibiotic infusion.

During an observation and interview on 9/24/12 at 11:46 a.m., RN 3 was not able to insert a new IV site. RN 3 stated she was not able to find a suitable vein, no access sites. Surveyor informed RN 3 and Patient 20 that the PICC line insertion nurse was enroute to place a PICC line. Patient 20 stated he would no longer have to be poked for further laboratory blood samples; the blood samples could be drawn from the PICC line.

At 12:55 p.m., RN 4 stated the original September PICC line nurse schedule showed RN 5 scheduled for 9/22/12, the date on the PICC line order. A second September PICC line nurse schedule had written over, in a black marker, the name of RN 5 and replaced with the name of RN 6 for 9/22/12. RN 4 stated she was not aware when the second schedule has been posted on the unit. RN stated the order had been called to RN 5 by the unit secretary on 9/22/12.

During an interview, on 9/24/12 at 1:12 p.m., RN 6 stated she made out the monthly PICC line nurse schedules. RN 6 stated she had been out sick and returned to work on 9/22/12, and thus had changed the schedule from RN 5, who filled in when RN 6 was not available. RN 6 stated she was the only full time PICC line insertion nurse for the hospital. RN 5 and a second RN had other full time nursing positions within the hospital. RN 6 stated she never received a call for the PICC line insertion, nor did RN 5, if she had received a call, inform her of an order for Patient 20.

During an interview, on 9/24/12 at 1:28 p.m., the 7 West nursing unit secretary (US), stated she places a call via pager number to the PICC line insertion nurse on the day's schedule and leaves the patient's name and room number. When the PICC lines nurse calls back, she documents the date and time on the order. The US was asked what was done when the nurse did not call back on 9/22/12, US stated she did not do a follow up call. US stated that was her practice, she places the call for the PICC line nurse via pager, does not put in a follow up call if there was no reply, nor does she place a call to another PICC line nurse. The US stated she was not aware the September PICC nurse schedule had been changed. The US kept her own copy of the schedule and was not aware that there had been a change in nurses for 9/22/12. The US stated she had no idea the PICC line had not been placed. She stated the nurse who co-signed the orders should have followed it up.

5. Record review, on 9/25/12, showed the facility admitted Patient 22 on 9/24/12, with multiple medical diagnoses, which included chronic renal disease with hemodialysis while hospitalized. During the hemodialysis procedure blood is removed from the body through a vascular access and filtered through a man-made membrane - a dialyzer, or artificial kidney, and then the filtered blood is returned to the body.
During an observation and interview, on 9/25/12 at 8:40 a.m., in the dialysis room, Patient 22 was in a recliner chair. Patient 22's son arrived with food for Patient 22 to eat prior to hemodialysis. RN 7 stated Patient 22 had not eaten breakfast this morning prior to arrival in the dialysis room.

Review of the "Physician Orders" for admission, dated 9/24/12, showed the orders had not been noted by a registered nurse. The orders had been faxed by the nursing unit secretary.

RN 8, on 9/25/12 at 10:15 a.m., checked and verified Patient 22's renal diet order had never been entered into the "OAS", their electronic ordering system.

During an observation, on 9/25/12 at 10:46 a.m., of Patient 22 nursing unit room, showed there was no sequential compression devices (SCDs) on the bed or in the room. SCDs therapy massage the legs in a wavelike, milking motion that promotes blood flow and deters clot formation. (Lippincott's Nursing Procedures, 5th ed., 2009, pg. 241)

During an interview, on 9/25/12 at 10:50 a.m., RN 8 stated "faxed" meant the unit secretary had fax the orders to the pharmacy department and also if a patient was on telemetry, which Patient 22 was, the orders would be faxed to the step down unit, which did the remote telemetry monitoring. RN 8 verified the SCDs order was never carried out. Orders for patient equipment, such as SCDs, were called to "UHS" - Universal Hospital Services by the unit secretary or nurse. An entry beside the order was done to document the order had been called to UHS. Once the request call was placed UHS staff would deliver the equipment.

On 9/25/12 at 2 p.m., with RN 8's assistance, Patient 22's physician's admission orders were review for completeness. Only the renal diet and SCDs orders were not followed through. RN 8 stated the SCDs was for deep venous blood clot prevention.

Review of the hospital policy and procedure, "Documentation:Transcriptions and Noting Orders", dated 1/2010, showed the purpose was, "To transcribe, note and initiate action on physician orders for individual patients." Physician's orders were transcribed by the medical clerk/unit secretary or by a licensed nurse. "No action may be taken on any order until it has been checked and countersigned by an RN: ...b. A Control Number is evidence that the order has been entered into the computer." Orders were to be signed with date and time.



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Based on observation, staff interview and record review, the facility failed to ensure that the registered nurses evaluated the blood sugar levels, rendered the services ordered by the physicians and performed pain assessments for six (Patients 60,61,20,22,102 and 103) of 35 sampled patients.

1. For Patients 60 and 61, both newborn babies, the registered nurses failed to evaluate and monitor the blood sugar levels in a timely manner following the administration of D10, an intravenous drug of highly concentrated glucose (sugar) solution that can draw water out of the cells. D10 is used to increase the blood sugar level which according to the manufacturer's instructions of Dextrose Injections USP, "blood glucose concentrations should be frequently monitored when dextrose is prescribed to pediatric patients, particularly infants, neonates, and low birth weight infants." This failure had the potential to result in undetected adverse effects related to a sudden increase in blood sugar level in newborn babies.

2. For Patient 61, there was no documentation that the staff nurses notified the doctor when the patient's blood sugar was 150 mg/dl, an hour after D10 drip was started. According to the facility's Point-Of-Care Test Reference Ranges, approved on 10/21/11, normal range of neonatal blood glucose was from 45 to 110 mg/dl. This failure had the potential to result in a preventable medication error from an overdose of concentrated blood sugar solution.

3. For Patient 20, the registered nurses failed to communicate effectively to ensure the timely insertion of a PICC Line (peripherally inserted central line) which had the potential to result in unnecessary needlesticks that could cause discomfort and pain.

4. For Patient 22, the registered nurse did not note and carry out the admission orders for a renal diet and sequential compression device which resulted in the patient's receipt of a non-therapeutic diet and had the potential for poor circulation and development of blood clots in the lower extremities.

5. For Patients 102 and 103 who received patient controlled analgesia (narcotic pain relief) infusion, the pain levels were not evaluated to measure the effectiveness or further need of more pain medication which had the potential to result in unnecessary drug administration or unrelieved pain.


Findings:

1. During an observation on 9/24/12 at 10:32 a.m., as observed with RN 11 in NICU (neonatal intensive care unit), Patient 60 was on D10 (concentrated dextrose in water) IV (intravenous) infusion at 5 ml per hour, and Patient 61 was on D10 IV infusion at 6 ml per hour.

According to the manufacturer's instructions of Dextrose Injections USP, "blood glucose concentrations should be frequently monitored when dextrose is prescribed to pediatric patients, particularly infants, neonates, and low birth weight infants."

On 9/24/12 at 11 a.m., review of Patient 60's medical record with RN 12 showed that Patient 60 was a newborn with a birth weight of five pounds and 12 ounces. Patient 60's blood glucose reading was 38 mg/dl at 9 a.m. on 9/23/12 when D10 IV infusion was started at 9 ml per hour. The first blood glucose check was done five hours after the start of D10 IV infusion.

In a staff interview on 9/24/12 at 1:21 p.m., Physician 2 said she expected nurses to check newborn's blood glucose around one hour after starting D10 IV infusion. If the rechecked reading was stable, then the nurses could check blood glucose every six hours under stable readings. Review of Patient 60's medical record with Physician confirmed that Patient 60 should have received a blood glucose check at 10 a.m. on 9/23/12 after D10 IV infusion was initiated at 9 a.m. on 9/23/12. There was no blood glucose check until 2 p.m. on 9/23/12.

In a staff interview on 9/26/12 at 9:40 a.m., RN 9 acknowledged that she should have checked Patient 60's blood glucose at 10 a.m. on 9/23/12 after D10 IV infusion was initiated at 9 a.m. on 9/23/12.

DON(MCH) said it was a nursing practice of NICU to check blood glucose one hour after D10 IV infusion was started. Then, nurses could check blood glucose every six hours if the blood glucose readings were stable during D10 IV infusion. DON(MCH) acknowledged that the Policy of Neonatal Blood Glucose Monitoring was not clear what needed to be done for blood glucose monitoring after notifying doctor for blood glucose less than 50 mg/dl and starting D10 IV infusion with no oral feeding yet.

During a staff interview on 9/26/12 at 10:39 a.m., Physician 1 said she expected nurses to check blood glucose within an hour after D10 IV infusion was started. If the blood glucose reading was stable, check another blood glucose in an hour. If it was stable again, then nurses could check every three or six hours during D10 IV infusion.

During a staff interview on 9/26/12 at 10:41 a.m., DON(MCH) said different physicians had different expectations on blood glucose monitoring frequency, and nurses also had different nursing practice about blood glucose monitoring. She said the administration was working in the update of neonatal blood glucose monitoring.

On 9/27/12 at 11:42 a.m., DON(MCH) said that the hospital's leadership recognized that the Policy of Neonatal Blood Glucose Monitoring was ambiguous not to address what needed to be done next if newborns were not feeding but on prescribed D10 IV infusion for blood glucose less than 50 mg/dl .

2. In a staff interview on 9/26/12 at 10:39 a.m., DON(MCH) said that nurses need to notify the physician when neonatal blood glucose was out of 45 to 110 mg/dl according to the Test-Of-Care Test Reference Range (approved on 10/21/11).

In a staff interview on 9/26/12 at 10:50 a.m., review of Patient 61's medical record with DON(MCH) confirmed that there was no documentation to show that the doctor was notified about high blood glucose reading of 150 mg/dl at 10:10 a.m. on 9/23/12 after D10 IV infusion was started at 9 a.m. on 9/23/12.

3. During a staff interview on 9/26/12 at 10:41 a.m., review of Patient 61's medical record with DON(MCH) confirmed that Patient 61 on D10 IV infusion should have received a blood glucose check at around 7:57 p.m. on 9/23/12 that was six hours from 1:57 p.m. on 9/23/12 with 95 mg/dl in blood glucose reading. There was no blood glucose checked until 9 p.m. which was around seven hours from previous blood glucose check at 1:57 p.m. on 9/23/12.



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6. A concurrent interview and medical record review,on 9/25/12 at 12:30 p.m., showed the hospital admitted Patient 103 hospital on 9/18/12. Review of the records showed a PCA (patient controlled analgesia) physician order. Further review of the PCA, dated 9/22/12 at 6:10 a.m., showed, Nursing Management: "Monitor respiratory (breathing) rate, sedation (wakefulness) score and pain level every 15 minutes for initial hour, then every 2 hours for 8 hours, then every 4 hours thereafter. "Review of the medication administration record (record of medication administration) showed the PCA was started on 9/22/12 at 8:30 a.m. Continued review of the records showed the first documented pain score, after 9/22/12 at 8:30 a.m., was on 9/22/12 at 2:23 p.m. The Director of Pharmacy acknowledged the first pain score documented, after the start of the PCA, was on 9/22/12 at 2:23 p.m.

A concurrent interview and medical record review, on 9/25/12 at 1:25 p.m., showed Patient 102 was admitted to the hospital on 9/24/12. Review of the records showed a PCA order. Further review of the PCA orders, dated 9/24/12 at 4:45 p.m., showed, Nursing Management: "Monitor respiratory rate, sedation score and pain level every 15 minutes for initial hour, then every 2 hours for 8 hours, then every 4 hours thereafter. "Review of the medication administration record showed the PCA was started on 9/24/12 at 10:15 p.m. Continued review of the records showed pain scores on 9/24/12 at 10:15 p.m., 9/25/12 at 12 a.m., 12:22 a.m., 1:05 a.m. and 4:41 a.m.

An administrative record, of the hospital's policy and procedure for Patient Controlled Analgesia (PCA) (Date Revised: 12/2010) showed, Policy, RN Responsibilities, d."The RN/LVN will assess and record respirations, sedation score and level of pain on the PCA flowsheet at the following intervals., 1. Q [every] 15 minutes x 4, 2. Q 2 hour for 8 hours, 3. Then Q 4 hours thereafter on the PCA flowsheet."

Based on observation, review of facility documents and staff interviews, the facility failed to ensure that three of three food service works were able to accurately test the chemical concentration of the sanitizing solution used on food contact surfaces. The presence of food debris or dirt on nonfood contact surfaces "may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food" (Food Code 2009.) The use of a chemical sanitizer will minimize the amount of microorganisms on the non-food contact surface that could result in food-borne illness.

Findings:

On September 24, 2012 at approximately 1:50 p.m., FSW 10 was asked to test the chemical concentration of the liquid in the red sanitizing bucket stored in her work area. FSW 10 was observed immersing the test strip in the water in the machine for approximately three seconds and then matched the strip to the color strip on the container. She then stated "500", implying 500 parts per million (ppm.) The actual reading was approximately 200 ppm.

Another employee FSW 11 was also asked to test the chemical concentration of sanitizer in the same red bucket. FSW 11 immersed the test strip swinging back and forth for approximately eight seconds. When asked how long he had immersed the strip, he stated for ten seconds and that he had counted quietly. Although there was a clock on the wall, neither of these FSWs used the clock to ensure that the immersion time was correct.

The Food Service Manager who was present during both observations indicated that the facility practice was that one employee and supervisor were responsible for refilling the red buckets and testing to ensure appropriate concentration. The employee (FSW 12) whose responsibility it was to test the sanitizing bucket was asked to check the concentration of another red bucket in the kitchen. FSW 12 immersed the test strip for over 20 seconds and responded that the sanitizer concentration was 400 ppm.

FSW was allowed to retest after teaching to count appropriately in the absence of a clock. The strip was 150 ppm.

Review of the manufacturer's instructions indicated that none of the employees had followed the correct procedure. The instructions on the label indicated "Dip the strip into the sanitizing solution for 10 seconds, then instantly compare the resulting color with the enclosed color chart which matches concentrations of 0-150-200-400-500.
According to the 2009 Food Code, "In addition, "Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and too much sanitizer in the final rinse water could be toxic."
The recommended chemical concentration for quaternary ammonia is 200 ppm.

Based on observation, review of hospital menus, hospital documents and policies and procedures, clinical record review and staff interviews, the hospital failed to ensure four ( Patients 122, 123, 124 and 126) of 35 sampled patients received the following: the menus consisted food preferences of the patients; the staff interviewed patients for their food preferences or through the use of a selective menu; the choices and preferences are honored by the food service staff; the therapeutic diets were implemented in a manner that was consistent with physician ordered diets and the parameters set forth in the physician approved diet manual.

For Patient 122, the hospital did not determine and provide the patient's food preferences upon admission. This failure had the potential to result in decreased food intake and avoidable weight loss during hospitalization.

For Patient 123, the hospital did not determine the patient's food preferences until two days after admission. This failure had the potential to result in decrease food intake during the first two days of admission.

For Patient 124, the hospital did not determine the patient's food preferences till three days after admission. This failure had the potential to result in decreased food intake and avoidable weight loss during the first three days of admission.

For Patient 126, the hospital did not determine the patient's non-religious food preferences that resulted in receiving meals for three days that were not the patient's choices. This failure had the potential to result in poor food intake.

For patients in the acute psychiatric campus, the menus provided less protein and calories than was planned and approved by the dietitian and the physicians in the hospital policy and procedure. Failure to follow physician ordered diets may result in further compromising medical status of patients.

Findings:
1. In an interview on 9/24/12 at approximately 10:00 am, the Clinical nutrition manager (CNM) stated the hospital provides a non-select menu to its patients. (A non-select menu is a menu that does not allow the patient to choose food items from a list of selected foods on the menu or alternative food list.) She further stated during the same interview that no menus are passed out or posted in the room to enable patients make decisions about their food choices. She stated the nutrition assistants visit patients to find out about food likes and dislike and that registered nurses (RN) document food preference during the initial screening process.
Review of several patient records revealed that food likes and dislikes were not included in the list of questions reviewed by the RN's. The only food related questions were food allergies, cultural or religious food preferences.
The hospital policy titled " Nutrition Care Process (Screening Process Assessment) For Acute Patients " revised 07/12 indicated that the Nutrition Assistant will visit the patient to obtain food preferences, allergies and intolerances " . It did not however indicate within the time frames it should have been completed. The hospital has only one individual in the position of the nutrition assistant at the acute care campus. It was unclear who performed the activity in her absence and the policy did not delegate the activity to other staff in her absence. The Nutrition Assistant was not available for interview on 9/27/12, at approximately 2:00 pm, she had left for the day.
Random review of documentation in the patient profile cards showed documentation that some of the patients were visited as late as three days after admission or when diet orders had been written by physicians allowing patients to eat. Some patients were not revisited because they were asleep when the nutrition assistant had initially visited them. Other profile cards did not document that food preferences were taken. In an interview with two registered dietitians (RDs) (RD 1 and 2) on 9/27/12 they indicated that they do evaluate patients for food preferences when they meet with patients as part of nutrition assessments or consults. Based on time frames developed in the hospital policy, food preferences conducted by the RDs are usually after 48 hours after admission or longer, because most patients are not assessed by the RDs until about then.
Clinical record review of four patients revealed varying amounts consumed. The lack of choice may have contributed to the poor intake all of these patients experienced before food preferences were taken. For example, Patient 122 was admitted on 09/15/12. Her physician ordered a regular vegetarian diet on 09/21/12. The amount consumed by Patient 122 was poor during the first few days (9/22 to 9/23) varying between 10% to 50%. The RD conducted a nutrition assessment and documented on 9/23/12 " poor PO (oral) intake of hospital food ..... " Food preference obtained which may help with increasing PO intake. " Intake improved after food preference was obtained. Dinner intake on 9/23/12 was 80%, first meal after food preferences were honored, despite eating meal from home a few hours earlier.
Patient 123 ' s food preference was noted two days after admission when RD conducted an assessment. Patient 124, food preference, noted 09/24/12, three days after admission. Patient 126 ' s food preferences were noted on 09/20/12, 7 days after admission. Intake also improved.
The hospital ' s lack of an effective system to ensure that patients ' non-religious food preferences were obtained has resulted in patients ' receiving meals for up to three days before food choices and dislikes were honored, which may have contributed to poor food intake.
2. During initial kitchen tour on 9/24/12 beginning at 10:20 am, it was noted that the hospital was using convenience items such as lasagna, as well as pre-cooked pork loin, meatloaf and turkey for patient menus.

During trayline observations on 9/24/12 beginning at 12 pm, it was noted that with the exception of regular diets the physician ordered therapeutic diets consisted primarily of consistent carbohydrate, a sodium restricted, low cholesterol, low fat, cardiac diet and 2 gram sodium diets. In an interview with the Clinical Nutrition Manger (CNM) on 9/26/12 beginning at 1pm, she stated that the consistent carbohydrate diet parameters were 60 grams of carbohydrate (CHO) at breakfast and 75 grams of CHO at lunch and dinner, for a total of 210 grams/day. Similarly diets that had a low fat component would be limited to 50 grams of fat per day and the 2 gram sodium diets would have 2,000 milligrams of sodium per day.

On 9/26/12 beginning at 11am, the hospitals' comprehensive nutritional analysis was reviewed for compliance with physician ordered diets. It was noted that the nutritional analysis did not consistently meet physician ordered parameters.

1a. Review of the consistent carbohydrate renal diet revealed that for 2 of 7 breakfasts the carbohydrate content was 50 and 51 grams respectively. Similarly at lunch and dinner meals the carbohydrate content for several meals ranged between 80 and 85 grams of CHO. The purpose of utilizing a carbohydrate consistent diet is to plan meals that offer meals with a comparable carbohydrate content from day to day as well as from meal to meal if an effort to facilitate blood glucose levels (Diabetes Care, January 2004).

b. Review of the 2 gram sodium/low fat/cardiac diet analysis revealed that 2 of 7 days exceeded the physician ordered parameter of 2,000 milligrams of sodium. In an interview on 9/26/12 at 11 am, with the CNM she stated that the analysis was based on the recipes prepared from raw and fresh ingredients, rather than the convenience items that were currently used in food production. She also acknowledged that the nutritional analysis would not be accurate in light of the substitutions. The CNM also stated that the low fat component of the diet would not exceed 50 grams of fat per day. Review of the nutritional analysis for Week 1 of the menu revealed that for 2 of the 7 days, the fat content was 56 and 58 grams respectively, exceeding the physician approved parameters for fat.

In an interview on 9/26/12 beginning at 1:30 pm, with the CNM she stated that while she evaluated the menu for calories and protein as well as ensuring there was no repetitiveness she acknowledged that she had not evaluated the menu to ensure consistency with physician ordered diets and the diet manual.

In an interview on 9/26/12 beginning at 1:30 pm, with the CNM she stated that while she evaluated the menu for calories and protein as well as ensuring there was no repetitiveness she acknowledged that she had not evaluated the menu to ensure consistency with physician ordered diets and the diet manual.







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Based on observation, interview and record review, the hospital failed to ensure that all hospital diets met the nutritional needs of inpatients as evidenced by analysis of regular and therapeutic diets that did not meet the standard of practice based on guidance by National Academies of Science 2004. The hospital also failed to provide or follow-up the nutrition recommendation or plan as recommended by the registered dietitian or ordered by the physicians for three (Patients 122, 123 and 126) out of 35 sampled patients.

For Patient 122, admitted on 9/15/12, the physician ordered a regular vegetarian diet on 9/21/12. The staff did not consider to determine the patient's food preferences which resulted in poor intake of hospital food for seven days until the RD obtained food preferences.

For Patient 123, the RD (registered dietitian) recommended a renal consistent carbohydrate diet due to the high levels of kidney function lab results that may indicate poor kidney function. The dietary recommendation was not relayed to the physician for consideration until three days after the written recommendation. This failure had the potential to result in higher levels of lab results indicative of worsening kidney function.

For Patient 126, the RD recommended to change the diet to low fat low cholesterol because of the patient was 155% over his ideal body weight and his triglyceride level was high. The facility staff failed to follow-up the recommendation with the physician that resulted in Patient 126 receiving a regular diet, a non-therapeutic diet for weight loss and triglyceride control.

Findings:

1. The goal of meal planning for individuals would be to have a low probability of inadequacy of particular nutrients while minimizing the risk of excess of each of the nutrients. Nutritionally adequate meal plans incorporate the use of the recommended dietary allowances and adequate intakes based on age and gender as a benchmark for meal planning (National Academy of Sciences 2004.)

On 9/26/12 beginning at 1 p.m., the hospital's nutritional analysis was reviewed in the presence of the CNM. While the hospital developed a comprehensive analysis it was noted that the menus did not consistently meet patient nutritional needs based on recommendations from the National Academy of Sciences. It was noted that the menu did not meet the recommended intake for all vitamins and elements. As an example the benchmark for menu adequacy of Vitamin C was listed as 60 milligrams; however the range of recommended intakes range was from 75-120 milligrams depending on age and gender. In addition the menu did not meet the recommended intake for fiber listing the adequate intake as 25 grams rather than the range of 21-38 grams which was also dependent on age and gender.

In an interview on 9/26/12 beginning at 1:30 p.m., the CNM acknowledged that she had not fully evaluated the menu to ensure that the daily values of the vitamins and elements met the standard of practice.

According to hospital policy titled "JGPP (John George Psychiatric Pavilion) Meal Trays," dated 3/2011 and last reviewed 7/12, "patients admitted to the facility will have a meal plan that meets their needs during the acute phase of their illness." When a physician ordered a regular diet for the patients in JGPP, the patients will be given in between meal snacks and the meal pattern as listed below:
Breakfast: ½ cup orange juice, ½ cup hot cereal or 1 oz cold cereal, 2 slices of Toast or muffin and 1 oz protein, 1 cup LFM (low fat milk), 1 cup decaffeinated coffee, 2 margarine(s), and Jelly.
Mid-Morning Snack: Yogurt and Fruit
Lunch: 6 oz soup or 1 cup salad, 4-5 oz protein, 1 cup of starch, ½ cup vegetable, 1 slice bread or dinner roll,1 tsp (teaspoon) margarine, ½ cup fruit or other dessert, 1 cup IT (ice tea).
Mid-Afternoon Snack: 2 pg. Graham crackers, Chocolate milk.
Dinner: same as lunch except that ice tea is replaced with 1 cup LFM and 1 cup decaffeinated coffee.
After dinner snack: cheese stick with saltine crackers or peanut butter and crackers
During lunch tray line observation on 9/25/12 at approximately 11:40 a.m., patients at JGPP did not receive, on their trays, items described in the policy above. Patients received the following: 3 oz pork loin, ½ cup green beans, 1 cup of mashed sweet potato, 1 roll. This meal was missing the soup or 1 cup salad, and 1-2 oz pork loin . FSW 13 who served the entree explained at approximately 11:50 a.m. that all residents received "double the starch". He was not observed to have served the other food items in the correct amounts described in the policy.
Further observation revealed that the diet spreadsheet used by FSW 13 did not have the increased nutritional needs described in the policy and procedure. This failure of the hospital to provide the staff with an accurate therapeutic menu/spreadsheet resulted in all patients admitted to the JGPP to have received food that was less than the protein, calories and other nutrients planned.
Review of the nutrient analysis of the JGPP diet revealed that the in-between meals snacks were not incorporated into the analysis. This exclusion resulted in the hospital's inability to demonstrate that the planned menu met the nutritional needs of the patients during the acute phase of their illnesses.
In addition, patients who were on therapeutic diets, such as consistent carbohydrate received more carbohydrates than was allowed on their diets, because FSW 13 served all patients regardless of the prescribed diets, the double portion of mashed sweet potato
2. The clinical record review of three patients revealed varying amounts consumed. It could not be determined whether the lack of choices was a factor in al cases.
2a. Patient 122 was admitted on 9/15/12. The physician ordered a regular vegetarian diet on 9/21/12. The amount Patient 122 consumed varied between 10% to 50% from 9/22/12 to 9/23/12 on a regular diet. The RD conducted a nutrition assessment and documented on 9/23/12, "poor PO (oral) intake of hospital food...." Food preference obtained which may help with increasing po intal." Patient 122's intake improved after food preference was obtained. Dinner intake on 9/23/12 was 80%, the first meal after food preferences were honored, despite eating a meal from home a few hours earlier.
2b. Patient 123 was admitted to the hospital on 09/22/12 with diagnoses including hypertension (high blood pressure), acute renal failure and diabetes. His physician ordered diet was diabetic renal on 09/22/12, regular on 09/23/12 and diabetes consistent carbohydrate on 09/24/12 according to nursing notes.
He was assessed by the registered dietitian (RD) on 09/24/12 as a result of a nurse referral. The RD recommended a " renal consistent carb diet due to current renal function " His laboratory values indicated high levels of BUN (blood urea nitrogen)and Creatinine (Cr) BUN and Cr are blood tests used to evaluate kidney function. High levels may indicate poor kidney function.
On 09/25/12 his BUN was 28 and 32 on 09/26/12. Normal is 6 - 20. In addition, his Cr was 3.3 on 09/25/12 and 3.4 on 09/26/12. Normal 0.6 -1.2.
Interview was conducted with the RD 2 who made the diet recommendation on 09/27/12 at approximately 10:45 am. RD 2 indicated that she could not remember whether or not she paged or texted the physician regarding the recommendations. There was no acknowledgement of her recommendations by the physician as 09/27/12, three days after the recommendations were made. Patient 123 remained on the consistent carbohydrate diet without renal restrictions.
2 c. Patient 126 was admitted on 09/13/12 with diagnoses including diabetes, hypertension (high blood pressure), and back pain. His physician ordered diet was a regular diet. Patient 126 is 6 ft 5 ins tall weighing 114 kg (250.8 lbs). He was 155 % over his ideal body weight range. He was initially assessed by the RD on 09/15/ 12 due to referral from the RN due to poor food intake.
She recommended that his diet be changed to low fat low cholesterol when his po (oral) intake is > 75 %. This was based on a high triglyceride level of 274. Normal level is below 150. Triglycerides are a type of fat found in the blood and fat tissue. High levels can lead to the hardening and narrowing of arteries and increases the chance of heart attack or stroke. High cholesterol levels occur with high triglyceride levels.
On 9/20/12, he was reassessed by the RD who noted a weight loss of 8 kg. Food preferences were noted. Appetite seemed to improve after 9/20/12 ranging mostly from 75 to 100% with occasional 25 -50 %. However, the diet remained the same; there was no change to the low fat low cholesterol. The communication with the physician regarding the change in diet was not evident in the clinical record. The RD had changed his nutritional risk from high to medium risk, resulting in follow up time of 7 days. There was no other RD intervention.
The hospital lacked an effective system of communication and follow-up between the registered dietitians resulting in non-implementation or acknowledgement of diet or nutrition -related recommendations.

3. The goal of meal planning for individuals would be to have a low probability of inadequacy of particular nutrients while minimizing the risk of excess of each of the nutrients. Nutritionally adequate meal plans incorporate the use of the recommended dietary allowances and adequate intakes based on age and gender as a benchmark for meal planning (National Academy of Sciences 2004).

On 9/26/12 beginning at 1 p.m., the hospitals nutritional analysis was reviewed in the presence of the CNM. While the hospital developed a comprehensive analysis it was noted that the menus did not consistently meet patient nutritional needs based on recommendations from the National Academy of Sciences. It was noted that the menu did not meet the recommended intake for all vitamins and elements. As an example the benchmark for menu adequacy of Vitamin C was listed as 60 milligrams; however the range of recommended intakes range from 75-120 milligrams depending on age and gender. In addition the menu did not meet the recommended intake for fiber listing the adequate intake as 25 grams rather than the range of 21-38 grams which was also dependent on age and gender.

In an interview on 9/26/12 beginning at 1:30 p.m., the CNM acknowledged that she had not fully evaluated the menu to ensure that the daily values of the vitamins and elements met the standard of practice.






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Based on sanitation observations, dietary staff interview and dietary document review the hospital failed to ensure the development of an effective system for testing sanitizing solutions used in dietetic services as evidenced by routine testing that did not follow manufacturers' guidance. Failure to ensure manufacturers' guidance was consistently followed may result in sanitizer strengths that are either suboptimal or excessive.

Findings:

On 9/25/12 beginning at 11:15 am, Dietary Staff (DS) F was observed cleaning a large floor mounted steam kettle. He was observed washing, rinsing and sanitizing the equipment. In a concurrent interview with DS F the surveyor asked him to describe now he ensured the sanitizing solution was strong enough to be effective. DS F demonstrated testing of the solution using a test strip (whose width was approximately ¼ inch wide and 3 inches long) that measured the strength of the solution by changing color. He placed the strip in the solution for however there was no reaction. He further stated that the strength of the solution should have been 150 to 400 parts per million (ppm) and the color should have turned from orange to a light lime green shade.

DS F was asked to demonstrate filling the solution from the dispenser above the manual dishwashing sink. It was noted that while there was a color change on the strip, it was not a complete color change; rather had spots of lime green color on the orange strip, rather than a consistent color change. The temperature of the dispensed sanitizing solution was noted to be 110°F.

Concurrent review of the manufacturers' recommendation printed on the back of the package that contained the strips guided staff to test the chemical strength of the solution at a temperature of 65-75°F. Additional review of the manufacturers' guidance posted adjacent to the dispenser guided staff that "it is recommended the Quat Sink temperature should be rage of 75-110F to work most effectively."

An undated document provided by the vendor of the sanitizing solution guided staff that "it is important to realize that there is a difference between the temp requirements when using quat sanitizing solutions compared to temp requirements when testing them."

Review of in-service training dated 8/25/12 revealed that while the hospital provided guidance on sanitizing food contact services, the content of the training did not include the manufacturers' specific requirements with respect to the difference in testing the strength of the solution versus the sink temperature. Review of hospital document titled "Pot Sink Temperature & Sanitizer Log" dated 9/12 revealed that the temperature of the sanitizer sink ranged from 88-110°F. There was no indication that the sanitizer solution was tested within the parameters identified by the manufacturer for the 73 tests documented on the log.



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Based on food production observations, dietary staff interview and dietary document review the hospital failed to 1) ensure safe food handling practices as evidenced by the lack of development of a system to monitor time/temperature control of potentially hazardous foods while thawing, utilizing running water. Failure to develop effective time/temperature monitoring systems may result in the promotion of food borne illness in patients resulting in nausea, vomiting, gastrointestinal illness and in severe instances may result in death; 2) ensure the immunization of 1 of 12 dietary staff members per hospital infection control policy.

Findings:

1. Potentially hazardous foods (PHF's) are defined as those capable of supporting bacterial growth associated with foodborne illness. PHF's require time/temperature control at all times to ensure food safety. Protein based foods such as meats are PHF's. The standard of practice when thawing meats would ensure that it was completely submerged under running water:
(1) At a water temperature of 70° F or below,
(2) With sufficient water velocity to agitate and float off loose particles in an overflow, and
(4) For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41° F for more than 4 hours including:
(a) The time the food is exposed to the running water and the time needed for preparation for cooking, or
(b) The time it takes under refrigeration to lower the food temperature to 41° F (Food Code, 2009).

During food production observations on 9/24/12 beginning at 1:55 p.m., it was noted that Dietary Staff (DS) A was thawing plastic wrapped pork ribs by placing them in a sink with running water. In a concurrent interview with DS A he stated that he was thawing the meat by placing it in the sink for "about 2 hours" after which he would pull apart the rack of ribs after which he would place them on a sheet pan in the refrigerator to be cooked the following day. In a follow up observation on 9/24/12 at 3:20 p.m., it was noted that DS B was breading a chicken breast that was also pulled from the thawing sink. It was noted that the water temperature was 66° F and the temperature of the chicken was 48° F. In a concurrent interview with DS B he stated that he was preparing the chicken for the evening meal.

In an interview on 9/26/12 beginning at 1:30 p.m., with Dietary Management Staff (DMS) C he was asked if there was a policy related to thawing meat in running water. Concurrent review of the department's policy titled "Infection Control Procedures for Food and Nutrition Services" dated 7/12/12 guided staff that "4. Frozen meats ...requiring thawing are to be done under refrigeration or under cold running water." The surveyor asked DMS C to describe the system to ensure time/temperature parameters were maintained while thawing utilizing cold water. He stated that there was no system in place to ensure time/temperature parameters for food safety were met.

2. During review of employee health records, on 9/26/12 at 3 p.m., it was noted that 1 of 12 dietary staff was not immunized per hospital policy. Hospital policy titled Infection Control-Employee Health Program dated 8/09 revealed that the employee was to provide "3) proof of mumps measles, and rubella (MMR) immunity" either by proof of immunization records or a blood test. Additionally the policy also noted that a blood specimen for varicella (chicken pox) would be obtained if there was a vague or no history of the disease. It was noted that the employee health file for Dietary Staff (DS) E contained neither of these elements. In a concurrent interview with the Director of Employee Health she stated on 6/12/12 the employee was notified of the need to have blood work drawn. She also stated that it was the expectation that the employee comply within 30 days of notification. She also acknowledged that the employee health department should have followed up after the 30 day timeframe.



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