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Based on observation, review of hospital documents, review of personnel records, and staff interviews, the hospital failed to comply with state regulations.

Findings:

California Code of Regulations, Title 22, Section 70275(a) states "A registered dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultation services shall be provided on the premises on a regularly scheduled basis and of sufficient duration and frequency to provide continuing liaison with medical and nursing staffs, advice to the administrator, patient counseling, guidance to the supervisor and staff of the dietetic service, approval of all menus and participation in development or revision of dietetic policies and procedures and in planning and conducting in-service education programs."

Review of the organizational chart for the food and nutrition department indicated the Food and Nutrition Director (FND) directed the operation of the food and nutrition services. Review of the resume and job description of the FND revealed that he was not a registered dietitian. Review of the Clinical Nutrition Manager's (CNM) job description indicated the position as reporting to and being supervised by the FND. The CNM, a full-time registered dietitian, was therefore responsible for the activities/responsibilities described in the regulation.

Part of the responsibilities of the RD/CNM is to provide guidance to the dietary services supervisor, who according to state regulations has responsibilities for "the operation of food service (not nutrition services)." Guidance is defined in the dictionary as "action of guiding; direction; leadership." This subordinate-superior reporting relationship does not empower the RD to effectively provide guidance when she is being supervised by the same person she is to direct or lead.

The hospital also failed to comply with Section 70273(a)(4) which states, "Patient food preferences shall be offered through the use of a selective menu or substitutes from appropriate food groups," and (g)(4) which states, "Menu should be planned with consideration for cultural and religious background and food habits of the patients."

The dictionary defines "selective" as "having the power to select." It further describes "select" as "to pick out from a number; choose." Review of the hospital menu on May 10, 2010 revealed one main entree on all diets provided with no choice on the entrees. This observation was discussed with the FSD and CNM. The CNM stated that the patients are offered choice through the use of a "spoken menu" conducted daily by a dietary employee. She further explained that patients could order from the grill.

The following day, May 12, 2010 at approximately 9:05 AM, the dietary employee, DW (dietary worker) 4, was observed as she presented the "spoken menu" to approximately six patients. All of the patients were informed of the following day's menu and were not offered a choice of entree. The patients were asked whether or not they wanted the food offered, not which of the items they would like. Unless the patient indicated that they would not like the entree, they were not presented with a choice. It was only at this point that DW 4 offered them another entree. Of the two that indicated that they did not want the original entree offered, both were offered the same alternative, grilled chicken. They were not offered a choice of the substitute.

Two of the patients were extremely groggy and dozing off in between questions about the meal. Patients did not receive a copy of the menu to read. Copies of the menu or items that could be ordered from the cafeteria grill were not available in the patients rooms. If patients were not able to participate in the "spoken menu" system, and their families or other representatives are not available at the time, they are not able to make choices for them and patients will be sent the non-select entree. One of the patients that had been interviewed for the "spoken menu" stated in an interview on May 12, 2010 at approximately 9 :30 am, in response to choice and cultural preferences that he would have "liked more Mexican food". He stated he did not know he could have asked for it.

This comment was shared with the CNM to which she replied that the cafeteria usually would have a Mexican entree several times a week. Nurses who provide care were usually the hospital personnel that could offer substitutes if a patient refused a meal. In an interview with one of the nurses on May 12, 2010 at approximately 11:30 am, she indicated that she was not aware that patients could be offered meals from the cafeteria. Information about meals, choices, etc., were not part of patient orientation when they were admitted to the floors, making patients unaware of the choices available to them regarding their meals.

The hospital failed to ensure that state regulations in areas of personnel administration, patient choices and cultural appropriateness in the area of food were followed.

Based on interview and record review, the hospital failed to ensure all hospital departments and contracted services were monitored for effectiveness and safety of service and quality of care. This failure had the potential to result in the quality of services provided not being evaluated and improved by the hospital.

Findings:

During an interview with Staff A, on May 13, 2010 at 11 AM, she stated all departments report Performance Improvement Projects to the hospital's Quality Council. She reviewed the Quality Council Committee Reporting Schedule for January 2010 through December 2010, and the Clinical Quality Management Committee Unit Reporting Rotation Schedule for January 2010 through December 2010, and could not identify when Infection Control or the dialysis contracted services reported ongoing performance improvement projects to the hospital.

The hospital policy and procedure titled "Kern Medical Center Quality Management and Performance Improvement Plan," dated August 2008, indicated, "4) Annually evaluate the effectiveness of the organization's quality management and performance improvement activities, to include but not limited to the following: (b) Evaluate relative usefulness and effectiveness of the process in measuring, assessing and improving the quality of care and services to include by not limited to the following: ... (7) Contract agencies...(9) Reports from the following Committees (ii) Infection Control."

Based on interview and record review, the hospital failed to accurately assess pain and evaluate pain medication effectiveness. This had the potential to result in inappropriate pain management for patients.

1. The clinical record for Patient 4 was reviewed on May 11, 2010 at 10:40 AM. The physician order dated May 7, 2010 at 7:45 AM, indicated "morphine intravenous (in the vein) drip at 2 milligrams per hour, titrate (adjust) to pain. The Patient Care Flow Sheet indicated the morphine drip was started on May 7, 2010 at 11 AM at 8 milligrams per hour, and increased to a dose of 10 milligrams per hour at 6 PM.

During an interview with Staff E, on May 11, 2010 at 10:40 AM, she reviewed the clinical record and was unable to find documentation of a pain assessment on May 7, 2010 from 8 AM through 6 PM. She stated the staff are suppose to document the pain level with every vital sign, (when pulse, respirations and blood pressure are taken), monitor the effectiveness of the pain medication, and document the reason for titrating the dose of the medication.

2. The clinical record for Patient 5 was reviewed on May 11, 2010 at 11:30 AM. The Patient Care Flow Sheets dated May 7 and 8, 2010, indicated the fentanyl (a pain medication) intravenous drip was administered at 150-200 micrograms per hour.

During an interview with Staff E, on May 11, 2010 at 11:30 AM, she reviewed the clinical record and was unable to find documentation of a pain assessment on May 7, 2010 from 7 AM through 7 PM and on May 8, 2010 from 7 AM through 7 PM. She stated the staff are suppose to document the pain level with every vital sign and monitor the effectiveness of the pain medication.

The hospital policy and procedure titled "Pain Management" dated December 2008, indicated "...f. Pain will be rated with each set of vital signs or as needed by patient's condition. g. Patients receiving treatment/intervention (e.g. pharmacological [by medication] or nonpharmacological) will have their pain reassessed within 1/2 hour to determine the effectiveness of the interventions."

Based on observation, interview, and record review, the hospital failed to individualize the care plan for restraint utilization. This failure had the potential to result in incomplete information for the healthcare team and unnecessary continuation of restraint use.

Findings:

1. The clinical record for Patient 4 was reviewed on May 11, 2010. The Interdisciplinary Plan of Care dated May 3, 2010, indicated an active care plan for restraint utilization. The restraint indication and criteria for release from restraints were blank.

During an interview with Staff E, on May 11, 2010 at 10:40 AM, she stated the restraint care plan should be individualized and the blank portions filled in.

2. During an observation on May 11, 2010 at 11:30 AM, in the Intensive Care Unit (ICU), Patient 5 was in bed with a soft restraint applied to her left wrist.

The clinical record for Patient 5 was reviewed on May 11, 2010. The Interdisciplinary Plan of Care dated May 11, 2010, indicated an active care plan for restraint utilization. The 'restraint indication, alternatives have been considered and failed,' and 'criteria for release from restraints' were blank.

During an interview with Staff E, on May 11, 2010 at 11:50 AM, she stated the restraint care plan should be individualized and the blank portions filled in.

3. During an observation on May 11, 2010 at 11:55 AM, in the ICU, Patient 6 was in bed with soft restraints applied to both wrists.

The clinical record for Patient 6 was reviewed on May 11, 2010. The Interdisciplinary Plan of Care dated May 4, 2010, indicated an active care plan for restraint utilization. The intervention for criteria for release from restraints was blank.

During an interview with Staff E, on May 11, 2010 at 12 PM, she stated the restraint care plan should be individualized and the blank portions filled in.

The hospital policy and procedure titled "Restraints: Management of Non Violent, Non Self-Destructive Behavior (Non-Behavioral Health)" dated August 2008, indicated "...E. Plan of Care 1. Restraints use must be included in the patient's plan of care. 2. The Plan of Care will be modified to include... Interventions initiated and goals of interventions...".

Based on interview and record review, the hospital failed to ensure medication orders for pain management were complete and included the medication selected for a specific level of pain, as stipulated in the facility policy and procedure. This failure had the potential to result in inadequate pain management for patient comfort.

Findings:

The clinical record for Patient 4 was reviewed on May 11, 2010. The Medication Reconciliation Form Active Orders dated May 7, 2010 at 7:45 AM indicated morphine sulfate (an analgesic) was to be administered as an intravenous (in the vein) drip starting at 2 milligrams per hour and to titrate (adjust) to pain to a maximum of 20 milligrams per hour.

During an interview with Staff E on May 11, 2010 at 10:40 AM, she stated the level of pain should be included in the physician order.

The clinical record for Patient 6 was reviewed on May 11, 2010. The Medication Reconciliation Form Active Orders dated May 10, 2010 indicated morphine sulfate to be administered as an intravenous drip starting at 2 milligrams per hour and to titrate to pain to a maximum of 20 milligrams per hour.

During an interview with Staff E on May 11, 2010 at 11:55 AM, she stated the level of pain should be included in the physician order.

The clinical record for Patient 7 was reviewed on May 12, 2010. The Physician orders dated May 11, 2010, indicated morphine sulfate 4 milligrams to be given intravenously every 4 hours as needed for pain.

During an interview with Staff F on May 12, 2010 at 9:30 AM, she state there should have been a pain scale associated with the morphine order.

The facility policy and procedure titled "Pain Management" dated December 2008, indicated "...(V.) PROCEDURE: (2.) Physician Orders (c.) Physician Order must include medication, dose, route, frequency, duration, and the medication selected for a specific level of pain."

Based on observation, review of personnel records, hospital policy and procedure, and staff interviews, the hospital failed to ensure that information from patient records was protected from access by unauthorized persons.

Findings:

During the tour of the patient food storage areas on May 12, 2010 at approximately 1:10 PM, on one of the patient floors, a rolled up white paper was observed on a cart in the staff lounge. A review of the paper revealed that it was a Diet Worksheet and there were 2 lists, each five pages long with names of patients. The first list was dated May 7, 2010 and had 17 patients. The second list was dated May 10, 2010 and had 22 names. In addition to the patient names, the diet worksheet had patient room number/bed names, birth dates, ages names of the attending physicians, medical record numbers, another numerical patient identifier, kinds of diets, and allergies.

The Clinical Nutrition Manager (CNM), who was present during the observation, stated that the list was generated for use by the Patients Service Associates (PSA) whose responsibilities included passing out patient meal trays. The assistant director of housekeeping was interviewed on May 12, 2010, at approximately 1:50 PM about training provided to the PSA regarding the disposal of the list upon conclusion of the task. He stated that he was not sure of the content of the HIPPA training PSA 1 may have received, because she had been hired before his company took over the department. He could not specify what instructions the PSAs may or may not have received regarding the disposal/ storage of the lists.

The PSA who was responsible for that patient area (1) was interviewed on May 12, 2010 at approximately 2:05 PM. She stated that she had placed the lists on the cart because she did not know what to do with the list when she was done passing out the trays. She further stated, regarding patient confidentiality, that she had not been concerned because the cart was in the staff lounge and not in a public area. She stated she had not been told what to do with the list when she was done.

Another PSA (2) was interviewed on May 12, 2010 at approximately 2:21 PM. PSA 2 stated that she shreds the lists when she is done passing out the trays. Review of the job description/specification and personnel record for PSA 1 indicated HIPPA training. Job specifications did not state what to do with lists.

The hospital failed to ensure that patients' information was properly stored/disposed in a manner to prevent unauthorized access. The department lacked the development of a policy that directed the employees in the proper disposal of patient information.

Based on interview and record review, the hospital failed to obtain competences for their pharmacist staff to ensure the safe administration of medications in circumstances where pharmacists calculate and adjust doses, with the potential for providing unsafe and ineffective treatment.

Findings:

On May 11, 2010 at 9:23 AM, the Pharmacist Supervisor stated all pharmacy staff were competent to provide clinical services for the following medications: warfarin (blood thinning medication), heparin (blood thinning medication), low molecular weight heparin (blood thinning medication), and renal dosing (adjust doses to reduce potential for toxicity for patients that have poor kidney function). The pharmacists were currently providing these clinical services which involve calculating, adjusting doses, and providing safe and effective treatment. When the Pharmacist Supervisor was asked to provide documentation to demonstrate staff pharmacists were competent to provide these clinical services, he was unable to provide documentation that the staff had been examined annually for competency in adjusting doses of medications or initiating drug therapy for these clinical services under approved protocols.

On May 11, 2010 at 9:35 AM, during the interview with Pharmacist A, stated the annual competency examination had been developed. However, it was not yet fully implemented. The examination would still need to be put into the testing program, according to Pharmacist A.

Pharmacists were providing clinical services without supervision and documentation that ensured they were competent in providing these services.

ASHP (American Society of Health-System Pharmacists) has published, "Guidelines on Preventing Medication Errors in Hospitals," approved June 23, 1993, which states that policies and procedures should be developed which ensure proper evaluation of competency and supervision.

Based on observation, interview and document review, the hospital failed to maintain temperature monitoring for three refrigerators containing temperature-sensitive medications, located in the inpatient pharmacy, Sagebrush pharmacy and the drug storage area of the obstetrics and gynecology (OB/GYN) clinic. Temperatures registering outside the manufacturer's recommended range could result in loss of integrity and potentially harm patients by not providing the expected therapeutic effect.

Findings:

1. On May 11, 2010 at 1:15 PM, during an inspection of the inpatient pharmacy, Refrigerator No. 324 was located in the buyer's office. Numerous temperature-sensitive vaccines and protein-based drugs were found inside. Among the medications found were RhoGam 300 ug, Hepatitis B vaccines, Prostin VR pediatric 500 mcg and Survanta 8 ml. All of these medications were required to be kept in a tight temperature range between 36 degrees Farenheit (F), and 46 degrees F according to the manufacturers' guidelines to ensure effectiveness. Review of the first four months of 2010 temperature logs for Refrigerator No. 324 revealed that temperature monitoring was not consistently carried out by staff and was missing on the following dates: January 20 to 25, March 27 to 31, April 1 to 5, and April 16 to 19, 2010.

According to the hospital policy on refrigerator/freezer temperature logs for vaccinations, "...refrigerator contains vaccinations, temperature will be logged twice daily on the refrigerator/freezer temperature log (vaccines)."

Interview with the Pharmacy Supervisor, he acknowledged the temperatures for Refrigerator No. 324 should have been monitored on those days, and he was not sure why they were not being done.

2. On May 10, 2010 at 3:25 PM, inspection of the drug storage area of the OB/GYN area of the medicine clinic revealed Hepatitis B vaccines in the refrigerator. Review of the February 2010 temperature log indicated missing temperature records for the following dates: February 11, 12, 17, and 26, 2010.

During interview with the Pharmacy Director, she acknowledged that the hospital's policy and procedure on refrigerators would apply to those in the medicine clinic in which temperatures in refrigerators that contain vaccination must be verified twice daily.

3. On May 12, 2010 at 5:20 PM, during a tour of the Sagebrush main pharmacy, the pharmacy Refrigerator No. 95 was noted to have a reading of -12 C according to the temperature wheel on the outside. At the same time, the digital display was showing 3.6 C. When the Pharmacist in Charge was asked about the discrepancy between the two readings, she stated she was not aware of the issue since they had not been using the temperature wheel as reference for some time. However, she agreed to contact maintenance to have this issue resolved.

Review of the February 2010 temperature log for Refrigerator No: 95 revealed temperatures were not monitored on the following dates: February 2, 2010 and February 4, 2010 as required according to the hospital's policy and procedure on refrigerator/freezer temperature log.

Based on interview and record review, the hospital failed to ensure competency assessments were validated by laboratory personnel for Respiratory Therapists performing arterial blood gas analysis. This failure had the potential for inaccurate measurement of blood gases, affecting patient care.

Findings:

During an interview with Laboratory Manager (LM) on May 13, 2010 at 8:10 AM, he stated Staff B had worked with the Respiratory Therapy Department to validate the competency for Respiratory Therapy Clinical Coordinators who, in turn, validated the competency of the hospital respiratory therapists to perform arterial blood gas (ABG) analysis in the Neonatal Intensive Care Unit (NICU). LM stated the laboratory personnel should oversee the competency validation process for Respiratory Therapy.

During an interview with Staff B on May 13, 2010 at 9:25 AM, he stated he had not been involved in competency validations for Respiratory Therapy since 2008.

During an interview with Respiratory Therapy Manager (RTM) on May 13, 2010 at 9:40 AM, he stated Respiratory Therapists perform ABG measurements in the hospital's NICU. He stated staff competency to perform the test was validated on an annual basis by the Respiratory Therapy Clinical Coordinators. RTM stated the Respiratory Therapy Clinical Coordinators competency was validated by laboratory personnel but he could not find any documentation of such validation.

The NICU Respiratory Therapist Skills Checklist for Staff C was reviewed on May 13, 2010. The skills checklist was dated April 7, 2010, and indicated "ABG Machine" skills are marked as completed and evaluated by Staff D, a Respiratory Therapy Clinical Coordinator.

Based on observation, review of hospital policy and procedures, manufacturers' instructions, and staff interviews, the hospital failed to ensure that dietary employees were competent in accurately testing the chemical concentration of the sanitizing buckets and three-compartment sink. Food service workers also failed to practice proper infection control procedures by preventing contamination of sanitized food service equipment.

Findings:

1. On May 10, 2010 at approximately 1:57 PM, a red sanitizing bucket was observed stored on the lower shelf underneath the hand washing sink in the grill area. The red bucket had a cloth soaking in the clear solution in the bucket. The food service worker (FSW) 1 that was present was interviewed at approximately 1:58 PM on the use and preparation of the solution. She stated in the interview that she had not prepared the solution and that another employee had. But that she used the rag to wipe down countertops. When she was asked to test the sanitizer she stated, "Why should I test it. I have never tested it before."

After instructions from the director of food service, FSW 1 and the director both tested the solution. Using test strips, one was immersed in the solution for approximately four seconds the first time and a second strip was immersed for about seven seconds, time with no change in the color of the test strips either time. The solution was discarded and new solution was added to the bucket. The Food Service Director (FSD) stated that the sanitizer was Quaternary Ammonium ("quat.").

On May 11, 2010 at approximately 11:10 AM, another food service worker (FSW 2) was asked to test the sanitizer in the pots and pan sink. Using the test strips, FSW 2 tested the sanitizing solution three times, with immersion times ranging from five to seven seconds. FSW 2 was asked how long she needed to leave the test strip in the sanitizer. Reading off the poster adjacent to the pots and pans sink, she stated, "10 seconds." However, she continued to immerse and remove the test strip before the appropriate time had elapsed.

FSW 2 did not wear a watch and was not observed to look around the kitchen for a clock or other time measuring devices to determine the appropriate time to keep the strip in the solution. There was no color change observed on the strip until she was told to leave the test strip in the sanitizing solution for approximately 10 seconds with the surveyor counting off the seconds.
Review of the manufacturer's instructions on the test strip container indicated that the strip was to be immersed in the solution for ten seconds. Neither of the food service workers followed manufacturer's instructions on the required length of time to properly test the sanitizing solution. Review of facility policy and procedure (P/P) on May 13, 2010 indicated the P/P entitled "Sanitizing Food Contact Surfaces," outlined the procedures of testing the quaternary ammonium compound solution. The P/P described the appropriate concentrations that should be achieved depending on the strip used. The P/P did not discuss the length of time that was required to accomplish the test.

Another food service worker stated in a concurrent interview that she had not been taught to count off the seconds while leaving the strip immersed in the solution.

2. On May 10, 2010 at approximately 2:10 PM, a food service worker (FSW 3) was observed unloading dishes off the washer conveyor belt in the dish room. She had a stack of trays and was observed wiping the trays down with a towel. In an interview at that time, with the FSD present, she stated that the trays come out of the machine wet, so she dries the trays to "prevent patient tray mats (paper) from sticking" to the trays. In the same interview, she was asked how long the practice of wiping down trays had been occurring. She stated that she had worked in the hospital for 11 years and that she had always wiped down the trays.

The FSD stated that that was not the correct practice. A review of the P/P titled "Dishmachine temperatures" was conducted. The policy states, "All silverware, trays, dishes, etc must be air dried. These items may not be towel dried." Section 4-901.11 (A) and (B) of the 2009 Food Code, Equipment and Utensils, Air-Drying Required states, "After cleaning and sanitizing, equipment and utensils (A) Shall be air-dried or used after adequate draining .......; and (B) "May not be cloth dried...."
The use of the cloth after the sanitizing process could introduce dirt and possibly microorganisms that could contaminate the already cleaned and sanitized surface. The FSW failed to follow hospital policies.
The hospital staff failed to ensure that its staff were competent in testing chemical sanitizers and knowledgeable in infection control procedures by avoiding the use of cloth in drying sanitized food service equipment.

Based on observation, review of menus, staff interviews, and review of hospital documents, the hospital failed to ensure that its menu met the needs of its patients, and that substitutes provided were of equal nutritional value to meet the basic nutritional needs of the patients.

Findings:

1. According to the menu on May 11, 2010, the patients were to receive the following: Pork roast with pineapple salsa, 1/2 cup sweet potatoes and Scalloped apples, 1/2 c green beans amandin, dinner roll, margarine, triple chocolate cookie. During the tray line observation at approximately 11:25 am, Food Service Worker (FSW) 3 was observed serving portion sizes that appeared less than what the menu called for. For example, the patients were served one piece of sweet potato approximately 1 x 1/2 inch and two pieces of sliced apples. Tongs were used to serve the green beans.

FSW 3 was interviewed on portion sizes for the food that had been served and was asked especially about the sweet potato. She stated that it was 4 ounces and proceeded to weigh 4 ounces of sweet potato on the scale. Vegetables were to be measured by volume and not by weight. Review of the production menu indicated the amount and the serving utensil to serve the vegetables. The serving size was to have been a 1/2 cup scoop.

The registered dietitian was interviewed on what correct amount of food the patients should have received, and to clarify if the vegetables should have been weighed or measured. She concurred that the food should have been measured. The food service worker did not serve patients the correct amount of food, thereby providing less nutrition than was planned by the dietitian or ordered by the physician.

2. At approximately 11:30 AM on May 11, 2010, a note posted in the kitchen was reviewed. The memorandum dated April 13, 2010 titled "New Continental meals for Patients" indicated that patients who did not have their food before 9 AM (due to various reasons ranging from advancement from NPO (nothing by mouth) or from liquids to solids, or tests being done), would be served late trays and that these late trays would consist of cereal, milk and fruit. The memorandum further stated that for patients who did not have meals ordered before 1 PM would receive a late lunch tray. This late tray would consist of a soup and sandwich. This memorandum was signed by the registered dietitian and Food Service Director (FSD).

The items served for both late breakfast and late lunch were significantly lower in nutrition than the meals these patients would have received had they been served breakfast or lunch. For example, the breakfast late tray did not have a main source of protein. The approximate calories from a continental breakfast was 230 calories, and 10 grams (gm) protein. Review of the nutrient analysis for breakfast indicated that the protein content on a regular diet was supposed to be between approximately 24.8 and 39 gm per meal. The calories should have ranged from 687 calories to 904 calories.

The nutrient analysis revealed that the calories and protein from lunch should be approximately 643 to 877 calories and 18.8 and 35.3 gm of protein. The approximate calories from the late tray lunch would be about 350 calories and 14 gm of protein.

The Registered Dietitian and FSD were both interviewed regarding the changes made to the late lunch policy. They both stated that it was to prevent waste on patient units from the excessive amount of cold boxes sent to patient pantries. No explanation was given for why the nutrient content was not comparable to that of the main meals. Review of pharmacy and therapeutic minutes from 2010 did not reveal a discussion of the changes.

The hospital failed to ensure that the menu was nutritionally balanced and met the needs of the patients.

Based on observation, review of documents, and staff interviews, the hospital failed to ensure that therapeutic diets were ordered appropriately by the attending physicians. Physicians ordered non-specific or out-dated diets and were not educated on new therapeutic diets. Instead, the food and nutrition staff interpreted the diets and served the diets without physician's orders.

Findings:

Review of the hospital menu revealed that one of the therapeutic diets served was the consistent carbohydrate diet. The consistent carbohydrate (CC) is the diet prescribed to patients who are diabetic. This diet is consistent with the 2002 recommendations and position statement of the American Diabetes Association in which it recommended that the term "ADA diet no longer be used, since ADA no longer endorses any single meal plan or specified percentages of macronutrient..."(Diabetes Care Vol 25, Supplement 1, January 2002).

Although the CC diet is available in the hospital diet manual, the hospital resource for diet ordering, some of the hospital physicians have continued to order the ADA diet. Review of clinical records showed that Patient N2 was admitted on May 4, 2010 with diagnoses including acute pyelonephritis (kidney infection), diabetes mellitus and cerebral vascular accident (stroke). His physician diet order was 1800 calorie ADA. Patient N3 was admitted on May 10, 2010 with diagnoses including uncontrolled diabetes, dehydration and UTI (urinary tract infection). His physician-ordered diet was 1800 kcal (calorie), low salt diet.

The Clinical Nutrition Manager (CNM) stated in an interview on May 11, 2010 at approximately 9:30 AM that the patients were not served the ADA diet but a CC diet. She shared the hospital policy titled "Diet Order" which described how the food and nutrition Department interpreted "incorrect diet terminology." The 1800 calorie ADA diet was under the classification of a non-specific nutrition order. Under this policy, patients would be served a 195 gram CC diet, not an 1800 calorie diet.

In response to a question why physicians were not provided the education on ordering the proper diet, she stated that it was not going to be beneficial as the new electronic medical record system being proposed for use in the next few months had the same incorrect terminology (ADA diet.). She stated that the hospital had been informed that changes in the new electronic medical record system related to updating diet orders to match the current up-to-date terminology of "CC" could not be accommodated. This practice of ordering outdated diets to match a computer system is not consistent with current practices and not beneficial to patients or physicians and medical students being trained in the hospital.

Other diets being ordered included the low sodium, renal cardiac and heart healthy diets. When these diets were ordered, the food and nutrition department also provided a different diet. For example, the patient on a renal diet would be provided a 70 gram protein, 2-3 gram sodium, 2-3 gram potassium diet.

Based on observation, review of menus, staff interviews and review of hospital documents, the hospital failed to ensure that nutritional needs of its patients, and the food substitutes provided were in accordance with recognized dietary practices.

Findings:

1. At approximately 11:30 AM on May 11, 2010, a note posted in the kitchen was reviewed. The memorandum dated April 13, 2010 titled "New Continental meals for Patients" indicated that patients who do not have their food before 9 AM (due to various reasons ranging from advancement from NPO [nothing by mouth], or liquids to solids, or due to tests will be served late trays and that these late trays will consist of cereal, milk and fruit. The memo further stated that for patients who do not have meals ordered before 1 PM will receive a lunch late tray. This late tray would consist of a soup and sandwich. This memorandum was signed by the registered dietitian and Food Service Director (FSD).

The items served for both breakfast and lunch were significantly lower in nutrition than the meal these patients would have received had they been served breakfast or lunch. For example, the breakfast late tray did not have a main source of protein. The approximate calories from the continental breakfast was 230 calories and 10 grams (gm) protein. Review of the nutrient analysis for breakfast indicated that the protein content on a regular diet should be between 24.8 to approximately 39 gm per meal. The calories ranged from 687 kcal (calories) to 904 calories.

The nutrient analysis revealed that the calories and protein from lunch were approximately 643 to 877 calories and 18.8 to 35.3 grams of protein. The approximate calories from the late tray lunch should be about 350 calories and 14 gms of protein.

The Registered Dietitian (RD) and FSD were both interviewed on the changes made to the late lunch policy. They both stated that it was to prevent waste on patient floors from the excessive amount of cold boxes sent to patient pantries. No explanation was given for why the nutrient content was not comparable to that of the main meals. Review of pharmacy and therapeutic minutes from 2010 did not reveal a discussion of the changes.

The hospital failed to ensure that the menu was nutritionally balanced and met the needs of the patients.

2. Clinical record review of Patient N1 revealed that he was an eight month old infant admitted to the hospital on May 12, 2010 with diagnoses of croup, r/o retropharyngeal (throat) abscess. According to the hospital policy and procedure on nutritional screening, the registered nurse was responsible for screening patients using a set of criteria. For pediatric patients, one of the criteria is whether or not the child's weight was appropriate. If the child's weight is not appropriate, a referral is made to the RD for further assessment.

For children under the age of two, the CDC growth chart is the common assessment tool used to determine whether a child's weight and height are appropriate for their age, underweight or overweight. It is unclear whether the hospital's assessment included weight/height assessment or only weight for age. According to the screening tool in the health record, the nurse documented that Patient N1's weight was appropriate. There was no growth chart present in the chart and it was unclear how the nurse may have made the determination.

The Clinical Nutrition Manager (CNM) who was present stated on May 13, 2010 at approximately 9:25 AM that a growth chart should have been used in the determination of weight for age appropriateness. The screening criteria weight-for-length <5th percentile measures underweight, thinness or wasting. Underweight is used as an indicator for acute malnutrition, recent starvation, persistent diarrhea or both, (www.cdc.org). The child's weight was recorded as 8.165 kilograms (kg) and height as 75 centimeters (cm). Using the the year 2000's CDC growth chart, Patient N1 was below the 5th percentile for weight-for-length and therefore was underweight based on the assessment tool. The patient should have been referred to a registered dietitian based on the height /weight documentation. Visual observation however, did not support this assessment. It revealed the child to be plump and did not appear underweight or malnourished. As a result of the visual observation, the surveyor requested that the child be re-weighed.

On May 13, 2010, at approximately 2:58 PM, the child's weight was found to be 8.4 kilograms and the length was 70 centimeters, (5 less centimeters than he had actually been documented.) The use of a growth chart would have correctly identified the inaccurate measurement. The hospital's system of screening without the use of a growth chart could result in inaccurate screening, and therefore delay assessment of children that could benefit from nutrition intervention.

Based on observation and interview, the hospital failed to maintain the hospital environment to ensure the safety and well being of patients and the public.

Findings:

On May 13, 20010 at 9:30 AM, during an environmental tour and inspection of the hospital:

1. A handrail observed on the wall just inside the door to the Intensive Care Unit was found to have a loose section that posed a pinching hazard. Also, if the section of handrail did not support the weight of a person using it, a fall could result. When shown this section of handrail, the POS said it should be repaired.

2. Outside the Emergency Department, 24 dirty and bloody paramedic backboards were observed propped against the wall outside the ambulance entrance and inside a small storage shed next to the ambulance entrance. No structure supported the backboards, (other than for the 4 located inside the shed), and they posed a hazard for toppling over. The backboards were located in an area that was not shielded from foot traffic, and could pose a danger of falling toward anyone touching or bumping into them.

3. A decontamination room located just inside and to the right of the ambulance doors was observed to be cluttered with equipment. Equipment would need to be removed before decontamination in this room could be performed. By not having immediate access to the room, delay could occur in cleaning off a contaminated patient.

4. A threshold to the hospital near the Magnetic Resonance Imaging (MRI) trailer was observed to have a plastic or rubber mat attached to the floor. This mat was curling up on one end, posing a trip hazard.



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5. Observations made on May 12, 2010 and May 13, 2010 revealed patient pantries and employee lounges in need of cleaning. There were food debris in the three of six drawers on the fourth floor employee lounge. For example, there was a dirty apple corer, with a piece of dried, brown substance on it. There was a rusted dirty can opener. There was a dirty food cart used for patient food storage with a dried-on, brown colored spill. The microwave in this area was dirty. The interior was stained with food and was brown colored, the glass tray had dried on, caked-on food.

In other areas of the hospital, patient food pantries had crumbs and other food debris in them.

The assistant director of housekeeping was interviewed on May 12, 2010 regarding house keeping responsibilities. He stated that the housekeeping staff was responsible for cleaning all the horizontal space and exterior of the pantries and employee lounges and that nursing was responsible for the interior of the microwave ovens.

One of the Patient Service Associates (PSA) 1 responsible for cleaning the floor was interviewed on May 12, 2010 at approximately 2:07 PM. She stated that the kitchen staff cleaned the patient refrigerators and she cleaned counter tops, etc., in the patient pantry areas. In response to cleaning the drawers in the patient pantries and employee lounges, she stated, "I do not mess with that." Review of the duty list for the position of PSA 1 was conducted on May 12, 2010. The duty list revealed a "10 step interactive cleaning" among other duties for the PSA position. The list required the PSA to empty waste receptacles, high dust above high level 2 times per week, sanitize all horizontal surfaces, spot clean all vertical surfaces, clean the restroom, dust mop the floor, inspect the room, damp mop the floor. The two other steps were to interact with patient, guest or customer.

According to the duty list, the PSA had 30 minutes to complete the 10-step process in nine rooms, of which the employee lounge was part on the fourth floor. This list allowed less than three minutes per room and did not include opening drawers for cleaning.

The hospital failed to ensure that all areas of the hospital were maintained in a sanitary manner.

Based on observation, staff interviews and review of hospital documents, the hospital failed to ensure that it implemented an effective food safety system (HAACP) that would minimize growth of microorganisms and food borne illness during the cooling process of food production for its patients and personnel; the hospital failed to ensure that its policies on sanitizing the ice machines were consistent throughout the various departments; the hospital failed to maintain a sanitary physical environment that would minimize exposure to blood born pathogens on ambulance backboards propped outside the emergency department; the hospital failed to protect food being served on the cafeteria tray line from possible debris falling into it from ceiling breakdown.

Findings:

1. During the tour of the hospital kitchen on May 10, 2010 at approximately 2:57 PM a cart was observed in the walk-in refrigerator. Stored on the cart were three trays of cooked meat. Each tray had two or three roasts of varying sizes. The cart was not labeled or dated. The interview with the food service supervisor who was present during the observation indicated that the meat was roast pork, the menu entree item for lunch the following day. The trays were lukewarm and as such the hospital cooling procedure and supporting documents were requested.

The executive chef (EC) was also interviewed on the hospital cooling procedures. He stated that the pork was placed in the refrigerator at approximately 11:30 AM. He denied the presence of a cooling log. He was not able to produce documented evidence that the hospital had a system in place to monitor proper cooling.

After three and three quarter hours of refrigerated storage, the temperature of the pork roast was as follows: 79.9 degrees F (Fahrenheit), 80.2 degrees F, 67.6 degrees F, 65.6 degrees F, 72.1 degrees F, 78.0 degrees F, 86.3 degrees F and 90.1 degrees F.

According to Section 3-501.14 of the 2009 Food Code. (A) Cooked potentially hazardous food (time/temperature control for safety food) shall be cooled: (1) Within 2 hours from 57 degrees C (centigrade), (135 degrees F) to 21 degrees C (70 degrees F); and (2) Within a total of 6 hours from 57 degrees C (135 degrees F) to 5 degrees C (41 degrees F) or less. It is unclear whether any of the roasts met the required temperature in the first two hours.

The EC and Food Service Director (FSD) both indicated that they had planned to implement a food safety system to document proper cooling but had not been able to execute it due to inadequate staff. Review of the hospital's policy and procedure titled, "Production, Purchasing and Storage" was reviewed. It indicated that food needed to be cooled following the same principles described in the Food Code. However, the temperature range was slightly different. It reflected the outdated (2001 Food Code) principle requiring food to be cooled from 140 degrees Fahrenheit instead of the present 135 degrees Fahrenheit.

The meat was later discarded. The hospital failed to follow acceptable food safety standards on proper cooling of food. Food left in the danger zone (41 to 135 degrees Fahrenheit support the growth of micro organisms that could cause harm especially in the susceptible hospital population with compromised immune systems).

2. A review of the nursing department's policy (P/P), titled Cleaning Schedule for Patient Care Equipment, was reviewed on May 11, 2010. Included in the policy was a cleaning schedule for patient care equipment including cleaning ice machines. It revealed the use of a disinfectant (Product 1) for cleaning both the internal areas and drains under the ice machine. It identified the engineering staff as responsible for the cleaning.

In an interview with the food and nutrition department dietary supervisor on May 11, 2010 at approximately 8:40 AM, she indicated that the interior of the ice machine was to be cleaned with a quat (iodine based) sanitizer and the exterior was to be cleaned with a multi-purpose cleaner. The P/P provided supported the practice described by the supervisor. The FSD further stated in a concurrent interview that the engineering staff does quarterly cleaning and sanitizing of the internal components not accessible to dietary staff.

On May 12, 2010 at approximately 10:41 AM, the engineering supervisor was interviewed on his department's procedure of cleaning the ice machines. He stated that the sanitizer used was Product 2, a sanitizer specially designed for ice-machines. He denied the use of Product 1, (Product 1 being a disinfectant according to the manufacturer that is appropriate for external surfaces and non-food contact surfaces). This product would not be appropriate for the internal cleaning of the ice machines as described in the nursing P/P.
The hospital failed to ensure that its policy reflected and was consistent with its practices and policies of other departments performing the same infection control activities.



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3. During an environmental tour conducted with the Plant Operations Supervisor (POS) on May 13, 2010 at 9:45 AM, the cafeteria tray line was observed. The ceiling over this area showed signs of breaking down, with fiber showing in some places, and an overall blistering/swelling appearance to the surface. This potentially could cause debris to drop into the food below, exposing staff and the public to contaminated food.

4. During the environmental tour conducted with the Plant Operations Supervisor on May 13, 2010, the area right of the ambulance doors leading into the Emergency Department (ED) were observed to have 24 dirty and bloody paramedic backboards propped against the outer wall. Some of the backboards were contained in a small plastic shed with its doors open. On the floor of the shed was a tangle of strapping used to secure patients to the backboards. These items were all unsecured from public or staff and could be touched by anyone passing by, posing a contamination risk.