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Based on observation, interview, and record review, the facility failed to:

1. Take reasonable procedural and/or physical privacy safeguards to reduce incidental disclosures of patients' protected health information (PHI);
2. Secure names of patients seeking treatment in the Rural Health Clinic from being easily accessed as per facility policies and procedures.

These failures had the potential to result in PHI being unprotected.

Findings:

1. During an observation of the medical records counter in the hospital lobby and interview with the Health Information Management Technician (HIMT), on 11/4/19, at 1:00 PM, transactions with multiple walk-in patients, including hospital employees, were observed being conducted in a public, high traffic area serving as a main entrance to the hospital. Behind the desk was the Security Department and immediately adjacent to the counter was a workstation occupied by a Security Officer. The HIMT stated the procedure is for the technician to verbally ask the patient requesting medical records for information, such as full name, date of birth, date of service, and the specific type of information requested, which often included the complaint, problem, and diagnoses of the patient. The HIMT stated there is a need to better safeguard patients' protected health information.

During an interview with the Health Information Management Director (HIMD) and Health Information Management Manager (HIMM), on 11/6/19, at 10:15 AM, both acknowledged the need to better safeguard patients' protected health information.

During a review of the hospital's policy and procedure titled "Patient Privacy Administration and Compliance Requirements" dated 8/28/2017, indicated "Process. . . Section IV. Safeguards: A. It is the responsibility of each member of the District workforce to prevent intentional and unintentional use or disclosure of patients' protected health information. B. Each Department shall follow the safeguards established by Information Systems policies including Information Security Administration, Physical Access Control Procedure, Network Security, Data Integrity Controls and Logical Access Control. Department Directors shall implement additional department-specific policies as may be necessary to protect patient privacy in their own department."

2. During an observation and interview with the Clinical Manager of Rural Health Clinic (CMRHC), on 11/6/19, at 9:50 AM, the CMRHC stated, "We have between seven and eight thousand patient visits monthly. The clinic has a cleaning service every night." The Patient Access Specialist (PAS) was observed writing a patient's name, date of birth, and medical record number on a dated sheet of computer paper. PAS stated she and another employee who assists patients to register to be seen fill out these papers each day. PAS stated, "By the end of the day, these computer papers are filled with patients' names seen that day." PAS showed where these papers are stored: in an open (no door) cabinet in the reception area, approximately five feet from the floor (easily seen). PAS stated, "These papers are kept here for 30 days and then we shred them." The stack of computer papers with names, dates of birth, and medical record numbers was measured by the CMRHC and she stated it measured five inches thick. The top paper had the date 11/5/19 and the bottom sheet of paper was dated 9/21/18. The CMRHC stated, "I guess they are not shredded every month." The CMRHC verified these papers were easily accessible to anyone in the clinic, including the nightly cleaning service. CMRHC stated, "They should be secured with a lock instead of being so available."

During a review of the facility policy and procedure titled "Confidentiality Securing and Integrity of Health Information" dated 8/26/19, it indicated "Purpose: To ensure the confidentiality, integrity, and availability of all Protected Health Information/electronic-Protected Health Information (PHI). . . 'Health Information' is patient information gathered during examination treatment from any media. Patient Health Information is confidential and shall only be accessed and/or released in accordance with [hospital] policy and State and Federal laws governing release of information. . . II Access to patient identifiable information shall be granted by job title or function to the minimum level of access necessary to perform the required job and/or to provide patient care. . . XI. PHI shall be secured against loss, destruction, unauthorized intrusion, corruption, or damage. . ."

During a review of the facility policy and procedure titled "Access and Release of PHI" dated 8/26/19, it indicated "Policy: I. It is the legal and ethical responsibility of all [hospital] staff, volunteers, residents, physicians, and affiliates to protect the privacy and confidentiality of patients' PHI. . . II. Accessing, disclosing, or communicating PHI not associated with your job responsibility is considered a violation . . . PHI will be maintained with appropriate physical and electronic security to prevent unauthorized access. . ."

Based on interview and record review, the facility failed to ensure there were distinct performance improvement projects proportional to the scope and complexity of the facility's Food and Dietetic Service. There were several deficient practices in the food service operations identified during the survey from 11/4/19 to 11/6/19. The facility had not implemented an effective ongoing performance improvement program to self-identify and effectively address concerns in the food and nutrition services. (Cross Reference A620, A621 and A713)

This failure allowed the deficient practices observed during the survey to continue without remediation and put patients at risk of compromised nutritional status and food borne illness.

Findings:

During a review of the job description for the Director of Food and Nutrition Services, it stated the position was responsible for both the food service and clinical nutrition program for the downtown hospital campus and the rehabilitation hospital campus.

During an interview with the Director of Food Nutrition Services (DFN), on 11/5/19, at 11:00 AM, the DFN described his role as director over the Food Service operation and clinical nutrition hospital wide which included two off-site food service and clinical nutrition operations. DFN stated there were three performance improvement projects which were all clinical nutrition areas. DFN did not present any performance improvement projects which reflected the scope of the food service operations.

During an interview with the Clinical Nutrition Manager (CNM), on 11/6/19, at 1:10 PM, she was unable to provide documentation of a performance improvement program from the quality meeting. CNM stated that she had been tracking data on timeliness of nutrition assessment completions by the clinical dietitians. However, the CNM stated she had only collected the data on timeliness and had not written a plan for improvement or presented this to the quality improvement committee.

During an interview with the CNM and record review of the data collected, on 11/6/19, at 2:35 PM, the CNM stated the Food and Nutrition Services Department began data collection in April 2019 on timeliness of nutrition assessments by the dietitians, but she had not analyzed the data. The CNM further stated tracking the timeliness of nutrition assessment completions by dietitians would be useful information for the department to monitor. In addition, the CNM stated that she noticed a trend of late nutrition assessments completed on Mondays, indicating inadequate clinical dietitian staffing on weekends. She stated that she was discussing possible solutions for this trend, but had not developed or implemented a plan at the time of the interview.

Based on interview and record review, the facility failed to follow its policy and procedure related to staffing nurse-to-patient ratio. This failure had the potential to result in unmet nursing care needs.

Findings:

During an observation of the hospital's telemetry-medical surgical floors and interview with 2 South Nurse Manager (2SNM) and 4 South NM (4SNM), on 11/4/19, at 10 AM, there were two floors out of state-mandated ratio of one nurse for four patients if telemetry (portable, continuous heart monitoring for the patient) had been utilized. 2SNM stated one nurse on her floor had been assigned to care for five patients, one of which was on telemetry. 2SNM stated she was aware her floor was out of ratio. 2SNM stated she had not notified the nursing office nor had she requested more staff in order to maintain ratio. 4SNM stated she was aware her floor was out of ratio, as one nurse on her floor had been assigned five patients, one of them on telemetry.

During a review of the facility policy and procedure titled "Staffing and Scheduling Protocols" dated 4/24/18, it indicated ". . . B. Responsibility for staff schedules rests with the nurse manager or designee. . . E. Staffing guidelines . . . 1. An acuity tool will be used to classify each patient daily. Staffing recommendations from the tool will be used in conjunction with mandated staffing ratios to establish daily staffing. . . J. Nurse managers utilize one of the following methods in the development and management of staffing guidelines: . . . 2. Allocation of staff based on mandated ratios. . ."

During a review of California Title 22, 70217 (a) 10, dated 2017, it indicated "The licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. 'Telemetry unit' is defined as a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients . . ."

Based on observation, interview, and record review, the facility failed to:

1. Follow manufacturer's directions regarding the distance a patient stood from a visual acuity chart (used to test vision). This failure had the potential to negatively affect visual acuity assessments.
2. Ensure registered nurses evaluated the nursing care for oneof 47 sampled patients (Patient 13) when daily weights were not monitored as ordered by the physician. This failure resulted in unknown weight shifts for Patient 13, with possible fluids retention changes that went undetected and had the potential to affect the overall medical status of the patient.

Findings:

1. During an observation of the hospital's Urgent Care Center and interview with the Licensed Vocational Nurse Clinical Supervisor (LVNCS) and the Urgent Care Director (UCD), on 11/4/19, at 2:20 PM, an "Eye Test Chart For 10 feet" was posted on a wall. The LVNCS stated it was utilized to assess visual acuity was checked any time vision could be impacted, such as after head or eye trauma or a chemical spill into the eyes. The LVNCS stated, "This is a ten foot chart [a patient should stand ten feet from the chart for accurate assessment]." He verified there was no ten foot marking on the floor to indicate where a patient being tested was to stand to read the chart's letters. LVNCS stated the staff LVNs tested patients' visual acuity routinely.

During an observation and interview with LVN 1, on 11/4/19, at 2:35 PM, she stated she tests patients' visual acuity "several times a week." LVN 1 identified where she instructs patients to stand prior to testing visual acuity. The distance was measured by the UCD and LVNCS to be 13 feet from the eye test chart.

During an observation and interview with LVN 2, on 11/4/19, at 2:35 PM, she identified where she instructs patients to stand before testing for a visual acuity. LVNCS and UCD measured the distance to the eye test chart to be 10 feet 11 inches.

During an observation with the UCD and LVNCS of the Urgent Care Overflow Area, on 11/4/19, at 2:45 PM, another eye test chart was posted, again with no indication on the floor where a person undergoing the visual acuity test was to stand. The UCD indicated on the floor where he would position a patient to test for visual acuity. It was measured by the UCD and LVNCS to be 9 feet 10 inches from the eye test chart.

During an observation and interview with LVN 3, on 11/4/19, at 2:45 PM, she identified where she instructs the patient to stand when she tests for visual acuity. The UCD and LVNCS measured the distance to be 13 feet from the eye test chart.


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2. During a review of the clinical record for Patient 13, on 11/4/19, at 12:15 PM, the history and physical (H & P) dated 10/27/19 indicated Patient 13 was admitted to the hospital on 10/27/19 with diagnoses which included Type 2 Diabetes (a chronic condition affecting the way the body processes blood sugar) and acute hypoxic respiratory failure (difficulty breathing with low blood oxygen levels) secondary to congestive heart failure (CHF) exacerbation (a chronic progressive condition that affects the pumping power of the heart muscles. The H&P indicated the plan of care for Patient 13 included daily weight monitoring. The initial nursing assessment, dated 10/27/19, indicated Patient 13's weight was 60.6 kilograms (133.6 pounds). There were no weights for Patient 13 documented after the initial assessment.

During an interview with the Quality Manager (QM), on 11/4/19, at 12:20 PM, the QM verified there were no follow-up weights in Patient 13's clinical record.

During a review of the clinical record for Patient 13, the weight documentation dated 11/4/19, at 6:55 PM, indicated his weight was 55.5 kilograms (122.4 pounds). This represented an 11.2 pound weight loss in eight days, which was not being monitored.

During a review of the facility's Standard of Care SOC-4T1 for Nursing dated 2/5/19, it indicated for patients with a diagnosis of health failure "The RN (registered nurse) is responsible for interventions. . . (including) daily weights. . ."

Based on interview and record review, the facility failed to administer medications in accordance with professional standards of practice and manufacturer's instructions for two of 47 sampled patients (Patient 42 and Patient 43). This failure had the potential to result in adverse medication reactions for Patient 42 and Patient 43.

Findings:

During a review of Patient 42's clinical record, the physician's order (PO), dated 11/03/19, indicated Patient 42 was to receive Enoxaparin (a blood thinning medication) 40 mg (milligrams - a unit of measurement) subcutaneously (administered by a needle just under the skin) once daily to prevent venous thromboembolisms (VT - blood clots). The Medication Administration Record (MAR) indicated Patient 42 had received Enoxaparin injections in the following locations:

-11/4/19: Right Lower Quadrant
-11/5/19: Right Lower Quadrant

During a review of Patient 43's clinical record, the PO, dated 11/03/19, indicated Patient 43 was to receive Enoxaparin 40 mg once daily to prevent VT. The MAR indicated Patient 43 had received Enoxaparin injections in the following locations:

-11/3/19: Left Lower Quadrant
-11/4/19: Left Lower Quadrant
-11/5/19: Left Lower Quadrant

During an interview with Registered Nurse (RN) 4, on 11/5/19, at 1:50 PM, RN 4 stated she administered Enoxparin to Patient 43, on 11/3/19, 11/4/19, and 11/5/19. She stated she had injected the medication in the same site each time. RN 4 acknowledged that by not rotating the injection site, there could be an increased risk for adverse side effects, such as bleeding and hematoma (bruising).

During a review of the Lippincott Procedures for subcutaneous injections, it indicated "Subcutaneous injections. . . For subcutaneous injections administered repeatedly. . . rotate sites. Choose one injection site in one area, move to a corresponding injection site in the next area, and so on. When returning to an area, choose a new site in that area. . ."

During a review of the Enoxaparin manufacture's insert, it indicated "Patients should be lying down and Lovenox [Enoxaparin] administered by deep SC injection. . . Administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall. . ."

Based on interview and record review, the facility failed to maintain accurate records of the disposition of a narcotic when the hospital pharmacy failed to accurately account for Clobazam (medication to treat seizures). This failure had the potential to result in narcotic diversion or a medication error.

Findings:

During a review of the Open Discrepancy Report, it indicated a Clobazam 20 mg (milligrams - a unit of measurement) tablet was currently missing from the narcotic CII Safe (narcotic dispensing machine). The report indicated there should have been one dose in the CII Safe, but none were there.

During an interview with the Director of Pharmacy (DOP), on 11/4/19, at 3:15 PM, the DOP stated he was not aware a dose of Clobazam was missing. He stated his staff had not reported a missing dose of Clobazam to him. The DOP acknowledged the missing dose could either be a medication error or narcotic diversion.

During an interview with the Pharmacy Technician (PT), on 11/5/19, at 8:18 AM, the PT stated the missing Clobazam narcotic occurred more than a month before, on 10/17/19. The PT stated she did not report the missing dose to the DOP. She said that she could not account for the Clobazam.

During a review of the facility policy and procedure titled "Drug Procurement/Inventory Control" dated 9/19/19, it indicated "Any discrepancy between the receipt and quantity of the controlled substances actually received shall be brought to the attention of the Director of Pharmacy (or his/her designee) for proper reporting as required by law. "

Based on observation, interview, and record review, the facility failed to store medications in accordance to professional standards of practice when:

1. The facility stored "protect from light" medications under direct light;

2. The facility stored medications with cleaning solutions;

3. The facility did not maintain a drug supply that met the immediate needs of patients in ready-to-use containers in the Pyxis (medication dispensing machine).

These failures had the potential to result in ineffective, degraded, or unsafe medications for patients.

Findings:

1. During an observation the inpatient pharmacy and interview with the Director of Pharmacy (DOP), on 11/5/19, at 8:20 AM, multiple vials of Lidocaine with Epinephrine (medication used to block pain) and Dexamethasone (medication used to treat inflammation) were found under direct light. The labels of both the Lidocaine with Epinephrine and Dexamethasone indicated "protect from light". The DOP stated was not aware these medications were being stored under direct light, and they should not be.

During a review on the facility policy and procedure titled "Storage and Security of Medication" dated 7/19/18, it indicated "All medications are stored in a manner such that. . . medication integrity is maintained. . . storage requirements such as protection from light. . . will. . . be addressed."

2. During an observation of the laboratory flammable cabinet and interview with the DOP, on 11/5/19, at 8:38 AM, the following medication, cleaning agent, and chemical were found stored together:

-Medication: Ethyl Chloride (medication for pain control)
-Cleaning Agent: 70% Isopropyl Alcohol (disinfectant)
-Chemical: Spray Adhesive

The DOP stated he did not know that the medication, cleaning agent, and chemical were being stored together, and they should not be.

During a review of the facility policy and procedure titled "Storage and Security of Medication" dated 7/19/18, it indicated "All medications are stored in a manner such that. . . potential dispensing errors are minimized through appropriate segregation. . . Test agents, germicides, disinfectants and other household substances shall be stored separately from drugs."

3. During an observation in the Emergency Department, on 11/5/19, at 12:56 PM, approximately five vials of 2% Lidocaine (injectable medication for pain relief) 50 ml (milliliters - a unit of measurement) were stored in the Pyxis machine (medication dispensing machine).

During an interview with Pharmacist (Pharm) 2, on 11/6/19, at 10:15 AM, Pharm 2 stated the maximum dose of 2% Lidocaine administered to a patient would be 15 ml for both local anesthesia and topical anesthesia. He confirmed the 50 ml 2% vials exceeded the maximum dose by over three times. Pharm 2 stated 50 ml 2% Lidocaine vials were also available in the Operating Room (OR) Pyxis machines.

During an interview with Emergency Department Physician (EDP) 1, on 11/6/19, at 10:45 AM, EDP 1 stated 2% vials of Lidocaine were rarely used by the physicians in the emergency department. He also stated he never uses the 2% Lidocaine himself because of the potential for serious side effects. Pharm 1 said storing smaller vials of 2% Lidocaine would meet the needs of the Emergency Department.

During an interview with OR Physician (ORP) 1, on 11/6/19, at 11:00 AM, ORP 1 stated physicians in the OR use about 5 ml of the 50 ml 2% Lidocaine vials. He stated there is no need for the bulk 50 ml vials of the 2% Lidocaine. ORP 1 stated smaller vials of 2% Lidocaine would meet the needs of the OR.

During a review of the Institute for Safe Medication Practices (ISMP - a nationally recognized medication safety organization) document titled "Guidance on the Interdisciplinary Safe use of Automated Dispensing Cabinets [ADC]" dated 2015, it indicated "Hazardous drugs or medications that require extensive dilutions or calculations should not be part of ADC standard inventory. Bulk drug supplies should be avoided and all medications. . . should be in ready-to-use, unit-dose or unit-of-use containers. . ."

Based on observation, interview, and record review, the hospital failed to ensure 65 hydromorphone (a Schedule II controlled drug used to treat moderate to severe pain) suppositories were stored in a secure manner in the pharmacy. This failure had the potential to result in unauthorized access and diversion of this Schedule II controlled drug.

Findings:

During an observation in the inpatient pharmacy and interview with the Director of Pharmacy (DOP) and Pharmacist (Pharm) 1, on 11/4/19, at 2:45 PM, hydromorphone 3 mg (milligram - a unit of measurement) suppositories were observed stored in the unlocked refrigerator. Pharm 1 confirmed that the refrigerator was unlocked. Pharm 1 stated Environmental Services (EVS) staff and maintenance staff had access to the pharmacy.

During an observation in the inpatient pharmacy and interview with Pharm 1, on 11/5/19, at 10:05 AM, EVS staff was observed in the pharmacy. Pharm 1 stated Schedule II medication, such as hydromorphone suppositories, should be kept locked in a secure location.

During an interview with the Assistant Director of Pharmacy (ADOP), on 11/6/19, at 11:30 AM, the ADOP confirmed hydromorphone suppositories should be kept locked in the refrigerator.

During a review of the facility's policy and procedure titled "Storage and Security of Medication" dated 7/19/18, it indicated ". . . All medications are stored in a manner such that unauthorized personnel are prevented from obtaining access to the medication. . ."

During a review of the facility's policy and procedure titled "Controlled Substance Distribution System" dated 11/30/17, it indicated ". . . All bulk storage of Schedule II controlled substances are stored in a secure, locked area of the Department of Pharmacy. . ."

Based on observation, interview, and record review, the facility failed to ensure expired medication and medication kits were removed from stock and unavailable for patient use. This failure had the potential to result in patients receiving outdated supplies and medications which may not provide intended benefits.

Findings:

1. During an observation in the Obstetrical Operating Room and interview with the Assistant Nurse Manager of Labor and Delivery (ANMLD) and Pharmacist (Pharm) 1, on 11/5/19, at 1:30 PM, two Multi-Med Central Venous Catheter (CVC) kits (used to insert central intravenous lines) with expiration dates of 6/30/19 and 7/31/19, were stored in a supply cart. The contents of the kits were reviewed and found to include Lidocaine (a local anesthetic medication). Pharm 1 verified Lidocaine was included in the CVC kits.The ANMLD verified the CVC kits were expired and stated they should have been discarded.

2. During an observation in Cardiovascular Operating Room 9 and interview with the Director of Cardiovascular Operations (DCVO) and Pharm 1, on 11/5/19, at 2:45 PM, two 1000 ml (milliliters - a unit of measurement) bags of 0.9% sodium chloride (a fluid used for intravenous hydration) with expiration dates of 7/13 and 5/14, were stored in a bag hanging on a blood warmer. The DCVO confirmed these IV solution bags were expired and stated these IV solution bags should have been discarded.

During a review of the facility's policy and procedure titled "Outdated/Expired Supplies - Removal of Disposable Items" dated 5/16/19, it indicated ". . . As Sterile Processing performs their scheduled restocking, any items that will be expired/outdated are to be removed. . . Areas that are not stocked by Sterile Processing - staff in these areas will be responsible for monitoring their outdates. . ."

Based on observation, interview, and record review, the facility failed to ensure the current medication dosing guidelines for neonatal emergency medications were immediately available to staff. This failure had the potential to result in inappropriate neonatal medication administration during an emergency.

Findings:

During an observation and interview with Registered Nurse (RN) 5, on 11/5/19, at 4:05 PM, in the Emergency Department, the neonatal crash cart (a cart containing supplies and medications used in the event a baby experiences cardiac or respiratory arrest) had a laminated card containing neonatal emergency medication dosing guidelines affixed to the outside of the cart. RN 5 stated the laminated card had the wrong dosing guidelines when compared to the current Neonatal Resuscitation Program Guidelines (NRP - a nationally recognized medical resource for neonatal resuscitation). She stated the laminated card was out of date and should be immediately removed from the cart. RN 5 acknowledged the laminated cards could result in an incorrect medication dosage being administered during a neonatal emergency.

During a review of the laminated card and current NRP guidelines, the doses of Epinephrine (medication used to treat low blood pressure and improve breathing) and Bicarbonate (medication which helps to decrease acid buildup in the body during cardiac arrest) were different.

Based on observation, interview, and record review, the facility failed to ensure:

1. The Director of Food and Nutrition Services (DFN) met the requirements of the California
Health and Safety Code 1265.4 (HSC 1265.4) to employ a full-time, qualified dietetic services supervisor at the downtown hospital campus production kitchen. This failure occurred when the DFN supervised two hospital campuses and therefore was not full-time at the downtown campus. In addition, the Executive Chef (EC) who supervised the downtown campus kitchen did not meet the qualifications outlined in the HSC 1265.4;

2. Dishmachine final rinse temperature was maintained within manufactures specifications;

3. Food service staff (Cooks 2 and 3) were covering all facial hair;

4. Label and dating of foods were maintained to monitor the shelf life of opened foods or foods removed from the original boxes. Expired foods were discarded.

These failures had the potential to result in unsafe food handling and sanitation practices to occur in a kitchen that prepares food for a medically vulnerable patient population.

Findings:

1. During an interview with DFN, on 11/6/19 at 10:00 AM, the DFN stated that he was responsible for the food service of both hospital campuses. The DFN further stated that the Executive Chef was the full time dietetic supervisor over the chefs providing food for the downtown hospital campus, hospital production kitchen.

During a review of personnel record of the EC, on 11/6/19, at 9:40 AM, the EC is responsible for the supervision of day to day operations of the downtown hospital production kitchen, EC did not have the educational and certification required by state law:

California Health and Safety Code 1265.4 requires that a licensed health facility (hospital) that does not have a full time registered dietitian with oversight of the hospital production kitchen shall employ a full -time dietary services supervisor who meets some educational requirements. The requirements outlined include: "(1) a baccalaureate degree with major studies in food and nutrition, dietetics or food management and one year of experience in a licensed health facility (2) a graduate of a dietetic technician training program ..... (3) a graduate of a dietetic assistant training program.... (4) a graduate of a dietetic services training program approved by the Dietary managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains Certification ..... (5) a graduate of a college degree with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility (6) a graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision .... (7) Received training experience in food service supervision in the military ...."

During a review of the personnel document, the document verified that the Executive Chef (EC) did have an Associate's Degree from a culinary college, but did not have the required certified managers credentialed by the Dietary Managers Association, maintain certification and had received at least six hours of in-service training on the specific California dietary service requirements in Title 22 of the California Code of Regulations prior to assuming full time duties as a dietetic services supervisor at the health facility.

2. During an observation on 11/4/19, starting at 10:20 AM, the low temperature dish machine final rinse at the downtown hospital campus kitchen was observed at 185 degrees Fahrenheit (F).

During a review of the Dish Machine Temperature logs from 10/13/19 to 11/4/19, showed documented final rinse temperatures were above 180 degrees F 59 time out of 67 entries (88 percent).

The dishmachine manufactures specification plate, attached to the dishmachine, stated "Important keep temperature between 120 and 150 degrees F."

During an interview with the DFN, on 11/4/19, at 10:40 AM, DFN stated that there were no work orders or concerns brought to him regarding the final rinse temperatures above specification. DFN could not state that the dishware processed with the final rinse temperatures that were not maintained within manufacturers specification were sanitizing the dishware as required.

According to the 2017 FDA (Food and Drug Administration) Food Code, a warewashing machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved.

3. During a downtown hospital campus kitchen observation and interview with the DFN, on 11/4/19, at 2:00 PM, Cook 2 and Cook 3 were observed with mustache facial hair not covered by the beard restraint (beard cover).
The DFN stated the beard covers should cover all facial hair and acknowledged Cook 2 and Cook 3's mustaches were not covered as required.

According to the 2017 FDA Food Code, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped singleservice and single-use articles. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair.

4. During a downtown hospital campus kitchen observation on 11/4/19, starting at 10:00 AM, the following were not meeting food storage requirements:

a. Number two walk in refrigerator contained one package cut onion with no expiration date, one package cut onions dated expired on 10/31.Also observed was one package green onions expired 11/3/19, chopped celery with no expiration date and an opened, one-gallon jar of peeled garlic with no open date or expiration date.

b. Number one walk refrigerator had two flats of shell eggs with no label or expiration date and were removed from their case.

c. Freezer 26 contained five roast beef with no label or date.

During an observation and interview with the DFN, on 11/4/19, at 10:45 AM, DFN stated the garlic was good until it was moldy. The DFN further stated that the roast beef and eggs had been removed from the case so should have been dated. The DNF could not explain why the expired product had not been discarded.

During a review of the policy titled Production, Purchasing, Storage (undated) stated, for refrigerated and frozen storage; to date and rotate items.

Based on observation, interview, and record review, the facility failed to ensure nutritional aspects of patient care were effectively implemented and supervised by a Registered Dietitian (RD) for six of 47 sampled patients when:

1) Four patients (Patient 1, Patient 2, Patient 3, and Patient 4) with high nutrition risk did not have a nutrition care plan;
2) Three patients (Patient 1, Patient 2, and Patient 20) screened at high nutrition risk did not have a timely nutrition assessment completed by an RD according to hospital policy;
3) One patient (Patient 4) receiving an oral nutritional supplement did not have the intake monitored by the RD to determine the effectiveness;
4) One patient (Patient 11) lacked timely RD follow-up to ensure the tube feeding and nutrition care was appropriate to meet nutrition needs; and
5) One patient (Patient 13) did not receive timely screen for nutrition risk by the RD per hospital policy.

This failure resulted in the nutritional needs of these high risk patients going unmet and had the potential to further compromise their medical status.

Findings:

During a review of the Nutrition Admission Screening form 11/4/19, completed by Nursing for all admitted patients, the following questions were noted: able to assess nutritional screening; difficulty chewing or swallowing; unintentional weight loss; diarrhea/loose stools; skin breakdown or pressure injury; and home diet. An answer of 'No' by the patient to the first question automatically triggered an alert to the RD to complete a nutrition screening and assessment within 48 hours. An answer of 'yes' to the remaining questions automatically triggered an alert to the RD to complete a nutrition screening and assessment within 48 hours.

1a). During a review of the clinical record for Patient 1, Patient 1 was a premature newborn part of a set of triplets born and admitted on 10/25/19. Patient 1 had diagnoses to include: prematurity at 32 weeks of gestation, respiratory distress (difficulty breathing), and alterations in nutrition. Patient 1's nutrition assessment progress note dated 10/28/19, was completed by the neonatal RD. The progress note indicated Patient 1 had a high nutrition risk level. The note also indicated Patient 1 had a birth weight of 1640 grams and current weight of 1445 grams on 10/28/19, a weight loss of 195 grams. The note further indicated Patient 1 was on TPN (total parenteral nutrition) tube feeding with a nutrition diagnosis of "increased nutrient needs related to prematurity as evidenced by gestational age" and nutrition goal "achieve weight gains of 15-20 g/kg/day once ...birth weight is regained." RD 1, CNM (Clinical Nutrition Manager), QM (Quality Manager, Registered Nurse), and the NICM (Neonatal Intensive Care Unit Manager) were present during the record review.

During an interview with the RD 1 and CNM, and review of the clinical record for Patient 1, on 11/5/19, at 9:25 AM, review of the Plans of Care (interdisciplinary care plan) dated 10/25/19-11/4/19 was conducted. There was no nutrition care plan initiated for Patient 1 in the electronic medical record (EMR). RD 1 and CNM acknowledged Patient 1 was at high nutrition risk, and should have had a nutrition care.

1b). During a review of the clinical record for Patient 2, Patient 2 was an adolescent admitted on 11/1/19, with diagnoses to include right side pneumothorax (collapsed lung), asthma (difficulty breathing), chest pain, and SOB (shortness of breath). Patient 2's nutrition assessment progress note dated 11/4/19,was completed by the pediatric RD. The progress note indicated Patient 2 had a high nutrition risk, had a BMI (body mass index) of 16.48 (below 18 is underweight), and nutrition intake ranges from 26-100 percent of meals. There was a nutrition recommendation of " ...encourage menu selections", and nutrition goal of "achieve greater than 75 percent of most meals received."

During an interview with the RD 1 and CNM, and review of the clinical record for Patient 2, on 11/5/19 at 11:25 AM, review of the Plans of Care dated 11/1/19-11/4/19 was conducted. There was no nutrition care plan completed or initiated for Patient 2 in the EMR. RD 1 and CNM acknowledged Patient 2 was at high nutrition risk and did not have a care plan initiated. Both RD 1 and CNM stated Patient 2 should have had a nutrition care plan because the patient was at high nutrition risk.

1c). During a review of the clinical record for Patient 3, Patient 3 was admitted on 10/26/19 with diagnoses to include hypoxia (difficulty breathing), respiratory distress, and renal (kidney) failure. Patient 3's nutrition assessment progress note was completed by the RD on 11/1/19. The progress note indicated Patient 3 had a high nutrition risk level. The progress note further indicated Patient 3 had nutrition diagnosis of "increased protein/energy needs related to renal dysfunction as evidenced by patient on hemodialysis (a process to remove waste products from the blood) due to end stage renal disease (ESRD)" and experienced a 5.9 pound weight loss in four days. The diet order was renal/diabetic/cardiac and nutrition intake ranged from 0-100 percent of four meals. The nutrition recommendation was "1) continue with renal/diabetic/cardiac diet; 2) provide Nepro BID (2 times a day) ..."; and nutrition goal was "meet greater than 75 percent of estimated nutrition needs by next follow up ..."

During an interview with the RD 1, RD 2, and CNM , and review of the clinical record for Patient 3, on 11/5/19 at 11:06 AM, review of the Plans of Care dated 10/31/19-11/5/19 was conducted. RD 1, RD 2, CNM, QM, Licensed Nurse (LN) 1, and Certified Nursing Assistant (CNA) 1 were present during the record review. RD 1, RD 2, and CNM acknowledged Patient 3 was at high nutrition risk and a nutrition care plan should have been initiated.

1d). During a review of the clinical record for Patient 4, Patient 4 was admitted on 10/30/19, with diagnoses to include hematemesis (vomiting blood), SOB, and moderate protein calorie malnutrition. Patient 4's nutrition assessment progress note was completed by the RD on 11/1/19. The progress note indicated Patient 4 had a high nutrition risk. The progress note further indicated Patient 4 had nutrition diagnosis of "severe malnutrition related to chronic illness as evidenced by ...severe muscle loss ...and severe fat loss ...", nutrition intake: clear liquids, not adequate to meet estimated nutrition needs with intakes ranging from 0-100 percent of meals since admission, nutrition intervention: "1) advance to goal of soft/bland diet as medically able, 2) provide Ensure Clear TID and switch to Ensure Enlive as oral diet allows ...", and nutrition goal of "1) diet advancement over the next 2-3 days, 2) establish an oral intake of greater than 50 percent of meals."

During an interview with the CNM and RD 1, on 11/5/19 at 1:35 PM, a review of Patient 4's EMR was conducted. There was no nutrition care plan for Patient 4 in the EMR. The CNM and RD 1 confirmed that Patient 4 was at high nutrition risk due to his medical status and should have had a nutrition care plan initiated.

2a). During an interview with the CNM and RD 1, on 11/5/19, at 9:30 AM, and review of the clinical record for Patient 1. Patient 1 was born on 10/25/19, and the nutrition assessment progress note was completed by the RD on 10/28/19. RD 1 and CNM confirmed Patient 1 was a high nutrition risk patient and stated the nutrition assessment was not completed within the 48-hour timeframe according hospital policy.

2b). During an interview with the CNM and RD 1, on 11/5/19, at 9:35 AM, the clinical record for Patient 2 was reviewed. The assessment progress note was completed by the RD on 11/4/19, and indicated Patient 2 was admitted on 11/1/19. Review of Patient 2's hospital admission nursing screen did not trigger for nutrition concerns. The CNM stated Patient 2's low BMI of 16.48 should have triggered an RD assessment with the Dietitians to be completed within 48-hours. CNM and RD 1 acknowledged the nutrition assessment was not completed within the hospital's timeframe for pediatric patient admissions.

2c). During a review of the clinical record for Patient 20, the admission date was 10/18/19, with admitting diagnosis of stroke with bleed in brain. The Nutrition progress note was dated 10/23/19, 5 days after admission. Patient 20's Nutrition Assessment showed nutrition risk as Moderate. Medical history included dysphagia (compromised swallow), Hemorrhagic Stroke, Diabetes Mellitus type 2 (compromised blood sugar control). Diet was renal diet, may have food from outside, offer Nepro (renal supplement) if patient eats less than 50 percent of meal. Provide soup BID. Meal intake was recorded at 0-25 percent for 6 meals and 25-50 percent for 3 meals.
Review of admission nursing screen did not trigger for nutrition concerns.

During an interview with RD 5, on 11/5/19 at 11:00 AM, RD 5 reviewed the admission nursing screen, and stated it did not trigger for nutrition assessment. The policy was to follow patients at day 5 of their stay if the admission nursing screen did not trigger for a nutrition assessment. RD 5 confirmed Patient 20 was missed and she had not accessed his nutrition assessment.

3). During an interviews with RD 1, RD 2, LN 1, and CNA 1, and 11/5/19, at 11:30 AM, review of the clinical record for Patient 4, the nutrition assessment progress note completed by the RD, dated 11/1/19 was conducted on 11/5/19. RD 2 stated she entered an oral nutrition supplement order a couple of days ago for Patient 4 into a computer system in the Food and Nutrition Services department for kitchen staff to send the supplement to Patient 4 at meals. LN 1 stated Patient 4 was her patient but she was unaware Patient was receiving an oral nutrition supplement. The oral supplement ordered by RD 2 was not found in the patient's EMR a part from the nutrition progress note. CNA 1 stated she also cared for Patient 4 and she saw the oral nutrition supplement in Patient's 4 room. CNA 1 stated Patient 4 drank about half of the supplements and she entered the amounts in the 'Oral Intake' row of the EMR's Intake and Output section. However, the 'Oral Supplement' section of the Intake and Output section was left blank. CNA 1 stated she did not know about the oral supplement row. RD 2 stated she did not know where the CNAs entered the oral nutrition supplement intake in the EMR. RD 2 also stated a nutrition communication note could have been sent to the patient's interdisciplinary medical care team to inform them of the oral nutrition supplement order.

Review of hospital policy dated 10/17/19, titled Interdisciplinary Pt Assessment, Reassessment & Care Planning for the Acute Setting indicated " ...IV. Assessments are performed by each discipline within its scope of practice ...; V. Care decisions will be based upon data and information gathered in assessments and reassessments. This data will be utilized in prioritizing patient care needs and selecting appropriate interventions ..."

Review of hospital policy dated 5/21/2018, titled Nutrition: Adult & Pediatric Assessment, indicated " ...Patients will be initially screened for nutritional risk within 24 hours of admission by an RN, all patients identified during the initial nursing screen ...will be assessed within 2 days ...by an RD. The RD will follow-up with those patients identified at nutritional risk ...VI. The RD will screen ...patients at possible nutritional risk to include ...the following indicators: BMI<19, Patients identified as having unknown nutrition risk at nursing admission screen ..., VIII ...An RD will screen all pediatric patients for nutritional problems within 48 hours of admission and complete nutrition assessment if ...high nutrition risk is identified ..."



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4) During a review of the medical record for Patient 11, indicated Patient 11 was admitted to the hospital on 10/26/19, with diagnoses including acute hypoxemic respiratory failure (difficulty breathing with low blood oxygen levels), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), sepsis (infection in the blood), and coma (a state of deep unconsciousness that lasts for a prolonged or indefinite period).

During a review of the "Nutrition Note" completed by RD 3 and dated October 28, 2019, it indicated Patient 11 was at "High" nutrition risk. The nutrition assessment indicated Patient 11 was intubated (with a tube inserted into the windpipe for ventilation or mechanical breathing), and was receiving dialysis (a treatment that keeps the body in balance by: removing waste, salt and extra water to prevent them from building up in the body) for acute kidney injury. The nutrition goal according to the note was to initiate a nutrition regimen in the next 48 to 72 hours and progress toward meeting the patient's estimated nutrition needs over the next 5 to 7 days. The nutrition recommendations included to initiate a continuous tube feeding (device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation), as medically able.

During a review of the of the Intake and Output form in the EMR dated 10/28/19, indicated the estimated nutrition needs for Patient 11 were 2174 calories and 174 grams protein daily.

During a review of the nutrition note by RD 3, dated 10/30/19, indicated Patient 11 was not being fed but the physician ordered to start the tube feeding that day. A second nutrition noted by RD 3 also dated 10/30/19, indicated that Patient 11 had a pressure injury (bedsore) and the tube feeding was to start that day with a high protein formulation to aid with healing.

During a review of the follow-up nutrition note by RD 3, dated 11/1/19, indicated Patient 11 remained at "High" nutrition risk. The note also indicated that the tube feeding for Patient 11 was being held since the previous night for GRV (gastric residual volume - volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) from 280 and 340 ml (milliliters). The nutrition diagnosis was "Inadequate nutrition regimen related to decreased ability to consume sufficient energy as evidence by NPO (nothing by mouth) with nutrition support (tube feeding) on hold." The nutrition recommendations and goals remained the same as the 10/28/19 nutrition assessment.

According to the American Society for Parenteral and Enteral Nutrition (ASPEN) 2016 guidelines, gastric residual volume (GRV) measurements may not need to be used as part of routine care to monitor ICU patients on enteral nutrition (tube feeding). For those patient care areas where GRVs are still utilized, holding tube feeding for GRVs <500 mL in the absence of other signs of intolerance should be avoided.

During a review of the medical record for Patient 11, there was no nutrition follow-up note on Saturday (11/2/19) and Sunday (11/3/19). The record review also indicated that Patient 11 did not receive any nutritional intake via tube feeding starting from 10/31/19 (at night) until 11/4/19, Patient 11's tenth admission day. A review of the medical record also indicated that Patient 11 had developed a pressure injury (bedsore) during this time.

During a review of the nutrition note by RD 3, dated 11/4/19, indicated that Patient 11 was receiving Cleviprex (a medication for high blood pressure) infused in a lipid (fat) emulsion which provided 768 calories from fat per day since overnight 11/2/19 to 11/3/19. The patient was still NPO and was not receiving tube feeding. RD 3's note indicated that RD 3 discussed with the physician about restarting the tube feeding and the physician was okay with restarting it. A review of the physician orders indicated an order to start a tube feeding dated November 4, 2019.

During an interview with RD 3, on 11/4/19, at 3:25 PM, RD 3 stated that on the weekends there is no RD who attends the patient care rounds for the patients in the unit. She further stated that there was not adequate RD coverage on the weekends for the RDs to attend the rounds.

During a follow-up interview with RD 3, on 11/6/19, at 11:30 AM, RD 3 stated there did not appear to be a reason to hold the tube feeding for Patient 11. She stated that Patient 11's record indicated that his abdomen was soft, non-distended and a lack of bowel movements would not be an indication for holding the tube feeding. RD 3 further stated that she should have left a note to the weekend RDs to follow-up with Patient 11 to request that the tube feeding be restarted by the physician.

5) During a review of the medical record for Patient 13, the history and physical (H & P) document, dated 10/27/19 indicated Patient 13 was admitted to the hospital on 10/27/19. According to the H & P, Patient 13 was admitted with diagnoses which included Type 2 Diabetes (also known as adult onset diabetes, a chronic condition that affects the way the body processes blood sugar), acute hypoxic respiratory failure (difficulty breathing with low blood oxygen levels) secondary to congestive heart failure (CHF) exacerbation (a chronic progressive condition that affects the pumping power of the heart muscles). The H & P indicated for Patient 13 to have daily weight monitoring, a cardiac (heart heathy) diet with low sodium (low salt), and fluid restriction.

The Nursing Nutrition Screen, dated 10/27/19, indicated Patient 13 did not have any of the nutrition risk triggers that would have required a referral to RD. The initial nursing assessment, dated 10/27/19, indicated Patient 13's height was 170 centimeters (5 foot 7 inches) and his weight was 60.6 kilograms (133.6 pounds).

A review of Patient 13's medical record on 11/4/19, at 12:15 PM, indicated that there was no nutrition screen completed by an RD to determine the patient's nutrition risk level. In addition, there were no documented follow-up weights for Patient 13 after the admission weight of 133.6 pounds.

During an interview with the Quality Manager (QM), 11/4/19, at 12:20 PM, the QRN verified the findings.

During a review of the Medical records for Patient 13, indicated that a weight was taken for Patient 13 on 11/4/19, at 6:55 PM, which indicated his weight was 55.5 kilograms or 122.4 pounds. This represented an 11.2 pound weight loss in 8 days that was not being monitored per the hospital's standard of care and the plan according to the H & P.

According to the hospital's Standard of Care number SOC-4T1 for Nursing (dated February 5, 2019) for the unit Patient 13 was on, for patients with a diagnosis of health failure, "The RN (registered nurse) is responsible for interventions .....(including) daily weights ..."

According to the hospital's policy number FNS.801 titled "Food and Nutrition Services: Adult and Pediatric Assessment" (approved September 9, 2019), a length of stay of 7 days without a previous referral was an indication for an RD to screen patients for possible nutrition risks.

Based on observation, interview, and record review, the facility failed to ensure the trash area of the Food Service Department was appropriately maintained free from debris. This failure had the potential to result in an infestation of insects and vermin.

Findings:

During an observation on 11/4/19, at 2:10 PM, the area under the trash compactor lift cart was noted to have a black residue and trash debris.

During an interview with the Environmental Service Lead (EVSL 1) on 11/4/19, at 2:20 PM, EVSL 1 stated the area was supposed to be cleaned by environmental services. EVSL 1 acknowledged the area immediately under the lift card needed to be cleaned.

According to the 2017 FDA (Food and Drug Administration) Food Code, proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils. In addition, storage areas for garbage and refuse containers must be constructed so that they can be thoroughly cleaned in order to avoid creating an attractant or harborage for insects or rodents. In addition, such storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse.