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Based on interview and record review, the facility failed to ensure the governing body maintained responsibility for services provided in the hospital that were furnished under contracts. This failed practice had the potential to result in the provision of poor quality services.

Findings:

On July 20 and 21, 2010, the committee meeting minutes for GB, MEC, and QAPI were reviewed. There was no documented evidence indicating the committee members were discussing the quality of services furnished under contracts.

On July 21, 2010, at 3 p.m., the QRM was interviewed. She stated each facility department where a contracted service was provided, was responsible for grading the performance of the individuals providing the service in their department. The QRM stated the completed evaluations were given to administration and were not placed in the file for the contracted service. The QRM did not provide any documentation related to grading the performace of services provided by contract.

On July 21, 2010, the contract for the provision of PT services was reviewed. The original contract, dated March 5, 2008, indicated the services performed included initial evaluations, follow-up care pursuant to the agreed upon care, meetings as requested by the hospital, and participation in survey activities including but not limited to TJC, CDPH, and CMS. An amendment to the contract became effective on March 1, 2010 and expired on March 1, 2011.

On July 21, 2010, at 3:15 p.m., the PT provider was interviewed by telephone. The PT stated he had never been invited to attend any of the facility committee meetings. He stated no one from the facility ever asked him to provide input or participate in any facility QAPI projects.

On July 21, 2010, at 4:45 p.m., the QRM was interviewed and she stated contracted PT services were not included in the QAPI process but should be.

Based on staff interview and document review, the facility failed to measure aspects of PI data that assessed the facility process of nutritional screening, assessment and reassessment based on the interdisciplinary P&P in place.

Findings:

During the re-certification survey with an exit date of July 22, 1010, multiple deficient practices were identified as it related to the inter-disciplinary procedure for nutritional screening and assessment (Cross Refer A-630) to ensure patients receive timely, accurate and complete nutrition care to meet their needs.

On July 21, 2010, at 8:45 a.m., the PI plan for specific departments was requested to ensure all were represented.

A review of the documents provided for the Nutritional Services Department showed the last quarter of 2009, the nutrition department had collected and reported information on a sanitary kitchen.

The fourth quarter sanitary kitchen information had been presented to Pharmacy and Therapeutics on February 14, 2010.

On April 8, 2010, the "Quality/IDCP Council Minutes" showed there was no nutritional data presented, while the FSD manager was present. On April 23, 2010, "Dietary Services" was to present "Old Business" regarding Nutritional Services during the Performance Improvement Committee (PIC). The minutes for the meeting, showed the FSD needed to revise department projects further before presenting to the committee for approval. At this point, the first quarter of 2010 had not been initiated. There had been no recommendation or actions by the committee to direct the PI process to the problem prone interdisciplinary process of nutritional screening and assessment.

A review of the "Quality Council Meeting" agenda for May 13, 2010, showed Nutritional Services PI for the first quarter was to be presented.

On July 21, 2010, at 9:30 a.m., the CNO stated there was no QAPI data indicating the nutritional screening and assessment process had been reviewed. The CNO acknowledged there were problems with the interdisciplinary process, and there was no data.

A review of the Palo Verde Performance Improvement Projects 2010 showed the Nutritional Services criteria chosen was the timeliness of cardex completion in the diet office within eight hours of diet notification. According to the grid, the indicator had been presented to PIC on April, 23, 2010, which was inconsistent with the minutes reviewed above. In addition, the criteria did not identify the high volume, problem prone area of interdisciplinary nutritional screening and assessment which had the impact to potentially impact nutrition care.

On July 21, 2010, at 11:15 a.m., a telephone interview with the FSD was conducted. The FSD stated that he had previously collected data on screening and assessment. A copy of the screening/assessment data PI report was requested at that time. The FSD was unable to explain what the screening/assessment data had shown, where the data had been reported and why the cardex criteria was chosen over the interdisciplinary process of nutritional screening/assessment. The MSD was present at the time of the phone interview and verified she would try to locate the report with phone guidance with the FSD. No nutritional screening/assessment report or data was provided to the survey team by the exit conference on July 22, 2010.

On July 21, 2010, at 2:50 p.m., the QRM stated the facility chooses indicators based on high volume, problem prone areas that have the potential to impact patient care.

On July 21, 2010, at 3 p.m., the QRM stated the departmental PI plan was formulated by the manager and then taken to QC for discussion which included project selection. The QRM was unable to state why there was no data collected or presented by the Nutritional Service Department or why there had been no recommendations or actions made by the Quality Council.

According to the facility "Performance Improvement Plan-2010" (reviewed March 2010 showed it was the Quality Council Committee responsibility to establish goals and priorities for PI activities; assure that facility managers have the support for PI activities; and evaluates the effectiveness of the PI process.

Based on staff interview and document review, the hospital's governing body failed to ensure the hospital wide QAPI efforts were ongoing, implemented, and maintained.

Findings:

On July 21, 2010, at 8:45 a.m., the QAPI plan was reviewed to ensure all the facility departments were represented.

According to the "Quality Council Minutes", dated February 14, 2010, there was no "New Business", and the 2009 fourth quarter reports from six departments were presented.

The Performance Committee met on April 23, 2010, and the agenda included Developmental PI Projects with eight of 23 departments participating as verified by the meeting minutes.

The "Quality Council Meeting" agenda dated for May 13, 2010 showed four departments (Imaging Services, human resources, pharmacy and Nutritional Services) were set to present first quarter 2010 PI data. A copy of the Nutritional Services First Quarter 2010 PI results was requested at that time.

A review of the Palo Verde Hospital Performance Projects 2010 showed there were 23 departments represented in the plan. The grid provided for criteria for PI Projects to travel through two committees before being presented to the Governing Body. According to the grid 23 of 23 departments had presented their department plan to the "Performance Improvement Committee". After that, only 11 of 23 departments had presented to "Quality Council" to obtain approval of their PI Projects. According to the grid, none of the departmental PI Projects had been presented or approved by the governing body.

Some departments had already Nutritional Services Department had not begun collecting or reporting data despite the fact the re-certification survey date was seven months (two quarters) into the 2010 reporting year (Cross refer A-267).

The Governing Body and Quality Council had not been provided the opportunity to review, discuss, modify, change or develop individual departmental PI indicators to assess processes of care, hospital service, and operations.

On July 21, 2010, at 3 p.m., the QRM stated each departmental PI plan is formulated by the manager and then taken to Quality Council for discussion which would include indicator selection. The QMR verified the grid provided to the surveyor was current.

According to the "Performance Improvement Plan-2010" reviewed March 2010, showed the governing body is responsible for establishing and maintaining the PI program. The Medical Staff and the CEO had been delegated the responsibility for implementation of the program. The Quality Council had been delegated the responsibility of oversight through the Quality Council. The plan further showed the effectiveness of the performance improvement activities will be evaluated and reported to the Governing Body. Finally, the Quality Council was to provide regular reports to the Governing Body.

Based on observation and interview, the facility failed to ensure the confidentiality of patient records by storing discarded x-ray films, folders, and reports containing PHI in an area that could be entered by individuals who were not authorized to have access. This failed practice had the potential to result in medical identity theft and/or fraud.

Findings:

On July 21, 2010, at 9:30 a.m., the IMRM was interviewed. The IMRM stated the patients' records were kept on-site for seven years with the exception of records for children which were kept until the child reached age 19. She stated the Department of Radiology was responsible for maintaining their own x-ray records.

On July 21, 2010, at 4:15 p.m., the biohazardous waste storage area, located outside and in the back of the facility, was inspected with the POS and QRM present. The area was surrounded by a locked chain-link fence with no cover which could be entered by climbing over the top of the fence. The area contained one open trash barrel partially filled with x-ray films. The x-ray films had PHI including the patients' name, age, date of birth, and medical record number. The area also had two open trash barrels partially filled with x-ray folders and reports that included the same PHI as the films and in addition included the name of the x-ray procedure and the results.

The POS stated the x-ray films were recycled for silver recovery and when the barrels were full the facility arranged pick-up. The QRM stated the radiology records and films were being stored in an unacceptable manner.

Based on interview and record review, the facility failed, for two of six patients who received blood transfusions (Patients 17 and 25), to obtain the patients' informed consent prior to the administration of blood products in accordance with the Paul Gann Blood Safety Act, Health and Safety Code 1645(b). Failure to explain the risks versus benefit of a blood transfusion had the potential to result in a violation of the patient's right to refuse treatment.

Findings:

1. On July 20, 2010, the record for Patient 17 was reviewed. Patient 17, a 27 year old female, was admitted to the hospital on June 27, 2010, with a diagnosis of an IUP of 38 weeks and three days with fetal demise (infant death). After attempted induction of labor, the patient refused continuation of labor induction and opted for a Cesarean section delivery.

The physician progress notes included documentation, dated June 28, 2010, at 6 p.m., for POD #1, "Pt doing very well. No complaints...Stable." The physician's documentation for POD #2, dated June 29, 2010, at 1:10 p.m., included, "Pt c/o weakness and dizziness when standing...with symptomatic anemia (low blood cell count)."

The physician orders, dated June 29, 2010, at 1:20 p.m., included, "Please transfuse 2 unit of PRBC."

A review of the "Transfusion Record(s)", dated June 29, 2010, indicated Patient 17 received two units of PRBC.

The physician progress notes did not contain documentation indicating the risk versus benefits of a blood transfusion were explained to the patient. The record did not contain an informed consent form signed by Patient 17 for a blood transfusion.

On June 22, 2010, at 9:30 a.m., the Interim CNO reviewed the record for Patient 17. During a concurrent interview with the CNO, she stated the facility usually had the patient sign an informed consent form before a blood transfusion and, "No, I don't see a consent for a blood transfusion."

2. On June 22, 2010, the record for Patient 25 was reviewed. Patient 25, a 33 year old female, was admitted to the hospital on July 4, 2010, with a diagnosis of an IUP of 37 weeks, premature rupture of membranes, and breech presentation. A baby boy was delivered by Cesarean section on July 4, 2010 at 9:10 p.m.

The physician progress notes, dated July 5, 2010, at 6 p.m., and July 6, 2010 at 1 p.m., both indicated, "Pt doing ok. No complaints."

The physician orders, dated July 7, 2010, at 9:15 a.m., included, "Please transfuse 2 unit of PRBC."

A review of the "Transfusion Record(s)", dated July 7, 2010, indicated Patient 25 received two units of PRBC.

The physician progress notes did not contain documentation indicating the risk versus benefits of a blood transfusion were explained to the patient. The record did not contain a form titled, "Authorization For And Informed Consent to Surgery Or Special Diagnostic Or Therapeutic Procedures", signed by Patient 25 for a blood transfusion.

On July 22, 2010, at 1:30 p.m., the Manager of Medical Records reviewed the record for Patient 25 and stated the record did not contain an informed consent form for a blood transfusion signed by Patient 25.

On June 22, 2010,the form titled, "Authorization For And Informed Consent to Surgery Or Special Diagnostic Or Therapeutic Procedures", was reviewed. A blood transfusion was one of four procedure types printed on the consent form, and the form included the following statement:
"I agree that my physician has informed me of the:
1. Diagnosis or probable diagnosis.
2. Nature and benefit of treatment or procedures recommended.
3. Risks, complication, and problems related to recuperation involved in such treatment or procedures.
4. Anticipated results of treatment.
5. Available alternative forms of treatment, including non-treatment. I acknowledge that I have read and fully understand this consent. I have sufficient information to give my informed consent."

On July 22, 2010, the facility P&P titled, "Blood and Blood Products Administration", was reviewed. The P&P indicated the required forms included an, "Authorization For And Informed Consent to Surgery Or Special Diagnostic Or Therapeutic Procedures".

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

1. Systems were in place for safe medication administration after pharmacy hours by failing to ensure a pharmacist reviewed medication orders for appropriateness prior to administration. This failed practice had the potential to result in medication errors, medication interactions, inappropriate use of medications, and harm to the patients.

2. Appropriate medications were available for use in pediatric resuscitation by supplying one half the strength of sodium bicarbonate that was necessary, resulting in the potential for failed resuscitation efforts and the death of an infant or child.

Findings:

1. The record for Patient 3 was reviewed on July 19, 2010. Patient 3, a 63 year old male, was admitted to the ICU on July 14, 2010, at 3:30 p.m., with diagnoses including HTN, DM, CAD, CHF, and asthma. The only medication ordered on admission was an inhaler every four hours as needed for asthma. A Physician's Order, dated July 15, 2010, at 12:15 a.m., indicated 10 additional medications were ordered by the admitting physician while the pharmacy was closed.

During an interview with RN 1 on July 19, 2010, at 2:50 p.m., she stated when medication orders were written after the pharmacy's regular hours of operation, the nurses took the medications out of the ADC (an electronic cabinet for storage and dispensing medications) and administered them. RN 1 stated the nurses had access to all of the ADCs throughout the facility, they could get any medication for any patient using the critical override feature, and there was no limit to the number of medications the nurses could remove from the ADC. She stated the nurses faxed the orders to the pharmacy, but they were not required to wait for approval from a pharmacist prior to administering medications.

During an interview with Pharmacist 1 on July 21, 2010, at 3:30 p.m., he stated the pharmacy's regular hours of operation hours were 8 a.m. to 5 p.m. He stated during regular hours of operation the nurses could not get newly ordered medications for their patients until the order had been reviewed by the pharmacy and put into the patient profile in the ADC. He stated the pharmacists reviewed all medication orders during normal operating hours, but orders written after hours were not reviewed until the following day. He stated if orders were written for new medications after regular operating hours, the nurses got the medications out of the ADC using the critical override feature and administered the medications without being reviewed by a pharmacist.

The facility policy titled, "Overriding Drugs From Automatic Dispensing Machine After Hours", was reviewed on July 22, 2010. The policy indicated prior to removing medication from the ADC, "The nurse must perform a first dose mini profile," which included reviewing the patient's current medications and consider the following:

a. Appropriateness of and indication for the drug;
b. Drug allergies and sensitivities;
c. Duplication of medications and therapies;
d. Contraindications for the drug;
e. Drug, dose, frequency, and route of administration;
f. Potential drug and food interactions; and,
g. Variation from approved override medications.

The policy did not indicate this activity would be done by a pharmacist prior to a nurse administering the medication.

According to the ISMP, administering a drug before a pharmacist has reviewed the order and screened it for safety increased the risk of a medication error, most notably administering drugs to which patients are allergic, at unsafe doses, or with unrecognized food or drug interactions. Facilities are required to have a pharmacist review all medication orders before administration except in emergency situations when time does not permit review.

2. During a tour of the ED on July 19, 2010, at 3 p.m., accompanied by the QRM, an inspection of the pediatric emergency cart was conducted and the following noted:
a. The top of the cart had a book titled, "Medication Guide for Pediatric Resuscitation and Emergency Infusions".
b. The reference book indicated sodium bicarbonate (used for treatment of acid build-up in the body when the heart and lungs stop working) 1 mEq/ml was the strength used to calculate the amount of the medication to be given during a pediatric resuscitation.
c. The top drawer of the cart contained a medication tray with sodium bicarbonate 0.5 mEq/ml.

The QRM stated the book was the facility reference guide for administration of medications during a pediatric (infant or child) resuscitation. Since the strength of sodium bicarbonate specified in the reference book did not match the strength supplied in the pediatric emergency cart, the patient would have received half of the needed dose.

Based on observation, staff interview, and document review, the hospital condition of participation for food and dietetic services was not met as evidenced by:

1. The hospital failed to ensure the daily management of dietary services by the FSD was organized due to lack of policies and procedures or systems to provide staff guidance as it related to washing/sanitizing dished; a cleaning schedule to maintain refrigeration equipment; a system to record and monitory time and temperature standards regarding cooling of PHF;utilization of food safe storage containers; and maintain an effective pest control program, (Cross refer A-620).

2. The hospital failed to ensure the DSS was trained and competent to provide managerial oversight during the absence of the FSD (Cross refer A-622).

3. The hospital failed to ensure the facility inter-disciplinary process for nutritional screening and assessment was initiated, completed, accurate and timely in order to meet the nutritional needs of patients (Cross refer A-630).

4. The hospital failed to ensure there was an approved hospital diet manual available to medical and nursing staff in all patient care areas (Cross refer A-267)

5. The hospital failed to ensure the on-going dietary services QAPI program was comprehensive and identified the problem prone and high volume activity of nutritional needs (Cross refer A-267).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure safe food handling to prevent the potential of food borne illness; to ensure competent staff; to ensure quality and coordinated nutrition care was provided to patients; and to ensure the hospital medical and nursing were provided approved resources to ensure menus meet the needs of the patients.

Based on observation, staff interview and document review, the hospital FSD failed to ensure the daily management of the Food and Nutrition Department as evidenced by:

Findings:

During the re-certification survey starting on July 19, 2010, the FSD was on vacation. On July 19, 2010, at 1:30 p.m., the DSS stated that she had been recently promoted to "Cook Supervisor" and was responsible to provide all food oversight in the absence of the FSD. The DSS state she was qualified based on her work experience. A review of the DSS file showed that she had been recently promoted on June 13, 2010.

1. On July 19, 2010, starting at 1:10 p.m., a tour of the hospital kitchen was initiated. FSW 1 was asked to demonstrated the mechanical dish washing procedure. FSW 1 stated the machine uses chlorine bleach to sanitize the dishes. Upon testing with a chemical testing strip, there was no color change to indicate the concentration of the chemical being used to sanitize the patient lunch dishes.

At that point, FSW 1 re-tested the machine and there was no color change of the strip. FSW 1 continued to wash and sanitize the dishes.

On July 19, 2010, at 4:25 p.m., the DSS stated that she had not been notified that the chemical in the dish washing machine had not been reading at the appropriate level. A review of the dish machine sanitizing log did not document what corrective action was taken.

A review of the following policies and procedures titled: "Machine Dish Washing" (revised 5/09); "Sanitizing Agent PPM Testing" (revised 5/09); and "Equipment Safety/Operation" (reviewed 5/09); all written by the FSD showed the chemical testing of the dish machine had been addressed. However, none of the policies directed staff on the procedure should the dish machine not reach the appropriate chemical concentration in order to ensure proper cleaning and sanitizing of dishes, flatware and glasses.

2. On July 19, 2010, at 2 p.m., the DSS stated that the ice machine is cleaned one time per week. After the ice is removed from the bin, the DSS stated the unit is wiped with a bleach and water sanitizing solution. After that, the DSS stated the procedure included wiping the sanitizer off with a clean, clear water rinse and dry with a towel.

A review of the facility policy and procedure titled "Cleaning Procedure: Ice Machine" showed the correct procedure was to rinse first with clean and hot water, then sanitize and allow to air dry.

According to the competency assessment tool used for the FSD and the "Cook Supervisor" it was the expectation that both of the positions required demonstration of the skills for knowledge of the procedures followed to clean various work areas in the kitchen; a thorough understanding of infection control practices and processes; and demonstration of ability to supervise and provide oversight of kitchen workers.

3. On July 19, 2010, at 2:15 p.m., the reach-in refrigerator metal wire shelves appeared to be coated with an orange/black residue. A clean paper towel sweep showed the residue could be easily removed. The DSS stated the cleaning of the refrigerator shelves was not on a regular cleaning cycle to ensure that they be cleaned on a regular basis. She was unable to state when the last time the wire shelves had been cleaned.

According to the 2009 "Food Code" non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris and shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

On July 21, 2010, at 11:15 a.m., during a phone interview with the FSD, he stated that he uses a tool to identify sanitation and maintenance issues within the department to assess quality. According to the tool, quality standards related to the wire shelf observation include:
*All shelves are clean and not rusted and that the refrigerators shall be maintained as clean.

A review of the "Nutritional Services Director" Competency Assessment dated March 20, 2010, showed a FSD shall have a thorough knowledge of federal, state and local regulatory compliance regulations and standards; knowledge and understanding of infection control practices and processes; provide oversight of staff and manages staff requirements.

A review of the FSD job duties showed it was the FSD's job to develop procedures governing sanitation of the department.

4. On July 19, 2010, at 2:25 p.m., the cook's reach-in refrigerator was inspected and did not feel like the ambient temperature was that cool. The ICP touring with the surveyor verified the unit did not feel as cold as it should be.

The refrigerator contained a pan measuring approximately 10 inches by 8 inches and 6 inched deep of brown rice dated July 12, 2010. It also contained a sheet pan of cooked bacon. The DSS stated the bacon had been cooked earlier that morning at around 8:30 a.m. The temperature of both foods were taken at that time and the temperature of both foods was between 48 and 50 degrees F.

On July 19, 2010, at 2:40 p.m., the DSS stated that it was not the facility practice to save previously cooked foods.

a. When asked if the brown rice had been cooled down as per the facility policy, she stated that it was probably cooked for a renal patient who cannot receive potatoes and re-used specifically for that patient. The DSS was unable to show any time and temperature monitoring indicating the brown rice had been safely cooled down and reheated to safe temperatures to minimize food borne illness risk.

According to the facility P&P titled, "Cooling Procedures" (revised May 2009) showed that cooling procedures shall be followed in order to decrease the risk of the development of food borne illness. The procedure consisted of monitoring time and temperature from 140 degrees F in two hours and then from 70 degrees F to 40 degrees F within an additional four hours. There was no system in place for the FSD to verify the procedure had taken place correctly. In addition, the facility policy showed that if the food did not meet 70 degrees F after two hours, it would be separated into smaller portions and an ice bath would be used. There was no staff guidance which directed staff to document the time and temperature findings on a log.

According to the "Food Code", PHF shall be cooled down according to specific time and temperature standards and monitoring. Elements of an effective food safety management system may include the following: monitoring procedures and record keeping.

On July 21, 2010, at 11:15 a.m., during a phone interview with the FSD, he stated that he uses a tool to identify issues with the department. According to the tool, the "Food Code" standards shall be maintained for cooking and reheating "high risk" foods.

b. At that time, the DSS confirmed it was the facility policy to only keep previously cooked PHF for three days. The DSS was unable to state why the brown rice was still being stored four days past the facility three day standard. A review of the posted document titled, "Refrigerated Storage Guidelines" showed there was no storage recommendations for previously cooked foods such as noodles and rice.

On July 21, 2010, at 11:15 a.m., during a phone interview with the FSD, he stated that he uses a tool to identify quality issues with the department. According to the tool, leftover foods shall be used within 72 hours (three days).

A review of the FSD job duties showed it was the FSD's job to develop policies and procedures governing handling and storage of supplies. In addition, the FSD was to supervise food production.

5. On July 19, 2010, at 3:15 p.m., the walk-in refrigerator temperature log posted on the refrigerator door showed the refrigerator temperature was 42 degrees on July 17 and 18, 2010. On July 19, 2010 the walk-in refrigerator temperature was logged at 45 degrees F.

According to the instructions on the log, the acceptable temperature range for the refrigerator was between 36 and 40 degrees F. The log directed staff to note the discrepancy and document the "corrective action." There was no corrective action documented and the DSS was unaware that the temperature of the refrigerator had been increasing over the last three days.

According to the competency assessment tool used for the Food Services Director and the "Cook Supervisor" it was the expectation that both the positions required demonstration of the skills needed for monitoring the food refrigerator temperature log.

6. On July 19, 2010, at 3:20 p.m., the walk-in refrigerator contained five pound cottage cheese containers to store leftover foods. Upon questioning, the DSS stated she was unaware that they were meant only for one time use for cottage cheeks and were not intended to store other foods.

According to the 2009 "Food Code" published by the Food and Drug Administration, multi-use food contact surfaces of equipment shall be able to be constructed in order to routinely clean and sanitize surfaces so that it potentially could not harbor food pathogens.

7. On July 19, 2010, the kitchen contained live ants in numerous areas including the dish room area, near the ice machine and in the food production area. In addition, the separate dry food storage area, located in a small building in the parking lot, showed there were large quantities of dead bugs on the floor. The bottom of the door to the small building measuring approximately three feet contained an open gap measuring one-half inch all along the approximate three foot sweep of the door.

On July 19, 2010, at 4 p.m., the DSS identified the bugs as dead beetles. She further stated that no sooner would the staff clean them up, they would return the next day.

On July 19, 2010, at 11:15 a.m., during a phone interview with the FSD, he stated that he uses a tool to identify sanitation and maintenance issues within the department to assess quality. According to the tool, quality standards related to general work areas include pest control in place with no signs of rodents or insects.

A review of the department policy and procedure titled, "Pest Control" revised May 2009) showed that a pest control program included doors that shut tightly.

Based on staff interview and document review, the facility failed to ensure that the DSS who had been left in charge of the dietary department was trained and competent in the FSD/supervisor duties during there FSD absence.

Findings:

During the re-certification survey starting on July 19, 2010, the FSD was on vacation. On July 19, 2010, at 1:30 p.m., the DSS stated that she had been recently promoted to "Cook Supervisor" and was responsible to provide all food service oversight in the absence of the FSD. The DSS stated she was qualified based on her work experience. A review of the DSS file showed that she had been recently promoted on June 13, 2010, from "Lead Cook" to a "Cook Supervisor."

During the survey, deficient practice as it related to food service sanitation and food safety criteria were identified (Cross refer A-620). Specific examples include:
*Lack of knowledge by the DSS regarding the correct procedure to sanitize the ice machine to ensure food safety.
*Lack of oversight by the DSS regarding the cooling of a PHF, brown rice. In addition, this food was being stored four days beyond it's time frame in a refrigerator that was not maintaining safe food temperatures.
*Lack of monitoring and follow-up of the walk-in refrigerator for three days to ensure food safety.
*Lack of knowledge regarding appropriate containers to use for food storage.
*Lack of follow-up by the DSS regarding the presence of live ants in the main kitchen and an ongoing problem with beetles in the dry storage area.

On July 19, 2010, at 3:40 p.m., the DSS stated she knows that she has many areas related to facility policies and procedures and standards of practice that she needs to learn more about to ensure food service sanitation and food safety. At that time, the DSS stated that she was learning a lot of new things based on the survey findings and interviews.

On July 20, 2010, at 11:45 a.m., the DSS was asked about the correct chemical concentration required for the three compartment sink manual dish washing procedure and for chemical buckets used for surface cleaning and sanitization. The DSS stated she was unfamiliar with what concentration the chlorine or quaternary ammonia chemical solution should be to ensure the chemical was sanitizing the equipment and surfaces.

A review of the hospital human resources file for the DSS showed the employee had been promoted from a "Lead Cook" to "Cook Supervisor" on June 13, 2010. A further review of the file, showed there was not signed job description or competence assessment in the file for the promoted employee.

On July 22, 2010, at 9 a.m., the HRO confirmed that it was the facility practice for a signed job description to be in the file.

On July 22, 2010, at 9 a.m., the HRO provided the surveyor with a blank "Cook Supervisor" job description and competence assessment documents. The HRO confirmed the documents should have been signed when the employee had been promoted.

At that time, the HRO confirmed the competence criteria had not really changed from "Lead Cook" to "Cook Supervisor". A review of both documents showed there were criteria to address deficient practice issues on the "Lead Cook" document related to dish washing; cleaning work areas; a "thorough understanding of infection control practices and processes"; ability to supervise Nutritional Services' employees; refrigerator logs; dishwashers; storage areas; etc. A review of the "Lead Cook" document, dated February 23, 2010, showed the FSD and the DSS both had signed the document verifying the information as "accurate and complete."

This competence was inconsistent with the deficient practice observed during the survey and with the DSS interview.

Based on staff interview and document review, the hospital failed to meet the nutritional needs of Patients 28, 1, 3, 4, 5, 6, and 7 by failing to ensure the nutritional screening and assessment P&Ps were initiated, completed, accurate and timely in order to meet the nutritional needs.

Findings:

Medical record reviews were conducted on July 19 through 22, 2010.

A review of the facility policy and procedure titled, "Nutritional Screening, Assessment, Reassessment and Education" (revised May 2009) showed the following:
*Screening by the nurse will be conducted within 24 hours of admission.
*Patients are further screened by the Dietary Manager within three days of admission utilizing the "Initial Nutrition Screening" form. The form signature line shows that this form could also be completed by a RN or a DTR.
* If after screening the patient is identified as being at nutritional risk the patient will be referred to the RD for further assessment within within 48 hours from referral time. Based on the policy, a patient identified with nutritional risk would not receive a nutritional assessment for five days on admission.
*In addition the policy also indicates that patients on TPN or enteral feedings will be seen every 3-4 days. Other follow-up reassessment criteria indicate when there is a change of condition which negatively effects meal intake or requires a new complex therapeutic diet. This criteria did not provide any reassessment time frames.
*The policy directed the RD to initiate planned nutrition interventions after the assessment to address nutritional or diet changes to meet patient needs.

1. The record for Patient 28 was reviewed on July 20, 2010. Patient 28, a 57 year old female, was admitted to the facility on May 3, 2010, with diagnoses that included DM, HTN, and renal (kidney) failure. The physician's H&P dictated on May 4, 2010, indicated the patient needed dialysis due to renal (kidney) failure.

The physician's orders, dated May 3, 2010, at 9 p.m., included an order for a 2000 calorie ADA diet for Patient 28, with no documentation of any special nutritional needs related to the renal failure.

The nursing form titled, "Patient Assessment/Care Plan/Discharge Referral/Adult", dated May 3, 2010, indicated the nurse did not identify Patient 28 to be at risk for nutritional problems.

The form titled, "Initial Nutritional Screening", completed by the FSD/RD on May 5, 2010, included multiple abnormal laboratory values, which indicated the patient was in renal failure. The form did not specify a further assessment would be done by the RD, although renal failure was listed as one of the diagnoses that should lead to further assessment.

A nutritional assessment completed by the FSD/RD on May 6, 2010, indicated Patient 28's current nutritional needs were not being met, and Patient 28 needed a low protein renal diet, with MVI, Vitamin B complex, and limited potassium intake.

A physician's order, dated May 7, 2010, indicated the diet was changed to a 2000 calorie ADA with two grams of sodium (low salt). Patient 28 was discharged from the facility on May 10, 2010, seven days after 7 after admission, with instructions to seek treatment for dialysis. There were no instructions provided for dietary changes that were necessary for a patient with renal failure. There was no documentation indicating the physician reviewed the FSD/RD recommendations or why the recommendations were not followed.

A review of the facility diet manual on July 20, 2010, indicated patients with renal failure should be on a renal diet with low protein and low potassium.

2. Patient 1, a 37 year old male, was admitted to the ICU on July 15, 2010, with a diagnoses that included metastatic cancer. According to the transfer summary dictated on July 18, 2010, Patient 1 had been admitted to the ICU with fever and chills and needed to be rehydrated.

According to the Nutrition/Gastrointestinal Care Plan which included a "High Nutritional Risk Screen", the patient had been identified at high nutritional risk based on constipation. The interventions checked did not include a clinical nutrition consult.

On July 16, 2010, the physician had ordered intake and output fluid monitoring, a soft diet, and colace (stool softner).

There was no three day nutrition screening by the nurse or the dietary manager using the policy form to identify nutrition risk during the four day admission time frame during the survey as per the facility policy and procedure.

In addition to the policy and procedure criteria as above, another P&P titled, "Nutritional Status, Nurse Screen, Dietitian Assess & Intervene" (revised April 2010), showed the admitting nurse will screen patients further for admissions with new, progressive or terminal cancer. At this point the policy directs staff to request a physician dietary consult.

There was no nutrition assessment by the RD during the four day admission time frame to evaluate the nutrition status of Patient 1 and address the constipation/hydration concerns identified through food and fluid interventions. There was no evaluation by the RD regarding the impact of the metastatic cancer on Patient 1's nutritional status.

3. Patient 3, a 63 year old male, was was admitted to the hospital on July 14, 2010, to the ICU with diagnoses of complaints of being short of breath. On July 14, 2010, the physician ordered for a cardiac diet and daily weights.

According to the Nutrition/Gastrointestinal Care Plan which included a "High Nutritional Risk Screen", the patient had been identified at nutrition risk based on constipation for an "unknown" reason. The interventions checked did not include a clinical nutrition consult.

Further review of the record showed on July 15, 2010, there was no documentation by nursing of the % intake of the cardiac diet for lunch and dinner. On July 16, 2010, the nurse documented, Patient 1 ate breakfast but did not eat lunch or dinner. On July 17, 2010, the nurse's documentation showed "appetite poor." According to the nurse's entry at 11 a.m., on July 17, 2010, the fasting blood sugar was 79 and orange juice had to be given to increase the blood sugar. The nurse further documented that the lunch tray was given, but the patient "refuses everything." On July 18, 2010, the nurse documented a 50% intake for breakfast and lunch, but the physician had ordered clear liquid diet due to abdominal distension.

On July 20, 2010 at 10:45 a.m., the ICU Nurse Manager was asked why the nurse had not initiated a consult based on the nutrition risk criteria or based on the poor intake Patient 3 was experiencing, she stated the nurse is not able to order a RD Consult without a physician order. This was inconsistent with the facility approved P&P.

The ICU monitoring nurse verified there was no "Dietitian Consult" form completed for Patient 3 either after the initial assessment or once the patient's diet intake remained low. According to the nursing plan of care, the patient was to tolerated the prescribed diet and to maintain adequate nutrition status.

There was no nutritional assessment or plan of care interventions by the RD during the five day period during the admission and the surveyor review to evaluate the patient's nutritional status and address nutritional interventions.

4. Patient 4 was admitted to the facility on June 12, 2010, with diagnoses of a small bowel obstruction. According to the "Transfer Summary" the patient had complaints of abdominal pain and had a history of small bowel obstruction. On admission, the physician ordered nothing by mouth and a naso-gastric tube for suction was placed.

On July 12, 2010, the nurse assessment/care plan documented Patient 4 was six feet tall and weighed 197 pounds. The document showed the patient followed a vegetarian diet at home; was receiving TPN for nutrition and had altered nutrition less than body requirements. Interventions checked did not include nutrition consult.

There was no "Initial Nutritional Screening" form in the entire record completed by the Dietary Manager/DTR/RN as per facility policy.

On June 15, 2010, the pharmacist discontinued the fat component of the parenteral nutrition due to "nationwide shortage." The fat was a major component of calories provided by the parenteral nutrition."

During the course of the entire 12 day hospital stay, the patient weight on June 22, 2010, was 184.5 which was a loss of 12.5 pounds. The patient albumin had dropped to 2.9 mg/dl on June 19, 2010, and was 217 mg/dl on June 21, 22, and 23, 2010. According to the policy "Initial Nutritional Screening" form a patient on TPN or with an albumin of less than 3.0 mg/dl should be referred to the RD for nutritional assessment.

There was no RD Nutritional Assessment or reassessment during the entire admission (12 days) to evaluate nutritional support interventions;or to assist with dietary by mouth progression.

5. Patient 5 was admitted to the facility on May 7, 2010, with diagnosis of possible sepsis. According to the H&P indicated the patient was 37 years old with multiple sclerosis that was being fed using a GT. In addition, the patient had previous pressure sores which were according to the physician were well cared for with some scarring.

According to the nursing "Patient Assessment/Care Plan/Discharge Referral/Adult", initiated on May 7, 2010, the "High Nutritional Risk Score" was checked based on the identification by the nurse that the patient was on tube feeding; bowel incontinence and altered nutrition. The interventions checked did not include a clinical nutrition consult. The expected outcome was for the patient to maintain adequate nutrition.

A review of laboratory test results, dated May 7, 2010, indicated the Patient 5's albumin was 2.8 mg/dl and glucose was 201 mg/dl on admission.

According to the "Initial Nutrition Screening" completed on May 16, 2010, which should have been completed on May 10, 2010, according to policy time frames (six days late) showed Patient 5 had a Stage III right hip decubitus ulcer. The screening also showed the patient's albumin was 2.8 mg/dl with an elevated blood sugar of 215. According to the criteria, an albumin less than 3.0 and the presence of wounds should have been referred to an RD.

6. Patient 6 was admitted on April 28, 2010. According to the hospital P&P an "Initial Nutritional Screening" was to be conducted within three days of admission. The "Initial Nutritional Screening" was completed on May 2, 2010. The form had not been completed as per the facility P&P.

7. Patient 7 was admitted on May 18, 2010, with diagnosis of colon tumor. According to the transfer summary, the patient was 81 years old with a history of gastrointestinal bleeding, Alzheimer's disease, type 2 diabetes, and diabetic neuropathy.

On May 18, 2010, the physician ordered NPO. On May 22, 2010, the physician ordered clear liquids. On May 23, 2010, the physician ordered full liquids.

According to the nursing "Patient Assessment/Care Plan/Discharge Referral/Adult", initiated on May 18, 2010, the patient was 5 feet 4 inches tall and weighed 214.7 pounds. The "High Nutritional Risk Screen" showed bowel incontinence and altered nutrition was checked. The interventions checked did not include a clinical nutrition consult. The expected outcome was for the patient was to maintain adequate nutrition.

A review of the "Initial Nutrition Screening" was completed on May 23, 2010, by the RD should have been completed by May 20, 2010. The "Initial Nutrition Screening" was completed two days later than the policy time frames. The screen showed the patient was potentially at nutrition risk based on an elevated blood sugar, increased BUN (Blood Urea Nitrogen) and "other high risk diagnosis."The screening had not identified that the patient had been either NPO or on a clear liquid diet for greater than three days. The diets would not have provided the patient adequate nutrition for those days.

On May 24, 2010, the RD "Nutritional Assessment" identified the patient's diet had been advanced to full liquid. The goal was to maintain normal nutritional therapy. The area identifying when follow-up would occur was left blank. There was no plan by the RD to verify tolerance and monitor dietary progression to ensure nutritional adequacy.

Based on observation, staff interview, and document review, the facility failed to have an approved diet manual that was available to all medical and nursing staff.

Findings:

On July 19, 2010, during the entrance conference, a copy of the facility approved diet manual was requested. The facility provided a yellow diet manual that had an approval page dated March 2008.

On July 20, 2010, starting at 10 a.m., the ICU was toured. RN 1 stated she was a regular nurse on the unit. RN 1 was asked to locate the facility approved diet manual for the unit. She was unable to find it. At that time, the ICU Manager was also unable to locate the diet manual for the unit.

On July 21, 2010, the Medical/Surgical nursing unit was toured. A licensed nurse was asked to provide the facility approved diet manual used by the nurses and physicians on the unit. The nurse directed the surveyor to a different manual then the one provided at entrance. The manual was published in 2000 by the American Dietetics Association and did not contain a signed approval sheet.

A review of the facility P&P titled, "Diet Manual" (revised 5/09), showed it was the policy of the facility to have "one standard diet manual" as a basis for ordering modified diets. The purpose of the manual was to serve as a communication tool for nursing, medical staff and the nutrition services department. The policy showed that only one copy would be housed in the Medical Surgical Unit and the other in the nutritional services department. There was no provision for a copy to be housed in the four bed ICU. This would require the nurse to leave the unit to retrieve the diet manual. In addition, The P&P provided the manual would be reviewed and/or updated annually, and that approval is conducted by the P&T Committee.

On July 21, 2010, at 11:15 a.m., during a phone interview with the FSD, he stated the manual is only kept in the medical/surgical unit and the nutrition services department. He was not able to explain why the copy provided at entrance was different than the on the unit and why there was no approval page on the unit version.

A review of the P&T Committee minutes from January 26, 2009, through the survey date showed there was no review, approval, or discussion regarding the facility diet manual during the past 19 months.

Based on interview and record review, the facility failed to have a UR committee comprised of institution staff or a group outside the institution consisting of two or more practitioners to carry out the UR function. This failed practice had the potential to result in the provision of inappropriate care or prolonged LOS.

Findings:

On July 21, 2010, at 10:20 a.m., the CM was interviewed. The CM stated the UR committee just started, the first UR committee meeting was scheduled for Thursday July 22, 2010, and thereafter the meetings were to be held on the second Thursday of each month.

On July 22, 2010, at 8:30 a.m., the QRM was interviewed and she stated the facility had not had a UR committee since September 2009. She stated the facility planned to following InterQual (organization providing evidence-based clinical decision support for providers) criteria. The QRM stated the UR committee meeting schedule for July 22, 2010, was canceled due to the survey.

On July 22, 2010, at 10:15 a.m., the CNO was interviewed and she stated the facility tracked the average LOS for inpatients and provided a current report. The CNO stated the average LOS had been 3.8 days and since the facility hired a CM, the average LOS decreased to 3.2 days in June 2010. The CNO stated the Chief of Staff evaluated two to three patients per week for appropriateness of care and LOS. She stated the facility was still working on the structure for the UR committee.

On July 22, 2010, the facility's written UR plan was reviewed. The effective date of the plan was April 2006 and the last update was June 2010.

On July 22, 2010, the Quality Council meeting minutes for September 2009 through July 2010 were reviewed. From September through December 2009, the UR report to the committee included only patients transferred from the ER to other facilities for a higher level of care. There was no documentation regarding the discussion of the appropriateness of inpatient care or LOS. The minutes from January through July 2010, indicated no UR report was presented at the QC meetings.

Based on observation, interview, and record review, the facility failed to maintain a system for ensuring routine preventative maintenance was performed on all medical equipment. This failed practice resulted in the potential for failure of the equipment and harm to patients.

Findings:

On July 19, 2010, at 1:28 p.m., a tour of the ICU was conducted. The equipment in the unit was inspected and noted to have stickers titled, "Biomedical Engineering". The observed items and numbers written on the stickers were as follows:
a. Two IV pumps were on a pole next to bed three, "3-10;"
b. One IV pump was on a pole beside bed one, "3-10;" and,
c. A cardiac monitor was mounted on the wall above bed three, "1-09." written on it.

On July 19, 2010, at 1:45 p.m., the Biomedical Engineer was interviewed. He stated the dates on the stickers indicated the date the last PM expired and the new PM was due to be done. He stated his current practice was to do the new PM, but not put a new sticker on the piece of equipment because he was, "Trying to get away from stickers." He stated there was no way for the staff at the bedside to identify an equipment item that was due for PM.

During an interview with RN 1 on July 19, 2010, at 2 p.m., RN 1 stated she did not know how to tell if the PM on a medical equipment item was current or expired.

During an interview with the Biomedical Engineer on July 19, 2010, at 4:15 p.m., he stated there was no system in place to identify the due date for PM for each equipment item, as the PM schedule for the facility was done by department and not by each equipment item. He stated he did not track equipment that may have been moved from department to department, such as IV pumps, feeding machines, and pneumatic stocking machines (for alternating pressure on the legs). The engineer stated those equipment items could be missed and, "That's where I'm lacking."

On July 22, 2010, at 11:35 a.m., the biomedical equipment PM records were reviewed with the Biomedical Engineer present. The engineer was not able to locate current PM records for seven of 50 IV pumps.

A review of the plan for PI indicators on July 21, 2010, indicated there were no quality studies being done to determine the effectiveness of the biomedical engineering program.

On July 21, 2010, at 2:45 p.m., the QRM was interviewed. She stated the Plant Operations department planned to select PI indicators, but had not yet done so. The QRM stated the Plant Operations department included biomedical engineering, but there were no quality studies currently being done to determine the effectiveness of the biomedical engineering program.

2. During the kitchen tour with the ICP on July 19, 2010, deficient practice with regards to potential food safety risks and cleaning and sanitizing issues were identified The following deficient practices were identified (Cross refer to A-620).

According to the "Infection, Prevention and Control Plan" (revised May 2009), showed the goals of the ICP were to protect patients, visitors, and health care personnel through an interdisciplinary approach to infection surveillance, prevention and control. The plan included surveillance of areas "needing further study" as identified through requests by departments and environmental rounds.

A review of the document provided by the ICP, which addressed the Infection Control component of environmental rounds showed the only food safety related criteria were refrigerator temperature log completion and the cleanliness of the refrigerator and microwave. There were no specific kitchen food handling and preparation criteria to ensure food safety. There was no criteria addressing cleaning and sanitizing of dishes, utensils, surfaces and equipment. There was no criteria addressing pest control.

On July 21, 2010, at 2:10 p.m., the ICP was interviewed. The ICP was asked regarding her role in the dietary kitchen areas to ensure compliance with infection control and food safety concerns. The ICP stated that she had not participated in the dietary kitchen oversight or monitoring of food service activities during 2009 and 2010. She verified that she had never taken an active role in effective pest management.



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Based on observation, interview, and record review, the facility failed to ensure the ICP implemented a complete system for identifying, reporting, investigating and controlling infections that included all areas of the facility by failing to ensure:

1. Two of two oscillating fans used for cooling patients in the ICU were cleaned regularly. This failed practice resulted in the potential for contamination and spread of infection in the ICU.

2. The ICP maintained an active role in the dietary kitchen areas to ensure compliance with infection control and appropriate food safety practices. This failed practice had the potential to result in the spread of food borne illnesses.

Findings:

1. On July 19, 2010, at 1:55 p.m., a tour of the ICU was conducted. Two standing oscillating fans, approximately four feet tall, were observed next to bed two, one on each side of the bed. The metal cases housing the blades on both fans were covered in a gray, fuzzy, dust like substance starting at the inner circle and moving out to the center of the housing.

On July 19, 2010, at 2 p.m., RN 1 was interviewed. RN 1 stated the fans were routinely used in the ICU and pointed toward the patients to keep them cool.

On July 20, 2010, at 1:05 p.m., the ICU housekeeper was interviewed. The housekeeper stated she cleaned the fans sometimes, but did not know how often. She stated the fans were not on a regular cleaning schedule. Upon looking at the housing of the fans, the housekeeper stated the fans needed to be cleaned and said, "Ooh, it's bad."