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Based on document review and staff interview, the hospital failed to ensure the RD took physician telephone orders within their scope of practice according to the Business and Professions Code under 2586(b).

Findings:

During the re-certification survey, a medical record review on August 26, 2010, showed Patient 41 had a telephone order written by an RD on August 22, 2010, to start PPN (Peripheral Parenteral Nutrition) per pharmacy. The order was not signed by a physician. Further review of the record showed the pharmacist initiated the parenteral nutrition on August 22, 2010.

A review of the Medical Staff Rules and Regulations showed that verbal/telephone medication orders can be taken by a dietitian within their scope of practice. All verbal orders shall be signed, dated, and timed by the prescribing practitioner within 48 hours.

According to the Business and Professions Code at 2586(b), an RD may take verbal orders to implement medical nutrition therapy. The definition of medical nutrition therapy at 2585(a) does not include drugs or the administration of intervenous nutrition as a component of medical nutrition therapy.

On August 26, 2010, at 1:45 P.M., the Director of Pharmacy verified he thought RD's could take telephone/verbal orders for parenteral (intravenous) nutrition, and that the drug orders shall be signed by the physician within 48 hours.

Based on observation, interview, and record review, the facility failed to effectively notify a patient of his rights regarding the administration of antipsychotic drugs (medications to treat mental illness).

Findings:

On August 25, 2010, at 2:07 p.m., a review of Patient 40's medical record revealed an informed medication consent that was signed by the patient on August 19, 2010, at 4:30 p.m., and witnessed by LVN 1. According to the hospital's policy and procedure (P & P) entitled, "Informed Consent for Antipsychotic/Psychotropic Medication", which states, "The purpose is to educate patient's about the risks, benefits, and alternatives to antipsychotic/psychotropic medication and to certify that the patient has been offered an explanation of the antipsychotic/psychotropic medication by the physician." The P & P further states, "After the above information has been discussed with the patient and the patient has given consent to take the medication, the patient must sign the Consent Form for the specific drug and dosage amount."

A review of Patient 40's clinical record indicated that the patient was a Spanish speaking individual. However, the consent form used to educate the patient about the antipsychotic drugs prescribed for him, and signed by the patient, was written in English. The nurse manager indicated that the patient spoke some English but on interview the patient could not understand English spoken to him by the surveyor.

Based on chart review, the hospital failed to ensure that the prescribing practitioner for Patient's 11 and 35 verified, dated, timed, and signed all verbal orders in accordance with State and Federal Requirements.

Findings:

1. On August 24, 2010, at 11:13 a.m., a review of Patient 11's medical record revealed one verbal order taken over the telephone on August 20, 2010, containing five medications, and one verbal order taken on August 21, 2010, containing one medication protocol, were not verified, dated and timed, and signed by the prescribing practitioner.

2. On August 25, 2010, at 10:14 a.m., a review of Patient 35's medical record revealed one verbal order taken over the telephone on August 19, 2010, containing five medications, was not verified, dated and timed, and signed by the prescribing practitioner.

California Code of Regulations, Title 22, Section 70362(g) states, "Verbal orders for drugs shall be given only by a person lawfully authorized to prescribe or furnish and shall be recorded promptly in the patient's medical record, noting the name of the person giving the verbal order and the signature of the individual receiving the order. The prescriber or furnisher shall countersign the order within 48 hours.

Verbal orders were not countersigned by the prescriber within 48 hours.

Based on observation, interview, medical record review, document review, and policy
and procedure review, the hospital failed to ensure that pharmaceutical services carried out its full and complete oversight to meet the needs of the patients in the hospital.
The cumulative effect of these systemic problems identified resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Findings:

1. Pharmaceutical services failed to ensure that two of two RN's (RN 1 and RN 2) in the ED were able to quickly and accurately calculate doses of emergency medications and prepare them for administration during a pediatric mock code blue (for theoretical pediatric patients during a medical emergency). (See A0500 #1)

On August 24, 2010, at 3:15 p.m., Administration was notified that an immediate jeopardy was called as a result of the ED nurses inability to accurately and quickly prepare doses of emergency medications for pediatric patients.

The immediate jeopardy was abated on August 26, 2010, at 10:05 a.m., after accepting the hospital's plan of correction and observing another pediatric mock code with two ED registered nurses calculating and preparing emergency medications for theoretical patients.

2. Pharmaceutical services failed to ensure the safe use of multiple dose vials when they were shared among patients. (See A0500 #2)

3. Pharmaceutical services failed to provide timely and sufficient information to Patient 40 before he was requested to sign the informed medication consent for Depakote (a medication to treat psychological illnesses) and Prozac (a medication to treat depression). (See A0500 #3)

4. Pharmaceutical services failed to ensure that five nurses did not have access to medications stored in automated drug dispensing cabinets after the nurses had separated from the hospital. (See A0502)

5. Pharmaceutical services failed to list the contents of the emergency medications on the outside of the pediatric emergency medication cart located in the ED, and failed to list the contents of all emergency medications on the outside of the malignant hyperthermia cart located in the surgery department. (See A0500 #4)

6. Provide parenteral nutrition managed by the pharmacist to meet the nutritional needs of Patient 41, as per the facility policy and procedure and standards of parenteral nutrition management. (See A0500 #5)

7. To provide education in Spanish to a Spanish speaking patient (Patient 42), when educating the patient and answering his concerns, before he is required to sign an informed medication consent form. (See A0500 #6)

Based on observation, interview, medical record review, and administrative document review, the hospital failed to:
a.) Ensure that two of two emergency department (ED) registered nurses (RN 1 and 2) were able to quickly and accurately calculate doses of emergency medications and prepare them for administration during a pediatric mock code blue (for theoretical pediatric patients during a medical emergency).

On August 24, 2010, at 3:15 p.m., the hospital administration was notified that an immediate jeopardy was called as a result of the ED nurses inability to accurately and quickly prepare doses of emergency medications for pediatric patients. The immediate jeopardy was abated on August 26, 2010, at 10:05 a.m., after accepting the hospital's plan of correction and observing another pediatric mock code with two ED registered nurses calculating and preparing emergency medications for theoretical patients.

b.) Ensure the safe use of multiple dose vials when they were shared among patients.

c.) Provide timely and sufficient information to Patient 42 before he was requested to sign the informed medication consent for Depakote (a medication to treat psychological illnesses) and Prozac (a medication to treat depression).

d.) List the contents of the emergency medications on the outside of the pediatric emergency medication cart located in the emergency department, and failed to list the contents of all emergency medications on the outside of the malignant hyperthermia cart located in the surgery department.

e.) Provide parenteral nutrition, managed by the pharmacist, to meet the nutritional needs of Patient 41, as per the facility policy and procedure and standards of parenteral nutrition management.

f.) Provide medication education in Spanish when requesting a Spanish speaking patient, Patient 42, to sign an informed medication consent.

Findings:

1. On August 23, 2010, at 2:07 p.m., RN 1 in the ED was asked to draw up into a syringe, pediatric doses of three emergency medications for a theoretical pediatric patient. RN 3 and the interim DOP were present as an observer. RN 1 was given a height for a theoretical patient. The first medication she was asked to draw into a syringe was atropine (a medication to increase the heart rate). She used a Broselow tape to determine the weight of the patient. Broselow tapes provide weights which correspond to a patient's height. The Broselow tape also provides doses of emergency medications which correspond to each of the weights. RN 1 used the Broselow tape to determine the dose of the medication. RN 1 drew into the syringe the correct dose of atropine (1.7 milliliters). RN 1 subsequently was asked to prepare a dose of sodium bicarbonate (a medication to balance the blood) for the same theoretical patient. She again used the Broselow tape to determine the dose which corresponded to the patient's height. The correct dose was 8.5 milliliters, but RN 1 drew in the syringe a dose of 7.5 milliliters. RN 1 was again asked to prepare a dose of another medication, Lidocaine (a medication to treat irregular heart beats). She again used the Broselow tape to determine the dose which corresponded to the patient's height. The correct dose was 0.85 milliliters, but RN 1 could not find a small enough syringe to accurately draw up this dose. Instead she drew up the dose in a 3 milliliter syringe, which does not have the hash mark lines on the side to accurately draw up this small dose.

On August 24, 2010, a review of the hospital's policy and procedure entitled, "Code Blue" described the responsibilities of each code blue team member. Under #7, "Designated pharmacist (in the absence of a pharmacist an ACLS RN will assume the role. Prepares medications as ordered by the physician or ACLS RN)." On August 23, 2010, at 9:50 a.m., the interim DOP stated there were no pharmacists in the hospital from midnight to 6 a.m. During this time, nurses are solely responsible for drawing up medications during code blues (medical emergencies requiring CPR).

On August 24, 2010, at 1:08 p.m., RN 2 in the ED was asked to draw up into a syringe, the same pediatric medications that RN 1 was asked to draw up on August 23, 2010, at 2:07 p.m. Present in the room were RN 3 and the interim DOP as observers. RN 2 was given a height for a theoretical patient. RN 2 was unable to correctly use the Broselow tape to determine the patient's dose. She did not know at what end to start the Broselow tape and according to her placement of the tape, the dose was located in the "White" zone instead of the correct zone which was "Red." White zone doses are larger and indicated for taller and heavier pediatric patients, which could have overdosed this theoretical patient. Atropine was the first medication that RN 2 was asked to draw up in a syringe. The correct dose was 1.7 milliliters and RN 2 drew up 4.0 milliliters (a 57% increase in dose from what it should have been). The next medication RN 2 was asked to draw up in a syringe was sodium bicarbonate. The dose she drew up in the syringe was 15.4 milliliters (almost double the correct dose). The correct dose should have been 8.5 milliliters. The last medication RN 2 was asked to draw up in a syringe was lidocaine. RN 2 could not determine the dose to give for this medication and gave up.

On August 24, 2010, at 1:41 p.m., the interim DOP stated that mock codes were not conducted for training in the emergency department, but were conducted on the floors of the hospital. He stated the reason for this was that ED nurses were involved in actual codes more often and it was felt they didn't need the additional training. He also stated RN 2 did worse today than RN 1 yesterday.

On August 25, 2010, a review of RN 1's employee profile revealed there was no specific documentation that she was competent in using the Broselow tape or in participating in mock pediatric codes.

On August 25, 2010, a review of RN 2's employee profile revealed that she received Broselow tape training in October 2009 and had documentation as being competent in this area. RN 2 was unable to correctly use the Broselow tape during the mock code on August 24, 2010.

The immediate jeopardy was abated on August 26, 2010, at 10:05 a.m., after RN 2 and RN 4 demonstrated they could accurately calculate and draw up correct doses of medications during a pediatric mock code conducted earlier in the morning. All ED nurses received immediate training on the Broselow tape, pediatric emergency medication calculations, and how to accurately and safely draw up doses in appropriate syringes.

2. During an interview on August 23, 2010, at 2:39 p.m., the DOP stated patients in the hospital share multiple dose vials such as Insulin (medication to treat high blood sugar levels) and certain vaccines such as PPD (protein purified derivative).

On August 24, 2010, at 9:15 a.m., the interim DOP stated the hospital does not have a policy and procedure to ensure the safety of the patient when different patients share the same vial. The interim DOP provided a Policy and Procedure entitled, "Medication: Disposition of Discontinued and Expired Medications", which describes the expiration date of multiple dose vials as being 28 days after opening, but does not describe the procedures to prevent the potential for transmitting an infection when using the same vial to withdraw medications for several patients.

The APIC (Association for Professionals in Infection Control) Position Paper: Safe Injection, Infusion and Medication Vial Practices in Healthcare, June 2009, states, "APIC strongly supports adherence to the following safe injection, infusion and medication vial practices." Pertaining to multiple dose vials, "Use multi-dose medication vials for a single patient whenever possible and access all vials using a new sterile syringe, needle/cannula and adherence to aseptic technique. The risk of transmission posed by multi-dose vials has been clearly demonstrated and mandates a practice of one vial per one patient whenever possible. Infection transmission risk is reduced when multi-dose vials are dedicated to a single patient."

The hospital continues to share multiple dose vials among patients which has the potential for spreading infection and jeopardizing patients' health.

3. On August 25, 2010, at 2:07 p.m., review of Patient 42's medical record revealed an informed medication consent that was signed by the patient on August 19, 2010, at 4:30 p.m. and witnessed by LVN 1. The hospital's policy and procedure (P & P) entitled, "Informed Consent for Antipsychotic/Psychotropic Medication," states, "The purpose is to educate patient's about the risks, benefits, and alternatives to antipsychotic/psychotropic medication and to certify that the patient has been offered an explanation of the antipsychotic/psychotropic medication by the physician." The P & P further states, "After the above information has been discussed with the patient and the patient has given consent to take the medication, the patient must sign the Consent Form for the specific drug and dosage amount."

Patient 42 was requested to sign the informed consent for Depakote and Prozac before the physician was able to discuss and address concerns and questions the patient might have. The physician signed the consent after the patient and the witness (LVN 1) on August 20, 2010, at 1:50 a.m.

On August 25, 2010, at 2:31 p.m., LVN 1 stated the physician informs the patient about the medication and then the patient is asked to sign and date the informed consent. Once the patient signs the consent, the witness signs and dates the form to verify that the medication was adequately explained to the patient and the document was completed as required.

4. During a tour of the ED on August 23, 2010, at 1:52 p.m., the pediatric code blue cart was found to be missing a list on the outside of the cart of all emergency medications stored within.

During the tour of the surgical department on August 26, 2010, at 10:44 a.m., the malignant hyperthermia (life threatening elevated body temperature) cart, which contained emergency medication to treat malignant hyperthermia, did not have a list of medications posted to the outside of the cart. The Director of the department stated he did not know where the list was.

The California Code of Regulations, Title 22, 70263(f)(2) states, "The emergency drug supply shall be stored in a clearly marked portable container which is sealed by a pharmacist in such a manner that a seal must be broken to gain access to the drugs. The contents of the container shall be listed on the outside cover and shall include the earliest expiration date of any drugs within."

5. Patient 41 was admitted to the facility on August 12, 2010, with diagnoses of obstructed gallstones. The medication reconciliation orders showed the patient was on two oral diabetic medications as well as a "low" insulin sliding scale. On August 13, 2010, the physician ordered a "high" insulin sliding scale. On admission, Patient 41 was 188 pounds (85 kg).

On August 14, 2010, the physician ordered Total Parenteral Nutrition, per pharmacy protocol, with a clear liquid diet. On August 16, 2010, the physician ordered for Patient 41 to be weighed.

On August 15, 2010, Patient 41 was status post ERCP which included a stone extraction.

On August 15, 2010, the RD Nutritional Assessment determined Patient 41 was at "high" nutrition risk based on the following information:
* poor appetite
* nausea and vomiting
* elevated glucose (281 mg/dl)
* low serum albumin (2.0 mg/dl) and low prealbumin (9.3 mg/dl) both protein status indicators.
* elevated amylase (217) and lipase (275) which were both trending downward.
* possible malnutrition with nutrition assessment nutrient calculations based on "repletion." Calorie goals were calculated as 1665 to 1943 calories per day.

The RD set the following nutrition goals based on the assessment:
* tolerance of food by mouth > 50%.
* maintenance of hydration.
* improvement of protein stores and prealbumin level of > 18.
* maintain glucose less than 150 mg/dl.

On August 15, 2010, the patient was receiving 716 calories. The pharmacist notes showed an addition of fat was considered, but was cancelled due to amylase and lipase values as still too elevated. On August 15, 2010, the patient's triglyceride level was 133, which was normal as per the pharmacist cardex.

On August 17, 2010, the RD reassessment showed Patient 41 was to have a laproscopic open cholecystectomy (removal of the gall bladder). At that time, the patient was receiving 796 calories with no lipids for calories. According to the pharmacist cardex, the reason no lipids were added was due to alkaline phosphatase levels still being elevated. The blood sugar readings showed the blood glucose ranging from 221 to 421 throughout the day. The pharmacist documented no increase in dextrose due to the elevated blood sugars. Recommendations by the RD at that time included consideration of increasing the insulin either in the TPN bag, or use of a long acting insulin to better manage the glucose, so that calories could be increased.

On August 19, 2010, the RD reassessment showed the blood glucose was 207 on August 19, with accuchecks ranging from 237 to 417 the day before on August 18, 2010. At that time, the TPN had not been reordered post-operatively. The patient was ordered advancement of diet on August 18, 2010, with a soft diet to be initiated at lunch. However, the patient was unable to tolerate the meals. The RD indicated the protein energy intake was inadequate. Recommendations included resumption of parenteral nutrition if the liquid diet trial was not tolerated after 24 hours.

On August 22, 2010, the RD re-assessment indicated the patient was taking nothing by mouth and was to receive peripheral parenteral nutrition. At this time, the blood glucose level was 174 mg/dl and the accucheck ranges were 180 to 202. The lipase was 407 U/L. The goal set by the RD was for the patient to receive 1800 calories.

According to the pharmacist cardex entry on August 22, 2010, the patient had a PICC line with one working port. This would allow administration of the parenteral nutrition as a central line formula.

On August 23, 2010, the RD note showed, based on the parenteral nutrition formula, the patient was receiving 914 calories. According to the pharmacist cardex, the patient was on a "medium" sliding scale. The plan was to decrease the carbohydrate. There was no plan to add lipids to the next bag for increased calories. At that time, the patient triglycerides were 77 which was within normal range.

On August 24, 2010, the pharmacist cardex showed the patient now weighed 73 kilograms (160 pounds), which was a 28 pound weight loss since admission 12 days earlier. According to the cardex, the amylase was 91 U/L, which according to the facility lab reference values, was within normal limits. However, the pharmacist cited that the calories were 800 total, and the plan was not to add lipids to the next parenteral nutrition bag. The pharmacist documentation showed the amylase was elevated which was inconsistent with the facility lab values.

On August 25, 2010, the pharmacist parenteral nutrition cardex continued to cite the increase in lipase and amylase with the elevated lipase as the reason intralipid was not added as a fat calorie source to meet patient needs.

On August 26, 2010, at 12:45 p.m., the CNM stated fat could be added to the parenteral nutrition solution as a calorie source for parenteral management of pancreatitis.

On August 26, 2010, at 1 p.m., Clinical Pharmacist 1 stated, when the parenteral nutrition is being managed by the pharmacist, they take into account the RD recommendations regarding nutrient goals. However, he stated Patient 41's calories could not be increased based on the blood sugar issues Patient 41 was having. He stated the insulin is usually managed as a combination of basal, sliding scale and scheduled insulin. When asked if an insulin drip was ever considered to manage the blood sugar, he stated that from the notes, it does not appear the pharmacists had contacted the physician regarding an insulin drip and the impact that it was having on the patient's nutritional status. Clinical Pharmacist 1 stated there is literature to support that some fat may be added to a parenteral nutrition regimen, but stated that the facility often manages these patients in a "conservative" manner.

A review of the policy and procedure titled "Clinical Monitoring of TPN" (review date of January 2008) for parenteral nutrition ordered by "pharmacy protocol", showed the pharmacist shall consult with the physician "as appropriate." There was no evidence that the physician was consulted regarding the impact the elevated lab values had on the ability of the pharmacist to meet the nutritional needs of the patient.

According to the American Society of Parenteral and Enteral Nutrition (ASPEN) Core Curriculum published in 1995, Total Parenteral Nutrition (TPN) Fat Emulsion as a calorie source for patients with pancreatitis can be safely administered daily and would be contraindicated in patients with hyperlipidemia.

6. On August 26, 2010, at 2:07 p.m., a review of Patient 42's medical record revealed an informed medication consent that was signed by the patient on August 19, 2010, at 4:30 p.m. and witnessed by LVN 1. The hospital's policy and procedure (P & P) entitled, "Informed Consent for Antipsychotic/Psychotropic Medication," states, "The purpose is to educate patient's about the risks, benefits, and alternatives to antipsychotic/psychotropic medication and to certify that the patient has been offered an explanation of the antipsychotic/psychotropic medication by the physician." The P & P further states, "After the above information has been discussed with the patient and the patient has given consent to take the medication, the patient must sign the Consent Form for the specific drug and dosage amount."

A review of Patient 42's clinical record indicated the patient was a Spanish speaking individual. However, the consent form used to educate the patient about the antipsychotic drugs prescribed for him, and signed by the patient, was written in English. The nurse manager indicated that the patient spoke some English, but on interview the patient could not understand English spoken to him by the surveyor.

Based on staff interviews, and administrative document reviews, the hospital failed to ensure that five nurses did not have access to medications stored in automated drug dispensing cabinets after they had been separated from the hospital. This failure compromised security of medications stored in the hospital.

Findings:

On August 24, 2010, at 9:20 a.m., the DOP was interviewed and stated users of the automated drug dispensing cabinets (Pyxis) were removed from being able to access medications, including narcotics, following termination.

A list of Pyxis user personnel was obtained from the hospital's computer on August 23, 2010, at 3:58 p.m. An employee termination report for the last 12 months was also provided. Five registered nurses (RN's 4, 5, 6, 7, and 8) were listed on the user report as remaining active and having access to Pyxis, but were terminated from employment within the last twelve months.

Based on observation, interview, and record review, the facility failed for one of four anesthesia machines, to ensure that a used vial of medication was discarded within 24 hours, as per manufacturer's recommendation, by failing to label the vial with a date or patient name. This failed practice had the potential to result in the use of expired medications for a patient.

Findings:

While conducting a tour of the surgical suite on August 23, 2010, at 2 p.m., an open glass vial of lidocaine 2% 100 mg/5 ml was observed on top of the anesthesia machine in operating room 4. The vial contained approximately 60% remaining volume and was not labeled with the date opened or a patient name.

On August 23, 2010, at 2 p.m., the operating room director was interviewed. She stated the open vial of lidocaine should not have been left on top of the anesthesia machine and should have been discarded after use.

Based on observation, staff interview, and document review, the hospital failed to ensure the Food Service Director ensured a sanitary environment in the cafeteria; failed to ensure the kitchen environment was maintained to ensure a comprehensive and effective pest management program; and to have a system in place to store a PHF (frozen chicken) as per manufacturer guidance.

Findings:

On August 23, 2010, starting at 10 A.M., a tour of the main hospital kitchen was initiated. The following issues were identified as it related to maintaining a sanitary environment, an effective pest control program, and food safety/quality systems.
* The external delivery door contained a gap measuring approximately 1/2 inch or greater along the bottom of the door. In the corner of the door was a gap measuring approximately one inch or greater in diameter. This would potentially allow for pest/rodent entry into the kitchen area (Cross Refer A-749.)
* The light cover in the cafeteria area contained four dead bugs (Cross refer A-749.)
* The floor area under equipment in the cafeteria servery area was littered with dirt, food and paper debris. The areas included under the counter top servery area, under the pass through counter top refrigerators, and under the grill near the cook reach-in freezer. The area under the pass through refrigerator contained two PVC pipes that were resting on the floor for approximately eight feet in length, as they collected moisture to feed into the floor drain. This precluded the staff's ability to thoroughly clean the floors on a regular basis (Cross refer A-749.)
* There were missing tiles behind the cafeteria grill area by the reach-in freezer, providing for a potential area to collect dirt and food debris, affecting the facility's ability to ensure a sanitary environment (Cross refer A-749.)
* The wall under the counter in the back of the cook's hot food production area was patched and had large gaps, which potentially could be a pest harborage area (Cross refer A-749.)
* Chicken packaged as, to be kept frozen, was stored in the refrigerator with no system in place to monitor the length of time it had been thawed or held outside the recommended storage.

a. A review of the pest control reports showed maintaining structural integrity would eliminate potential pest harborage/breeding sites. In addition, the Riverside Environmental Health Report dated June 3, 2010, had cited the facility kitchen under vermin proofing. The report directed the facility to "repair the bottom gap of delivery door."

On August 23, 2010, the FSD stated that the repair had been made, but it had probably been damaged again. The FSD failed to ensure the county deficiencies were maintained for two and a half months after being identified.

b. On August 23, 2010, at 11:15 a.m., the FSD stated that she was also responsible for the EVS Department management. She stated the EVS department cleans the cafeteria floors. The FSD stated that she conducts monthly "tracers" in the food service department to identify potential sanitation issues.

A review of the monthly tracers, dated from February 2010 through August 2010 (seven reports), showed there were criteria relating to the floor and underneath equipment being maintained clean and free of debris. All seven of the reports identified the area as being in compliance. The FSD verified the criteria was focusing on the main kitchen area and did not account for the cafeteria floors.

A review of the "Nutritional Services Daily and Weekly Janitor Cleaning List" showed cleaning of the floors in the cafe, kitchen, storeroom, and other dietary areas were signed off as completed by the staff. On August 23, 2010, at 11:30 a.m., the FSD stated the supervisor is responsible to verify compliance with the cleaning list.

c. On August 24, 2010, starting at 10:40 a.m., the Magnolia kitchen was toured. The hospital walk-in refrigerator walls were painted. numerous areas, the paint was chipping and provided a potential for environmental cross contamination of food. The facility Chef stated the walk-in had been painted approximately one year ago and he had not notified the PO Department to repair.

d. On August 24, 2010, at 11:15 a.m., the FSD stated the frozen chicken was received in the department on July 26, 2010. There was a date on the box written by staff as "7/10". The manufacturer case showed the product was to be kept frozen. The FSD confirmed that was the day it was received and placed into the freezer. The FSD stated that there was no system in place to track the date the chicken was removed from the freezer and thawed or held in the refrigerator.

The policy and procedure titled "Departmental Infection Control Policy and Practices" (reviewed June 2010), showed the policy purpose was to have guidelines to ensure compliance with infection control standards. The policy documented efforts shall include that cross contamination is minimized. The policy procedures include the following:
* Employees will be trained on cleaning and sanitizing equipment and the physical plant.
* Nonfood contact surfaces or equipment are cleaned according to a cleaning schedule to keep them in a clean and sanitary condition.
* The objective of pest control is to maintain a sanitary environment preventing contamination and transmission of disease by insects and rodents. The policy further specified that rubber strips are applied to all entrance doors to prevent the entrance of pests.
* The objective is to maintain the greatest degree of sanitation possible in all food areas. The cleaning of the floors and walls in the cafeteria were documented to be the responsibility of the EVS Department.
* The environmental specific procedures are to be supported by definitive checklists with delegation of responsibility.

Based on patient and staff interviews, and document review, the hospital failed to meet the nutritional needs of Patients 23, 24, and 28.

Findings:

Nutritional Medical Record reviews were conducted on August 23, 24, and 26, 2010.

1. Patient 23, an 83 year old female, was admitted on August 12, 2010, with diagnoses of acute pancreatitis. According to the physician history and physical examination, the patient had been experiencing nausea and vomiting for two to three days.

According to the "Patient Admission Assessment" dated August 12, 2010, Patient 23 had been experiencing nausea. The nurse documented Patient 23 was five feet two inches in height, and weighed 125 pounds. In addition, Patient 23 had no skin issues upon admission, as documented by the nurse.

From August 12 through August 16, 2010, Patient 23 was receiving either nothing by mouth, or a clear liquid diet (five days). On August 17, 2010, the physician ordered a nutritional supplement drink, three times a day, to supplement the inadequate diet.

On August 13, 2010, the RD assessed the patient and considered the patient to be at "High" nutritional risk. The assessment showed the following:
* the patient had inadequate intake related to nausea.
* the patient's skin integrity as "intact".
* an albumin level of 2.8 mg/dl, which was below the normal range (a potential indicator of visceral protein status).
* patient energy needs as 1136 to 1420 calories (based on 20 to 25 calories per kg body weight).
At this time, the RD goals were to maintain hydration, improve visceral protein status, and to initiate feeding within 48 hours.

On August 16, 2010, the RD re-assessment showed the patient albumin level had declined further, with an Albumin level of 2.1 mg/dl. At this point, the patient was receiving nothing by mouth. The RD recommended a clear liquid diet and a clear liquid nutrition supplement. If intake could not be initiated within 24 hours, parenteral nutrition should be considered. The goal also included improvement of the patient albumin level.

On August 18, 2010, the physician ordered parenteral nutrition per pharmacy management. The physician orders also initiated twice weekly weights on Monday and Thursday, while on parenteral nutrition. There also was an order to have a prealbumin drawn on August 19, 2010.

A review of the parenteral nutrition order sheet, completed by the pharmacist, showed on August 18, 2010, the patient had received 596 calories, and on August 19, 2010, the patient had received 836 calories.

On August 19, 2010, the RD re-assessment showed the albumin level as further declining to 1.4 mg/dl. The results of the pre-albumin were documented as 6.8 mg/dl. According to the lab reference range, a level of 17 to 34 mg/dl was normal for a pre-albumin.

On August 19, 2010, the RD documented that no weight was done as per the order, but there was no plan developed by the RD to address the fact that the physician order had not been implemented, which would have provided potential information to address the patient's nutrition status.

In addition, the RD documented the patient was only receiving approximately 52% of calorie needs and 54% of protein needs. A review of the note showed the patient had been on a "previous diet" of clear liquids and nutritional supplements as "noted". However, there was no documentation by the RD to address if the patient was taking and tolerating either the clear liquid diet or the supplement, and how it potentially affected the nutrient intake of the patient.

On August 20, 2010, the physician order showed the patient was to initiate a low fat diet and the patient was to taper off parenteral nutrition. A review of the pharmacist order sheet and the pharmacist cardex for Patient 23 showed the parenteral nutrition was discontinued, even though tolerance and intake of the newly ordered low fat diet had not been addressed.

On August 20, 2010, the wound care nurse documented the patient now had a deep tissue injury on both heels. While the wound care nurse addressed the parenteral nutrition, she documented the RD would follow-up with nutrition to help with wound healing. At this point, the patient had been in the hospital for eight days with inadequate calories or protein amounts during the admission.

According to the "National Pressure Advisory Panel" (February 2007) the development of a deep tissue injury is due to pressure or shear. The "Nutrition Management of Pressure Ulcers", published in Nutrition in Clinical Practice by the American Society of Parenteral and Enteral Nutrition (ASPEN) in February 2010, shows there is a correlation between poor food intake and pressure ulcer development in post operative patients. Non nutrition risk factors also included age, female sex, mobility and serum albumin level. Patient 23 had met all the nutrition and non-nutrition criteria.

On August 23, 2010, the RD re-assessed Patient 23. The note verified the patient intake was poor (30%). According to the RD, the PO intake over the previous two days was 68%. There was no mention of the nutritional supplement the physician had previously ordered. There was no mention of the follow-up of the patient weight in order to assess the nutrition progress by the patient during the hospital course. One of the nutrition goals at that time, was for the patient to tolerate 50% of the diet.

A review of the nutrition care plan updated by the RD on August 23, 2010, showed the provision of nutritional supplements was not a selected intervention.

On August 23, 2010, at 3:15 p.m., Patient 23 stated that she was receiving the nutritional supplement with her trays, and that she was trying to drink it. Patient 23 stated a few days ago the problems on her heels had been identified. She stated she had developed terrible pain in both her heels, and that is how the staff had found out about the deep tissue injury that had developed in both her heels.

A review of the nurses notes showed that there was no documentation to show how much of the supplement Patient 23 was taking, after the parenteral nutrition had been discontinued.

On August 23, 2010, at 3:20 p.m., Nurse 41 stated the nutritional supplement is monitored via the intake and output (I&O) sheet. A review of the I&O document showed there were recorded numbers for fluid intake, but there was no way for the RD to know how much of that volume was attributed to the nutritional supplement. On August 23, 2010, at 3:25 p.m., the Medical/Surgical Nurse Manager stated that not all patients on supplements have orders for I&O.

On August 23, 2010, at 3:30 p.m., the CNM stated that it appeared the patient was still receiving the supplement. S he verified that a complete nutrition assessment should have included the fact that the patient still had been ordered the nutritional supplement, as well as documentation to address the intake and patient tolerance.

At that same time, the FSD verified the calories served on the regular low fat diet would provide between 2000 to 2200 calories. A nutrition goal of 50% intake to tolerance, as documented by the RD, would just barely meet the calculated nutrition needs of 1100 calories on admission. The FSD stated, that based on all the nutrition issues that Patient 23 had faced, it was not a very appropriate goal.

2. Patient 24, a 77 year old skilled nursing resident, was admitted on August 18, 2010, with an 1800 calorie renal (kidney) diet order. On admission, the physician had ordered an RD evaluation.

A review of the nutrition assessment dated August 18, 2010, showed the previous medical history included diabetes, chronic obstructive pulmonary disease, and poor appetite previous to admission. The assessment showed the patient was at 81% of his ideal body weight and had a "severe" involuntary weight loss over the last five months. The lab values referenced by the RD included high blood glucose (240 mg/dl) and an albumin level below the normal range (2.9 mg/dl.). The RD had designated the patient was at high nutrition risk with "possible malnutrition." The nutrition goals included adding a nutrition supplement three times a day, to improve calorie and protein intake and maintain blood glucose below 150 mg/dl.

A follow-up note by an RD on August 20, 2010, showed the patient's glucose was 186 mg/dl, and the accuchecks were ranging from 168 to 338. The RD at that time changed the nutrition risk level to moderate. There was no documentation in the record to show how much of the supplement the patient had been taking, based on the physician order, in order for the RD to assess the intervention effectiveness. There was no plan by the RD to address the glucose level that had not met the nutrition goal.

3. Patient 28 was admitted to the Willows Behavioral Health Unit on August 11, 2010. According to the history and physical examination, Patient 28 had a history of non-insulin dependant diabetes. On admission, Patient 28 was five foot ten inches in height, and weighed 242 pounds.

A review of the RD Nutritional Assessment dated August 12, 2010, showed the RD had identified Patient 28 as "Grade I obesity", and the patient had experienced a 14 pound weight gain since his last admission. At that time, the RD had provided diet education on a no concentrated sweet (NCS) diet, and had assessed the patient had a good understanding of the diet. A review of the RD intervention, recommendations, and goals showed there was no plan to address the weight gain and obesity Patient 28 was experiencing.

On August 24, 2010, at 10 30 a.m., the CNM and the BUM, were interviewed simultaneously. The BUM verified, that often the medications for this patient population could cause weight gain. The CNM confirmed that there was no assessment by the RD of the psychiatric medications that could have caused the weight gain, and there was no plan to address Patient 28's obesity.

Based on staff interview and document review, the hospital failed to ensure the therapeutic diet manual included guidance for medical staff, nursing, and food service, to meet the dietary needs of the pediatric population served by the hospital.

Findings:

On August 26, 2010, at 9:50 a.m., the pediatric unit was toured. At that time, RN 40 confirmed that "diet for age" was often ordered for pediatric patients. According to the CNM, the foods provided would be dependant on the age of the pediatric patient. The CNM confirmed, that depending on age, certain foods should not be sent because they may be a choking hazard.

RN 40 located the printed diet manual, but was unable to find any written guidance for the staff to reference addressing "diet for age." The CNM confirmed the guidance was not available in the printed or the on-line approved manual. The CNM confirmed the information should be a part of the approved manual, and that the information needed to be taken to the medical staff for approval.

Based on observation, staff interview, and document review, the hospital failed to ensure the ICP provided a system to ensure a sanitary environment in the cafeteria and the 2 North patient nourishment space, and failed to ensure the kitchen environment was maintained to ensure a comprehensive and effective pest management program.

Findings:

On August 23, 2010, starting at 10 a.m., a tour of the main hospital kitchen was initiated. The following potential infection control issues were identified, as it related to maintaining a sanitary environment and an effective pest control program:
* The external delivery door contained a gap measuring approximately 1/2 inch or greater along the bottom of the door. In the corner of the door was a gap measuring approximately one inch or greater in diameter. This would potentially allow for pest/rodent entry into the kitchen area.
* The light cover in the cafeteria area contained four dead bugs.
* The floor area under equipment in the cafeteria servery area was littered with dirt, food, and paper debris. The areas included under the counter top servery area, under the pass through counter top refrigerators, and under the grill near the cook reach-in freezer. The area under the pass through refrigerator contained two PVC pipes that were resting on the floor, for approximately eight feet in length, as they collected moisture to feed into the floor drain. This precluded the staff's ability to thoroughly clean the floors on a regular basis.
* There were missing tiles behind the cafeteria grill area, by the reach-in freezer, providing for a potential area to collect dirt and food debris, affecting the facility's ability to ensure a sanitary environment.
* The wall under the counter in the back of the cook's hot food production area, was patched and had large gaps, which potentially could be a pest harborage area.

A review of the pest control reports showed maintaining structural integrity would eliminate potential pest harborage/breeding sites. In addition, the Riverside Environmental Health Report, dated June 3, 2010, had cited the facility kitchen under vermin proofing. The report directed the facility to "repair the bottom gap of delivery door."

On August 23, 2010, at 10:50 a.m., the EVS Supervisor stated that the cafeteria area floor cleaning is the responsibility of the EVS Department. The EVS Supervisor was shown the floor area in the ateria, and she acknowledged the area was heavily littered. The EVS Supervisor stated the floor under equipment is cleaned on an "as needed" basis. There was no system in place to maintain the cafeteria floors on a regular, on-going schedule. The EVS Supervisor was unable to state or show when the floors had been last cleaned.

On August 23, 2010, at 11:15 a.m., the FSD stated that she was also responsible for the EVS Department management. The FSD stated that she conducts monthly "tracers" in the food service department to identify potential sanitation issues. At that time, the FSD stated the ICP has participated in staff in-services, and updated the policy and procedure manuals for the FS and EVS Departments. The FSD was unable to state when the ICP had conducted environmental surveillance rounds, specific to the kitchen/cafeteria area to identify potential infection control issues.

A review of the monthly tracers dated from February through August 2010 (seven reports), showed there were criteria relating to the floor and underneath equipment being maintained clean and free of debris. All seven of the reports identified the area as being in compliance. The FSD verified the criteria was focusing on the main kitchen area and did not account for the cafeteria floors.

On August 23, 2010, at 11:50 a.m., the POM was shown some of the environmental conditions identified. The POM stated the door sweep and the condensation pipe could be easily fixed. He did not offer any explanation as to why those areas had not been previously identified by the facility. He verified that the pipes in the cook area had to be placed when the new steamer was installed. The POM stated the patching of the wall had not been done correctly.

On August 23, 2010, at 2:15 p.m., the 2 North Pantry Food Storage room contained a vent which was observed to be coated with a grey, fuzzy substance. Some of the protruding substance measured approximately 3/4 inch from the surface components of the vent. The vent was located directly above the unit microwave, which is used to heat patient food as needed.

The POM was shown the vent and verified that it was a return air vent, and it was heavily coated with dust/dirt. He stated that it looks like it needed to be cleaned. When asked if there was a system in place to maintain the vents, he stated he would find out and get back to the surveyor.

On August 24, 2010, starting at 10:40 a.m., the Magnolia kitchen was toured. The hospital walk-in refrigerator walls were painted. In numerous areas, the paint was chipping and provided a potential for environmental cross contamination of food. The facility Chef stated the walk-in had been painted approximately one year ago, and he had not notified the PO Department to repair.

On August 24, 2010, at 2:55 p.m., the POM stated that there was no system in place to regularly clean and maintain the vents. The POM stated he waits for the department manager to submit a work order, in order to initiate cleaning of the vents.

On August 26, 2010, at 11 a.m., the ICP and the RM were interviewed. The RM stated the facility utilizes an "Environment of Care Risk Survey" to identify safety concerns. The RM stated the cafeteria review had recently been conducted. A review of the risk survey conducted on August 21, 2010, showed the one report covered the following areas: Emergency Department, Diagnostic Imaging, Laboratory, Catheterization Laboratory, and the Kitchen. A review of the criteria on the report showed there was no criteria to address the cleanliness of the kitchen area. The report was signed by the ICP.

The policy and procedure titled, "Departmental Infection Control Policy and Practices" (reviewed June 2010), showed the policy purpose was to have guidelines to ensure compliance with infection control standards. The policy documented efforts shall include that cross contamination is minimized. The policy procedures include the following:
* Employees will be trained on cleaning and sanitizing equipment and the physical plant.
* Nonfood contact surfaces or equipment are cleaned according to a cleaning schedule to keep them in a clean and sanitary condition.
* The objective of pest control is to maintain a sanitary environment preventing contamination and transmission of disease by insects and rodents. The policy further specified that rubber strips are applied to all entrance doors to prevent the entrance of pests.
* The objective is to maintain the greatest degree of sanitation possible in all food areas. The cleaning of the floors and walls in the cafeteria were documented to be the responsibility of the EVS Department.
* The environmental specific procedures are to be supported by definitive checklists with delegation of responsibility.