HospitalInspections.org

Based on review of Governing Body Bylaws, employee time sheets, job descriptions, policy and procedures, and staff interviews, it was determined that the Governing Body failed to maintain a qualified Food Services Manager since 3/14/23 and Registered Dietician since 2/24/23. The failure to provide a qualified Food Service Manager has affected the dietary needs of 93 patients currently admitted to the facility at the time of survey. The failure to provide a Registered Dietician has led to 23 out of 93 patients being admitted to the facility with a dietary evaluation for appropriate dietary needs.

Cross refer A-0620 as it relates to the failure of the facility: to ensure that Food Services were organized, directed, and staffed to ensure that the needs of patients were met, the facility employed an interim Food Services Manager, not qualified by education, experience or training.

Cross refer A-0621 as it relates to the facility failure to not having a contractual agreement for a Registered Dietician to evaluate patients' dietary needs.

Based on a review of time sheets, email correspondence, job descriptions, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that Food and Dietetic Services were organized, directed, and staffed to ensure that the nutritional needs of the patients were met in accordance with physician orders and standards of practice.

Findings include:

1. An interim Food Services Manager, not qualified by education, experience or training was appointed 3/14/23.

2. Since 2/24/23, the facility failed to have a registered dietician on staff that was available on a consistent basis to assess and recommend diet therapies for patients.

Cross refer A-0620 as it relates to the failure of the facility: to ensure that Food Services were organized, directed, and staffed to ensure that the needs of patients were met, the facility employed an interim Food Services Manager, not qualified by education, experience or training.

Cross refer A-0621 as it relates to the facility failure to not having a contractual agreement for a Registered Dietician to evaluate patients' dietary needs.

Based on a review of employee time sheets, job descriptions, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that the Director of Food and Dietetic Services was a full-time employee who is responsible for the daily management of the dietary services and is qualified by experience or training. The facility appointed an unqualified Interim Director of Food and Dietary Services on 3/14/23. The Interim Director of Food and Dietary Manager does not meet the facility qualifications for Director of Food and Dietary Services and does not have the required experience or training.

Findings included:

A review of the facility's policy titled "Food Service Supervision," no policy number, effective 4/1/08, revealed that the food service manager is hired by the facility administrator and is responsible for the safe, sanitary, economical, and nutritional operation of the food service department. The Food service manager is to be qualified according to the position ' s job description. The food service manager is the immediate supervisor of the cooks and dietary staff.

A review of the facility's policy titled "Food Safety and Sanitation," no policy number, effective 11/10/18, revealed that all local, state, and federal standards and regulations were to be followed in order to assure a safe and sanitary food service department.

A review of the job description for Manager of Food & Nutritional Services revealed that education/experience/skill requirements included:

1. A bachelor's degree in food service management, human nutrition, or a related field was preferred.
2. Four of [sic] more years experience in a food services role with two plus years experience in a supervisory capacity in food services.
3. Licenses/Designations/Certifications included required completion of the coursework and a passing score on the examination for Certified Dietary Manager or being in the active pursuit of license/certification

A review of Dietary Manager (DM) II's timesheets dated 3/2/23 through 3/12/23 revealed that DM II's last day of work at the facility was 3/12/23.

An interview was conducted with Behavioral Health Assistant (BHA) AA on 3/29/23 at 9:30 a.m. in the conference room. BHA AA stated that he took over the DM position on 3/14/23 after the permanent DM went on medical leave. BHA AA continued to explain that he had worked at the facility for three years as a BHA before working as the Interim DM. BHA AA said he had been ServSafe (food and beverage safety training) Certified since working in the kitchen. BH AA stated that as Interim DM, it was his responsibility to manage the staff's schedule, making sure the food was cooked and served on time for each meal, ensuring stored and frozen foods were rotated on the shelves, and placing orders for deliveries. BHA AA said that it was his responsibility to ensure that all meals were prepared and ready on time. BHA AA confirmed he had no formal training or education in dietary services.

An interview was conducted with Risk Management Director (RDM) OO on 3/30/23 at 9:30 a.m. in the conference room. RMD stated that he had worked at the facility for a few years and had a professional background in food services. He continued to explain that he was unaware of the severity of requirements for the position of the Interim Dietary Manager.

An interview was conducted with Chief Nursing Officer (CNO) NN on 3/29/23 at 12:35 p.m. in the conference room. CNO NN stated that DM II last worked a full day at the facility on 3/12/23. She continued to explain that DM II had worked at the facility for less than one year but missed several days of work due to an illness. CNO NN stated that DM II came to the facility on 3/28/23 to speak with Chief Executive Officer (CEO) regarding his illness and advised the CEO that he would need extended time off work due to his illness. CNO NN continued to say that she learned earlier today, 3/29/23, that DM II called in his resignation effective immediately due. CNO NN stated BHA AA would fill in and cover as Dietary Manager in DM II's absence. CNO NN stated that BHA AA began working full-time as the Interim DM on 3/14/23. CNO NN stated that BHA/Interim DM AA had completed all the necessary competencies required to work in the kitchen as the Interim DM.

Based on a review of timesheets, email correspondence, and staff interviews, it was determined that the facility failed to ensure that adequate provisions for dietary consultation were available when the 'as needed' dietician was unavailable. Specifically, the registered dietician's employment status changed effective 2/23/23 to 'as needed,' and had not seen patients or been available for consultations since 3/9/23.

Findings included:

A review of the facility's Registered Dietician (RD) GG's timesheets dated 2/26/23 through 3/30/23 revealed she had not worked at the facility to see patients since 3/9/23. Further review revealed RD GG worked on 3/29/23 for one hour and 15 minutes, which she confirmed on 3/29/23 at 7:15 p.m. She was at the facility this day to train kitchen staff.

A review of RD GG's email to this surveyor dated 3/30/23 at 12:10 a.m. revealed that she confirmed submitting a two-week notice on 2/10/23 to the facility to move from part-time to PRN until the Registered Dietician position was filled. A continued review of the email revealed RD GG has 23 requests for dietician consultations waiting to be completed, dated 2/25/23 through 3/29/23.

Further review revealed the following breakdown of patients waiting for a dietician consultation:

2/25/23- Four patients
2/26/23- One patient
3/2/23- One patient
3/3/23- One patient
3/9/23- One patient
3/10/23- One patient
3/11/23- One patient
3/12/23- One patient
3/13/23- One patient
3/14/23- Two patients
3/17/23- Two patients
3/18/23- Two patients
3/20/23- Two patients
3/26/23- One patient
3/28/23- One patient
3/29/23- One patient


A telephone interview was conducted with RD GG on 3/29/23 at 7:15 p.m. RD GG stated that she currently worked PRN without a set schedule at the facility. RD GG explained that she turned in her two-week resignation notice on 2/10/23 to go from a part-time dietician to a PRN dietician. RD GG said that her last day as a part-time RD was 2/23/23, and she stated that she did agree to help the facility until a replacement was found, but she no longer had a set schedule. RD GG said that she had not been to the facility to see patients for at least two weeks since turning in her resignation. RD GG stated she had been a part-time RD from October 2022 through February 2023, with 30 hours per week. RD GG said that she worked at the facility on 3/29/23 to update the kitchen staff on their training competencies by training two new employees and re-training one current employee. RD GG stated that when she reported to the facility to see patients, she checked her email to see what units had sent patient information to her. She continued to explain that she only visited patients that had orders for a dietician consult or follow-up with a dietician. RD GG confirmed that because she had accepted another position, she was doing her best to see patients at the facility but had not been there for two weeks, and her emails were probably backed up.


An interview was conducted with Risk Management Director (RDM) OO on 3/30/23 at 9:30 a.m. in the conference room. RDM OO said that he believed that RD GG was working at the facility on a regular PRN schedule and that she was making regular visits to the facility to see patients. RDM OO said that based on the email RD GG sent to the Chief Executive Officer (CEO), RD GG did not resign; RD GG took on a full-time position, but she would continue to work at the facility on a PRN basis. RMD OO stated that he planned to speak with RD GG to get a solid schedule in place to catch up on the patients waiting to be seen by a dietician.