HospitalInspections.org

Based on interview and record review, the provider failed to ensure:
*Staff served a therapeutic diet as ordered by the physician for one of three sampled patients (1) identified with a no bread restriction mechanical soft diet to prevent potential choking and aspiration.
*Two of two mental health associates (MHA) (D and E) and one of one food service worker (F) followed the facility policy to confirm patients' meal tickets matched the physician's ordered therapeutic diet for one of one sampled patient (1).
*A One of one certified dietary manager (CDM) (G) had implemented a process to monitor the accuracy of menu updates, meal tray tickets, and tray line assembly service for all patient meals.
*All staff responsible for meal service had completed the required training on diet orders and definitions prior to working their next shift or the due date of 9/10/21.
Findings include:

1. Review of the 9/4/21 progress note from physician assistant certified (PA-C) H regarding patient 1 revealed:
*A code blue had been called for him due to choking while eating breakfast.
*The Heimlich maneuver had been performed by staff.
-He had become unresponsive, and cardiopulmonary resuscitation (CPR) was initiated.
*The emergency medical technicians (EMTs) arrived and contacted the doctor (physician name) at the (hospital name) emergency department.
*The emergency physician at (hospital name) ordered discontinuation of resuscitation efforts.
*The EMTs pronounced the patient's death at 9:13 a.m.
*PA-C H had arrived at 9:22 a.m. and confirmed the patient's death.

Interview on 9/15/21 at 11:49 a.m. with MHA E regarding patient 1 revealed:
*MHA D had delivered him his tray.
*He had a mechanical soft diet ordered.
*She:
-Was aware he should not have received bread items.
-Had not processed the cinnamon roll as a bread item and had given it to him.
-Then went into the kitchen to make snacks.
*Everyone available was responsible for passing out trays.
*Reading the meal tray ticket and comparing it to the food sent should have been done before serving his breakfast tray to him.

Interview on 9/15/21 at 12:30 p.m. with MHA D regarding patient 1 revealed:
*She:
-Had delivered his tray to him.
-Was aware he should not have received bread items.
-Had taken the meal ticket from underneath the plate, knew the bread item should not have been there, but had not removed the cinnamon roll from the tray.
-Had been focused on ensuring his liquids were thickened and no dairy items on the tray.
*His behaviors had been different that morning:
-He had more arm gestures than normal and his speech had been difficult to understand.
-Had informed the nurse of his behaviors.
*The nurse informed her he had been having seizure activity and not to have him eat at that time.
*She had pulled his tray away from him and placed it on the other side of a pillar.
*Another patient said, "Hey guys something's going on."
*She had called registered nurse (RN) C, asked if she should call code blue, and was told yes by the nurse.
*Staff started doing the Heimlich maneuver, no food was dislodged, and CPR was started.

Interview on 9/15/21 at 1:25 p.m. with food service director I revealed:
*Net Menu was the electronic program used for food service menus.
*CDM G was responsible for manually updating and adding diet orders, food restrictions, limitations, and removing food items listed on meal tickets that should not have been there.
*Any changes made in Net Menu to meals/diets would have shown up the next time that meal was served.
-Until those changes had been made, the CDM would have whited out, scratched off, or stamped any restrictions to a patient's physician ordered diet onto their meal tray ticket.
*Patient 1 was on a mechanical soft diet with restrictions for no bread and no lettuce.
*On 9/4/21 the diet restrictions were on patient 1's meal ticket and the caramel roll was a food item listed:
-The caramel roll had not been removed from that meal ticket.
-Food service worker F had pulled that meal ticket for tray line assembly.
-Staff had not checked what food items should not have been on his tray.
*Staff members F and G had received written counseling related to their performance for meal service.
*After 9/4/21 registered dietitian J reviewed and updated all meal tray tickets as needed prior to tray line assembly.
*No monitoring or audits of the meal tray assembly line had been initiated.

Interview on 9/15/21 at 1:40 p.m. with dietary aide (F) regarding patient 1 revealed:
*She had been on the breakfast meal tray assembly line on 9/4/21.
*She had pulled the breakfast meal tickets that morning which had included his meal ticket.
*She had been responsible for putting cold items on the trays which included bread items.
*Staff on the meal tray assembly line pull all food items according to the meal ticket and place those items on trays.

Review of the 9/4/21 breakfast and lunch meal tickets for patient 1 revealed:
*The breakfast meal ticket:
-Was for a lactose rest, mechanical soft diet, and nectar fluids (any liquids served should have been the consistency of nectar).
-"NO BREAD, NO STRAWS, NO LETTUCE" had been typed in the row under his name.
-No bread and no lettuce had been highlighted green.
-A "caramel roll" had been listed on that meal ticket.

*Lunch meal ticket:
-The lunch meal ticket was for a lactose rest, mechanical soft diet, and nectar fluids.
-"NO BREAD, NO STRAWS, NO LETTUCE" had been typed in the row under his name.
-"NO BREAD" had been highlighted green. "NO LETTUCE" had not been highlighted and should have been.
-"Brunswick Stew (8 Fl oz) [fluid ounce]" had been listed on that meal ticket. There was no indication the stew should have been ground.
-A "Biscuit" had been listed on that meal ticket.
-"Lettuce Salad No Tomato (1/2 Cup Shredded)" had been listed on that meal ticket.
-"Snicker Doodles Cookie" had been listed on that meal ticket.
*Meal tickets are shredded after each meal service therefore, no additional meal tickets for patient 1 were available for review.

Interview on 9/17/21 at 11:22 a.m. with director of nursing (DON) A confirmed:
*The staff responsible for serving patient 1 his meal tray had not followed the facility's meal service policy.
*Staff should have read the meal ticket and compared the items listed on it to the food on the patient's tray.
*MHAs D and E had received a counseling letter for not following the facility's meal service policy.
*The patient was on a mechanical soft diet and should not have received bread items.
*A caramel roll was on his food tray and the staff had not removed it before serving it to him.
*Training on diet orders and definitions had been provided to all staff after patient 1's choking incident.
-That training information and a sign-in sheet had been posted on the units for staff to review.
-Staff should have read and signed off they had completed the education before the start of their next shift.
-The required reading had been due by 9/10/21 and the sign-in sheets were due to administration on 9/17/21.
-The dietary training information had been sent via email to staff.
-The training information had also been posted on the units in several different spots to include on the meal carts.

Interview and review of the required reading information and sign-in sheets on 9/17/21 at 12:20 p.m. with DON A revealed:
*There were 11 direct care staff members that had worked a shift by 9/10/21.
-They had not signed off on the required diet order and definitions reading.
-There were 514 staff members listed for the required reading.
*Those 11 staff members that have not completed the required dietary training will not be allowed to work until the required reading has been completed.

Review of the provider's 2/25/21 Meal Service policy, in the section titled Mealtime, paragraph number four revealed "Staff shall ensure tray is given to the correct patient and that the patient receives the correct diet by reading the tray ticket. If there is any question, chart shall be checked."

Review of the provider's June 2018 MHA job description revealed the MHA abilities included interpreting and following established policies, operations memoranda, procedures, and guidelines.

Based on interview, record review, audits review, and food contract review, the provider failed to ensure:
*Patients had received food items in accordance with their physician ordered therapeutic diets for one of one sampled patient (1).
*At the time of meal service, direct care staff had served meal trays to patients in accordance with their therapeutic diet order.
*Patients on therapeutic diets with food restrictions were not served those food items.
*Meal tickets utilized to assemble meal trays were monitored for accuracy.
*The contracting agency responsible for meal preparation:
-Had submitted a written quality assurance plan that described the complaint resolution process for addressing complaints.
-Had clearly described how they would have ensured the quality of their products and services.
Findings include:

1. Review of the facilities Test Tray Assessment quality assurance improvement audits from 9/15/20 through 4/22/21 revealed:
*Test Tray Assessments stopped after 4/22/21 and began again after 9/4/21.
*There was no data collected or monitored to ensure patients had received food items in accordance with their physician ordered therapeutic diets.
*There was no data collected or monitored to ensure at the time of meal service direct care staff had served meal trays to patients in accordance with their therapeutic diet orders.
*There was no data collected or monitored to ensure patients on therapeutic diets with food restrictions had not been served those food items.
*The same quality assurance quality indicators had been monitored during the above stated timeframe for:
*Food temperature before delivery, food temperature on the unit, portion size, appearance, and accuracy.
*Temperature data had been collected on soup or hot cereal, hot entree, cold entree, starch, condiments, vegetable, salad, dessert/fruit, milk, and juice.
*Depending on the meal served each item would have been scored for acceptability (accuracy).

Interview and review on 9/17/21 at 11:05 a.m. with compliance officer (B) regarding food quality assurance and the food agency contract confirmed:
*The hospital only received the contract food agency Operational Plan and not the Quality Assurance Plan.
*When the contract referenced "Provider" that meant the contract food agency.
*Prior to 9/4/21 there was no quality assurance process in place to ensure therapeutic diets were assembled and served in accordance with physician orders and food restrictions.
*Patient 1 was on a mechanical soft diet with restrictions of no bread items.
*On 9/4/21 patient 1 had received a caramel roll for breakfast which should not have been on his plate.
-After an unsuccessful Heimlich and CPR resuscitative effort for choking, he was pronounced dead.

Review of the Provider 8/26/20 contract Agreement Amendment #1, paragraph 17, Quality Assurance Plan, page 19, revealed "The Provider [contract food agency] shall provide a written quality assurance plan that describes the complaint resolution process in place for addressing complaints from patients and inmates, and clearly describes how the Provider will ensure the quality of the products and services being provided."

Review of the quality assurance section in the undated Operational Plan revealed:
*There was no language addressing a process to ensure:
-Therapeutic diets were assembled in accordance with physician orders.
-Food trays were assembled to ensure restricted food items were not served to patients.
*The Operational Plan should have been completed on 5/30/21 by the management team.
*The quality assurance section revealed the following:
*"1). Be certain that all cooks are following Net Menu cycle menu and that [food agency name] recipes are in place
2). Production sheets should be utilized to ensure correct portioning and forecasting
3). Production meetings need to take place so that expectations on quantity, preparation, portion size and plate presentation are adhered to
4). Mangers to set up meeting with [company name] to outline expectations of inmates, ensure that understanding of expectations are in place and that [food agency name] representatives have the opportunity to interview inmates before they begin working in the department
5). Safe Food Handler course offered and certificate provided for all inmates working in the food Service Operation."

Review of the Contract Performance Evaluation forms revealed:
*Specifications evaluated on 4/30/21 included utilization, quality, and complaints.
*Specifications evaluated on 8/2/21 included year-end meeting expectations.
*There was language that addressed monitoring accuracy of menus and meal tray tickets.

2. Review of the 9/4/21 breakfast and lunch meal tickets for patient 1 revealed:
*The breakfast meal ticket:
-Was for a lactose rest, mechanical soft diet, and nectar fluids (any liquids served should have been the consistency of nectar).
-"NO BREAD, NO STRAWS, NO LETTUCE" had been typed in the row under his name.
-No bread and no lettuce had been highlighted green.
-A "caramel roll" had been listed on that meal ticket.

*Lunch meal ticket:
-The lunch meal ticket was for a lactose rest, mechanical soft diet, and nectar fluids.
-"NO BREAD, NO STRAWS, NO LETTUCE" had been typed in the row under his name.
-"NO BREAD" had been highlighted green. "NO LETTUCE" had not been highlighted but should have been.
-"Brunswick Stew (8 Fl oz) [fluid ounce]" had been listed on that meal ticket. There was no indication the stew should have been ground.
-A "Biscuit" had been listed on that meal ticket.
-"Lettuce Salad No Tomato (1/2 Cup Shredded)" had been listed on that meal ticket.
-"Snicker Doodles Cookie" had been listed on that meal ticket.
*Meal tickets are shredded after each meal service therefore, no additional meal tickets for patient 1 were available for review.