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Based on observation, interview, and hospital policy review, it was determined that the hospital's Governing Body failed to ensure oversight of the total hospital's Dietary services (C 279) and policy development and review by a committee of professionals (C 272). The Governing Body failed to perform adequate monitoring of policies governing the Critical Access Hospitals (CAH's) total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment (C 241) The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview, review of the hospital's Governing Body minutes and operational policies; it was determined that the CAH's Governing Body failed to ensure ongoing monitoring of operational policies and practices including Dietary Services, Peer Review, Infection Control, and Professional Committee functions.

Findings include:

1) On 4/13-14/2011 a Recertification survey was conducted. A review of the operational policies and procedures lacked evidence of any development provided by a group of professionals.

On 4/14/2011 at 9:30 AM CST, an interview was conducted with a Advanced Registered Nurse Practitioner (ARNP) and one of the Physicians. Neither of them recalled being involved in any policy development of reviews.

On 4/14/2011 at 12:00 PM CST, an interview was conducted with the hospital's Director of Nursing and she stated that after checking with the Administrator, the hospital did not have a group of professionals, to include the 3 ARNP's practicing at the hospital, responsible for the development and review of policies.

2) Interviews with the facility Dietary Manager which began on the morning of 4/13/11 and took place through midday on 4/14/11 revealed that she is responsible for providing nutritional assessments on all patients admitted to the hospital who are not fed via a feeding tube. She also disclosed that she is responsible for doing patient and family diet counseling when this is needed after a new diagnosis or if there are questions on how the patient is to follow his or her diet after discharge from the facility.

This was confirmed with the facility RD's statement--during a telephone interview which took place on 4/14/11 at about 11:00 a.m.-- that she really only assesses and makes recommendations for patients who need tube feeding recommendations and that the Dietary Manager handles all of the other nutritional assessments and patient counseling activities needed by patients. The RD stated the reason for this was because she is only onsite at the facility once a month and she is too far away. It is unknown how RD recommendations are provided to other professionals and disciplines at the facility.

The Dietary Manager further disclosed that the way the assessments and recommendations for tube fed patients are done is that she gathers the anthropometric, biochemical, medical history and clinical information on the patient on the "Tube Feeding Worksheet" form. This is Faxed to the RD at a remote location (RD lives in Gulf Breeze, Florida). The RD then Faxes her assessment and recommendations for these patients back to the facility and the Dietary Manager places this information on the patient's chart. The RD does not do any physical observation and assessment of the patient as a part of this assessment. She does not consult with the patient's physician or nurse. She does not evaluate the patient's tolerance to the tube feedings or any patient's tolerance of their therapeutic diets. She does not review the patient's chart. All of the RD's assessments and recommendations are based on the Dietary Manager's reviews.

The Dietary Manager does not possess adequate experience or credentials to do these patient reviews adequately or provide any form of nutrition therapy and counseling to hospital patients. She passed the Certified Dietary Managers test in 1992 and--per an interview on 4/13/11--she has not done any formal or informal continuing education in the interim. The RD stated in the 4/14/11 11:00 a.m. telephone interview that she did not provide any in servicing or oversight to the Dietary Manager because the Dietary Manager was not receptive. The RD was asked if she was comfortable with the Dietary Manager doing essentially all of the medical nutrition therapy for the facility patients. She stated that she was aware that this was what was happening and that she was not comfortable with the situation. When asked what she thought the facility expectation was from her she stated that five years ago she had updated all of the assessment forms and that people (at the facility) don't want to change. A copy of the Dietary Manager's job description was requested and provided by the administrator. It was dated May 2004 and states as a requirement that membership to the Certified Dietary Managers Association must be maintained by the manager. An interview with Dietary Manager on 4/14/11 at 1:30 p.m. revealed that she is not currently a member of this organization. Counseling patients and family members on therapeutic diets was not in this description as a duty of this position.

The Dietary Manager and the RD stated that the RD had not provided regular in services on pertinent topics to the other Food Service staff members at the facility.

The administrator was asked during the survey if the RD provides any reports to him or the Chief of Staff. He was unable to produce any reports provided by the RD. He stated that he does not receive any reports from the RD. The Dietary Manager produced some kitchen inspection reports that the RD did during her visits to the facility. These are kept in the Dietary Manager's office.

An interview with the Director of Nursing on 4/13/11 at about 2:00 p.m. revealed the following: "The RD is here monthly as far as I know. I don't know if this is often enough to meet our needs."

Reviews of patient's medical records revealed consistently inadequate nutritional screening, absent or inadequate nutritional assessments, and absent or inadequate nutritional therapy of all types. There was no evidence of patient follow-up or effective nutritional discharge teaching found on any of the charts. The lack of professional intervention in therapeutic nutrition was widespread.

The RD stated on 4/14/11 at 11:00 a.m. that she last reviewed the Food and Nutritional Services Policy and Procedures six years ago. The RD had signed off on the Diet Manual, that the Dietary Manager stated was currently in use at the facility, in March 2011. This Diet Manual was the Florida Diet Manual from 2005. The Dietary Manager had been Xeroxing information from this outdated Diet Manual and giving it to patients to follow at home. A check online revealed that this manual is updated every other year. No updates were in use in the facility at this time.

3) During the survey the hospital's Infection Control program and committee minutes were reviewed. The programmatic design listed that a physician would be a participant in the hospital's infection control committee, however none of the committee minutes reflected the attendance of a physician.

On 4/14/2011 at 10:55 AM CST, an interview was conducted with the Director of Nursing. She stated the hospital's Medical Director is notified of the meetings, but has not been attending.

4) On 4/13-14/2011 a Licensure survey was conducted and a review of Governing Body minutes was performed. The meeting minutes failed to reflect any indication of Peer review.

On 4/14/2011 at approximately 9:45 AM CST, an interview was conducted with the hospital's Administrator and Administrative Assistant. They stated the hospital had an outside physician reviewer in the past, but last year the hospitals medical staff decided to conduct their own peer review, but it did not occur.

5) A review of the Governing Body's minutes lacked any discussions or recognitions of Dietary Services that did not meet the requirements, no Peer review, failure of any physician to attend the Infection Control committee meetings, and the failure to have a committee of professionals to develop and review hospital policies.

Based on observations, interviews, review of hospital policies and clinical records; it was determined that the hospital failed to ensure the provision of services regarding a professional committee to develop and review operational policies (C 272), failed to ensure Nutritional Services were provided in accordance with professional standards (C 279), and failed to ensure the consistent development of Nursing Care Plans (C 298). The cumulative effect of these systemic problems resulted in the CAH's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review it was determined that the hospital failed to ensure policies were developed with a group of professionals that included Nurse Practitioners.

Findings include:

1) On 4/13-14/2011 a Recertification survey was conducted. A review of the operational policies and procedures lacked evidence of any development provided by a group of professionals.

2) On 4/14/2011 at 9:30 AM CST, an interview was conducted with a Advanced Registered Nurse Practitioner (ARNP) and one of the Physicians. Neither of them recalled being involved in any policy development of reviews.

3) On 4/14/2011 at 12:00 PM CST, an interview was conducted with the hospital's Director of Nursing and she stated that after checking with the Administrator, the hospital did not have group of professionals, to include the 3 ARNP's practicing at the hospital, responsible for the development and review of policies.

Based on interview and record review the facility failed to ensure that medical nutritional therapies and nutritional assessments were provided to patients according to currently accepted standards of practice. And failed to ensure that these therapies and assessments were done by the appropriate professional--a Registered Dietitian (RD). The facility failed to ensure that the Food Service Director/ Dietary Manager functioned within her scope of practice and was provided with substantial and effective oversight by the RD.

Findings Include:

Interviews with the facility Dietary Manager which began on the morning of 4/13/11 and took place through midday on 4/14/11 revealed that she is responsible for providing nutritional assessments on all patients admitted to the hospital who are not fed via a feeding tube. She also disclosed that she is responsible for doing patient and family diet counseling when this is needed after a new diagnosis or if there are questions on how the patient is to follow his or her diet after discharge from the facility.

This was confirmed with the facility RD's statement--during a telephone interview which took place on 4/14/11 at about 11:00 a.m.-- that she really only assesses and makes recommendations for patients who need tube feeding recommendations and that the Dietary Manager handles all of the other nutritional assessments and patient counseling activities needed by patients. The RD stated the reason for this was because she is only onsite at the facility once a month and she is too far away. It is unknown how RD recommendations are provided to other professionals and disciplines at the facility.

The Dietary Manager further disclosed that the way the assessments and recommendations for tube fed patients are done is that she gathers the anthropometric, biochemical, medical history and clinical information on the patient on the "Tube Feeding Worksheet" form. This is Faxed to the RD at a remote location (RD lives in Gulf Breeze, Florida). The RD then Faxes her assessment and recommendations for these patients back to the facility and the Dietary Manager places this information on the patient's chart. The RD does not do any physical observation and assessment of the patient as a part of this assessment. She does not consult with the patient's physician or nurse. She does not evaluate the patient's tolerance to the tube feedings or any patient's tolerance of their therapeutic diets. She does not review the patient's chart. All of the RD's assessments and recommendations are based on the Dietary Manager's reviews.

The Dietary Manager does not possess adequate experience or credentials to do these patient reviews adequately or provide any form of nutrition therapy and counseling to hospital patients. She passed the Certified Dietary Managers test in 1992 and--per an interview on 4/13/11--she has not done any formal or informal continuing education in the interim. The RD stated in the 4/14/11 11:00 a.m. telephone interview that she did not provide any in-servicing or oversight to the Dietary Manager because the Dietary Manager was not receptive. The RD was asked if she was comfortable with the Dietary Manager doing essentially all of the medical nutrition therapy for the facility patients. She stated that she was aware that this was what was happening and that she was not comfortable with the situation. When asked what she thought the facility expectation was from her she stated that five years ago she had updated all of the assessment forms and that people (at the facility) don't want to change. A copy of the Dietary Manager's job description was requested and provided by the administrator. It was dated May 2004 and states as a requirement that membership to the Certified Dietary Managers Association must be maintained by the manager. An interview with Dietary Manager on 4/14/11 at 1:30 p.m. revealed that she is not currently a member of this organization. Counseling patients and family members on therapeutic diets was not in this description as a duty of this position.

The Dietary Manager and the RD stated that the RD had not provided regular inservice's on pertinent topics to the other Food Service staff members at the facility.

The administrator was asked during the survey if the RD provides any reports to him or the Chief of Staff. He was unable to produce any reports provided by the RD. He stated that he does not receive any reports from the RD. The Dietary Manager produced some kitchen inspection reports that the RD did during her visits to the facility. These are kept in the Dietary Manager's office.

An interview with the Director of Nursing on 4/13/11 at about 2:00 p.m. revealed the following: "The RD is here monthly as far as I know. I don't know if this is often enough to meet our needs."


Reviews of patient's medical records revealed consistently inadequate nutritional screening, absent or inadequate nutritional assessments, and absent or inadequate nutritional therapy of all types. There was no evidence of patient follow-up or effective nutritional discharge teaching found on any of the charts. The lack of professional intervention in therapeutic nutrition was widespread.

The RD stated on 4/14/11 at 11:00 a.m. that she last reviewed the Food and Nutritional Services Policy and Procedures six years ago. The RD had signed off on the Diet Manual, that the Dietary Manager stated was currently in use at the facility, in March 2011. This Diet Manual was the Florida Diet Manual from 2005. The Dietary Manager had been Xeroxing information from this outdated Diet Manual and giving it to patients to follow at home. A check online revealed that this manual is updated every other year. No updates were in use in the facility at this time.

Based on interview and record review the facility failed to develop a care plan for 1 of 12 patients. (#8)

Findings include:

1) A chart review was completed on patient # 8 ' s chart on 4/14/11. The record revealed an admission date of 4/11/2011, but lacked evidence of a care plan.

2) An interview was conducted with the Charge Nurse on 4/14/11 at approximately 10:30 am. When she was requested to find the care plan for patient #8 in the chart, she replied, " now that should not be hard to find " . She checked in the chart and verified, " No there is no care plan in the chart " .