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Based on record review and staff interview, the facility failed to ensure the position duties for the DTR reflected the scope of work of that profession as outlined in California Law. Failure to ensure paraprofessional staff position duties were limited to professional standards may further compromise medical status.

Findings:

California Business and Professions Code §2586(d)(1) and §2586(2)(A) guides "notwithstanding any other provision of law, a dietetic technician, registered meeting the qualifications set forth in Section 2585 may, under the direct supervision of a registered dietitian, assist in the implementation or monitoring of services specified in subdivision (a), but may not develop nutritional or dietary therapy or treatments. (2) (A) For purposes of this subdivision, "direct supervision" means the supervising registered dietitian shall be physically available to the dietetic technician, registered for consultation whenever consultation is required."

In an interview on July 10, 2012, with the DTR at 11:05 a.m., she was asked to describe her functions at the Arlington campus. She stated she was the primary person that reviewed patient charts for nutrition care. She stated she usually completed approximately 20 assessments per day and attempted to evaluate all new inpatients within 24 hours, as well as reviewing lower risk patients a minimum of every seven days. She further stated if a high risk patient was admitted she would refer to the Registered Dietitian. On July 11, 2012, review of hospital position description titled, "Dietetic Technician", dated April 24, 2007, under the section titled examples of essential duties, "... recommends enteral and supplemental formulas."

On July 11, 2012, at 12:40 p.m., in an interview with the DFS and RD 3, they stated the scope of practice of the DTR was to screen patients for nutritional risk and provide general nutritional instructions. RD 3 stated the DTR should not be involved in recommending supplements, but should refer to the RD for those recommendations

Medical record review conducted July 10, 2012, revealed the DTR developed nutrition therapy for two of three patients (Patients 400 and 404) reviewed for nutrition care at the Arlington campus (Cross Reference A621 and A630).

Based on interview and record review, the facility failed to ensure one of 36 records reviewed (Patient 210's) contained accurate information. Patient 210's record contained cardiac monitoring strips with an incorrect time stamp. This failure resulted in cardiac monitoring strips imprinted with the wrong time and the failure to establish a time when the monitoring took place.

Findings:

On July 10, 2012, the record for Patient 210 was reviewed. The patient's paper record included the "Emergency Department," notes, signed patient consents, outside prehospital reports, code sheets and cardiac monitor forms.

According to the documentation on the "Emergency Department" form, Patient 210 presented to the facility's ED at 11:35 a.m., on June 6, 2012.

The "Cardiopulmonary Resuscitation Record" for patient 210 indicated at 3:57 p.m., Patient 210 was undergoing intubation (tube placed in throat to open airway and facilitate respiration) and chest compressions. At 4:14 p.m., the nurse documented "Vtach (rapid heart rate) noted on cm (cardiac monitor)." Ventricular tachycardia is a potentially life-threatening cardiac arrhythmia.

The cardiac monitor forms contained strips of paper, printed with the date and time the monitor strip was run, and the patient's current cardiac rate and rhythm. The first strip was imprinted with June 6, 2012, at 1516 (3:16 p.m.) and contained the following notation: "***VFIB/VTACH (VFIB - quivering heart that is not pumping blood)." Additional strips were all imprinted with sequential times, beginning with 1516 (3:16) and ending with 1518 (3:18 p.m.).

In an interview with the ER Manager on July 10, 2012, at 2:45 p.m., the Manager verified the time on the cardiac monitor strips and stated the times were probably wrong, as the time should correspond with the code sheet documentation.

At 3:30 p.m., the ER Manager stated the time imprint on the cardiac monitors was off by an hour. The Manager stated staff should be verifying the time. The Manager stated the time should be checked when the staff check the monitor and it should be checked when printed and placed in the patient's record.

Based on observations, staff interviews and document review, the facility failed to ensure the specific food and dietetic services organization requirements were met. The lack of organization and oversight of the dietary department resulted in deficient practice in multiple areas related to disaster planning, menu planning, food service and sanitation.

Findings:

During several interviews with the DFS from July 9-11, 2012, there were observations made that reflected lack of oversight of food service operations. During the interviews conducted with the DFS, she indicated that while she bore the ultimate responsibility of foodservice operations, she had only been employed at the hospital for six weeks and had not been providing day to day oversight of operations at the Arlington Campus.

On July 11, 2012, beginning at 8 a.m., during a review of the Arlington Campus Organizational Chart, and job duties of the DFS, Assistant DFS, and RD3, it was confirmed there was no other qualified dietary staff member with the designation that provided for oversight of dietary operations at the Arlington Campus.

On July 10, 2012, beginning at 8:00 a.m., during an inspection of food service operations at the Arlington Campus, it was noted a Food Service Policy and Procedure manual was not available onsite for staff reference.

Issues that affected sanitization practices, employee competency, disaster food supplies, meal service and patient care were noted. For example, approximately half of the disaster food supply at the Arlington Campus had expired, staff could not demonstrate competency in thermometer calibration, coffee carafes used for patient meal service were not properly sanitized, patient meals were not served in accordance with hospital policies and guidelines and high risk patient nutrition assessments were not completed per policy. (Cross Reference A620, A621, A622, A630, A701, A749).

Based on document review and staff interviews, the facility failed to ensure that adequate provisions were made for dietary consultation that met the needs of three of three patients reviewed at the Arlington Campus (Patients 400, 401 and 404), when the dietitian regularly assigned to that campus was unavailable, and that the dietitian was involved in modifying therapeutic diets as needed to meet the nutritional needs of the patients.

This failure could result in nutritional needs of patients not being met in accordance with practitioners' orders and acceptable standards of practice.

Findings:

1. On July 10, 2012, the medical record for Patient 400 was reviewed. Patient 400 was admitted to the Arlington campus on June 22, 2012. A comprehensive nursing admission assessment, dated June 22, 2012, did not note any nutritional risk factors; however noted the patient stated she was pregnant and had borderline diabetes. A blood test for pregnancy dated July 5, 2012, noted the patient was three to four weeks pregnant. A nutrition screening, completed by the DTR, noted an average dietary intake of 43% with a plan to continue to monitor dietary intake and weight. The DTR completed a follow up screening on July 2, 2012, which noted the patient's intake increased to 60% and there was a "*concern: pregnancy". There was no indication a referral was made to the RD.

A final nutrition screening dated July 9, 2012, noted a suggestion for a prenatal vitamin. In an interview with the DTR, she was asked to describe the process for referring patients to the RD. She stated referrals were either done directly through nursing staff or by her. She also stated if there was a referral for the RD she would list the patient's name in the referral book and the RD would review the book when she arrived.

2. On July 10, 2012, the medical record for Patient 401 was reviewed. Patient 401 was admitted on July 5, 2012, to the Arlington campus. The admission diet order, dated July 5, 2012, was a 2200 calorie diet. A comprehensive nursing admission assessment, dated July 5, 2012, noted the patient was at high nutritional risk, with a score of 6, and noted the patient required a nutritional consultation. There was no documentation the consult request was sent to the main campus. A nutrition screening completed on July 6, 2012 by the DTR, noted a patient height of 5 feet 7 inches and weight of 225 pounds. The screening also estimated the patient's caloric needs at 1800 calories, noted the patient was on a therapeutic diet and the patient frequently requested more food.

In an interview with the DTR on July 10, 2012 beginning at 11:15 am, she stated the nursing staff was not consistent with referring the high risk patients.

3. On July 10, 2012, the medical record for Patient 404 was reviewed. Patient 404 was admitted to the Arlington Campus on June 8, 2012. The patient was deemed to be at high nutritional risk via the nursing assessment (score of 12 on the nutrition screen portion) completed on June 8, 2012. On July 10, 2012, at 12:10 p.m., in an interview with RN 11, she pointed to a fax confirmation indicating a request for a dietary consultation was faxed to the dietary department on June 8, 2012. In addition, on June 10, 2012, a physician order for a dietary consult was also documented in the medical record.

RD 2 did not complete the nutritional assessment of Patient 404 until June 13, 2012, and noted the patient was at high nutritional risk. The RD also completed a follow-up note on June 19, 2012, but did not follow-up on the patient's status since that date. Patient 404 had been placed on a clear liquid diet due to dietary intolerance and stomach pain on June 27, 2012, and on June 29, 2012, the patient was prescribed a low residue, low fiber diet (typically prescribed to lessen irritation to the gastrointestinal tract and help it heal) with one can of Boost (nutritional supplement) three times per day.

Review of the facility policy titled, "Assessing and Meeting Patient Care Needs" showed the following: "Initial referrals from nursing with a score of 6 or greater and physician consult are seen within 48 hours of admission. Follow-up nutrition re-assessments are completed every seven days or less for high risk patients."

On 7/10/12 at 12:05 p.m., in an interview with RD 2, she stated the county was "short-staffed" with respect to dietitians, there was no RD coverage provided at the Arlington Campus on the weekends, and she also covered the Intensive Care Unit on the main campus, and those patients took priority over the patients at the Arlington Campus. She also stated she was on vacation from June 22, 2012 to July 2, 2012 and is unsure if anybody was assigned to cover her position.

On July 11, 2012, at 12:40 p.m., in an interview with the RD 3 she stated that at the Arlington Campus, there was no scheduled RD coverage over the weekends or for vacations. She stated if a consult was received then another RD would be sent to that location to complete the nutrition assessment.

RD 3 was asked for Quality Assurance/Clinical Indicators that were completed for the Arlington Campus. Data for the month of February 2012 was the only information provided to the surveyors as the information for other months was not readily available. The directions on the collection form indicated that at the Arlington Campus, 15 patient records per month were to be reviewed for each clinical indicator. Review of Criteria #3: "Is there a follow-up assessment every 7 days or less on high risk patient," showed only seven records were reviewed and four of the seven records (57%) were out of compliance. Under additional information, the following was documented for two of the four records that were not in compliance, "RD off 2/3 - 2/7" and "No RD Coverage, off 2/3, 4, 5, 6, 7." Completion of follow-up assessments was noted to be delayed up to 10 days.

Further review of the medical record showed the DTR had completed a nutrition screen on June 11, 2012, and suggested changing the patient's diet from 1800 ADA to NCS, low fat. On July 2, 2012, the DTR completed a nutritional follow-up note documenting the patient was receiving two cans of Boost per day and made the recommendation to change the supplement to Glytrol (a balanced formula to support blood glucose control in patients).

On July 11, 2012 at 12:40 p.m., in an interview with the DFS and the RD 3, they stated the scope of practice of the DTR was to screen patients for nutritional risk and provide general nutritional instructions. RD 3 stated the DTR should not be involved in recommending diet and nutritional supplement changes, but should refer to the RD for those recommendations.

Based on interviews and review of facility documents, the facility failed to ensure that patients determined to be at high nutritional risk were assessed and followed-up by the RD per hospital policy for two of 36 patients (Patients 401 and 404), and patients receiving calorie restricted diets were provided their diets as prescribed.

This had the potential for patients in the facility to not receive adequate nutrition or to receive diets that provided calorie levels above those prescribed by the physician and on which patient care was based.

Findings:

1. On July 10, 2012, the medical record for Patient 401 was reviewed. Patient 401 was admitted to the Arlington campus on July 5, 2012. The admission diet order dated July 5, 2012, was for a 2200 calorie diet. A nutrition screening dated July 6, 2012, which was completed by the DTR noted the patient's estimated caloric need at 1800 calories/day. The screening also noted the patient was at high risk due to excessive weight and the patient frequently requested more food. The DTR also stated that at the Arlington Campus, each patient received three snacks per day which provided an additional 600 calories.

In an interview on July 10, 2012, at 11:55 a.m., with the Contracted Food Service vendor, she stated that all calorie specific diets were divided into three meals/day and that any snacks the patient consumed were above the physician's calorie restrictions. In an interview with RD 2 on July 10, 2012, at 12:05 p.m., she stated she was the person responsible for reviewing patient menus. She also stated she had identified the issue surrounding the excess calories given in the form of snacks; however had not implemented any corrective actions.


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2) On July 10, 2012, the medical record for Patient 404 was reviewed. Patient 404 was admitted to the Arlington campus on June 8, 2012. The patient was deemed to be at high nutritional risk via the nursing assessment (score of 12 on the nutrition screen portion) completed on June 8, 2012. On July 10, 2012 at 12:10 p.m., in an interview with RN 11, she pointed to a fax confirmation indicating a request for a dietary consultation was faxed to the dietary department on June 8, 2012. In addition, on June 10, 2012, a physician order for a dietary consult was also documented in the medical record. RD 2 did not complete the nutritional assessment of Patient 404 until June 13, 2012, five days after the initial nursing request for dietary consultation and noted the patient was at high nutritional risk. The RD had recommended changing the Patient's diet from a NCS, Low Fat to 1400 Calorie, Consistent Carbohydrate, Cardiac, 2 gram Sodium Diet.
The RD also completed a follow-up note on June 19, 2012, noting the same diet recommendation as it had not been previously implemented, but did not follow-up on the patient's status since that date. Patient 404 had been placed on a clear liquid diet due to dietary intolerance and stomach pain on June 27, 2012 and on June 29, 2012, was prescribed a low residue, low fiber diet (typically prescribed to lessen irritation to the gastrointestinal tract and help it heal) with one can of Boost (nutritional supplement) three times per day. The dietary restrictions that had involved a control of carbohydrate or concentrated sweet intake and low fat recommendations were no longer in place. The patient had followed an 1800 ADA diet prior to and during admission and a NCS diet as of June 12, 2012, and continued to be at approximately 190% of Ideal Body Weight (IBW). There was also no evidence of nutritional education by the RD to the patient or any contribution by the RD to the plan of care revolving around nutritional status for the patient.

Review of the facility policy titled, "Assessing and Meeting Patient Care Needs" showed the following: "Initial referrals from nursing with a score of 6 or greater and physician consult are seen within 48 hours of admission. Follow-up nutrition re-assessments are completed every seven days or less for high risk patients."

On July 10, 2012 at 12:05 p.m., in an interview with RD 2, she stated the county was "short-staffed" with respect to dietitians, there was no RD coverage provided at the Arlington Campus on the weekends, and she also covered the Intensive Care Unit on the main campus, and those patients took priority over the patients at the Arlington Campus. She also stated she was on vacation from June 22, 2012 to July 2, 2012 and was unsure if anybody was assigned to cover her position.

Further review of the medical record showed the DTR completed a nutrition screen on June 11, 2012, and suggested changing the patient's diet from 1800 ADA to NCS, low fat. On July 2, 2012, the DTR completed a nutritional follow-up note documenting that the patient was receiving three cans of Boost per day and made the recommendation to change the supplement to Glytrol (a balanced formula to support blood glucose control in patients).

On July 11, 2012, at 12:40 p.m., in an interview with the DFS and RD 3, they stated the scope of practice of the DTR was to screen patients for nutritional risk and provide general nutritional instructions. RD 3 stated the DTR should not be involved in recommending diet and nutritional supplement changes, but should refer to the RD for those recommendations.

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Based on interviews and document review, the facility failed to ensure the availability of a diet manual that provided information that included a description of the diet, the indications of the diet, the nutritional adequacy, guidance for ordering the diet and a sample meal plan of the diet prescribed by the physician, that staff on the PCU was aware of how to access the diet manual and the diet manual was consistently used as guidance for preparing patient diets on the Arlington Campus.

This failure could result in the nutritional needs of the patients not being met in accordance with practitioners' orders and acceptable standards of practice.

Findings:

1. During trayline observations at the main campus beginning on July 9, 2012, beginning at 10 a.m., it was noted there were multiple patients with physician ordered carbohydrate controlled diabetic diets (CHO controlled). It was noted that the meal for one patient consisted of a deli sandwich without cheese and another one patient with a similar diet had cheese on the sandwich.

Comparison of the nutrition care manual on July 9, 2012, at 1:30 p.m., with the facility's crosswalk of diets, revealed a conceptual description of diets. This document provided a list of the facility's diets; however did not functionally describe the facility' s most commonly ordered diets nor did it accurately reflect the relationship between the facility's developed document, the menus served, and the Nutrition Care Manual developed by the American Academy of Nutrition and Dietetics. Similarly there was no defined meal pattern for the diets listed; only food selections that may be offered and/or avoided on specific diets were noted.

A diet manual would:

1. Ensure the diets offered met the current standards of practice;
2. Include a comprehensive description of the therapeutic diets offered;
3. Include the purpose of the diet, indications of the diet and nutritional adequacy; 4. Include sample meal plans consistent with the facility's menu; and
5. The standard of practice references for the diets.

While the facility's system for using the Nutrition Care Manual in conjunction with the facility developed diet cross-walk had some of the elements cited above, it did not contain all the elements for each routinely ordered facility diet, that would allow for facility and/or dietary staff to use the document as a comprehensive resource to order and/or prepare patient diets.

2. On July 10, 2012 at 4 p.m., on the PCU, RN 10 was asked about the availability of a Diet Manual on the unit. RN 10 stated the Diet Manual should be accessible through the computer. RN 10 then proceeded to log in to the program she perceived to be the one to provide Diet Manual information. However, after several attempts at locating the Diet Manual, RN 10 stated she must have the wrong site. The Unit Manager of the PCU stated if staff had dietary questions they would contact the RD assigned to the PCU. The regulatory requirement is that the therapeutic diet manual (or copies of it) must be available to all medical, nursing and food service personnel.

3. On July 10, 2012, review of the nutritional analysis of the menu provided by the Contracted Provider Service showed that the Low Sodium Diet was based on a daily value of 2400 mg of Sodium. Review of the facility Diet Manual recommendations listed the low sodium diet as one that provided 2000 mg of sodium.
On 7/11/12 at 1:30 p.m., in a telephone interview with RD 1, she stated she had reviewed the menu for adequacy and was routinely involved in modifying the patient meal provisions depending on the prescribed diet. When asked if RD 1 had ever had any discussions with any of the dietitians of the facility regarding the menu, or if she had reviewed the facility policies or Diet Manual to ascertain facility menu and diet standards and expectations, she stated "No".

Based on observation and staff interview, the facility failed to ensure that equipment such as the internal refrigerator thermometer in the PCU nourishment refrigerator, and patient meal re-thermalization carts at the Arlington Campus, was maintained to ensure an acceptable level of safety and quality. Failure to adequately maintain foodservice equipment could result in food items not being maintained at appropriate temperatures which places patients at risk for food-borne illness.

Findings:

1. On July 10, 2012, at 4:05 p.m., during an inspection of the patient nourishment refrigerator located on the PCU, the thermometer located in the refrigerator that was used to log temperatures was observed. The mercury "red line" used to ascertain refrigerator temperature was noted to stop at the 38 degree F mark and continue again at the 40 degree F mark up to the 44 degree F mark. The Nurse Manager of the PCU was asked what the temperature of the refrigerator was reading and stated it was 38 degrees F. He could not explain the gap in the mercury and why the red line started again from 40 degrees F to 44 degrees F. The Nurse Manager requested a new thermometer from RD 3.

2. On July 10, 2012, beginning at 10:45 am, at the Arlington campus the re-heating of patient meals was observed. The meals were placed in a system that allowed the re-heating of previously cooked foods on individual patient trays. The meal delivery system had the capability to re-heat items intended to be served hot and maintain refrigeration temperatures for items intended to be served cold. During observation of the re-heating process it was noted that on two of four of the units (Units 15 and 16) a yellow "fault" light was illuminated. In an interview on July 10, 2012, at 10:55 a.m., with FSW 3 she stated that if the fault light was on or the unit beeps it was an indicator that there was a problem at which point she would report it to the DFS or the contracted vendor. She also stated the "fault" light had been illuminated since the prior week.

In an observation and concurrent interview on July 10, 2012, beginning at 12:10 p.m. with FSW 3 and the contracted foodservice representative, it was determined on Unit 15 the heating element on tray slot 10 for the side dish element (intended for items such as soup) was not functioning. Similarly the side dish element was not functioning on tray slots 15-18 on Unit 16. The contracted food service representative stated she was notified that the unit was not functioning. She also stated she arranged for a service call "last week" and that while the service representatives arrived at the facility, they were unable to gain access to the electrical panel in the building and left. She also stated as of July 10, 2012, there was no a scheduled visit to address the problem. The contracted foodservice representative also stated the facility owned the re-heating unit, and the contract assumed responsibility for ensuring the equipment was functioning properly. Review of a copy of an electronic mail message provided by the contracted vendor dated July 10, 2012, at 12:25 pm, revealed there was no scheduled visit to repair the units.

Based on interview and record review, the hospital failed to ensure policy and procedure titled, "Standards of Practice," was implemented for one of 36 sampled patients (Patient 210) by failing to ensure vital signs were reassessed and documented for a patient in the emergency room. This failure had the potential to result in a delay in recognizing the patient's decline.

Findings:

On July 10, 2012, the record for Patient 210 was reviewed. The patient's paper record included the "Emergency Department," notes, signed patient consents, outside pre-hospital reports, code sheets and cardiac monitor forms.

According to the documentation on the "Emergency Department" form, Patient 210 presented to the facility's ED at 11:35 a.m., on June 6, 2012. There was no documentation as to the ESI - a triage score to indicate patients condition and need for service). The ED record indicated Patient 210's chief complaint was shortness of breath. Patient 210's initial vital signs were documented at 11:35 a.m., with the patient's blood pressure reading 96/36 mm HG (normal 120/80). The physician documented, "Bedside ultrasound shows large amount of ascites (fluid build up in the abdomen) - diagnostic tap done." The ED form, for documenting nursing notes and vital sign re-assessments, was blank.

The "Cardiopulmonary Resuscitation Record" for patient 210 was reviewed on July 10, 2012. The record indicated at 3:57 p.m., Patient 210 was undergoing intubation (tube placed in throat to open airway and facilitate respiration) and chest compressions. At 4:14 p.m., the nurse documented "Vtach (ventricular tachycardia-rapid heart beat), noted on cm (cardiac monitor)." Ventricular tachycardia is a potentially life-threatening cardiac arrhythmia.

In an interview with an Assistant Hospital Administration, on July 10, 2012, at 10:30 a.m., the Administrator stated patient records were now both in the computer and on paper. The Administrator stated additional information for Patient 210 may be documented in the computer.

On July 10, 2012, at 11 a.m., Patient 210's record was reviewed with RN 31, a resource nurse who worked in the emergency room. RN 31 was able to find documentation by the RN that indicated the following for June 6, 2012:

"12:15 p.m.-MD at bedside to draw fluid from abd (abdomen) 65/40 (BP documented in the note)
2:25 p.m.-Report from RN
2:35 p.m.-Central line by MD...
3 p.m.-2nd IV established...
3:20 p.m.-Rectal bag inserted...
3:45 p.m.-Foley with temp guard placed...
3:55 p.m.-patient noted gagging choking..."

The notes contained only one documented vital sign at 12:15 p.m. At that time the patient's blood pressure was documented as 65/40. In a review of the record with RN 31, there were no additional vital sign documented until a code sheet was started at 3:57 p.m.

In an interview with RN 31, on July 11, 2012, at 11:30 a.m., RN 31 stated the standard of practice in the emergency room was for vital signs to be reassessed every two hours. RN 31 stated with a blood pressure reading of 65/40 she would recheck the vital sign more frequently. In addition, RN 31 agreed vital signs should be rechecked when procedures such as abdominal tap and central line placement were conducted.

In an interview with the ER Manager on July 10, 2012, at 2:45 p.m., the Manager stated he would have expected more frequent vital sign documentation for this patient. The ER Manager stated he believed the care was in progress, but it was not documented.

The facility's policy and procedure titled "Standards of Practice," with a last revised date of May 2012, was reviewed on July 10, 2012. The policy indicated the purpose was to outline standards of practice for the emergency department based on the nursing process from the ANA and the ENA. The standards were divided into triage, assessment, nursing diagnosis, desired outcomes, plan of care, implementation, reassessment and discharge.

The policy indicated the triage RN will assign an ESI Level:

Level 1 need resuscitation-immediate care and includes but not limited to acute chest pain with systolic (top number of BP) of the patient below 70;

Level 2 emergent - major illness or injury that could easily deteriorate, includes abnormal vital signs- systolic blood pressure less than or equal to 90. Treatment and reassessment for Level 2 should occur within 5 to 15 minutes;

Level 3 Urgent- treatment and reassessment should occur within 15 to 45 minutes and includes conditions like acute abdominal pain, no cardiac pain, urinary retention.

The facility's policy and procedure titled, "Standards of Care: Emergency Department (ED)," with a last revised date of November 2011, was reviewed on July 10, 2012. The policy indicated the purpose was to provide basic standards of care to every patient presenting to the ED. The policy indicated vital signs were defined as blood pressure, temperature, pulse, respirations, and a pain scale. Baseline vital signs would be documented with initiation of the ED nursing EMR. According to the policy vital signs would be done:
Level 1 - every 5 to 15 minutes or less until stable then every hour:
Level 2 - every 5 to 15 minutes or less until stable then every one to two hours;
Level 3 - every 15 to 45 minutes or less until the patient was stable then every 2 hours.

On July 10, 2012, RN 32's personnel file was reviewed. RN 32 was assigned to Patient 210 on June 6, 2012. RN 32's Job Description "Registered Nurse Emergency Department," indicated the nurse would "reassess each patient's health needs whenever warranted..."

Based on interviews and review of facility documents, the facility failed to ensure that patients determined to be at high nutritional risk were assessed and followed-up by the RD per hospital policy for two of 36 patients (Patients 401 and 404), and patients receiving calorie restricted diets were provided their diets as prescribed.

This had the potential for patients in the facility to not receive adequate nutrition or to receive diets that provided calorie levels above those prescribed by the physician and on which patient care was based.

Findings:

1. On July 10, 2012, the medical record for Patient 401 was reviewed. Patient 401 was admitted to the Arlington campus on July 5, 2012. The admission diet order dated July 5, 2012, was for a 2200 calorie diet. A nutrition screening dated July 6, 2012, which was completed by the DTR noted the patient's estimated caloric need at 1800 calories/day. The screening also noted the patient was at high risk due to excessive weight and the patient frequently requested more food. The DTR also stated that at the Arlington Campus, each patient received three snacks per day which provided an additional 600 calories.

In an interview on July 10, 2012, at 11:55 a.m., with the Contracted Food Service vendor, she stated that all calorie specific diets were divided into three meals/day and that any snacks the patient consumed were above the physician's calorie restrictions. In an interview with RD 2 on July 10, 2012, at 12:05 p.m., she stated she was the person responsible for reviewing patient menus. She also stated she had identified the issue surrounding the excess calories given in the form of snacks; however had not implemented any corrective actions.


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2) On July 10, 2012, the medical record for Patient 404 was reviewed. Patient 404 was admitted to the Arlington campus on June 8, 2012. The patient was deemed to be at high nutritional risk via the nursing assessment (score of 12 on the nutrition screen portion) completed on June 8, 2012. On July 10, 2012 at 12:10 p.m., in an interview with RN 11, she pointed to a fax confirmation indicating a request for a dietary consultation was faxed to the dietary department on June 8, 2012. In addition, on June 10, 2012, a physician order for a dietary consult was also documented in the medical record. RD 2 did not complete the nutritional assessment of Patient 404 until June 13, 2012, five days after the initial nursing request for dietary consultation and noted the patient was at high nutritional risk. The RD had recommended changing the Patient's diet from a NCS, Low Fat to 1400 Calorie, Consistent Carbohydrate, Cardiac, 2 gram Sodium Diet.
The RD also completed a follow-up note on June 19, 2012, noting the same diet recommendation as it had not been previously implemented, but did not follow-up on the patient's status since that date. Patient 404 had been placed on a clear liquid diet due to dietary intolerance and stomach pain on June 27, 2012 and on June 29, 2012, was prescribed a low residue, low fiber diet (typically prescribed to lessen irritation to the gastrointestinal tract and help it heal) with one can of Boost (nutritional supplement) three times per day. The dietary restrictions that had involved a control of carbohydrate or concentrated sweet intake and low fat recommendations were no longer in place. The patient had followed an 1800 ADA diet prior to and during admission and a NCS diet as of June 12, 2012, and continued to be at approximately 190% of Ideal Body Weight (IBW). There was also no evidence of nutritional education by the RD to the patient or any contribution by the RD to the plan of care revolving around nutritional status for the patient.

Review of the facility policy titled, "Assessing and Meeting Patient Care Needs" showed the following: "Initial referrals from nursing with a score of 6 or greater and physician consult are seen within 48 hours of admission. Follow-up nutrition re-assessments are completed every seven days or less for high risk patients."

On July 10, 2012 at 12:05 p.m., in an interview with RD 2, she stated the county was "short-staffed" with respect to dietitians, there was no RD coverage provided at the Arlington Campus on the weekends, and she also covered the Intensive Care Unit on the main campus, and those patients took priority over the patients at the Arlington Campus. She also stated she was on vacation from June 22, 2012 to July 2, 2012 and was unsure if anybody was assigned to cover her position.

Further review of the medical record showed the DTR completed a nutrition screen on June 11, 2012, and suggested changing the patient's diet from 1800 ADA to NCS, low fat. On July 2, 2012, the DTR completed a nutritional follow-up note documenting that the patient was receiving three cans of Boost per day and made the recommendation to change the supplement to Glytrol (a balanced formula to support blood glucose control in patients).

On July 11, 2012, at 12:40 p.m., in an interview with the DFS and RD 3, they stated the scope of practice of the DTR was to screen patients for nutritional risk and provide general nutritional instructions. RD 3 stated the DTR should not be involved in recommending diet and nutritional supplement changes, but should refer to the RD for those recommendations.

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Based on interviews and document review, the facility failed to ensure the availability of a diet manual that provided information that included a description of the diet, the indications of the diet, the nutritional adequacy, guidance for ordering the diet and a sample meal plan of the diet prescribed by the physician, that staff on the PCU was aware of how to access the diet manual and the diet manual was consistently used as guidance for preparing patient diets on the Arlington Campus.

This failure could result in the nutritional needs of the patients not being met in accordance with practitioners' orders and acceptable standards of practice.

Findings:

1. During trayline observations at the main campus beginning on July 9, 2012, beginning at 10 a.m., it was noted there were multiple patients with physician ordered carbohydrate controlled diabetic diets (CHO controlled). It was noted that the meal for one patient consisted of a deli sandwich without cheese and another one patient with a similar diet had cheese on the sandwich.

Comparison of the nutrition care manual on July 9, 2012, at 1:30 p.m., with the facility's crosswalk of diets, revealed a conceptual description of diets. This document provided a list of the facility's diets; however did not functionally describe the facility' s most commonly ordered diets nor did it accurately reflect the relationship between the facility's developed document, the menus served, and the Nutrition Care Manual developed by the American Academy of Nutrition and Dietetics. Similarly there was no defined meal pattern for the diets listed; only food selections that may be offered and/or avoided on specific diets were noted.

A diet manual would:

1. Ensure the diets offered met the current standards of practice;
2. Include a comprehensive description of the therapeutic diets offered;
3. Include the purpose of the diet, indications of the diet and nutritional adequacy; 4. Include sample meal plans consistent with the facility's menu; and
5. The standard of practice references for the diets.

While the facility's system for using the Nutrition Care Manual in conjunction with the facility developed diet cross-walk had some of the elements cited above, it did not contain all the elements for each routinely ordered facility diet, that would allow for facility and/or dietary staff to use the document as a comprehensive resource to order and/or prepare patient diets.

2. On July 10, 2012 at 4 p.m., on the PCU, RN 10 was asked about the availability of a Diet Manual on the unit. RN 10 stated the Diet Manual should be accessible through the computer. RN 10 then proceeded to log in to the program she perceived to be the one to provide Diet Manual information. However, after several attempts at locating the Diet Manual, RN 10 stated she must have the wrong site. The Unit Manager of the PCU stated if staff had dietary questions they would contact the RD assigned to the PCU. The regulatory requirement is that the therapeutic diet manual (or copies of it) must be available to all medical, nursing and food service personnel.

3. On July 10, 2012, review of the nutritional analysis of the menu provided by the Contracted Provider Service showed that the Low Sodium Diet was based on a daily value of 2400 mg of Sodium. Review of the facility Diet Manual recommendations listed the low sodium diet as one that provided 2000 mg of sodium.
On 7/11/12 at 1:30 p.m., in a telephone interview with RD 1, she stated she had reviewed the menu for adequacy and was routinely involved in modifying the patient meal provisions depending on the prescribed diet. When asked if RD 1 had ever had any discussions with any of the dietitians of the facility regarding the menu, or if she had reviewed the facility policies or Diet Manual to ascertain facility menu and diet standards and expectations, she stated "No".