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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 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..."

25624

Based on interview and record review, the facility failed to ensure staff had the proper assessment for the correct stage of a pressure ulcer, for one of 36 patients (Patient 310). This failure had the potential to interfere with the healing process for facility patients with pressure sores.

Findings:

On July 9, 2012, the record for Patient 310 was reviewed. Documentation for the pressure ulcer on the sacrum, in the record, revealed the following;
a. On June 19, 2012, at 8 a.m., facility staff assessed the pressure ulcer as unstageable (difficult to assess due to black, dead tissue on the surface with underlying damage) for Patient 310;
b. On June 19, 2012, at 8 p.m., facility staff assessed the pressure ulcer as a Stage 2 (partial thickness loss, it is superficial and presents as an abrasion, blister or shallow crater); and,
c. On June 20, 2012, at 8 a.m., facility staff assessed the pressure ulcer as, "Unable to stage, site is black, appears like a scab, however edges are red..."

On July 9, 2012, at 2 p.m., the unit manager was interviewed. The manager agreed the documentation was not consistent or accurate.

On July 9, 2012, the facility policy and procedure titled, "Pressure Ulcer Prevention and Management," was reviewed. The policy revealed, " ...Documentation: ...Reassessment: Daily on flowsheet..."

Based on interview, and record review, the facility failed to ensure one of one ED staff (LVN 1) was competent to care for patients with assaultive behavior. This failure had the potential for unqualified staff to provide care to patients, and the potential for harm or death to patients with assaultive behavior.

Findings:

A tour of the ED was conducted on July 9, 2012, at 9:10 a.m. In a concurrent interview, the ER Manager stated there were two patients in the ER awaiting evaluation by the Behavior Team for possible admission to the inpatient psychiatric facility. The ER Manager stated all staff working in the ED received MAB training.

On July 10, 2012, the employee file for LVN 1 was reviewed. LVN 1 was hired in October, 2008. The ED Licensed Registry Staff Orientation and Competency Checklist was reviewed. The documentation under "Safety/Security", indicated a competency level of "3" or "Comfortable performing", on November 16, 2010, for the following:

"a... Identification & safety of suicidal patients;
b. 5150 patient safety: role of 1:1 sitter, primary nurse, charge nurse, ED sitter log (5150 - patients who are a danger to themselves or others); and, c. Safety in handling violent, irrational, altered, impaired, unconscious & patients under the influence of drugs or alcohol..."

There was no documentation of ED competency in LVN 1's file since November, 2010. There was no evidence of MAB training in LVN 1's file.

In an interview on July 10, 2012, at 3:55 p.m., the ER Manager stated, "The MAB training was done initially and annually." He stated, "I don't see anything here in the file related to MAB. There is no evidence that she actually had the class."


22764

Based on observation, interview and record review, the facility failed to:

1. Ensure an order for continuous infusion of sedatives was documented on the, "Analgesia/Sedation Protocol Adult ICU Physician's Orders," form and included the desired Ramsey Score (a sedation scale) for one of two patients, in the ACCU; and,

2. Ensure implementation of patient identification before medication administration;

These failures had the potential to result in over or under sedation of a patient receiving a continuous sedation infusion and the potential to administer medications the the wrong patients.

Findings:

1. On July 9, 2012, Patient 204's record was reviewed. The patient was admitted through the facility's ED, into the ACCU. The record contained a preprinted order form titled, "Propofol Infusion Adult ICU Sedation Physician's Orders," signed and dated, July 6, 2012, at 4:40 a.m. Instructions on the top of the form indicated, "Check appropriate boxes and fill in blanks..." The form contained descriptive information titled, "Modified Ramsey Sedation Scale Guidelines," and an area for the physician to select either light or deep sedation levels. This area of the form was unmarked. The orders indicated, " Increase by mcg/kg/min q 3-5 minutes until desired Ramsey score is achieved." There was no documentation in the orders indicating the desired sedation level.

On July 9, 2012, at 9:45 a.m., a tour of the ACCU Side 3 was conducted. Patient 204 was observed lying in bed. Patient 204 was intubated (tube placed in throat) and on a ventilator (receiving mechanical respirations). Patient 204 had multiple intravenous medications infusing, including Propofol (a sedating agent).

In an interview with RN 30, on July 9, 2012, at 9:50 a.m., the RN stated Patient 204 was sedated and the goal was to keep the patient's sedation between 3 and 4. RN 30 reviewed the patient's order for the propofol and stated it was an old form and she would obtain clarification as to sedation level requested by the physician.

In an interview with the Nurse Manager, on July 9, 2012, at 10 a.m., the Manager stated the order for Propofol should have been clarified. The Manager stated there was a new form and the orders for Patient 204's sedation should have been written on the new form.

The facility's policy and procedure titled "Medication Continuous Infusion: Sedation," with a last revised date of June 2011, was reviewed on July 10, 2012. The policy indicated the purpose was to establish guidelines for the continuous infusion of sedatives in the ACCU for sedation in intubated, ventilated patients. The policy further indicated the purpose was to maximize patient safety, drug efficacy and minimize adverse effects. The policy indicated the following:

"1. Sedation by continuous infusion will be used...in accordance with manufacturer's recommendations, and by physician order.

3. ACCU Analgesia/Sedation Protocol Physician Orders # 243 will be utilized when ordering continuous sedation and will include desired Ramsey Score..."

In the section titled, procedures, staff was instructed to verify physician orders and titrate infusion to Ramsey Score goal per physician order.



22465

2. The medication pass was observed with LVN 2 on July 10, 2012, at 8:50 a.m. LVN 2 prepared morning medications for Patient 500. There was no identification bracelet to identify the patient before the medications were administered.

During a concurrent interview, RN 501 stated the bracelet could be easily removed by the patients and that nurses needed to replace the bracelets for many patients every day. RN 501 also stated the wrist bracelet needed to be present before medications were given to the patients.

During a concurrent interview, LVN 2 indicated patients would remove their bracelets themselves or would remove each other's wristband and agreed it was easy to remove them. LVN 2 also stated pictures were used to identify the patients before administering medications. Patient 500's picture was missing.

During a concurrent interview, the Administrator stated all patients admitted would have their pictures taken and placed in three different places used to identify the patients, in addition to the names and the dates of birth of the patienst.

During a concurrent interview, DOP acknowledged there was a potential for patients who were unable to state their name and their date of birth to not be identified.

On July 10, 2012, the facilitys policy and procedure titled, "Medication Administration," was reviewed. The policy indicated,

"Verify patient identification by asking the patient their name and date of birth. If the patient is unable to respond, the patient's identification bracelet shall be checked against the medication records for correct name and patient medical record number or date of birth prior to administering the medication."

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 interview and document review, the facility failed to ensure audit of CS use was implemented in accordance with the facility's policy and procedure and failed to readily identify loss or diversion of all CS.

This failure resulted in the inablility to minimize the time frame between the actual loss or diversion to the time of detection and determination of the extent of loss or diversion.


Findings:

On July 9, 2012, during review of the facility's policy and procedure titled, "Drug Diversion Monitoring and Reporting" was reviewed. The policy addressed monitoring of controlled substance use by authorized staff for inappropriate access. The policy indicated the facility would do the following on a monthly basis as a proactive monitor for controlled substance drug diversion:

"Identify individuals who have removed significantly more controlled substances than their peers (two (2) standard deviations or more). Run this report by specific units to compare like patient types. Run this report by all units, compare users such as float nurses who have access to multiple units."

A review of the facility's document titled, "Proactive Diversion Report" for the month of May 2012, indicated the report generated the list of authorized users that fit the parameter of more than three standard deviations above the mean.

A review of the facility's document titled, "Proactive Diversion Report" for the month of June 2012, indicated the report generated the list of authorized users that fit the parameter of more than two standard deviation's above the mean.

During an interview on July 9, 2012, at 1 p.m., the DOP indicated the Proactive Diversion Reports were generated with wrong parameters that did not match the facility's policy and procedure.

Based on observation, interview, and record review, the facility failed to control pain medications delivered by PCA. This failure had the potential of staff not recognizing the signs of breathing difficulties timely.

Findings:

The PCA pump for Patient 501 with hydromorphone (potent narcotic pain reducer) was observed with a monitoring module, on July 11, 2012 at 9 a.m. Inside the patient's room, it was noted the modules were programmed to sound the alarm to alert the staff if the patient received too much or too little medication.

During the same observation it was also noted the patient was in contact isolation and the door to the patient's room remained closed to prevent spread of infection. The alarm, that sounded to alert the staff the patient was not breathing normally, could be heard from inside the room but was not loud enough to be heard from outside the room if staff was not near the door.

During a concurrent interview, RN 502 agreed the alarm could not be heard from outside the closed room and stated the monitoring of the PCA and the module was done hourly, so it would be possible for the alarm to go unnoticed for up to an hour.

During a concurrent interview, the DOP stated the facility modules could be equipped with a device that allowed the facility to remotely monitor for alarms but the devices were separately purchased from the manufacturer at an additional cost. The DOP acknowledged that it would be a concern for staff to not be able to respond timely to the alarms.

According to the publication, Medication Safety Alert! By ISMP (Institute for Safe Medication Practices), a nationally recognized organization devoted to preventing medication related errors,

"When monitoring the effects of PCA Develop monitoring requirements for patients who are receiving PCA and be alert for signs of oversedation. At a minimum, evaluate the patient's level of pain, alertness, and vital signs, including rate and quality of respirations, every 4 hours...Establish risk factors that could increase respiratory depression (e.g., obesity or low body weight, concomitant medications that potentiate opiates, preexisting conditions such as asthma and sleep apnea) and determine the level of enhanced monitoring that would be required if these patients use PCA (e.g., capnography, apnea alarms at night). Identify the infrequent situations where critical care patients may be suitable for nurse-controlled analgesia, and the level of enhanced monitoring that would be required for these patients."



26881

Based on observation, interview and document review the facility failed to ensure that dietary services met the needs of all patients, as evidenced by failure to:

1. Provide organized dietetic services as evidenced by findings of lack of supervision of the dietary department at the Arlington Campus, and lack of staff competency in thermometer calibration (Cross Reference A619, A622).

2. Ensure the nutritional needs of patients were met, as evidenced by the lack of timely nutrition assessments and the absence of a diet manual used in menu planning (Cross Reference A630, A631).

3. Develop a comprehensive disaster plan that included adequate provision of food in the case of a disaster to all patients and the provision of appropriate food items to pediatric patients and patients prescribed therapeutic and mechanically altered diets. (Cross Reference A701).

4. Ensure safe and effective food storage/production practices (Cross Reference A749).

5. Ensure that paraprofessional nutrition care staff practiced within the California Business and Professions Code (Cross Reference A23).

The cumulative effect of these systemic problems resulted in the inability of the facility's food and nutrition services to direct and staff in such a manner to ensure the nutritional needs of the patients were met in accordance with practitioners' orders and acceptable standards of practice. The system problems resulted in the facility's inability to meet the Condition of Participation for Food and Dietetic Services.



18918

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 observations, staff interviews and document review, the facility failed to ensure that the DFS developed and monitored written procedures, according to standards of practice for operational processes. Failure to develop and monitor standardized procedures could result in patients being exposed to foodborne illness and cross contamination, which may further compromise medical status and result in appropriate food items not being available for patients in the event of a disaster.

Findings:

1. During several interviews with the DFS from July 9-11, 2012, and based on observations of staff, deficient practices in food service operations, particularly at the Arlington Campus, were noted. 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 that there was no other qualified dietary staff member with the designation that provided for oversight of dietary operations at the Arlington Campus.
2. On July 9, 2012 at 10:10 a.m., during an observation of meal service at the main campus, a lunch entrée consisting of turkey on a croissant was to be served for patients on regular diets. Patients prescribed carbohydrate controlled diets and other therapeutic diets were to receive the turkey sandwich on whole wheat bread. There was no whole wheat bread noted on the patient trayline. Dietary employees were noted to be using croissants or white bread for the service of the turkey sandwich.

On July 11, 2012, at 1 p.m., in an interview with the DFS, she stated that the Food Service Supervisor authorized the substitution in order to utilize the white bread before it spoils. Standard of practice is to utilize substitutions that are of the same nutritive value appropriate for the prescribed diets. If the fiber and other nutrients in the whole wheat bread, calculated as part of the total nutrient analysis for the day for the patients and part of the carbohydrate management for the diabetic patients, are compromised by the provision of white bread, then the substitution would be construed as inappropriate.

3a. On July 10, 2012, beginning at 10:17 a.m., during an observation of the lunch meal delivery from the Contracted Provider to the Arlington Campus, it was noted a patient menu was marked with the words "Double Portions", and the patient received a double entrée (enchilada and rice). On July 11, 2012, beginning at 8 a.m., review of the facility policy titled "Double Portions" showed the following direction to staff: "All orders for double portions (nurse, doctor, Dietitian, or Dietetic Technician generated) will be interpreted to mean double portions of starch and vegetables. Example: potatoes x2, Rice 2-#12 scoops. Entrees and eggs will only be increased when there is a specific protein requirement as stated in grams of protein, and a meal pattern meeting that the Dietetic Technician and/or Dietitian develop order. (Dietetic Technician must initial 2 or more entrees for 1 patient). The word "Doubles" will not be written on the menu. The foods to be doubled will be marked "x2" accordingly."

3b. Review of the nutritional analysis of the menu provided by the Contracted Provider Service showed 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 July 11, 2012, 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 ".

4. During initial tour on July 9, 2012, beginning at 9 a.m., it was noted there were greater than 15 cases of bread/baked products consisting of English muffins, crumb cake and cinnamon rolls that were held in the walk-in refrigerator. It was noted the manufacturer recommended storage guidance, printed on the boxes, was, "Keep frozen." In a concurrent interview with FSW 2, a supervising cook, he stated it was the standard of practice within the facility to store bread products in the refrigerator. Refrigeration pulls moisture from the bread changing the structure of the protein gluten which enhances the staling process (Scientific American, April 24, 2008: BeMiller, J,)



18918

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 observation, staff interviews and document review, the facility failed to ensure the competency of the staff member responsible for taking food temperatures as evidenced by her inability to accurately calibrate food thermometers. Failure to ensure staff competency in this task could result in foods being held at temperatures that support the bacterial growth associated with foodborne illness. Foodborne illness may result in nausea, vomiting and, in severe instances, death.

Findings:

On July 10, 2012, beginning at 10:30 am, FSW 1 was observed taking food temperatures of items on the food trays in patient carts at the Arlington Campus. Upon completion of the task, the surveyor asked if FSW 1 had calibrated the thermometer prior to use. FSW 1 stated it was a new thermometer and she had not calibrated it. The surveyor then requested FSW 1 to demonstrate the procedure for thermometer calibration. FSW 1 obtained a cup of hot water and a cup of ice. It was noted the cup was filled to the top with crushed ice. When asked which cup would be used for the calibration process, FSW 1 stated the cup of ice. When asked if the cup of ice was the only requirement for the calibration process, FSW 1 then proceeded to add water from a nearby coffee carafe to the cup of ice. The standard of practice would be to ensure that the ice/water mixture had enough ice to ensure a slushy mixture (University of Nebraska-Cooperative Extension, 2005).

While the thermometer temperature was adjusting to being placed in the ice/water mixture, FSW 1 was asked what the temperature goal was for the employee to consider the thermometer properly calibrated. FSW 1 stated as long as the thermometer temperature was below 40°F then the thermometer was calibrated. The standard of practice when calibrating a food temperature measuring device scaled in Fahrenheit, shall be accurate to ±2°F in the intended range of use (Food Code 2009). The temperature should be noted when the temperature has stabilized after 3 minutes and should be ±2°F from 32°F.

On July 11, 2012, the DFS provided a copy of a document titled, "RCRMC FNS Daily Huddle" on which was documented: " 6/19/12 - What are the 2 methods to calibrate a thermometer? 1. Ice-point method and boiling point method. Ice-point method uses 50% ice and 50% water, temp needs to be 32oF. 2. Boiling-point method uses boiling water, temp needs to be 212oF. 6/20/12 - Thermometer guidelines: Clean and sanitize your thermometer before and after using to prevent cross-contamination; calibrate your thermometer before each shift." It was not clear if FSW 1 attended the "daily huddle" as her work location was at the Arlington Campus.



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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 observations, interviews and document review, the facility failed to ensure the adequate availability of food items to be used in the event of disaster for patients and staff. This included provisions for pediatric patients and patients prescribed mechanically altered and therapeutic diets. Failure to develop a system to ensure adequate foods were available in the event of a disaster for the aforementioned population could result in inadequate food supplies, compromising the medical status of patients and the staff's ability to care for the patients due to lack of nutrition.

Findings:

On July 9, 2012, beginning at 9 a.m., the facility's disaster preparedness plan for meal service was reviewed with the DFS. It was noted the hospital had a shelf in the dietary kitchen dry storage area that contained two and one-half cases of baked beans, three cases of tuna, three cases of beef hash and five cases of gravy. The DFS stated that this supply was a secondary source of foods that would be utilized only in the event that the kitchen was accessible. The primary disaster food supply and water was stored in a disaster trailer and in an area designated "Alt 2".

On July 9, 2012, at 9:30 am, upon inspection of the disaster trailer, the DFS stated that the facility's plan was to feed and provide water for a total of 362 patients for 96 hours (4 days) in accordance with the licensed bed capacity at the main campus. No provisions were made for facility staff. An additional disaster trailer was located at the Arlington Campus and was equipped with disaster supplies for 77 patients in accordance with the licensed bed capacity at that campus. The disaster food supply at the main campus consisted of Meals Ready to Eat (MRE) bars designed to be distributed as one bar per patient per meal and the water supply was based on the availability of one gallon per person per day (4344 bars and 1448 gallons of water at the main campus). The DFS stated that the facility only had 2880 MREs (Mainstay 3600 or SOS Food Ration Bars) on hand and supplemented that with 1550 Special K Protein Meal Bars stored in "ALT 2" . The MREs in the disaster trailer were noted, according to the nutrition label, to provide 409 calories each, while the Special K bars provided 180 calories each, less than half the caloric value of the MRE bars.

On July 9, 2012, at 9:45 a.m., the DFS was asked what would be served to the pediatric patients as well as patients who were prescribed mechanically altered and therapeutic diets. The DFS stated that there were some baby food jars in the kitchen dry storage areas and on the floors that would be used for puree diets.

On July 9, 2012, at 10 a.m., inspection of the dry storage areas showed two cases (12 - 2.5 oz jars per case) of beef baby food, one case of chicken baby food, two cases of green bean baby food and one case each of bananas, carrots, sweet potatoes and pears There were also four boxes of baby rice cereal. The facility is licensed for 21 pediatric beds. The nutritional content of the baby food jars showed that they ranged in calories from 35-70 calories for the fruits and vegetables and 70-100 calories for the meat products. To be calorically equivalent to the 1200 calorie meal provided to patients receiving three MREs per day, the hospital would have to serve at least 12 jars of baby food to each patient prescribed a puree diet.

On July 9, 2012, at 1:23 p.m., review of the facility policy titled "Disaster Plan" showed no direction to staff regarding service of food during a disaster utilizing the MRE bars, service of foods to patients prescribed such diets as mechanical soft and puree, or to pediatric patients. It was also noted that the food service department did not have a comprehensive par level inventory established that ensured availability of adequate food supplies for pediatric, mechanically altered or therapeutic diets. The Disaster Plan policy also stated, "Meals to emergency department, employees, volunteers, and victims, as authorized by the hospital."

On July 11, 2012, at 10:35 a.m., in an interview with the Assistant Hospital Administrator responsible for the Environment of Care Committee, she stated that the Disaster Policy was being revised to include provisions for staff and visitors.

On July 10, 2012, at 9:05 a.m., an inspection of the disaster food supply at the Arlington Campus showed that the facility used a combination of "Heater Meals" (Individual meals ready to eat) and MRE food bars to provide for the patients at that campus in the event of a disaster. The plan was to feed 77 patients (licensed bed capacity) three meals per day for 96 hours and provide one gallon per person per day for 96 hours (total of 924 meals and 308 gallons of water). The inventory provided by the facility showed that the Arlington Campus had 360 meals and 282 MREs on hand, with a total of 642 food items. In addition, during the inspection of the Disaster Trailer at the Arlington Campus, it was noted that the boxes of heater meals were imprinted with a manufacturing date of 07/32. The DFS explained the date was a "Julian" date meaning the meals were manufactured on the 32nd day of the year in 2007, and had a shelf life of five years from manufacture date. The meals were manufactured on February 1, 2007, and expired on February 1, 2012. The manufacturer suggestions also included the following recommendation: "Manufacturer strongly suggests a 3 year inspection date to check for rancidity. If no problems are found, allow another 2 years before replacing."

The facility only had 282 MREs on hand to serve the licensed bed capacity at the Arlington campus for three meals for four days.



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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 observations, staff interviews and document review, the facility failed to ensure the infection control officer provided effective infection control oversight into food services when the facility staff failed to:

1. Ensure effective sanitation of the coffee carafes at the Arlington Campus;
2. Ensure food items originally re-thermed for service were not cooled down and re-thermed a second time; and
3. Ensure the Breast Milk refrigerator monitoring log displayed appropriate refrigeration parameters for breast milk storage.

These failures could potentially develop, transmit and spread hospital acquired infections.

Findings:

1. On July 10, 2012, beginning at 8:00 a.m., foodservice staff at the Arlington Campus was interviewed with regards to foodservice operations at that location. FSW 1 was asked about the process of cleaning and sanitizing the coffee carafes that were used for patient meal service. FSW 1 stated that the carafes were swirled with ice and salt and that was the extent of the cleaning and sanitizing process. On July 11, 2012, at 9:30 a.m., in an interview with the Infection Control Nurse, she confirmed that swirling the coffee carafe with ice and salt may remove the stains in the carafe but was not a sanitization process. On July 11, 2012, review of the facility policy titled, "Infection Control: Sanitation Precautions, " showed the following direction to staff, "All working surfaces, utensils and equipment are cleansed thoroughly and sanitized after each period of use." According to the 2009 Food Code: "Equipment food-contact surfaces and utensils shall be sanitized. Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning."

2. On July 10, 2012, beginning at 8 a.m., foodservice staff at the Arlington Campus was interviewed regarding patient meal service at that location. FSW 1 stated it was part of her job duties to make sure that food provided by the outside vendor is properly re-thermalized and served to the patients. (The foodservice at the Arlington Campus consisted of food being prepared at an outside location, cooked, chilled, transported on individual patient trays and re-thermalized in designated re-thermalization units.) FSW 1 further stated if the patients refused to eat at the time the meal was served, then their tray was dated, placed in the refrigerator, and the food was microwaved again at a later time when the patient requested the meal.

According to a guide from the US FDA, passing food through the "temperature danger zone" of 41 degrees F to 135 degrees F more than once carries greater "potential for the growth of spore-forming or toxigenic bacteria," as well as "the potential to be re-contaminated with Listeria , which could grow during refrigerated storage." In addition, there was no evidence the facility maintained a log to monitor the proper cooling of these meals that contained potentially hazardous food items.

3.On July 9, 2012, beginning at approximately 3 p.m., breast milk storage practices were reviewed with RN 12, the Unit Manager. It was noted in the neo-natal intensive care nursery refrigerator there were three bottles of breast milk that were not labeled. RN 12 stated it would be the standard of practice within the unit that once breast milk was removed from the freezer, it would be labeled with the removal date. She also acknowledged that without a label indicating when it was removed from the freezer, it would be difficult to know how long the milk was thawed. The unit's refrigerator log was also reviewed with RN 12. It was noted the log indicated that acceptable storage temperatures for breast milk would be between 2 and 8°C (Celsius) which would equate to a range of 35.6°F to 46.4°F.

The Academy of Breastfeeding Medicine, Protocol #8 noted that milk may be safely refrigerated at 39°F . There was no indication the protocol supported milk storage temperatures of up to 46°F.

Facility policy titled "Breast Milk Administration: Nursing Management", dated August 2008, noted thawed mild had an expiration of, "24 hours in a refrigerator."



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