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Based on observation, interview and record review, it was determined the facility failed to ensure the Condition of Participation for QAPI was met by failing to ensure:

1. The Food and Nutrition Service reported data as part of the Quality Assurance Performance Improvement program, to reflect the scope and nature of the services, and identify relevant opportunities for improvement, (A 267);

2. An ongoing quality assessment and performance improvement program that addressed and monitored the complexity and scope of Food and Nutrition Services was implemented. This resulted in the facility failing to identify issues in safe food handling practices which could result in food borne illness, and Clinical nutrition indicators impacting patients' nutritional needs, (A283);


3. Policies existed for standard foodservice operations such as manual dishwashing and were monitored for day to day clinical and foodservice practices, (A620, A630, A631, A749);

4. Nutritional needs of patients were met as evidenced by the lack of a comprehensive nutritional analysis of the menus, and lack of comprehensive nutrition assessments of patients, (A630, A628);

5. Performance improvement activities were developed that reflected the scope and nature of the services and that identified opportunities for improvement, (A283); and;

6. Safe and effective food storage/production practices were integrated in the facility's Infection control surveillance system (A749).


The cumulative effect of these systemic practices resulted in the failure of the facility to ensure high quality healthcare and a safe environment for all patients.

Based on observation, interview, and record review, the facility failed to ensure the Food and Nutrition Service (DFNS) data was part of the Quality Assessment Performance Improvement (QAPI) program, and reflected the scope and nature of the services, and identified relevant opportunities for improvement.

Findings:

On November 7, 2012, at 12:23 p.m., an interview was conducted with the Director of Food and Nutrition Services and the Quality Assurance (QA) Director. They both confirmed the food and nutrition department submitted data to the Performance Improvement Committee (PIC) on a quarterly basis.

The DFNS stated the foodservice indicators were based on HACCP (Hazard Analysis Critical Control Point - a systematic preventive approach to food safety), and included areas such as, temperature of food items upon receipt from vendors, temperature of food items during cold storage, and cool down temperatures. The same indicators had been monitored for approximately a year and reported data showed compliance at or above the established thresholds.

The QA Director described the focus area as Quality Control measures and not necessarily Quality Improvement measures.

The identified survey findings included deficient practices in areas such as manual warewashing, sanitation and cleanliness. There was no established QA/QI monitoring for these areas.

A review of the identified clinical nutrition indicators reflected a focus on whether nutrition assessments/reassessments and follow-ups were completed in a timely manner. There was no qualitative review of the assessments to see if they accurately reflected the patients status and captured nutritional concerns for follow-up purposes.

Two of the five nutritional indicators, correct transcription of physician diet orders on the diet list, and timeliness of patient tray delivery were interdisciplinary in nature. However, there was no established monitoring of other interdisciplinary systems such as follow-up by the physician with the registered dietitian's (RD) recommendations, and the availability of weekly weights in the medical record for RD follow-up.

Based on interview and record review, the hospital failed to have an ongoing quality assessment and performance improvement program that addressed and monitored the complexity and scope of Food and Nutrition Services. This resulted in the facility failing to identify issues in safe food handling practices which could result in food borne illness, and clinical nutrition indicators impacting patients' nutritional needs.

Findings:

During the survey from November 5 to November 7, 2012, deficient practices related to safe and sanitary food services operations (A749 and A620) and ensuring patient nutritional needs were met (A628) were identified.

On November 7, 2012, at 12:23 p.m., in an interview with the Director of Food and Nutrition Services and the Quality Assurance (QA) Director, they confirmed the food and nutrition department submitted data to the Performance Improvement committee (PIC) on a quarterly basis.

The DFNS stated the foodservice indicators were based on HACCP (Hazard Analysis Critical Control Point - a systematic preventive approach to food safety), and included areas such as: Temperature of food items upon receipt from vendors, temperature of food items during cold storage, and cool down temperatures. The same indicators had been monitored for approximately a year and reported data showed compliance at or above the established thresholds. The QA Director described the focus area as Quality Control measures and not necessarily Quality Improvement measures.

The identified survey findings included deficient practice in areas such as manual warewashing, sanitation and cleanliness. There was no established QA/QI monitoring for these areas.

A review of the identified clinical nutrition indicators noted a focus on whether nutrition assessments/reassessments and follow-ups were completed in a timely manner. There was no qualitative review of the assessments to see if they accurately reflected patient status and captured nutritional concerns for follow-up purposes.

Two of the five nutritional indicators: Correct transcription of physician diet order on diet list, and timeliness of Patient Tray Delivery were interdisciplinary in nature. However, there was no established monitoring of other interdisciplinary systems such as follow-up on registered dietitian (RD) recommendations by the physician, and the availability of weekly weights in the medical record for RD follow-up.

The lack of monitoring of these concerns would hinder the opportunity for corrective action that may impact the quality of care provided to the patients.

Based on interview and record review, the facility failed to ensure medical staff enforced bylaws to carry out the responsibilities related to coordination of four patients' care (Patients 300, 200, 202 and 105 ) by not following up on nutritional recommendations made by the Registered Dietitian (RD). This failure could result in compromised nutritional status of the patients.

Findings:

A review of the facility policy, "Assessing & Meeting Patient Care Needs (Revised Date: 2612)," was conducted. The policy indicated, "Patients requiring nutritional care and follow-up beyond the basic care level are seen by the Registered Dietitian within 48 hours after referral. The dietitian will communicate the recommendation to the physician, and documentation will be done in the Medical Record."

1. On November 7, 2012, at 10:20 a.m., a review of the medical record for Patient 300 was conducted. The patient was admitted on October 3, 2012. Upon admission, the patient had a "DTI" (deep tissue injury) on the right heel.

On October 4, 2012, RD 2 completed a nutritional assessment and documented the patient had inadequate oral intake and was not meeting ">75% of his estimated nutritional needs." RD 2 documented, "Consider appetite stimulant."

On October 11, 2012, RD 2 completed a nutritional follow-up and again documented the patient had inadequate nutritional intake and suggested considering an appetite stimulant. An order for an appetite stimulant was not made by the physician until October 16, 2012, twelve days after the RD's initial recommendation.

On November 5, 2012, at 2:42 p.m., in an interview, the Supervising Dietitian, stated there was no existing facility policy addressing the process of communicating RD recommendations to the physician.

The Supervising Dietitian stated the RD should attempt calling the physician directly with the recommendation, and if unsuccessful, then the RD could leave a, "Nutrition Alert" post-it on the record for the physician. She confirmed there was no expectation for the RD to follow-up to ensure the recommendation was acknowledged prior to the RD's next scheduled re-assessment date. For high risk patients, the RD follow-up could take up to seven days.

On November 7, 2012, at 11:05 a.m., in an interview, the Chief of Medical Staff, stated the expectation was for physicians to respond to RD recommendations within 24 hours. He could not explain the delay in the physician response to RD 2's recommendation for Patient 300. He was aware of the existing practice whereby the RD would leave a "Nutrition Alert" post-it on the patient record to alert the physician of a nutritional recommendation. The physician would then acknowledge the recommendation (agree/disagree). The Chief of Medical Staff acknowledged a delay in the implementation of RD recommendations could result in the patient not receiving planned nutritional interventions which could impact patient care.

On November 7, 2012, at 2 p.m., a review of the "Medical Staff Bylaws, Rules and Regulations, 2011-2012", indicated, under the "Medical Executive Committee (MEC)" section, "Duties...Evaluate the medical care provided to patients at the hospital."



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2. An interview was conducted with Patient 200 on November 5, 2012, at 10:15 a.m. Patient 200 stated the RD had spoken with her several times, and told her they were trying to control her cholesterol levels.

A review of Patient 200's record was conducted. Patient 200 was admitted to the facility on October 16, 2012, with diagnoses of a left foot diabetic ulcer, kidney disease, morbid obesity and hypoalbuminemia (low blood albumin-a type of protein).

Patient 200's , "Adult Initial Nutrition Assessment," dated, October 17, 2012, at 1:43 p.m. was reviewed. Patient 200 was currently receiving was a 2,200 Kilocalorie (Kcal) consistent carbohydrate diet.

The RD interventions/recommendations indicated to change the diet to a 1,800 Kcal, renal (kidney), consistent carbohydrate diet, with 65 grams protein with multivitamins. In addition, the recommendation also indicated to add one can of glytrol (liquid supplement) daily. Additional recommendations indicated to add a multivitamin daily along with vitamin C 500 milligrams (mg) twice a day, and zinc 220 mg. daily.

The nutrition diagnosis indicated Patient 200 had an excessively high cholesterol intake related to her current diet order and current calorie level intake.

On October 24, 2012, at 10:40 a.m., a nutrition re-assessment was conducted. The re-assessment indicated Patient 200 remained on a 2,200 Kcal, consistent carbohydrate diet. The recommendations suggested to change the patient's diet to a 1,800 Kcal consistent carbohydrate, renal 70 gm (gram) protein diet and to add an appetite stimulant to increase oral intake as appropriate.

Further record review failed to show the RD recommendations documented on October 17 and 24, 2012, were addressed by the physician.

On October 31, 2012, at 2 p.m., a third nutrition re-assessment was conducted. The re-assessment indicated Patient 200 was now receiving a 1,800 Kcal, consistent carbohydrate, cardiac diet. RD recommendations continued to suggest modifying the patients diet to a renal diet with 100 gm of protein and to include nephro (liquid supplement) three times a day if the patient was eating less than 50% of her diet.

Further record review on November 5, 2012, failed to show the RD recommendation regarding modifying the patient's diet to a renal diet with 100 gm of protein, and to include nephro were addressed by the physician.

An interview was conducted with RD 4 on November 5, 2012, at 12:10 p.m. RD 4 stated she would expect the physician to address the RD recommendations and indicate if they should or should not be implemented.

3. On November 6, 2012, at 8:30 a.m., Patient 202 was observed and an interview was conducted. The patient was walking about in the facility's day room.

Patient 202's record was reviewed. Patient 202 was admitted to the facility on November 3, 2012, with a diagnosis of mood disorder and a history of high blood pressure. An "Adult Initial Nutrition Assessment" was completed on November 4, 2012, at 10:30 a.m., by the RD. The assessment indicated the patient currently received a lowfat, low salt diet. The medical/nutrition issues indicated obesity, with the nutrition diagnosis as an excessive kilocalorie (Kcal) intake. The interventions and/or recommendations from the RD recommended the patient's diet be changed to a 1,600 Kcal, lowfat, low salt diet.

There was no documentation to indicate the RD recommendations for Patient 202 were brought to the attention of the patient's physician and there was no documentation to indicate the RD recommendations were addressed and/or implemented by the physician.

An interview was conducted with the Registered Nurse (RN) 20, on November 6, 2012, at 9:45 a.m. RN 20 stated if a dietary recommendation was written, the recommendation must be brought to the attention of the physician and the information communicated with the next nursing shift.




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4. Patient 105's record was reviewed on November 5, 2012, at 2 p.m. Patient 105 was a 47 year old male with history of hypertension, asthma, and Human Immunodeficiency Virus (HIV). Patient 105 was admitted to the hospital on October 9, 2012. On October 10, 2012, Patient 105's health status declined and he was transferred to the Intensive Care Unit (ICU). An initial nutritional assessment was completed in the ICU on, October 11, 2012. On October 23, 2012, Patient 105 was transferred to the Progressive Care Unit, after being treated for pneumonia in the ICU.

On November 1, 2012, a Nutrition Re-assessment was completed by the Registered Dietitian. The RD recommended to add a Boost (a nutritional drink that provides extra supplements) drink three times a day. The recommendation had not been reviewed and addressed by the physician.

On November 5, 2012, at 2:10 p.m., an interview was conducted with Registered Dietitian 4. RD 4 stated she usually called the physicians to let them know she had made a nutritional recommendation, but did not call Patient 105's physician on November 1, 2012. RD 4 stated the recommendation was not acted on because it was done over the weekend, but that the, "physician should come today" (November 5, 2012), to address the recommendation. The RD stated she had flagged the recommendation for the physician.

On November 7, 2012, at 2:45 p.m., a concurrent review of Patient 105's record and interview with Registered Dietitian 4 was conducted. There was no written documentation to indicate the physician had reviewed the RD's recommendation. There were no new orders for the boost supplement. RD 4 stated she had made the recommendation to aide in improving Patient 105's immune system, since he had been in the ICU with pneumonia, and did not want his health to deteriorate. The RD stated she did not know why the physician had not addressed her recommendation, six days later.

On November 7, 2012, at 11:05 a.m., in an interview with the Chief of Medical Staff, he stated the expectation was for physicians to respond to RD recommendations within 24 hours. The physician sees each patient daily. If the recommendation was completed after the physicians made their rounds, they would then address the recommendation the next day.

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Based on interview and record review, the facility failed to have nursing evaluate and assess the patient care by failing to ensure:

1. A physician's order for Patient 200 to maintain a fluid restriction of 1,500 milliliters (ml) was consistently implemented. This failure potentially could lead to fluid overload and medical instability;

2. All staff followed the same criteria for weighing patients, resulting in Patient 103 not being weighed as indicated by his medical condition; and,

3. Nursing staff completed 24 hour Intake and Output totals, monitored fluid intake, and reported abnormal fluid intake for Patient 108.

These failures had the potential to create a negative outcome in the quality of patient care.

Findings:

1. A review of Patient 200's record was conducted. Patient 200 was admitted to the facility on October 16, 2012, with diagnoses of a left foot diabetic ulcer, kidney disease, morbid obesity and hypoalbuminemia (low blood albumin-a type of protein).

The record reflected on October 29, 2012, at 5:45 a.m., a physician's order to maintain Patient 200 on a fluid restriction of 1,500 milliliters (ml) per 24 hours, to include both oral and intravenous fluids.

Patient 200's recorded intake levels were reviewed with the Assistant Nurse Manager (ANM) 2 on November 7, 2012, at 2:55 p.m. The record indicated on November 1, 2012, the patient's total intake was 2,180 ml., and on November 3, 2012, the patient's total intake was 1,730 ml.

ANM 2 further stated Patient 200's total fluid intake was greater than the physician ordered fluid restriction level of 1,500 ml. for both November 1 and 3, 2012.

2. In an interview conducted with RN 1 on November 5, 2012, at 1:45 p.m. RN 1 stated the care plan would indicate how often Patient 103 had to be weighed.

A record review was conducted for Patient 103. The patient was admitted to the facility on October 18, 2012, with diagnoses of stroke and left facial drooping. The patient was last weighed on October 19, 2012. Patient 103 was on enteral feeding and weighed 84.5 lbs. The nutritional care plan, (with no date and time of initiation) was incomplete. The care plan indicated there was an actual nutritional problem, but did not specify what the problem was. In the intervention section, the number 4 box was checked off. The number 4 box indicated how often the patient was to be weighed. This area was left blank.

In an interview conducted with RN 2, on November 5, 2012, at 2 p.m. RN 2 stated if the care plan did not indicate how often Patient 103 was to be weighed, the Kardex (a centrally held patient record system used for a quick patient reference) would direct staff on how frequently to weigh the patient. RN 2 did not know how often Patient 103 had to be weighed.

The Kardex was reviewed. There was no indication how often Patient 103 was to be weighed. In a concurrent interview, RN 2 stated Patient 103 would be weighed based on the physician's order. A review of the physician orders was done and there were no orders for how often staff was to weigh Patient 103.

In an interview with Registered Dietitian (RD) 1, on November 5, 2012, at 2:15 p.m., RD 1 stated Patient 103 was to be weighed at least weekly.

In an interview with RD 2, on November 5, 2012, at 3:30 p.m., RD 2 stated Patient 103 should have been weighed daily because she was on tube feeding.

On November 5, 2012, a policy and procedure for weights was requested. Facility staff stated they did not have a policy and procedure on how and when patients were to be weighed.

On November 7, 2012, a memorandum, dated, January 6, 2009 was provided to the survey team. The document indicated patients receiving enteral nutrition should be weighed daily.

3. Patient 108's record was reviewed on November 6, 2012. Patient 108 was admitted to the facility, on October 30, 2012, with diagnosis of Schizophrenia. The Initial Nutritional Assessment indicated Patient 108 had an inadequate oral intake related to poor appetite and refusing to eat. The record indicated Patient 108 had stopped eating and sleeping for three months. A physician order for Patient 108, dated November 1, 2012, indicated strict intake and output.

A review of the Intake and Output (I&O) sheets, dated, November 1 through 6, 2012, indicated that five of six days, Patient 108 did not meet the required minimum fluid intake. The 24 hours totals had not been completed by nursing. There was no nursing documentation to indicate the inadequate intake of fluids had been reported and that interventions had been taken to prevent negative outcomes, such as dehydration.

The facility's Intake and Output policy and procedure was requested. The Nurse Manager stated they did not have a facility policy and procedure for Intake and Output.

The Nurse Manager further stated, the facility used the Clinical Nursing Skills manual (2004) 6th edition by Smith, Duell, and Martin. The reference indicated the planning objective was to ensure a fluid intake of at least 1,500 - 2,000 milliliters. The reference further indicated under the section titled, Evaluation, the following: "The expected outcomes was for fluid intake of at least 2,000 ml, unless contraindicated by diagnosis. The reference further indicated, "Record 24-hour totals of I&O on bedside record and place in client's chart...notify physician of any significant imbalances..."

Based on interview and record review, the facility failed to ensure an interdisciplinary care plan which focused on Patient 200's fluid restriction of 1,500 milliliters was implemented. This failure could potentially lead to confusion with the provision of nursing care and negatively impact the patient's medical stability.

Findings:

A review of Patient 200's record was conducted. Patient 200 was admitted to the facility on October 16, 2012, with diagnoses of a left foot diabetic ulcer, kidney disease, morbid obesity and hypoalbuminemia (low blood albumin-a type of protein).

On October 29, 2012, at 5:45 a.m., a physician's order indicated Patient 200 was to be maintained on a fluid restriction of 1,500 milliliters per 24 hours, to include both oral and intravenous fluids.

A review of the patient's Interdisciplinary Care Plan did not reflect the patient was on fluid restriction.

A review of the facility policy, "Assessing and Meeting Patient Care Needs: Nursing Process (Revised Date: 03/2011)," was reviewed. The policy indicated, "An Interdisciplinary Patient Care Plan (PCP) will be developed for each patient and is based on the nursing assessment."

An interview was conducted with Patient 200's Registered Nurse (RN) 21, on November 7, 2012, at 2:45 p.m. RN 21 stated Patient 200 was on fluid restriction and this should have been included in the Patient 200's interdisciplinary patient care plan.


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Based on observation, interview, and record review, the facility failed to ensure the Condition Of Participation for Food and Dietetic Services was met by failing to ensure:

1. Policies existed for standard foodservice operations such as manual dishwashing and were monitored for day to day clinical and foodservice practices, (A620, A630, A631, A749);

2. The nutritional needs of patients were met as evidenced by the lack of a comprehensive nutritional analysis of the menus, and lack of comprehensive nutrition assessments of patients, (A630, A628);

3. A facility plan was in place to address any interruption of service that may impact food delivery by the outside foodservice vendor, (A620);

4. Performance improvement activities that reflected the scope and nature of the services and identified opportunities for improvement were developed, (A283); and,

5. Safe and effective food storage/production practices were integrated in the facility's infection control surveillance system ( A749).

The cumulative effects of these systemic practices resulted in the failure of the facility's food and nutritional services to ensure the nutritional needs of patients were met and high quality healthcare was provided for all patients.





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Based on observation, interview, and record review, the facility failed to ensure the Director of Food and Nutrition Service (DFNS):

A) Developed and monitored written procedures for foodservice operational processes and clinical nutrition practices; and,

B) Ensured data reported as part of the Quality Assurance Performance Improvement (QAPI) program, reflected the scope and nature of the services, and identified relevant opportunities for improvement.

These failures may result in patients being exposed to foodborne illness or not provided appropriate nutritional care which may further compromise patients medical status.

Findings:

A 1. On November 5, 2012, beginning at 9:48 a.m., during a tour of the kitchen at the main campus, the following observations were made:

a. In the dishroom, the three compartment sink was noted to be used for washing foodservice equipment. In a concurrent interview with Foodservice Worker (FSW) 2, she stated the dishmachine was not operable and the facility used the three-compartment sink to wash, rinse, and sanitize equipment. FSW 2 stated the temperature in the wash compartment should be 160 to 180 degrees Fahrenheit. FSW 2 stated the concentration of the sanitizer in the third compartment should be 200 parts per million (ppm).

Upon testing the sanitizer solution, the test strip displayed a concentration of approximately 100 parts per million. FSW 2 continued to use the same sanitizer solution during the dishwashing process, after she determined that the concentration of the sanitizer was not 200 ppm.

Further observation of the sanitizing compartment of the three compartment sink showed that a pair of tongs had been placed in that compartment after being washed and rinsed. Dried food particles were observed clinging to the tongs. FSW 2 acknowledged the tongs were still dirty.

b. The blade of the can opener located adjacent to the trayline area was noted to be dirty with a black residue and shards of tin adhering to it. The Director of Food and Nutrition Services (DFNS), present at the time of the observation, acknowledged the can opener needed to be cleaned.

c. In the walk-in freezer, dirt and debris was observed on the floor underneath the freezer shelves.

d. In the dry storage room, stored cans were observed with a layer of dust on the tops. In a section of the store room designated for "single cans", a #10 can of applesauce was noted with a dented rim and had a liquid residue clinging to the top of the can. A #10 can of chili sauce was noted with black particles clinging to the top of the can.
The following cake and muffin mixes were noted to be outdated;

Three 5-pound boxes of Basic Muffin Mix were imprinted with a manufacturer, "Best if Used By" date of September 8, 2012.

Three 5-pound boxes of Basic Muffin Mix were imprinted with a manufacturer, "Best if Used By" date of October 5, 2011.

One 5-pound box of Basic Muffin Mix was imprinted with a manufacturer, "Best if Used By" date of May 5, 2012.

Four 5-pound boxes of Yellow Cake Mix were imprinted with a manufacturer, "Best if Used By" date of July 5, 2011.

One 5-pound box of Yellow Cake Mix was imprinted with a manufacturer, "Best if Used By" date of January 5, 2012.

Three 5-pound boxes of Chocolate Cake Mix were imprinted with a manufacturer, "Best if Used By" date of February 8, 2012.

A review of the facility policy titled, "Food Preparation and Service - Revised 6/15/12", showed: "Foods are to be discarded by the expiration or, "use by" date.

Dirt and debris were observed in a corner of the store room on November 5, 2012, at 9:48 a.m. In a concurrent interview, Foodservice Worker (FSW) 3 stated the dry storage room was cleaned, swept and mopped every day. FSW 3 further stated the can racks were moved from against the walls two times per week for deep cleaning, and the last time that had occurred was Friday, November 2, 2012.

One of the can storage racks was moved. Behind the rack, a large black stain was noted on the floor. The wall was observed to be dirty with what appeared to be a dried liquid spill that had trickled down to the black stain. Dirt and debris had adhered to the dried stain.

The Director of Food and Nutrition Services (DFNS), present at the time of the observation, acknowledged the above observations.

A review of the facility policy titled, "Infection Control - Revised 1/16/12," indicated, "Responsibilities - Food and Nutrition Services Manager: To develop and maintain clean, sanitary work areas, storage areas and equipment for the handling of supplies in accordance with state and local health department standards...Infection Control Practices:...Storage areas shall be adequate, cleaned thoroughly weekly and inspected daily by the Food and Nutrition Services Manager or designee."

e. In the spice and preparation area, a chopper was stored on a counter. The DFNS, present at the time of the observation, stated the chopper was not in use and was stored as clean. Inspection of the chopper showed there was dried food debris clinging to the chopper.

f. In the hot food preparation area, two sanitizer pails were observed stored underneath the food preparation area. The sanitizer solution in the pails appeared clean.

On November 5, 2012, at 11:05 a.m., in an interview with Cook 1, he stated he filled the pails at approximately 10:30 a.m. He stated he used the sanitizer pails to sanitize his work station and would change the sanitizer every hour or when the solution became dirty. Cook 1 stated the concentration of the sanitizer should be 200 parts per million (ppm). Upon utilizing a chemical test strip, the chemical sanitizer concentration in both pails was noted to be 100 ppm.

A 2. On November 6, 2012, at 8:50 a.m., at the Arlington Campus food and nutrition services, Foodservice Worker (FSW) 4 stated she washed and sanitized foodservice equipment using three plastic containers. FSW 4 stated she filled the first container with water at 160 degrees Fahrenheit, filled the second container with clean water for rinsing, and filled the third container with sanitizer. FSW 4 did not know how much sanitizer to add, but stated the concentration should be 200 parts per million (ppm). FSW 4 was asked if she could retrieve a facility policy describing the manual handwashing process.

Upon review of the facility food and nutrition services policy and procedure manual, by FSW 4 and the Director of Food and Nutrition Services (DFNS), no policy delineating the process for manual warewashing could be found. No log was maintained by staff delineating the testing of the sanitizer solution before use.

On November 6, 2012, at 11:05 a.m., FSW 4 was asked to demonstrate the manual warewashing process.

FSW 4 retrieved three plastic containers approximately four inches deep and filled the first and second containers with approximately 2 inches of water, placed soap in the first container, and filled the third container with 2 inches of water with sanitizer. FSW 4 then retrieved a plastic container that was used to deliver snacks to the patient units. The plastic delivery container was noted to be deeper than the containers used for the manual warewashing process.

FSW 4 proceeded to wash the container by continuously rotating the container in the soapy water and using a sponge. For rinsing purposes, FSW 4 obtained a Styrofoam cup and splashed water on the container. FSW 4 then used the same cup to splash sanitizer on the delivery container while rotating it in the third plastic container. The sanitization process lasted approximately 20 seconds. The delivery container could not be submerged in the sanitizer as the delivery container was larger than the container used to house the chemical.

A review of the Food Code, 2009, Section 4-301.12, Manual Warewashing, Sink Compartment Requirements, indicated;

"(A) Except as specified in ¶ (C) of this section, a sink with at least 3 compartments shall be provided for manually washing, rinsing, and sanitizing equipment and utensils. Pf
(B) Sink compartments shall be large enough to accommodate immersion of the largest equipment and utensils. If equipment or utensils are too large for the warewashing sink, a warewashing machine or alternative equipment as specified in ¶ (C) of this section shall be used. Pf
(C) Alternative manual warewashing equipment may be used when there are special cleaning needs or constraints and its use is approved. Alternative manual warewashing equipment may include:
(1) High-pressure detergent sprayers;
(2) Low- or line-pressure spray detergent foamers;
(3) Other task-specific cleaning equipment;
(4) Brushes or other implements;
(5) 2-compartment sinks as specified under ¶¶ (D) and (E) of this section; or
(6) Receptacles that substitute for the compartments of a multicompartment sink."

On November 7, 2012, at approximately 4 p.m., the facility provided information from the Food Code 2009, Section 4-703.11(C) and the California Retail Food Code, Section 114099.6, both of which documented that during the manual warewashing process, the application of sanitizing chemicals can be made by, "immersion, manual swabbing, brushing or pressure spraying."

Neither of these application methods was observed on November 6, 2012, at 11:05 a.m., during the manual warewashing process. FSW 4 was not observed immersing the equipment in the sanitizer, or manually swabbing, brushing, or pressure spraying sanitizer on the equipment.

Further review of the California Retail Food Code document provided by the facility during the exit conference, showed a section highlighted by the facility that read, "Contact with a solution of 200 ppm (parts per million) quaternary ammonia for at least one minute." FSW 4 was not able to ensure that all parts of the delivery container being sanitized was in contact with the sanitizer for one minute since she had to continually rotate the container in the solution, and finished the sanitization process in approximately 20 seconds.

A 3. On November 6, 2012, at 11:20 a.m., a plastic container containing approximately six 4-ounce containers of yogurt was noted to be sitting on a counter on Unit C at the Arlington Campus. The yogurt containers were not delivered on ice. The nurse on the unit stated the yogurt containers were delivered at 10 a.m., by the food and nutrition service staff, as "snacks" for the patients. The six containers were leftover from the 10 a.m. delivery.

On November 6, 2012, at 2:30 p.m., an interview with the Registered Diet Technician (DTR) was conducted. The DTR worked full time at the Arlington Campus and provided some oversight of foodservice operations at that campus.

The DTR stated snacks sent to the patient units were usually fully consumed and nothing was returned to the food and nutrition department. The DTR stated there were no temperatures taken of the yogurt when removed from the refrigerator. She further stated if leftover yogurt containers were returned within a one and one half hour time frame, then the containers would be returned to the refrigerator for re-service.

A review of the 2009 FDA Food Code indicated the following;
"Section 3-501.19 Time as a Public Health Control" which referenced Ready to Eat food items held for service indicated;
"1. Time - maximum up to 4 hours: If time temperature control is used as the public health control up to a maximum of 4 hours;
(1) The food shall have an initial temperature of 5ºC (41ºF - Fahrenheit) or less when removed from cold holding temperature control...;
(2) The food shall be marked or otherwise identified to indicate the time that is 4 hours past the point in time when the food is removed from temperature control; (3) The food shall be cooked and served, served at any temperature if ready-to-eat, or discarded, within 4 hours from the point in time when the food is removed from temperature control."

There was no provision in the Food Code for returning Ready to Eat food item, that have not been monitored for appropriate temperatures (i.e. 41 degrees F or below if a refrigerated item), back to the refrigerator for re-service at a later time.

The yogurt containers were not delivered on ice, and there were no other temperature monitoring systems in place for the yogurt containers.

A 4. The DRI/RDA (Dietary Reference Intakes/Recommended Dietary Allowances) consists of nutrient based references whose purpose is to plan diets for individuals, focusing on optimizing health status, disease prevention and ensuring consumption of nutrients in adequate amounts.

The provisions of the DRI, which include the RDA's, Adequate intake, and Acceptable Macro and Micronutrient distribution ranges, developed by the Food and Nutrition Board under the auspices of the Institute of Medicine are used to evaluate nutritional adequacy of patient/resident menus.

On November 6, 2012, at 8:15 a.m., the facility's nutrient analysis of the facility diets for the main campus was reviewed. The analysis did not include an analysis of all vitamins and micronutrients as specified in the RDA or DRI.

On November 6, 2012, at 2:45 p.m., an interview was conducted with the Director of Food and Nutrition Services (DFNS). The DFNS stated she was not sure what standard or "Life Stage Group" the nutrient analysis was compared to but believed it was based on information from the USDA (United States Department of Agriculture).

The DFNS acknowledged without comparing the menus to the appropriate reference age group guidelines, and without analyzing all vitamins and micronutrients, it would be difficult to ensure the facility's developed menus met the nutritional needs of the patients according to the RDA/DRI.

A review of the facility policy titled, "Patient Menus - Revised 2/6/12", indicated, "Patient menus are written to supply the "recommended daily allowance," . . . Nutritional needs of the patient are met in accordance with the physician's order and, in far as the diet permits, meets the most recent Recommended Dietary Allowance of the Food and Nutrition Board of the National Research Council."

A 5. On November 6, 2012, at 11 a.m., an interview was conducted with the Director of Food and Nutrition Services (DFNS). The DFNS was asked if the facility had a plan in case of an interruption of service, that would impact the delivery of food to the Arlington campus by the contracted food provider. The DFNS stated there was no facility policy established for interruption of service, but the facility relied upon an "Emergency Plan" that had been developed by the contracted food service provider.

On November 6, 2012, at 2:45 p.m., a review of the "Emergency Plan" submitted by the contracted foodservice provider noted several scenarios for how the provision of food would be made should there be localized emergencies, delivery vehicle problems, or other disasters. The plans included preparation of food at alternate sites.

There was no indication of whether the therapeutic patient menu at the Arlington Campus would continue to be followed in the event of an interruption in service or whether modifications needed to be made in the menu would be honored.

B. On November 7, 2012, at 12:23 p.m., an interview was conducted with the Director of Food and Nutrition Services and the Quality Assurance (QA) Director. They both confirmed the food and nutrition department submitted data to the Performance Improvement Committee (PIC) on a quarterly basis.

The DFNS stated the foodservice indicators were based on HACCP (Hazard Analysis Critical Control Point - a systematic preventive approach to food safety), and included areas such as, temperature of food items upon receipt from vendors, temperature of food items during cold storage, and cool down temperatures. The same indicators had been monitored for approximately a year and reported data showed compliance at or above the established thresholds.

The QA Director described the focus area as Quality Control measures and not necessarily Quality Improvement measures.

The identified survey findings included deficient practices in areas such as manual warewashing, sanitation and cleanliness. There was no established QA/QI monitoring for these areas.

A review of the identified clinical nutrition indicators reflected a focus on whether nutrition assessments/reassessments and follow-ups were completed in a timely manner. There was no qualitative review of the assessments to see if they accurately reflected the patients status and captured nutritional concerns for follow-up purposes.

Two of the five nutritional indicators, correct transcription of physician diet orders on the diet list, and timeliness of patient tray delivery were interdisciplinary in nature. However, there was no established monitoring of other interdisciplinary systems such as follow-up with the registered dietitian's (RD) recommendations by the physician, and the availability of weekly weights in the medical record for RD follow-up.


18918

Based on interview and record review, the hospital failed to ensure:

1. The Registered Dietitian's (RD) input on the interdisciplinary plan of care was documented for one Patient, (Patient 300) who was at nutritional risk;

2. The RD comprehensively addressed the nutritional status of one patient, (Patient 302) in accordance with facility policy and standards of practice; and,

3. The nutritional needs of one sampled patient (Patient 301) were met as the patient sustained a significant weight loss of approximately 35 pounds in three weeks.
The failure to use current community standards in assessing or following up on these patients could potentially impact their nutritional and medical stability.

Findings:

1. A review of the record for Patient 300, indicated he was admitted to the main campus on October 3, 2012. The patient was admitted with a DTI (deep tissue injury) on the right heel and redness of the coccyx.

On October 4, 2012, the RD completed a nutritional assessment and documented the patient had a healed Stage II pressure sore on the sacrum, but did not reference the presence of a DTI to the right heel. The RD documented the patient had inadequate oral intake and was not meeting more than 75% of his estimated nutritional needs. The RD recommended an appetite stimulant.

On October 11, 2012, the RD completed a nutrition re-assessment and documented the patient was receiving Boost (a nutritional supplement) and had inadequate oral intake, and "only drinks juice". The RD made no reference to the patient's DTI. The RD again recommended an appetite stimulant, and made a recommendation for a tube feeding (feeding via a tube inserted directly into the stomach) should the patient continue with a poor oral intake. The same recommendations were made on October 18, 2012.

On October 25, 2012, the RD documented the patient had increased protein needs to promote wound healing as evidenced by a low prealbumin (a measure of protein stores. The RD reassessed the patient's protein needs from 68-99 grams per day (as initially assessed) to 68-102 grams per day. No new recommendations were established.

A review of the patient's plan of care, indicated no entry by the RD referring to Patient 300's compromised nutritional status, the provision of a nutritional supplement, or an appetite stimulant.

On November 7, 2012, at 3:45 p.m., in an interview with RD 2, she stated Patient 300 was at a high nutritional risk, and confirmed the absence of an entry on the active care plan in the patient's record. She acknowledged the availability of juice based nutritional supplements that could have been recommended for the patient since she documented the patient liked juice. She could not explain why she did not reference the DTI on her initial nutrition assessment, and why she did not identify the patient's increased protein needs for wound healing until October 25, 2012, even though the DTI was present on admission.

A review of the facility policy titled, "Assessing & Meeting Patient care Needs - Revised 2/6/12", indicated: "The Registered Dietitian will complete the interdisciplinary patient care plan for all patients at high nutrition risk."

2. A review of the medical record for Patient 302, indicated he was admitted to the Arlington Campus on September 11, 2012. The patient's admission height was documented as six feet two inches, his weight was 180 pounds. The RD completed an initial nutrition assessment on September 13, 2012, and documented the patient's ideal body weight (IBW) as 190 pounds. The patient was prescribed a low sodium, high fiber diet due to problems with constipation. The RD documented a recommendation to, "Monitor I/Os (intake and output), lab (laboratory), wt (weight), continue Diet RX (recommendation)."

A further review of the medical record indicated the patient's measured weekly weights, as documented on the nursing graphics flowsheet as follows:

October 7, 2012, - 193 pounds
October 14, 2012, - Refused
October 21, 2012, - 194.5 pounds
October 28, 2012, - 200 pounds
November 4, 2012, - 204 pounds.

Patient 302 gained 24 pounds from September 11, 2012, to November 4, 2012.

A review of the RD re-assessment dated, October 12, 2012, indicated that no new weight was available. The RD re-assessment dated, October 20, 2012, referenced the patient's refusal of weight on October 14, 2012, but did not address the patient's documented 13 pound weight gain as of October 7, 2012. On the RD re-assessments dated, October 27, 2012, and November 3, 2012, the RD documented "No new weight" was available. On each re-assessment, the RD documented "Monitor wt" as a recommendation.

On November 7, 2012, at 1:55 p.m., in an interview with RD 1, she stated she was familiar with Patient 302, but could not explain why she had not addressed the significant weight gain experienced by Patient 302, when the weekly weights were available on the nursing flowsheets on October 7, 21, and 28, 2012. The RD stated she did not attend team meetings at the Arlington campus, where the care of each patient was discussed with the multidisciplinary team.

A review of the facility policy titled, "Assessing & Meeting Patient Care Needs - Revised 2/6/12", indicated: "The Registered Dietitian will participate in multidisciplinary conferences on their assigned units.

3. Patient 301 was admitted to the hospital on August 13, 2012, with diagnoses including left sided weakness, and high blood pressure. Patient 301 was 6 feet 3 inches tall and weighed 180 pounds on admission. He was on NPO (nothing by mouth) pending a speech evaluation. In addition, the physician ordered a nutritional consult.

On August 14, 2012, a nutritional assessment was conducted by a registered dietitian. The recommendations included a low sodium diet with Boost three times a day (a nutritional supplement), after a swallow evaluation was completed. Additional recommendations included monitoring tolerance, laboratory values and consulting RD as needed.

On August 21, 2012, Patient 301 weighed 158.4 pounds, and had lost 21.6 pounds within a week. There was no documented evidence by nursing, nutrition, or medical staff to indicate Patient 301 had been reweighed to validate that this was not an error.

On September 3, 2012, Patient 301 weighed 144.8 pounds. Patient 301 loss an additional 13.86 pounds for a total of 34 pounds in three weeks. On September 4, 2012, a nutrition consult was ordered by the physician.

Patient 301 was reassessed on September 4, 2012, by another registered dietitian who recommended Patient 301 remain on a mechanical soft, chopped 2 gram sodium diet and to add Boost Plus three times a day. Boost Plus, a nutritional supplement has 100 more calories per can than regular Boost.

A review of the physician progress notes from August 17 through September 17, 2012, did not include documentation of problems with eating, chewing or swallowing. Nutrition notes indicated Patient 301 was eating between 50 to 100% of his meals or "po (oral) good."

On October 30, 2012, the RD recalculated the patient's caloric needs. She again recommended "Boost Plus three times a day to increase weight." No acknowledgement was observed in the record and Patient 301 remained on the less caloric supplement.

In an earlier interview on November 7, 2012, at 10:25 am, the Nurse Manager reviewed Patient 301's record and indicated there was no physician order for Boost Plus. She stated the RDs wrote their recommendations and posted the recommendations on the cover of the Patient's medical record.

In an interview with the Chief of Staff at 11 a.m., on November 07, 2012, he stated the RDs communicated their recommendations to physicians via a Post it note on the cover of the medical record. He stated the current system worked, but could be improved on. There was not an effective system to validate that the physician had seen the recommendation or concurred with the RDs.

In an interview with the Supervising Dietitian on November 7, 2012, at 3:20 p.m., she stated Boost Plus was carried by the hospital and was available with a physician's order.

A review of Patient 301's record indicated three different dietitians used different calculations to determine Patient 301's caloric needs.

The Supervising Dietitian did not provide information on why the three different dietitians used a different calculation when the Patient 301 was experiencing weight loss to determine the patient's caloric needs.

The Supervising Dietitian did not provide the rationale as to why the RDs followed a high risk patient once a week instead of increased frequency when recommendations had been made and indicated it was the hospital's policy to do so.

Patient 301 subsequently experienced a 16 % weight loss in less than a month. Patient 301's weight of 152 pounds on October 26, 2012, was less than his admission weight of 180 pounds.

A review of the hospital's policy, "Assessing & Meeting Patient Care Needs, (Revised Date: 2/6/12)," indicated ,"Follow-up nutrition re-assessments are completed every seven days or less for high risk patients."

The RDs failed to follow up on recommendations that they made or that had been made by their colleagues for this high risk patient. This failure resulted in the continued use of a supplement that provided less calories than had been recommended by the RDs. The RDs used incorrect nutritional calculations to determine his nutritional needs.

The recommendation to change Patient 301's supplement to a higher caloric one was not acknowledged by the physician and, as of November 7, 2012, over two months later, Patient 301 remained on the lower calorie supplement.

Further record review failed to indicate Patient 301's weights were accurate, and that interdisciplinary coordination of the patient's nutritional care needs were addressed according to current standards of practice.

3. Patient 105's record was reviewed on November 5, 2012, at 2 p.m. Patient 105 was a 47 year old male with history of hypertension, asthma, and Human Immunodeficiency Virus (HIV). Patient 105 was admitted to the hospital on October 9, 2012. On October 10, 2012, Patient 105's health status declined and he was transferred to the Intensive Care Unit (ICU). An initial nutritional assessment was completed in the ICU on, October 11, 2012. On October 23, 2012, Patient 105 was transferred to the Progressive Care Unit, after being treated for pneumonia in the ICU.

On November 1, 2012, a Nutrition Re-assessment was completed by the Registered Dietitian. The RD recommended to add a Boost (a nutritional drink that provides extra supplements) drink three times a day. There was no documentation to indicate the recommendation had been reviewed and addressed by the physician.

On November 5, 2012, at 2:10 p.m., an interview was conducted with the Registered Dietitian (RD) 4. RD 4 stated she usually called the physicians to let them know she had made a nutritional recommendation, but did not call Patient 105's physician on November 1, 2012. RD 4 stated the recommendation was not acted on because it was done over the weekend, but that the, "physician should come today" (November 5, 2012), to address the recommendation. The RD stated she flagged the recommendation for the physician.

On November 7, 2012, at 2:45 p.m., a concurrent review of Patient 105's record and interview with Registered Dietitian 4 was conducted. There was no written documentation to indicate the physician had reviewed the RD's recommendation. There were no new orders for the boost supplement. RD 4 stated she had made the recommendation to aide in improving Patient 105's immune system, since he had been in the ICU with pneumonia, and did not want his health to deteriorate. The RD stated she did not know why the physician had not addressed her recommendation, six days later.

On November 7, 2012, at 11:05 a.m., in an interview with the Chief of Medical Staff, he stated the expectation was for physicians to respond to RD recommendations within 24 hours. The physician sees each patient daily. If the recommendation was completed after the physicians made their rounds, they would then address the recommendation the next day.





22384

Based on observation, interview and record review, the facility failed to ensure the recommendations of the Registered Dietitian (RD) were addressed for Patients 200, 202, and 105. These failures could negatively impact patients' nutritional status and overall medical stability.

Findings:

A review of the facility policy, "Assessing & Meeting Patient Care Needs (Revised Date: 2012)," was conducted. The policy indicated, "Patients requiring nutritional care and follow-up beyond the basic care level are seen by the Registered Dietitian within 48 hours after referral. The dietitian will communicate the recommendation to the physician, and documentation will be done in the Medical Record."

1. An interview was conducted with Patient 200 on November 5, 2012, at 10:15 a.m. Patient 200 stated the RD had spoken with her several times, and told her they were trying to control her cholesterol levels (an indicator of potential heart disease).

A review of Patient 200's record was conducted. Patient 200 was admitted to the facility on October 16, 2012, with diagnoses of a left foot diabetic ulcer, kidney disease, morbid obesity and hypoalbuminemia (low blood albumin-a type of protein).

Patient 200's "Adult Initial Nutrition Assessment," dated, October 17, 2012, at 1:43 p.m. was reviewed. The assessment indicated Patient 200 was receiving was a 2,200 Kilocalorie (Kcal) consistent carbohydrate diet.

The RD interventions/recommendations indicated to change the diet to a 1,800 Kcal, renal (kidney), consistent carbohydrate diet, with 65 grams protein with multivitamins. In addition, the recommendation indicated to add one can glytrol (liquid supplement) daily. Recommendations also indicated to add a multivitamin daily along with Vitamin C 500 milligrams (mg) twice a day and Zinc 220 mg daily.

The nutrition diagnosis indicated Patient 200 had an excessively high cholesterol intake related to her current diet order.

On October 24, 2012, at 10:40 a.m., a nutrition re-assessment indicated Patient 200 remained on a 2,200 Kcal, consistent carbohydrate diet. The recommendations suggested to change the patient's diet to a 1,800 Kcal, renal consistent carbohydrate diet with 70 gm protein, and to add an appetite stimulant to increase oral intake as appropriate.

The documentation did not indicate if the RD recommendations documented on October 17 and 24, 2012, were addressed by the physician.

On October 31, 2012, at 2 p.m., a third nutrition re-assessment was conducted. The re-assessment indicated Patient 200 was now receiving a 1,800 Kcal, consistent carbohydrate, cardiac diet. RD recommendations continued to suggest modifying the patients diet to a renal diet with 100 gm of protein and to include nephro (liquid supplement) three times a day if the patient was eating less than 50% of her diet.

Further record review on November 5, 2012, failed to show the RD recommendations to modify Patient 200's diet to a renal diet with 100 gm of protein, and to include nephro were addressed by the physician.

An interview was conducted with RD 4 on November 5, 2012, at 12:10 p.m. RD 4 stated she would expect the physician to address the RD recommendations and indicate if they should or should not be implemented.


2. On November 6, 2012, at 8:30 a.m., an interview with, and an observation of Patient 202 were conducted. The patient was observed walking about in the facility day room. The patient was alert, her speech was clear as she stated she was on a low salt diet.

A review of Patient 202's record was conducted. Patient 202 was admitted to the facility on November 3, 2012, with a diagnosis of mood disorder and a history of high blood pressure. An, "Adult Initial Nutrition Assessment" was completed on November 4, 2012, at 10:30 a.m., by the RD. The assessment indicated the patient was on a lowfat, low salt diet. The medical/nutrition issues indicated obesity, with the nutrition diagnosis as an excessive kilocalorie (Kcal) intake. The interventions and/or recommendations by the RD recommended to change Patient 202's diet to a 1,600 Kcal, lowfat, low salt diet.

The document did not indicate the RD recommendations for Patient 202 were brought to the attention of the patient's physician nor were they addressed and/or implemented by the physician.

An interview was conducted with the Registered Nurse (RN) 20, on November 6, 2012, at 9:45 a.m. RN 20 stated if a dietary recommendation was written, the recommendation must be brought to the attention of the physician and the information communicated with the next nursing shift.

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

1) Standard menus were comprehensively analyzed for the nutritional components to meet the current national standards including the RDA (Recommended Dietary Allowances) and the DRI (Dietary Reference Intake) of the Food and Nutrition Board of the National Research Council, consistently provided the same amount of nutrients for mechanically altered diets and addressed the nutritional needs of all subgroups serviced at the facility;

2) Patient food items were served in accordance with prescribed orders; and,

3) Patient 201, an adolescent, had a specific therapeutic diet ordered after undergoing an appendectomy (surgical removal of the appendix).

These failures could potentially impact patients medical stability if their diet tolerance and/or their nutritional needs were not met.


Findings:

1a. The DRI/RDA consists of nutrient based references whose purpose is to plan diets for individuals, focusing on optimizing health status, disease prevention and ensuring consumption of nutrients in adequate amounts. The provisions of the Dietary Reference Intakes, which include the Recommended Dietary Allowances (RDA's), Adequate intake, and Acceptable Macro and Micronutrient distribution ranges, developed by the Food and Nutrition Board under the auspice of the Institute of Medicine, are used to evaluate nutritional adequacy of patient menus.

On November 6, 2012, at 8:15 a.m., the facility's nutrient analysis of the facility diets for the Main campus were reviewed. The analysis did not include an analysis of all vitamins and micronutrients as specified in the RDA or DRI.

On November 6, 2012, at 2:45 p.m., in an interview, the Director of Food and Nutrition Services (DFNS) stated she was not sure what standard or "Life Stage Group" the nutrient analysis was compared to but believed it was based on information from the USDA (United States Department of Agriculture).

The DFNS stated without comparing the menus to the appropriate reference age group guidelines, and without analyzing for all vitamins and micronutrients, it would be difficult to ensure the facility's developed menus met the nutritional needs of the patients according to the RDA/DRI.

A review of the facility policy titled, "Patient Menus - Revised 2/6/12," indicated: "Patient menus are written to supply the "recommended daily allowance"...Nutritional needs of the patient are met in accordance with the physician's order and, in far as the diet permits, meets the most recent Recommended Dietary Allowance of the Food and Nutrition Board of the National Research Council."

b. On November 6, 2012, at 2:42 p.m., in an interview with the Director of Food and Nutrition Services (DFNS), she stated the same Pediatric menu was used for all patients who were between the ages of one and eighteen, unless the physician specified differently. The DFNS could not explain why the pediatric menu analysis, reviewed for Cycle 1, Monday, indicated the pediatric population received more calories and protein than adults prescribed regular diets.

Further review of the nutrition analysis indicated the Monday pediatric menu provided 23.9 grams of fiber. This number may be sufficient for children between the ages one and eight, according to DRI/RDA reference tables, but would not be sufficient for males between the age of fourteen and eighteen, where the dietary fiber recommendation is 38 grams per day. The same was true of other nutrients reviewed.

A review of the facility policy titled, "Pediatric Menus - Revised 1/20/12" showed: "Pediatric menus are written to supply the "recommended daily allowance" for the specified age group."

c. On November 5, 2012, at 2:42 p.m., in an interview with the Supervising Dietitian, she confirmed the menus are not adjusted for pregnant or post-partum patients, and had not been specifically reviewed to ensure that they met the needs of that population, specifically the increased need for folate, iron and niacin, during the stages of pregnancy and/or lactation. She stated patients are offered regular diets and the non-select regular menu mirrors the menu that would be sent to any patient prescribed a regular diet at the hospital.

A review of the nutritional analysis of a "Regular" diet for Monday, Cycle 1, indicated the analysis was deficient in the nutrients indicated above, that require an elevated intake by obstetric patients, as follows:

Iron: Needs during pregnancy -
27 mg (milligrams)/day,
Amount provided on regular diet -
10.17 mg/day

Folate: Needs during pregnancy -
520 ug (micrograms)/day,
Amount provided on regular diet -
94 ug/day

Niacin: Needs during pregnancy -
14 mg/day,
Amount provided on regular diet -
2.094 mg/day

d. Further review of the menu analysis for Monday, Cycle 1, indicated a "Regular" diet provided:

2336 calories
24.2 grams of fiber, and
10.17 mg of iron.

In comparison a, "Mechanical Soft/Chopped" diet provided:

1715 calories
15.3 grams of fiber, and
1.81 mg of iron.

The Director of Food and Nutrition Services (DFNS) acknowledged the difference in nutritional content of the two diets and confirmed a Mechanical Soft/Chopped diet is not a Soft Diet where foods may be soft-textured and restricted in fiber.

e. On November 6, 2012, at 12:30 p.m., a review of the "Menu Nutrient Analysis Report" for the menus provided at the Arlington campus, indicated the menus were nutritionally analyzed for the following nutrients: Calories, Protein, Fat, Carbohydrates and Sodium.

On November 6, 2012, at 2:45 p.m., in an interview with the Director of Food and Nutrition Services (DFNS), she acknowledged the limitation in the nutritional analysis of the menus served at the Arlington Campus. She stated the menus were provided by an outside food contractor and they were responsible for the analysis. There was a comparison of the menu analysis to "Daily Values" but it was unclear as to what the "Daily Values" represented.

On November 6, 2012, at 11:22 a.m., a review of the record for Patient 302, indicated the patient was prescribed a Low Sodium, High Fiber diet. On November 6, 2012, at 1:55 p.m., in an interview with RD 1, she stated she checked the patient's tray for extra fruit or salad in order to determine whether "high fiber" was provided. RD 1 stated in her opinion, a normal fiber diet would provide 25-30 grams of fiber and a high fiber diet would be over 30 grams of fiber per day.

In a concurrent interview with the DFNS, she confirmed the absence of an analysis of the fiber content of the menus provided by the outside food contractor to determine the amount of fiber being provided. Review of the, "Physician's Guide to Ordering Nutrition Prescriptions" showed a "High Fiber" diet as one providing 25-35 grams of fiber per day.

2. On November 5, 2012, at 10 a.m., during an observation of the lunch trayline at the Main campus, the tray slips for two patients (Patients 300 and 301) indicated the patients should receive "Boost" (a nutritional supplement) with the meal. Both trays were loaded on the patient tray cart ready to be transported to the nursing unit without Boost being placed on either tray.

On November 5, 2012, at 10:10 a.m., in an interview with Foodservice Worker(FSW) 1, she reviewed the tray slips and the trays and acknowledged one carton of Boost should have been placed on each tray.

On November 7, 2012, at 10:20 a.m., a review of the medical records for Patients 300 and 301, indicated the Boost nutritional supplements were prescribed for each patient due to their compromised nutritional status.




17065




22384

3. Patient 201's record was reviewed on November 5, 2012. Patient 201 was admitted to the facility on November 3, 2012, with symptoms of appendicitis (infection of the appendix) and infectious colitis (infection of the colon). The patient had an appendectomy on November 3, 2012.

Prior to the patient's surgery the physician's diet order on November 3, 2012, at 11:45 p.m. indicated the patient could only receive sips of water in order to swallow his medications.

After the patient's appendectomy the physician's order on November 4, 2012, at 9:30 a.m. indicated, "ADAT (advance diet as tolerated)."

A review of the nurses documentation indicated on November 4, 2012, at 12 noon, the patient ate between 50% and 75% of his diet, and at 5 p.m., the patient ate between 25% and 50% of his diet.

An interview was conducted with the Charge Nurse (CN) 22, on November 5, 2012, at 2 p.m. CN 22 stated when a diet order is written the order was faxed and phoned to the dietary department. With an ADAT diet order it does not indicate what type of diet to start with. CN 22 stated the nurses start with clear liquids then jello or crackers and see how the patient does.

Further record review failed to specify what type of diet Patient 202 was given.

A review of the facility policy, "Nursing Guidelines to Nutritional Services (Revised Date: 8/1/08)," was conducted. The policy indicated, "Do not send Nutritional Services any DAT (diet as tolerated), DFA (diet for age), or age appropriate diets. Nursing staff must specify whether it will be: Regular, Soft, Mechanical Soft, Pureed."

An interview was conducted with CN 22 on November 5, 2012, at 2:30 p.m. CN 22, after reviewing Patient 201's record stated she was not able to determine what type of diet the patient received.

An interview was conducted with the Registered Dietician (RD) 16 on November 9, 2012, at 9:15 a.m. RD 16 stated if a physician's order is written ADAT or DAT (diet as tolerated), the diet would not be a regular pediatric diet, it should be the least stimulating diet and begin with clear liquids initially. The nursing staff would determine what diet to start the patient with. The nursing assessment would then indicate the type of diet the patient would receive

RD 16 further stated after reviewing the facility policy, "Nursing Guidelines to Nutritional Services," the policy does not reflect the facility's practice.

Based on observation, interview and document review, the facility failed to ensure the diet manual was consistently used as guidance for ordering and preparing patient diets.

Findings:

On November 7, 2012, at 3 p.m., a review of the facility policy titled, "Nutrition Services Diet Manual - Revised 8/1/08", indicated;

"The American Dietetic Association Nutrition Care Diet Manual shall serve as an effective resource to provide education and direction for appropriate nutritional care to the patient population...Physicians must order patient diets according to the approved Nutrition Care Diet Manual."

1. On November 5, 2012, at 10 a.m., during an observation of the lunch trayline at the Main campus, a patient menu slip with the following diet order was reviewed: "DFA (diet for age) 8 years." Only one type of pediatric menu was noted used on the trayline.

On November 5, 2012, at 2:42 p.m., a review of the facility diet manual indicated there were different food lists and nutritional recommendations in place for toddlers, school-age children and adolescents.

On November 6, 2012, at 8:15 a.m., the facility's nutrient analysis of the facility diets for the Main campus was reviewed. One pediatric diet menu analysis was provided as representative of what was being served to the pediatric population.

On November 6, 2012, at 2:45 p.m., in an interview with the Director of Food and Nutrition Services (DFNS), she confirmed the same Pediatric menu was used for all patients who were between the ages of one and eighteen. Modifications were made in the diet texture for different age groups but not in diet composition.

2. On November 5, 2012, at 2:42 p.m., in an interview with the Supervising Dietitian, she confirmed the menus are not adjusted for pregnant or post-partum patients, and have not been specifically reviewed to ensure that they meet the needs of that population, specifically the increased need for folate, iron and niacin, during the stages of pregnancy and/or lactation. She stated patients were offered regular diets and the non-select regular menu mirrored the menu that would be sent to any patient prescribed a regular diet at the hospital.

On November 7, 2012, at 2 p.m., a review of the facility diet manual recommendations for "Pregnancy Nutrition Therapy," indicated:
"Daily Meal Planning Guidelines: Have at least 3 cups of low-fat or fat-free dairy foods for adequate calcium and vitamin D intake...Eat at least 3 cups of vegetables (including at least 1 cup of dark green or orange vegetables that are high in vitamin C)."

The guidelines for Breastfeeding Women were as follows: "Breastfeeding requires more calories (about 500 more calories per day), protein, vitamins, and minerals than you needed before pregnancy...Daily Meal Planning Guidelines: Have at least 3 cups of low-fat or fat-free dairy foods for adequate calcium and vitamin D intake...Eat at least 2 1/2 cups of vegetables (including at least 1 cup of dark green or orange vegetables)."

A review of a "non-select" menu for a "Regular" diet for Monday, Cycle 1, indicated 2 cups of low-fat milk were served. No other low-fat or fat-free dairy foods were provided. The menu provided 2 ounces of lettuce and 1 slice of tomato for lunch, and for dinner a 3 ounce tossed salad and 4 ounces of zucchini blend was provided. The menu did not meet the diet manual recommendations for pregnant and lactating women.

3. On November 7, 2012, at 10:18 a.m., a review of the "Arlington Campus Diet List," noted five patients with "Low Salt" prescribed diets.

On November 7, 2012, at 2:45 p.m., in an interview with the Director of Food and Nutrition Services (DFNS), and concurrent review of the "Physician's Guide to Ordering Nutrition Prescriptions", an addendum to the facility diet manual, the DFNS acknowledged a "Low Salt" diet was not an approved facility diet.

On November 7, 2012, at 3 p.m., a review of the facility policy titled, "Nutritional Services Diet Manual - Revised 8/1/08," indicated, "Diet orders should be specified in terms of exact amount of restriction...The following diet orders are not acceptable...Low-salt or salt-free."


17065

Based on food production observations, dietary staff interview, and dietary document review, the hospital failed to ensure the infection control officer provided effective infection control oversight into food services when the hospital staff failed to:

A) Ensure effective sanitation procedures at the main campus and Arlington Campuses, including appropriate storage of food items in clean settings and within manufacturer "Use-By" dates, and effective cleaning of foodservice equipment; and,

B) Ensure the appropriate chemicals were used in the cleaning of the ice machine at the Arlington Campus.

These failures could potentially lead to the development, transmission, and spread of hospital acquired infections.

Findings:

A 1. On November 5, 2012, beginning at 9:48 a.m., during a tour of the kitchen at the main campus, the following observations were made:

a. In the dishroom, the three compartment sink was noted to be used for washing foodservice equipment. In a concurrent interview with Foodservice Worker (FSW) 2, she stated the dishmachine was not operable and the facility had resorted to use of the three-compartment sink to wash, rinse and sanitize equipment.

FSW 2 stated the temperature in the wash compartment should be 160 to 180 degrees Fahrenheit. FSW 2 stated the concentration of the sanitizer in the third compartment should be 200 parts per million (ppm). Upon testing the sanitizer solution, the test strip displayed a concentration of approximately 100 parts per million. FSW 2 continued to use the same sanitizer solution during the dishwashing process, even after she determined that the concentration of the sanitizer was not 200 ppm.

Further observation of the sanitizing compartment of the three compartment sink showed a pair of tongs had been placed in that compartment after being washed and rinsed. Dried food particles were observed clinging to the tongs. FSW 2 stated the tongs were still dirty, removed them from the sanitizer solution, and placed them in the first compartment to be washed again.

b. The blade of the can opener located adjacent to the trayline area was observed to be dirty with a black residue and shards of tin adhering to it. The Director of Food and Nutrition Services (DFNS), present at the time of the observation, acknowledged the can opener needed to be cleaned.

c. In the walk-in freezer, dirt and debris were observed on the floor underneath the freezer shelves.

d. In the dry storage room, stored cans were observed with a layer of dust on the tops. In a section of the store room designated for "single cans," a #10 can of applesauce was noted with a dented rim and a liquid residue clinging to the top of the can. A #10 can of chili sauce was noted with black particles clinging to the top of the can.
Cake and muffin mixes were observed to be outdated as follows:

Three 5-pound boxes of Basic Muffin Mix were imprinted with a manufacturer, "Best if Used By" date of September 8, 2012.

Three 5-pound boxes of Basic Muffin Mix were imprinted with a manufacturer, "Best if Used By" date of October 5, 2011.

One 5-pound box of Basic Muffin Mix was imprinted with a manufacturer, "Best if Used By" date of May 5, 2012.

Four 5-pound boxes of Yellow Cake Mix were imprinted with a manufacturer, "Best if Used By" date of July 5, 2011.

One 5-pound box of Yellow Cake Mix was imprinted with a manufacturer, "Best if Used By" date of January 5, 2012.

Three 5-pound boxes of Chocolate Cake Mix were imprinted with a manufacturer, "Best if Used By" date of February 8, 2012.

Review of the facility policy titled, "Food Preparation and Service - Revised 6/15/12," indicated, "Foods are to be discarded by the expiration or 'use by' date."

On a shelf in the dry storage room, two #10 cans of strawberry glaze were observed in a carton with an imprinted vendor label showing delivery of the product on August 11, 2005.

Dirt and debris were observed in a corner of the store room. In a concurrent interview with Foodservice Worker (FSW) 3, he stated the dry storage room was cleaned, swept and mopped every day. FSW 3 further stated the can racks were moved from against the walls two times per week for deep cleaning, and the last time that had occurred was Friday, November 3, 2012.

One of the can storage racks was moved from against the wall. Behind the rack, a large black stain was observed on the floor. The wall was noted to be dirty with what appeared to be a dried liquid spill that had trickled down to the black stain. Dirt and debris had adhered to the dried stain.

The Director of Food and Nutrition Services (DFNS), present at the time of the observation, acknowledged the above observations.

A review of the facility policy titled, "Infection Control - Revised 1/16/12," indicated, "Responsibilities - Food and Nutrition Services Manager: To develop and Maintain clean, sanitary work areas, storage areas and equipment for the handling of supplies in accordance with state and local health department standards...Infection Control Practices:...Storage areas shall be adequate, cleaned thoroughly weekly and inspected daily by the Food and Nutrition Services Manager or designee."

e. In the spice and preparation area, a chopper was stored on a counter. The DFNS, present at the time of the observation, stated the chopper was not in use and was stored as clean. Inspection of the chopper showed that there was dried food debris clinging to the chopper.

f. In the hot food preparation area, two sanitizer pails were observed stored underneath the food preparation area. The sanitizer solution in the pails appeared clean. On November 5, 2012, at 11:05 a.m., in an interview with Cook 1, he stated he filled the pails at approximately 10:30 a.m. He stated he used the sanitizer pails to sanitize his work station and he would change the sanitizer every hour or when the solution became dirty. Cook 1 stated the concentration of the sanitizer should be 200 parts per million (ppm). Upon utilizing a chemical test strip, the chemical sanitizer concentration in both pails was noted to be 100 ppm.

A 2. On November 6, 2012, at 8:50 a.m., at the Arlington Campus food and nutrition services, Foodservice Worker (FSW) 4 stated she washed and sanitized foodservice equipment using three plastic containers. FSW 4 stated she filled the first container with water at 160 degrees Fahrenheit, filled the second container with clean water for rinsing, and filled the third container with sanitizer. FSW 4 did not know how much sanitizer to add, but stated the concentration should be 200 parts per million (ppm).

FSW 4 was asked if she could retrieve a facility policy describing the manual handwashing process. Upon review of the facility food and nutrition services policy and procedure manual, by FSW 4 and the Director of Food and Nutrition Services (DFNS), no policy delineating the process for manual warewashing could be found. No log was maintained by staff delineating the testing of the sanitizer solution before use.

On November 6, 2012, at 11:05 a.m., FSW 4 was asked to demonstrate the manual warewashing process. FSW 4 retrieved three plastic containers approximately four inches deep and filled the first and second containers with approximately 2 inches of water, placed soap in the first container, and filled the third container with 2 inches of water with sanitizer. FSW 4 then retrieved a plastic container that was used to deliver snacks to the patient units.

The plastic delivery container was observed to be deeper than the containers used for the manual warewashing process. FSW 4 proceeded to wash the container by continuously rotating the container in the soapy water and using a sponge.

For the rinsing purposes, FSW 4 obtained a Styrofoam cup and splashed water on the container. FSW 4 then used the same cup to splash sanitizer on the delivery container while rotating it in the third plastic container. The sanitization process lasted approximately 20 seconds. The delivery container could not be submerged in the sanitizer as the delivery container was larger than the container used to house the chemical.

Review of the Food Code, 2009, Section 4-301.12, Manual Warewashing, Sink Compartment Requirements, indicated:

"(A) Except as specified in ¶ (C) of this section, a sink with at least 3 compartments shall be provided for manually washing, rinsing, and sanitizing equipment and utensils. Pf
(B) Sink compartments shall be large enough to accommodate immersion of the largest equipment and utensils. If equipment or utensils are too large for the warewashing sink, a warewashing machine or alternative equipment as specified in ¶ (C) of this section shall be used. Pf
(C) Alternative manual warewashing equipment may be used when there are special cleaning needs or constraints and its use is approved. Alternative manual warewashing equipment may include:
(1) High-pressure detergent sprayers;
(2) Low- or line-pressure spray detergent foamers;
(3) Other task-specific cleaning equipment;
(4) Brushes or other implements;
(5) 2-compartment sinks as specified under ¶¶ (D) and (E) of this section; or
(6) Receptacles that substitute for the compartments of a multicompartment sink."

On November 7, 2012, at approximately 4 p.m., the facility provided information from the Food Code 2009, Section 4-703.11(C) and the California Retail Food Food Code, Section 114099.6.

Both Codes documented that, during the manual warewashing process, the application of sanitizing chemicals can be made by, "immersion, manual swabbing, brushing or pressure spraying." None of these application methods was observed on November 6, 2012, at 11:05 a.m., during the manual warewashing process at the Arlington Campus. FSW 4 was no observed immersing the equipment in the sanitizer, or manually swabbing, brushing, or pressure spraying sanitizer on the equipment.

Further review of the California Retail Food Code document provided by the facility during the exit conference,indicated a section highlighted by the facility that read, "Contact with a solution of 200 ppm (parts per million) quaternary ammonium for at least one minute." FSW 4 was not able to ensure that all parts of the delivery container being sanitized was in contact with the sanitizer for one minute since she had to continually rotate the container in the solution, and finished the sanitization process in approximately 20 seconds.

A 3. On November 6, 2012, at 11:20 a.m., a plastic container containing approximately six 4-ounce containers of yogurt was observed to be sitting on a counter on Unit C at the Arlington Campus. The yogurt containers were not delivered on ice and there was no other temperature monitoring system in place for the yogurt containers. The nurse on the unit stated the yogurt containers were delivered at 10 a.m., by food and nutrition service staff, as "snacks" for the patients. The remaining six containers were leftover from the 10 a.m. delivery.

On November 6, 2012, at 2:30 p.m., an interview was conducted with the Registered Diet Technician (DTR), who worked full time at the Arlington Campus and provided some oversight of foodservice operations at that campus. The DTR stated the snacks sent to the patient units were usually fully consumed and nothing is returned to the food and nutrition department. However, she stated if leftover yogurt containers were returned within a one and one half hour time frame, then the containers would be returned to the refrigerator for re-service. She stated the temperatures of the yogurt were not taken.

A review of the 2009 FDA Food Code, "Section 3-501.19 Time as a Public Health Control" was conducted. This section referenced Ready to Eat food items held for service;

"Time - maximum up to 4 hours: If time temperature control is used as the public health control up to a maximum of 4 hours:

(1) The food shall have an initial temperature of 5ºC (41ºF - Fahrenheit) or less when removed from cold holding temperature control, or 57°C 0 Celsius (135°F) or greater when removed from hot holding temperature control;

(2) The food shall be marked or otherwise identified to indicate the time that is 4 hours past the point in time when the food is removed from temperature control;

(3) The food shall be cooked and served, served at any temperature if ready-to-eat, or discarded, within 4 hours from the point in time when the food is removed from temperature control."

There was no provision in the Food Code for returning Ready to Eat food items that have not been monitored for appropriate temperatures (i.e. 41 degrees Fahrenheit, or below, if a refrigerated item), back to the refrigerator for re-service at a later time.

B. On November 6, 2012, at 9:52 a.m., an observation of the ice machine located at the Arlington Campus was conducted. The ice machine was located outside the building, on the loading dock. Inspection of the ice chutes and collection tray located on the front of the machine showed an accumulation of a white scaly substance, with the appearance of limescale, and a discoloration of the inside of the ice chutes.


On November 6, 2012, at 1:42 p.m., in an interview with the Assistant Hospital Administrator (AHA) 1 at the Arlington Campus, he stated the ice machine was on a preventative maintenance schedule and service on the machine was scheduled for December 2012.


On November 6, 2012, at 3:20 p.m., in a subsequent interview with the AHA 1, he stated he was confusing the cleaning and preventative maintenance procedures. He stated the ice machines were cleaned on a daily basis.

In a concurrent interview with the Custodial Superintendent, responsible for oversight of cleaning activities at the Arlington Campus, she confirmed the ice machine was to be cleaned twice per day, and a supervisor should have been checking the work of the lead custodians assigned the cleaning task. The Custodial Superintendent provided a copy of the label that had been removed from the chemical used for the daily cleaning of the ice machines.

A review of the facility policy titled, "Cleaning Ice Machines - Effective 1/7/08", indicated, "Daily - Perform the following tasks: Wipe down the outside of the machine, clean and sanitize tray, thoroughly rinse all surfaces, pour 1 quart of disinfectant down the drain."

On November 6, 2012, at 3:40 p.m., a review of the chemical label provided by the Custodial Superintendent indicated it was "3M HB Quat Disinfectant Cleaner #25." The description of the chemical on the label showed that it was to be used on "Hard, non-porous surfaces, such as floors or walls, to clean, disinfect and deodorize."

On November 7, 2012, at 8:30 a.m., in a telephone interview with a 3M Chemical representative, she stated the "3M HB Quat Disinfectant Cleaner #25" was intended strictly for walls and floors and not for food-contact surfaces.

On November 7, 2012, at 12:55 p.m., in an interview with the Plant Operations Director and A/C Mechanic (responsible for ice-machine preventative maintenance activities), they stated they were responsible for preventative maintenance of the ice machine at the Arlington, Campus, but the daily cleaning was performed by facility staff that were not under their jurisdiction. They were not aware of the chemical being used to clean the ice machine at the Arlington Campus, but stated the chemicals they utilized for cleaning and sanitizing the machine were approved for use by the ice-machine manufacturer.

On November 7, 2012, at 2:20 p.m., the Assistant Hospital Administrator 2, provided an electronic mail from the Custodial Superintendent, indicating the chemical label provided on November 6, 2012, for "3M HB Quat Disinfectant Cleaner #25", was provided in error. The correct chemical should have been "3M Twist and Fill #16" - which was a "sanitizing agent used to clean the machine."

On November 7, 2012, at 2:52 p.m., in a telephone interview with the ice machine manufacturer representative, he stated the ice machine should be cleaned with an approved cleaner before being sanitized.

On November 8, 2012, at 9:45 a.m., in a telephone interview with a 3M Chemical representative, he stated the "3M Twist and Fill #16" was an approved sanitizer, intended to be used on surfaces that have been previously cleaned, and it was not designed as a descaler (to remove limescale)

On November 7, 2012, at 11:55 a.m., in an interview with the Infection Control and Prevention Coordinator, she stated she was not aware of the chemical being used to clean the ice machine at the Arlington Campus. She confirmed chemicals being used at the facility should be reviewed for appropriateness by her, as the Infection Control and Prevention Coordinator.

The Infection Control and Prevention Coordinator further stated the infection control department was involved in conducting departmental round two times per year at both the Main Campus and at the Arlington Campus. A review of the last "Dietary Surveillance" form completed at the Main Campus was dated June 1, 2012.

Several areas of the surveillance form were marked as, "Not Observed." Some of those areas such as "Dry Storage", "Food grinders, choppers, mixers, etc., will be cleaned, sanitized, dried, and reassembled after each use" coincided with areas identified with deficient practice during the course of the survey. There was no monitoring of the manual warewashing process.

The Infection Control and Prevention Coordinator stated sometimes she is unable to complete all sections of the surveillance tool due to inaccessibility of the designated areas. No other information was provided as to whether there was follow-up at a later date on areas that were "not observed" at the time of the "Dietary Surveillance."

A review of the "Infection Control and Prevention - EVS (Environmental Service) Rounds" conducted at the Arlington Campus, showed a completion date of April 13, 2012. The reference to dietary services was the "Meal Suite", which was deemed to be "In good standing." The areas reviewed on the form did not include a review of the manual warewashing system at the Arlington Campus or refrigerator temperatures.

The Infection Control and Prevention Coordinator stated the Director of Food and Nutrition Services should be conducting their own rounds within the foodservice department and reporting their findings at the Infection Control and Prevention Committee.




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