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Based on observation, interviews, and record reviews, the hospital failed to ensure the Food and Nutrition Services Department's Performance Improvement Plan effectively measured, analyzed, and tracked data that reflected the scope and nature of the services and identified opportunities for improvement.

Findings:

During the course of the survey, many deficient practices were noted in the Food and Nutrition Services Department related to safe food handling practices and clinical nutrition practice that did not ensure the nutritional needs of the patients were met.

The department's Performance Improvement (PI) Plan was reviewed with the Food and Nutrition Services Manager (FNSM) and the Supervising Dietitian (SD), on February 27, 2013, at 4 p.m. During a concurrent interview, the FNSM stated the department submitted their data to the Performance Improvement Committee quarterly.

The FNSM indicated she was collecting data based on the sanitation checks that she, the food service supervisors, and the Infection Control Preventionist completed regularly. She did not know why these sanitation checklists did not identify the deficient practices observed during the survey including:
A lack of monitoring of safe cooling of potentially hazardous foods;
A lack of effective cleaning and sanitation of ice machines;
A lack of general cleanliness in the dietary department;
A lack of monitoring of food storage practices; and,
A lack of staff knowledge regarding washing of produce and sanitizing of food contact surfaces. (refer to A 620 and A 749).

During the survey, a dietary staff and a dietary supervisor could not access the hospital's diet manual in the event they needed to reference the manual for the preparation of patient meals (refer to A 631). The department's PI plan included monitoring to determine if the nursing staff was able to access the facility's diet manual, but there was no monitoring to determine if the Food and Nutrition staff was able to access the diet manual.

A review of the clinical indicators noted they addressed the timeliness of nutrition assessments as they related to the policies, not in relation to whether or not the nutrition needs of the patient were met. During the survey, deficient practices were identified when the hospital's policy was followed but the nutrition needs of the patients were not met (refer to A 630). The department's PI plan evaluated if high nutrition risk patients received a nutrition assessment within 48 hours of admission and if follow-up re-assessments for high risk patients were completed every seven days or less. There was no data collected that evaluated if the seven day timeframe was effective in meeting the needs of the patients when the facility's average length of stay for patients was three to five days according to the Chief Nursing Officer.

During an interview with the Chief Executive Officer (CEO), on February 28, 2013, at 1:05 p.m., the CEO stated he was a member of the Governing Body through a Joint Conference Committee. The CEO stated the PI reports from the Food and Nutrition Service Department were presented to the Governing Body on a quarterly basis. The CEO stated he was not aware the data collected by the Food and Nutrition Services Department did not effectively reflect the scope and nature of services and did not identify opportunities for improvement.



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Based on observation, interview, and record review, the facility failed to ensure that weights were being monitored, patient care was being evaluated, assessments were accurately completed, and care plan interventions updated to meet the needs of each patient. These deficiencies had the potential for the facility to fail to identify health concerns, and the potential for delay in providing treatment and care.

Findings:

1. The medical record for Patient 3 was reviewed on February 26, 2013. Patient 3 was admitted to the facility on February 12, 2013, with diagnoses of Dementia secondary to Huntington Disease and Diabetes. According to the Initial Nursing Assessment, on admission, Patient 3 weighed 135 pounds. On February 24, 2013, Patient 3 weighed 151 pounds (a weight gain of sixteen pounds in twelve days). There was no documentation the physician, or Registered Dietitian (RD) had been notified about the significant weight gain.

An interview was conducted with RN 1 and Assistant Director of Nursing on February 26, 2013, at 10:45 a.m. RN 1 stated Patient 3 was weighed on the same scale and the weight was accurate. RN 1 reviewed Patient 3's medical record and was not able to find any documentation regarding notifying the physician, RD, or anyone else about the sixteen pounds weight gain in twelve days. RN 1 stated the weight gain of sixteen pounds was normal because the patient had experienced diarrhea for several days. RN 1 further stated the RD was aware that Patient 3 had diarrhea when admitted. RN 1 stated nursing made their notifications of weight gain/loss verbally. RN 1 did not see any problem with Patient 3's sixteen pounds weight gain in twelve days.

Further review of Patient 3's record was conducted with RN 1. There was a Internist Consultation Assessment done on February 16, 2013, because Patient 3 had frequent watery diarrhea for the previous six days. The nutritional re-assessment, dated February 20, 2013, did not address the episodes of diarrhea. A care plan initiated, on February 20, 2013, by the Nutrition/Dietary Department indicated, "Pt agreed to be weighed weekly, monitor weights, No dietary issues discussed at treatment team today."

The Adult Initial Nutritional Assessment, dated February 13, 2013, did not address Patient 3's episodes of diarrhea for the past several days. There was no nursing care plan initiated for the problems.


2 a. The medical record for Patient 4 was done on February 26, 2013. Patient 4 was admitted to the facility on January 21, 2013, with diagnoses including diabetes. On admission, Patient 4's weight was 135 pounds. On February 3, 2013, Patient 4's weight was 148 pounds (a weight gain of thirteen pounds). On February 10, 2013, Patient 4's weight was 155 pounds, for a total of twenty pounds weight gain in seventeen days. There was no documentation that the physician or dietary department had been notified.

An interview was conducted with RN 1 and Assistant Director of Nursing on February 26, 2013, at 11 a.m. RN 1 stated Patient 4 was weighed on the same scale and the weight was accurate. RN 1 reviewed Patient 4's medical record and was not able to find any documentation regarding notifying the physician, or RD about the weight gain of twenty pounds in a short period of time.

The policy and procedure for monitoring weights was requested. The policy and procedure titled, "Clinical Practice Providing Care: Patient Weight Practice," was reviewed. The policy did not include the procedure for when notification of the physician and/or the dietary department and/or Interdisciplinary team should be done regarding weight changes.

b. An interview was conducted with RN 1 and Assistant Director of Nursing on February 26, 2013, at 11 a.m. RN 1 stated Patient 4 was weighed on the same scale and his weight was accurate. RN 1 stated Patient 4 was noncompliant with his diabetic diet and would steal food from his peers during meals and snack times. RN 1 stated there was nothing that they could do about the behavior of stealing food and they had care planned the Patient's noncompliance.

During lunch, on February 26, 2013, at 11:45 a.m., Patient 4 was observed sitting at the table waiting for his lunch. Patient 4 was sitting closely between two other patients. Patient 4 was served his lunch, and as soon as staff turned away, Patient 4 reached over and grabbed bread and a salt packet from the patient sitting next to him.

The medical record for Patient 4 was reviewed on February 26, 2013. Patient 4 was admitted to the facility on January 21, 2013, with diagnoses that included diabetes. On admission, Patient 4 had a blood sugar level of 200, and was identified as being noncompliant with diabetic diet. On admission, January 21, 2013, Patient 4's weight was 135 pounds. On February 3, 2013, Patient 4's weight was 148 pounds (a thirteen pound weight gain). On February 10, 2013, Patient 4's weight was 155 pounds, for a total of twenty pounds weight gain in seventeen days. There was no documentation that the physician or dietary department had been notified.

There was a care plan, dated January 26, 2013, for Patient 4 to be compliant with his 1800 calorie diabetic diet. Interventions included: Instruct patient the importance of following diabetic diet, monitor patient to not get food from peers, and provide snacks as provided by dietitian. The care plan had not been updated to include interventions to prevent Patient 4 from stealing and eating food that he was not supposed to have. The care plans did not address the weight gain that staff related to stealing of food and noncompliance of diabetic diet.

c. The medical record for Patient 4 was reviewed on February 26, 2013. Patient 4 was admitted to the facility on January 21, 2013, with diagnoses that included diabetes. On admission the RN documented at 12 p.m., that Patient 4's blood sugar was 200 on admission, and Patient 4 was identified as being noncompliant with his diabetic diet. (A normal range for blood sugar levels is 70 to 100 milligrams per deciliter) The physician was notified about the high blood sugar and orders were written for insulin on a sliding scale.

The Initial Nutritional Screen was completed on January 21, 2013, at 3 p.m., by the Registered Nurse. The nurse scored Patient 4 as a "0". The nurse left the special diet section blank and did not indicate on the nutritional screen that a special therapeutic diet for diabetes was required. A score of "0" indicated that Patient A was not a high risk for nutritional problems and did not require an immediate nutritional consult. The Initial Nutritional Screen was not filled out properly. Under Adult Criteria there was a section that should have been circled if the patient had, "Diabetes with Blood Sugar at home over 180." Patient 4 came to the facility with a blood sugar of 200. (A normal range for blood sugar levels is 70 to 100 milligrams per deciliter) If the nurse would have filled out the Initial Nutritional Screen correctly, Patient 4 would have scored a "6," indicating that Patient 4 was a high risk patient and an immediate nutritional consult was required.





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Based on observations, interviews, and record reviews, the hospital failed to ensure the Condition of Participation for Food and Dietetic Services was met by failing to:

1. Develop an effective infection control surveillance system for identifying unsafe food handling practices in the dietary department. (Refer to A 749);

2. Ensure the Food and Nutrition Services Manager was not effective in the daily management of the dietary services in developing policies and procedures for standard food service operations and ensure the nutrition needs of the patients were met in accordance with standard of practice. (Refer to A 620, A 630, A 631);

3. Develop an effective plan for an interruption of service that may impact food delivery by the outside food service vendor. (Refer to A 620); and,

4. Develop performance improvement activities that effectively monitored for unsafe food handling practices and the effectiveness of the timing of nutrition assessments and re-assessments on meeting the nutrition needs of the patients.

The cumulative effects of these deficient practices resulted in the hospital failing to ensure that the food and nutrition services was organized in a way that provided for the safety of the patients and ensure that the nutritional needs of the patients were met.

Based on observations, interviews and record reviews, the Food and Nutrition Services Manager was not effective in the daily management of the dietary services as evidence by failure:

1. To ensure sanitary practices were followed in the dietary services department;

2. To ensure policy and procedures were developed to direct food service operations;

3. To ensure the staff and supervisors in her department were knowledgeable of the diet manual used for planning and preparing patient meals;

4. To ensure that the patients' nutrition needs were met in accordance with standards of practice;

5. To ensure an appropriate plan was in place in the event of an interruption of food services at the Arlington Campus; and,

6. and, failed to ensure the scope of the department's quality plan provided an accurate reflection of the practices in the department.

These failures had the potential to result in patients being exposed to food borne illness and a decline in medical status related to the patients' nutritional needs not being met.

Findings:

1 a. According to the 2009 US Food and Drug Administration's Food Code, safe cooling of potentially hazardous food (PHF - food capable of supporting bacterial growth) requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of PHF has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, PHF are subject to the growth of a variety of pathogenic microorganisms. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135 °F to 41°F in 6 hours, with cooling from 135 °F to 70 °F in 2 hours.

During a tour of the main campus kitchen on February 25, 2013, at 11:30 a.m., three pans labeled "Spanish rice use by February 27" and four pans labeled "refried beans use by February 27" were noted in the walk-in refrigerator. During a concurrent interview with the Food and Nutrition Services Manager (FNSM), she stated the rice and the refried beans had been previously cooked on February 24, 2013. She stated staff was supposed to log the safe cooling monitoring on the "Cooling Temperature Log".

A review of the "Cooling Temperature Log" dated February 24, 2013, revealed a blank log with the words "Did No Cooling Today" written across it. The form was signed by Food Service Supervisor (FSS) 1.

During an interview with FSS 1, on February 25, 2013, at 4:40 p.m., he verified he filled out the form dated February 24, 2013. He stated he did not find a log for February 24, 2013, so he filled out a blank form stating no cooling had occurred on that day. FSS 1 stated he did not check the refrigerators to verify if food had been cooked and cooled. He further stated the cook who had prepared the Spanish rice and refried beans on February 24, 2013 came in today (February 25, 2013) and filled out a Cooling Temperature Log for the beans and rice. He provided a copy of the log completed February 25, 2013. He stated the cook said she could not find a form to fill out on February 24, 2013, so she had written the times and temperatures on a piece of paper. FSS 1 verified the cook had not asked him for a log to fill out on February 24, 2013. FSS 1 was unable to state why he did not know that the rice and beans had been cooked and cooled on February 24, 2013, until the surveyor brought it to his attention.

During an additional tour of the main campus on February 25, 2013, at 4:40 p.m., there were individual portions of cooked cream of wheat observed in the trayline area reach-in refrigerator. The tray of dishes was labeled "cream of wheat use by February 28, 2013". During a concurrent interview with the FNSM, she stated the cooked cream of wheat had a three day shelf life so it was cooked that day, February 25, 2013.

A review of the Cooling Temperature Log" dated February 25, 2013, revealed no entry for cream of wheat.

An interview was conducted with the Food Service Worker (FSW) 4, on February 25, 2013, at 4:40 p.m. The GSW 4 stated the cream of wheat had been cooked on February 24, 2013. There was no entry on the Cooling Temperature Log, dated February 24, 2013, for the cream of wheat.

During an interview with the Assistant Dietary Services Manager, on February 25, 2013, at 4:50 p.m., the Assistant Dietary Services Manager stated she worked on February 24, 2013. The Assistant Dietary Services Manager verified she did not check the refrigerators to see if any foods had been cooked that needed to be monitored for safe cooling that day. She also stated the cook who prepared the food on February 24, 2013 did not request a "Cooling Temperature Log" from her.

According to the 2009 US Food and Drug Administration's Food Code, potentially hazardous food (PHF) shall be cooled within 4 hours to 41ºF or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna.

During a tour of the main campus kitchen on February 25, 2013, at 12:30 p.m., four pans of tuna salad were noted in the salad prep reach-in refrigerator. The pans were labeled "use by February 26, 2013." One of the pans looked different from the other pans. During a concurrent interview with the FNSM, she stated that the hospital received their tuna salad premade, and they do not generally make it in the hospital. She further stated the pan of tuna salad that looked different was made by the dietary staff on February 23, 2013. She did not know why the staff had made the one pan of tuna salad.

A review of the "Cooling Temperature Log," dated February 23, 2013, revealed no entry for the tuna salad. The FNSM verified the tuna salad was not on the log. The FNSM stated since it was not the usual practice to make the tuna salad, it was not the practice to monitor the safe cooling of the tuna. The FNSM also verified the tuna was not kept in the refrigerator, so the tuna salad was likely made from tuna obtained from the storeroom at ambient or room temperature.

A review of the "Cooling Temperature Log" instructions revealed that temperatures were to be recorded at the start of the cooling process, after the first hour, after the second hour, after the fourth hour (if required) and when item was transferred to the refrigerator. It further stated, "If no foods were cooled on any working day, indicate 'No Foods Cooled' in the Food Items column. The Food Service Supervisor or Supervising Cook will verify that the foodservice staff is cooling properly by visual monitoring employees throughout the shift."

b. During a tour of the main campus kitchen on February 25, 2013, at 12:40 p.m., a clean paper towel swipe of the ice machine yielded a black smear from the ice maker. The finding was concurrently observed by the Food and Nutrition Services Manager (FNSM). She stated the dietary staff did not clean the ice machine. The Plant Operations department cleaned and maintained the ice machine.

During further observation of the ice machine with Plant Operation Staff (POS) 1, on February 25, 2013, at 1:15 p.m., the ice maker portion of the ice machine was noted to have black specks covering the area where the ice was being made. Also noted were white plastic tubes (water lines) that had a pink tinge color. POS 1 stated that the ice machine was scheduled to be cleaned every six months and the last cleaning was done in September, 2012. It was due to be cleaned again next month. He was unable to state what the black smear was or why the water lines were pink. He did not know why the ice maker had black specks throughout.

A review of the manufacturer's service manual for the main campus ice machine revealed that "maintenance and cleaning should be scheduled at a minimum of twice a year." It further stated that for the ice storage bin, "the interior liner of the bin is in contact with a food product: ice. The storage bin must be cleaned regularly to maintain a sanitary environment. Once a week cleaning with soap and water, a hot rinse and an air dry is a basic procedure."

During an observation of the ice machine and interview with POS 2 at the Arlington Campus in the loading dock area, the maintenance of the machine was discussed. POS 2 stated the ice machine was cleaned and sanitized by the POS twice a year.

A review of the manufacturer's manual for this ice machine revealed the "maintenance and cleaning should be scheduled at a minimum of twice a year. Sanitizing of the ice storage bin should be scheduled for a minimum of four times a year."

A review of the hospital's policy titled, "Food & Nutrition Services: Infection Control" dated (revised) January 8, 2013, revealed that "the interior of the ice bin and dispenser shall be emptied and sanitized quarterly, and as needed, with a Nickel-Safe Ice Machine Cleaner."

During an interview with the FNSM on February 27, 2013, at 4:30 p.m., she stated she was not aware of the hospital's policy that the ice storage bin shall be emptied and sanitized quarterly.

During an interview with the Plant Operations Manager, on February 27, 2013, at 1:20 p.m., he stated he missed the directions for the ice storage bins to be sanitized a minimum of four times a year at the Arlington Campus and weekly for the ice machine in the kitchen at the main campus.

c. During a tour of the main campus kitchen on February 25, 2013 between 10:35 a.m. and 12:35 p.m., the following was observed:
1. in the clean area of the dishroom where clean dishes and utensils were stored, the counters and racks had a significant accumulation of dust and debris;
2. in the cook's area, a food storage baker's rack had a significant accumulation of dust and debris;
3. in the catering area, the coffee maker was noted to have an accumulation of dust; and
4. in the food storage shelves adjacent to the timecard area were noted to have an accumulation of dust.

These observations were concurrently verified by the Food and Nutrition Services Manager (FNSM). She stated that the Environmental Services (EVS) staff were responsible for doing a "deep cleaning" of the kitchen every night. The EVS manager was responsible for checking on the job his staff did. She stated the Food Service Supervisors also did a sanitation check daily that included general cleanliness of the department. She was unable to explain how there could be such an accumulation of dust and debris if the deep cleaning was being done nightly and the sanitation checks were being conducted daily.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control" dated (revised January 8, 2013), revealed that "all nonfood-contact surfaces, including floors will be cleaned at a frequency necessary to preclude accumulation of soil residues. Storage areas shall be adequate, cleaned thoroughly weekly and inspected daily by the Food and Nutrition Manager or designee." It further stated that "all kitchen areas shall be clean and free of litter and rubbish. They shall be protected from rodents, roaches, flies and other insects. All utensils, counters, shelves, tables, stoves, hooks and other equipment shall be clean and in good repair."

The FNSM stated the accumulation of dust and debris noted above was not noted in the daily inspections of the department.

During an interview with the Infection Control Preventionist on February 27, 2013, at 3 p.m., she stated she had been conducting weekly sanitation rounds in the kitchen. She did not note the accumulation of dust and debris in her observations. She was unable to state why she did not observe it.

d. During a tour of the main campus kitchen on February 25, 2013, at 10:35 a.m., a handwashing sink located in the clean area of the dishroom was noted to be adjacent to clean equipment, dishes and utensils. There was no splashguard on the sink to prevent contamination of the clean area during handwashing. This was verified by the Food and Nutrition Services Manager.

A review of the hospital's policy titled' "Food & Nutrition Services, Infection Control: Sanitation Precautions" dated (revised) January 24, 2012, revealed that "dishwashing and utensil washing equipment and techniques are conveniently located to sanitize all service ware and that prevent recontamination are used."

e. During a tour of the kitchen at the main campus on February 25, 2013, at 5 p.m., two bulk storage bins containing flour were noted with the scoops stored inside the bin with the handles touching the contents.

During a concurrent interview with the Food and Nutrition Services Manager (FNSM), she verified the finding and stated that the scoops should not be stored inside the bins.

A policy regarding the storage of scoops for use in the bulk storage bins was requested and was not provided. During an interview with the FNSM on February 27, 2013 at 5 p.m., she verified there was no policy directing the staff to store the scoops outside the bins.

f. During the tour of the main campus kitchen on February 25, 2013, at 10:50 a.m., the dishmachine was observed. The clean patient dishes that were emerging from the dishmachine were noted to be stained with brown spots. Some of the spots could be removed by scraping with a fingernail.

During a concurrent interview with the Food Nutrition Services Manager (FNSM), she confirmed the dishes were stained and that they were being used for patient's food service. She further stated the food did not contact the plates because they were served on a separate container that was placed on top of the plates. She agreed they were unsightly. She was unable to state how she could be assured that patients did not use the plates after their food was served to them.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control: Sanitation Precautions" dated (revised) January 24, 2012, revealed that "plastic ware, china and glassware that have lost their glaze or are chipped or cracked are discarded."

g. During the tour of the main campus kitchen on February 25, 2013, Food Service Worker (FSW) 3 was observed preparing fresh cauliflower. There was a colander filled with cauliflower in a food preparation sink with water running over the vegetable. It was observed that there was a chemical vegetable wash dispenser mounted on the wall.

During a concurrent interview with FSW 3, she stated the chemical vegetable wash was used to clean the produce. She demonstrated how she used the wash by rinsing the cauliflower with the chemical wash dispenser for approximately 10 seconds. She verified that 10 seconds was how long she typically rinsed fruits and vegetables. FSW 3 stated she also rinsed the produce under running water after she used the vegetable wash. FSW 3 stated she had not received training on how to use the vegetable wash. When she was directed to the posted instructions for the wash on the adjacent wall, she read that the spray must be used for a minimum of 45 seconds to be effective.

A review of the hospital's policy titled, "Food & Nutrition Services, Food Preparation and Service" dated (revised) June, 15, 2012, revealed that raw, unprocessed fruits and vegetables were to be washed under running water in designated preparation sinks. The policy did not have instructions on the use of the chemical vegetable wash.

During an interview with the Food and Nutrition Services Manager on February 27, 2013, at 4:30 p.m., she stated that she did not have a policy on the use of the chemical vegetable wash that was used to clean fruits and vegetables. She was unable to state why the hospital had dispensers in the kitchen when there was no policy on the proper use of the product.

h. During an interview with Food Service Worker (FSW) 6 on February 27, 2013, at 9:35 a.m., he demonstrated the use of the three compartment sink for manual warewashing. FSW 6 stated the first sink was filled with soap and hot water, the second sink with hot water for rinsing, and the third sink was filled with sanitizer. He demonstrated how he would check the concentration of the sanitizer with a test strip. FSW 6 then stated the concentration required was 400 parts per million (ppm). His test strip read 200 ppm and he said he was not sure if 200 ppm was okay. He further stated he had not been trained on the proper concentration for the sanitizer.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control" dated (revised) January 8, 2013, revealed that for the three compartment sink, the sanitizer concentration should be 200 ppm or per manufacturer's recommendations."

A review of the Food and Nutrition Services inservice records showed that FSW 6 had attended two inservices that included the proper use of the three compartment sink for manual warewashing in January 2013. Both inservices included a post test in which one of those tests asked the specific question regarding the proper sanitizer concentration for warewashing. FSW 6's test showed he answered the questions correctly that it should be 200 ppm.

During an interview with the Food and Nutrition Services Manager on February 27, 2013, at 4 p.m., she was unable to state why FSW 6 did not know the proper sanitizer concentration. The Food and Nutrition Services Manager stated she did not conduct a return demonstration to verify that FSW 6 was able to demonstrate the proper procedure.

i. During an interview in the main campus kitchen with FSW 2 on February 25, 2013, at 11:30 a.m., she stated she used the disposable cloths labeled "Wet Task" cloths for cleaning and sanitizing of food contact surfaces. FSW 2 stated she filled the container of dry cloths with sanitizer from the three compartment sink every four hours and checked the concentration of the sanitizer with a test strip. FSW 2 stated the concentration should be 200 ppm.

During an interview with FSW 6, on February 25, 2013, at 12:20 p.m., FSW 6 stated she used the disposable cloths labeled "Wet Task". FSW 6 stated she added the sanitizer solution to the container one time in her eight hour shift. She stated that the concentration of the sanitizer should be 400 ppm.

During a concurrent interview with the Food and Nutrition Services Manager, she stated the concentration should be 200 ppm. She was unable to state what the policy was for how often sanitizer solution needed to be added to the wipes.

During an interview at the Arlington Campus with FSW 5 on February 26, 2013, at 9:45 a.m., FSW 5 stated she used a disposable cloth for cleaning of the food contact surfaces in the meal suite. FSW 5 stated she did not have water, she just used the wipes. She indicated the wipes she used were disposable cloths labeled "CHIX:Pro-Quat Reusable Food Service Towels". FSW 5 stated she "got them from the hospital."

During a concurrent interview with the FNSM, she did not know what the cloths were but said she would find out. She later presented a policy regarding the cloths.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control: Wiping Cloths and Gloves" dated August 1, 2008, indicated, "...disposable wiping cloths that are used for wiping food spills shall be used for no other purpose. Disposable wiping cloths used for wiping food spills shall be: dry and used for wiping food spills from tableware and carry-out containers, or wet and cleaned, stored in chemical sanitizer, and used for wiping spills from food contact and nonfood contact surfaces of equipment." The policy also stated, "Wet wiping cloths [are] used with a freshly made sanitizing solution..." The policy was not specific as to how often the sanitizer solution should be added to the wipes. It also did not indicate the proper concentration of the solution.

j. During a tour of the main campus kitchen and concurrent interview with the Food and Nutrition Services Manager (FNSM), on February 25, 2013, starting at 11:45 a.m., she stated all foods that did not have a manufacturer's expiration date should be labeled by the staff with a "use by date." She stated most items in the dry storage were given a six month shelf-life from the received date. Multiple items were found in the dry storage room that did not have a manufacturer's expiration date or a use by date label. Undated items included: a #10 (large) can of lemon pudding, a #10 can of dark red kidney beans, a box of turkey gravy mix (received February 4), 3 boxes of ranch dressing (received January 18), 2 cases of #10 cans of spiced tomatoes, 8 cases of hot cocoa mix (received in December), 10 five pound bags of ground coffee, 10 cases of a coffee drink mix and nine 64 ounce bottles of coffee flavoring.

The FNSM stated ensuring that all items without a manufacturer's expiration date were labeled with a use by date was a part of the daily sanitation checks completed by the Food Services Supervisors. She was unable to explain how food that was delivered in December 2012 and January 2013 was never noted that it did not contain a use by date label. She verified that many items did not have a receive date and therefore there was no way to determine how long those items had been sitting on the shelves.

During a tour of the Arlington Campus meal suite on February 26, 2013, at 9 a.m., a case of frozen breakfast sandwiches was noted in the freezer with no manufacturer's expiration date and no use by date label. The FNSM confirmed the finding. The FNSM stated it should be labeled with a use by date.

The facility's policy that directed staff on monitoring the shelf life of dry/canned foods was requested. The FNSM stated there was no written policy that directed the staff to label dry/canned food without a manufacturer's expiration date with a use by date. She stated that was the expectation but there was no policy.

k. During a tour of the main campus kitchen on February 25, 2013, at 10:45 a.m., two brooms and a floor squeegee were observed stored in the dishroom clean dish/equipment storage area. During a concurrent interview with the Food and Nutrition Service Manager (FNSM), she stated that dirty cleaning equipment should not be stored in the clean dish area.

The same day at 12:10 p.m., grill bricks, used for cleaning the grill were observed in the dry storage room. The FNSM verified the finding.

A review of the hospital's policy titled, "Food & Nutrition Services, Food Products Storage" dated August 1, 2008, revealed that non-food items should be stored separately from food items.

2. During an observation and concurrent interview with Food Service Worker (FSW) 5, at the Arlington Campus meal suite ,on February 26, 2013, at 9:20 a.m., FSW 5 was asked to retrieve the hospital's diet manual. FSW 5 spent several minutes looking for the diet manual. She then stated that she could not find it.

During a concurrent interview with the Food and Nutrition Service Manager (FNSM), she pointed out the diet manual which was labeled "Nutrition Care Manual". She verified that FSW 5 did not know that was the hospital's diet manual.

During an observation and concurrent interview with Food Service Supervisor (FSS) 2 at the main campus, on February 27, 2013, at 10 a.m., when asked to retrieve the diet manual, she opened a notebook labeled "diet manual". When asked how she would use the manual as a reference in preparing the menu for a patient on a low protein diet. She stated she would use the information from the renal diet (a special diet for patients with kidney insufficiency or failure, not necessarily low protein).

During a concurrent interview with the FNSM, she stated that the notebook FSS 2 was looking at was not the hospital's approved diet manual, even though it was labeled diet manual. She stated that the hospital's diet manual was labeled "Nutrition Care Manual". She verified that FSS 2 did not know this was the hospital's diet manual that contained the hospital's approved diets and was to be used by the dietary staff for preparing patient meals.

3 a. The medical record for Patient 14 was reviewed on February 27, 2013. Patient 14 was admitted on January 29, 2013 with diagnoses that included septic shock (a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure) due to aspiration (entry of food into the respiratory tract), intubation (a tube placed in the windpipe to maintain an airway) and on mechanical ventilation (a breathing machine). Throughout Patient 14's hospital stay he was unable to take food by mouth and was dependent on tube feedings and parenteral nutrition (nutrition supplied directly into the blood) to meet his nutrition needs.

A review of the Nutrition Re-Assessment note by RD 3 dated, February 8, 2013, indicated Patient 14's tube feeding was off. It also indicated Patient 14's weight had decreased 6.8 kilograms (kg) or 15 pounds since admission to 63.2 kg. The recommendation by RD 3 was to re-start tube feedings if the patient was unable to take food by mouth.

A review of Patient 14's Intake and Output records (I/O's) showed that he did not receive tube feeding or food by mouth on February 7, 8, 9, 10 or 11, 2013.

The Nutrition Re-Assessment note, dated February 11, 2013, by RD 3 indicated that insertion of a feeding tube was attempted many times without success. The patient's weight on February 11, 2013, was 67.4 kg which was a gain of 9.25 pounds in three days. RD 3 indicated the weight gain was likely due to fluids. RD 3 recommended parenteral nutrition if tube feeding could not be restarted.

A review of the physician's orders showed that parenteral nutrition was started on February 13, 2013, for three days. A review of the nutrition notes indicated there was no RD reassessment during this time to determine if the parenteral nutrition was appropriate for Patient 14 to meet his nutrition and medical needs.

A Nutrition Re-Assessment note by RD 4 dated February 18, 2013, (seven days later) indicated the patient was on a tube feeding, Fibersource HN(a liquid tube feeding formula) at 55 milliliters (ml) per hour or 1320 ml in 24 hours. The RD indicated Patient 14 had tolerated the tube feeding well and recommended to continue current tube feeding. The note also indicated the patient's weight was now 56.2 kg, a 24.6 pound decrease from February 11, 2013. The note stated "weight up/down possibly secondary to body fluid up/down". There was no further evaluation of the severe weight loss. The recommendation was to monitor weight. There was no indication in the re-assessment that the patient had been on parenteral nutrition.

A review of Patient 14's I/Os for February 16, 2013, showed he received 814 ml of tube feeding; on February 17, 2013 - 774 ml; on February 18, 2013- 550 ml. Patient 14 did not receive the 1320 ml as indicated in the RD note dated, February 18, 2013.

A Nutrition Re-Assessment note dated, February 20, 2013, by RD 4 again indicated that the patient was receiving Fibersource HN at 55 milliliters (ml) per hour or 1320 ml in 24 hours. This provided 1584 calories and 70 grams protein.

A review of Patient 14's I/Os for February 19, 2013, indicated he had received 330 ml of tube feeding and on February 20, 2013, he received 285 ml of feeding. This was 25 percent or less than the amount of feeding the RD note indicated. There was no RD documentation regarding this discrepancy.

Further review of RD 4's note on February 20, 2013, indicated Patient 14's weight was now 54 kg, another 4.8 pound weight loss. This was a total weight loss since admission of 35.2 pounds. The RD note continued to indicate weight change was secondary to body fluid up/down. There was no evaluation of how much nutrition the patient was receiving related to the weight loss. The note recommended changing the tube feeding formula to Glytrol at 65 ml per hour (1560 ml in 24 hours) to provide 1560 calories and 70 grams protein. This was a slight decrease in calories. The recommendation to change the formula was due to an increase in the patient's potassium level and the need to control the amount of potassium in the feeding. An excessively elevated potassium level could have been potentially fatal. A review of the physician's orders showed an order for this recommendation the same day.

The February 20, 2013 RD note recommended to monitor the patient's potassium level, tolerance to tube feeding, labs and weights.

There was no follow-up note by an RD to evaluate if the new formula impacted the patient's potassium level and if it was tolerated until February 26, 2013 (six days later). This note by RD 5 indicated the patient was on Glytrol tube feeding "with goal rate [of] 65 ml per hour." It stated the feeding provided 1560 calories and 70 grams protein.

A review of the Patient 14's I/Os from February 21 through February 25, 2013, indicated the patient received an average of 419 ml of tube feeding a day. This was about 26 percent of the amount indicated in RD 5's note. In fact, other than three days of parenteral nutrition (February 13 - 15, 2013), the patient's I/Os indicated that Patient 14 never received more than 814 ml of tube feeding on any day between February 7 and February 26, 2013. This significant discrepancy was not addressed in any of the RD notes.

During an interview with the Supervising Dietitian (SD) on February 27, 2013, at 12 p.m., she stated it was the policy for patients with high nutrition risk to be followed up every seven days or sooner. She was unable to state what standard of practice the hospital used to determine that high risk patients could go seven days without a nutrition re-assessment.

A review of the hospital's policy titled' "Food & Nutrition Services, Assessing and Meeting Patient Care Needs" dated (revised) February 23, 2013, indicated that the purpose was to provide guidance for assessing and meeting patients' nutrition needs, It further indicated that "Nutrition services performed by the Registered Dietetic Technicians and Registered Dietitians shall be based on Standards of Care as follows: follow-up nutrition re-assessments are completed every seven days or less for high risk patients; follow-up re-screens are completed every 7 days or less for low risk patients."

During an interview with the SD and the Food and Nutrition Services Manager on February 27, 2013, at 3 p.m., they were unable to state what standards of care were used to determine that high risk patients would require re-assessments every seven days. They were unable to identify another health professional in the acute care setting that recommended medical interventions, then waited seven day to evaluate the effectiveness of the interventions.

b. The medical record for Patient 12 was reviewed on February 26, 2013. The record indicated that Patient 12 was admitted on February 19, 2013 with diagnoses that included Diabetes Mellitus (DM - a chronic condition where blood sugar levels are elevated) requiring insulin.

A review of the Adult Initial Nutrition Assessment dated February 20, 2013, by RD 6 indicated that the Patient 12's blood glucose levels were elevated and the patient was requesting more food. The recommendation was to start Glytrol (a liquid nutritional supplement for diabetics) twice a day. Review of RD 6's entry on the Multidisciplinary Treatment Plan dated, February 20, 2013, indicated, "No dietary issues to discuss at treatment plan meeting today." There were no further entries for the nutrition/hydration goal.

Further review of the medical records showed a physician order for the Glytrol as recommended. A review of the patient's blood glucose levels during his admission showed that 8 out of 36 blood glucose levels were considered normal for a person with diabetes. The other 28 values ranged from 181 - 417 mg/dl, normal levels were 65 - 180 mg/dl. A physician note dated, February 23, 2013, indicated the patient's medical problems were unstable or worsening related to his DM - unstable glucose [levels].

A review of the RN Shift Assessment note dated February 24, 2013, at 10:30 p.m. indicated, "Patient is focused on food; non-compliant with diet...gets easily agitated when he doesn't get the food that he wants." A review of the RN Shift Assessment note dated February 24, 2013, at 11:10 a.m. indicated the patient was "focused on food, said [he] ate 2 plates of food for breakfast, takes food from others, BS (blood sugar) 414 at 8:30."

A review of the patient's weights indicated that on admission, February 19, 2013, the patient was 6 feet tall and weighed 145 pounds. The Patient Care flowsh

Based on record review and interviews, the hospital failed to ensure the nutrition needs of the patients were met when:
1. the nutrition assessment/reassessments for Patient 14 failed to comprehensively address his inadequate nutrition intake and severe weight fluctuations according to community standards of practice;
2. the Registered Dietitian (RD) failed to monitor the nutrition status of Patient 12 when his blood sugars were unstable, he sustained a severe weight loss and he displayed negative eating behaviors that affected his nutrition and medical status;
3. Patient 11 did not receive a timely nutrition assessment in order to ensure a therapeutic diet was ordered to meet the medical needs of the patient;
4. The Dietary Department failed to ensure the nutritional needs of the patients were accurately and timely assessed/reassessed for four patients (Patients 1, 2, 3, and 4).

These failures resulted in the medical and nutrition needs of the patients not being met and had the potential to result in a decline in their medical status, and not to meet the needs of the patient in a timely manner.

Findings:

1.. The medical record for Patient 14 was reviewed on February 27, 2013. Patient 14 was admitted on January 29, 2013 with diagnoses that included septic shock (a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure) due to aspiration (entry of food into the respiratory tract), intubation (a tube placed in the windpipe to maintain an airway) and on mechanical ventilation (a breathing machine). Throughout Patient 14's hospital stay he was unable to take food by mouth and was dependent on tube feedings and parenteral nutrition (nutrition supplied directly into the blood) to meet his nutrition needs.

A review of the Nutrition Re-Assessment note by RD 3 dated February 8, 2013, indicated the patient's tube feeding was off. It also indicated Patient 14's weight had decreased 6.8 kilograms (kg) or 15 pounds since admission to 63.2 kg. The recommendation by RD 3 was to re-start tube feedings if the patient was unable to take food by mouth.

A review of Patient 14's Intake and Output records (I/O's) showed that he did not receive tube feeding or food by mouth on February 7, 8, 9, 10 or 11, 2013.

The Nutrition Re-Assessment note, dated February 11, 2013, by RD 3 indicated that insertion of a feeding tube was attempted many times without success. The patient's weight on February 11, 2013, was 67.4 kg which was a gain of 9.25 pounds in three days. RD 3 indicated the weight gain was likely due to fluids. RD 3 recommended parenteral nutrition if tube feeding could not be restarted.

A review of the physician's orders showed that parenteral nutrition was started on February 13, 2013, for three days. A review of the nutrition notes showed that there was no RD reassessment during this time to determine if the parenteral nutrition was appropriate for Patient 14 to meet his nutrition and medical needs.

A Nutrition Re-Assessment note by RD 4 dated February 18, 2013, (seven days later) indicated the patient was on a tube feeding, Fibersource HN(a liquid tube feeding formula) at 55 milliliters (ml) per hour or 1320 ml in 24 hours. The RD indicated Patient 14 had tolerated the tube feeding well and recommended to continue current tube feeding. It also indicated the Patient 14's weight was now 56.2 kg, a 24.6 pound decrease from February 11, 2013. The note stated "weight up/down possibly secondary to body fluid up/down". There was no further evaluation of the severe weight loss. The recommendation was to monitor weight. There was no indication in the re-assessment that the patient had been on parenteral nutrition.

A review of Patient 14's I/Os for February 16, 2013, showed he received 814 ml of tube feeding; on February 17, 2013 - 774 ml; on February 18, 2013- 550 ml. The patient did not receive the 1320 ml indicated in the RD note dated, February 18, 2013.

A Nutrition Re-Assessment note dated February 20, 2013, by RD 4 again indicated the patient was receiving Fibersource HN at 55 milliliters (ml) per hour or 1320 ml in 24 hours. This provided 1584 calories and 70 grams protein.

A review of Patient 14's I/Os for February 19, 2013, indicated he received 330 ml of tube feeding, and on February 20, 2013, Patient 14 received 285 ml of feeding. This was 25 percent or less than the amount of feeding the RD note indicated. There was no RD documentation regarding this discrepancy.

Further review of RD 4's note on February 20, 2013, indicated Patient 14's weight was now 54 kg, another 4.8 pound weight loss. This was a total weight loss since admission of 35.2 pounds. The RD note continued to indicate weight change was secondary to body fluid up/down. There was no evaluation of how much nutrition the patient was receiving related to the weight loss. The note recommended changing the tube feeding formula to Glytrol at 65 ml per hour (1560 ml in 24 hours) to provide 1560 calories and 70 grams protein. This was a slight decrease in calories. The recommendation to change the formula was due to an increase in the patient's potassium level and the need to control the amount of potassium in the feeding. An excessively elevated potassium level could have been potentially fatal. A review of the physician's orders showed an order for this recommendation the same day.

The February 20, 2013 RD note recommended to monitor the patient's potassium level, tolerance to tube feeding, labs and weights.

There was no follow-up note by an RD to evaluate if the new formula impacted the patient's potassium level and if it was tolerated until February 26, 2013 (six days later). This note by RD 5 indicated the patient was on Glytrol tube feeding "with goal rate [of] 65 ml per hour." The note indicated the feeding provided 1560 calories and 70 grams protein.

A review of the Patient 14's I/Os from February 21 through February 25, 2013, indicated the patient received an average of 419 ml of tube feeding a day. This was about 26 percent of the amount indicated in RD 5's note. Other than the three days of parenteral nutrition (February 13 - 15, 2013), the Patient 14's I/Os indicated he never received more than 814 ml of tube feeding on any day between February 7 and February 26, 2013. This significant discrepancy was not addressed in any of the RD notes.

During an interview with the Supervising Dietitian (SD) on February 27, 2013, at 12 p.m., she stated it was the policy for patients with high nutrition risk to be followed up every seven days or sooner. She was unable to state what standard of practice the hospital used to determine that high risk patients could go seven days without a nutrition re-assessment.

A review of the hospital's policy titled' "Food & Nutrition Services, Assessing and Meeting Patient Care Needs" dated (revised) February 23, 2013, indicated that the purpose was to provide guidance for assessing and meeting patients' nutrition needs, It further indicated that "Nutrition services performed by the Registered Dietetic Technicians and Registered Dietitians shall be based on Standards of Care as follows: follow-up nutrition re-assessments are completed every seven days or less for high risk patients; follow-up re-screens are completed every 7 days or less for low risk patients."

During an interview with the SD and the Food and Nutrition Services Manager on February 27, 2013, at 3 p.m., they were unable to state what standards of care were used to determine that high risk patients would require re-assessments every seven days. They were unable to identify another health professional in the acute care setting that recommended medical interventions, then waited seven day to evaluate the effectiveness of the interventions.

2. The medical record for Patient 12 was reviewed on February 26, 2013. The record indicated Patient 12 was admitted on February 19, 2013, with diagnoses that included Diabetes Mellitus (DM - a chronic condition where blood sugar levels are elevated) requiring insulin.

A review of the Adult Initial Nutrition Assessment dated February 20, 2013, by RD 6 indicated that the patient's blood glucose levels were elevated and the patient was requesting more food. The recommendation was to start Glytrol (a liquid nutritional supplement for diabetics) twice a day. Review of RD 6's entry on the Multidisciplinary Treatment Plan dated February 20, 2013, indicated "No dietary issues to discuss at treatment plan meeting today." There were no further entries for the nutrition/hydration goal.

Further review of the medical records showed a physician order for the Glytrol as recommended. A review of the patient's blood glucose levels during his admission showed that 8 out of 36 blood glucose levels were considered normal for a person with diabetes. The other 28 values ranged from 181 - 417 mg/dl, normal levels were 65 - 180 mg/dl. A physician note dated February 23, 2013 stated the patient's medical problems were unstable or worsening related to his DM - unstable glucose [levels].

A review of the RN Shift Assessment note dated February 24, 2013, at 10:30 p.m. indicated, "Patient is focused on food; non-compliant with diet...gets easily agitated when he doesn't get the food that he wants." A review of the RN Shift Assessment note dated February 24, 2013, at 11:10 a.m., indicated the patient was "focused on food, said [he] ate 2 plates of food for breakfast, takes food from others, BS (blood sugar) 414 at 8:30."

A review of the patient's weights indicated that on admission, February 19, 2013, the patient was 6 feet tall and weighed 145 pounds. The Patient Care flowsheet dated, February 24, 2013, indicated his weight was 131 pounds, or a 14 pound weight loss in four days.

During an interview with RD 7, on February 26, 2013, at 11:30 a.m., she stated she regularly spoke with Patient 12. RD 7 stated since he was eating all his food, she didn't feel that he required further nutrition assessment and intervention. She was not aware of the documented weight loss.

A review of the medical record showed that there were no further assessments or recommendations from an RD for Patient 12 that addressed his unstable blood sugars, his severe weight loss and his non-compliance with his diet.

On February 26, 2013, at 2:40 p.m., the Supervising Dietitian stated the patient's weight was recorded that day at 156 pounds. She stated that the patient was wheelchair bound and supported himself while being weighed; therefore his weights were not accurate. She was unable to explain how a nutrition assessment could be evaluated when the patient's weights were not accurate.

3. The medical record for Patient 11 was reviewed on February 26, 2013. Patient 11 was admitted on February 20, 2013 with diagnoses that included cirrhosis of the liver. The physician's orders included an order for a regular diet.

A review of the Adult Initial Nutrition Assessment dated February 26, 2013 indicated a recommendation for the patient to receive a 2 gram sodium diet (low sodium) due to the cirrhosis. Review of the physician's orders showed an order for a 2 gram sodium diet on February 25, 2013, five days after the patient was admitted.

During an interview with RD 7, on February 26, 2013, at 10:45 a.m., she stated Patient 11 was being discharged today. She verified that the recommendation for a low sodium diet was not timely and the patient would have benefited from the low sodium diet sooner.

During an interview with the Supervising Dietitian, on February 26, 2013, at 11:10 a.m., she agreed the intervention was not timely and the patient should have received a low sodium diet sooner.



21898

The facility's policy and procedure titled, "Assessing & Meeting Patient Care Needs," was reviewed. The policy indicated, "Low risk patients (with score less than 6) are seen by the registered Dietetic Technician or Registered Dietitian 72 hours..." The policy further indicated that follow-up nutrition re-screens are completed every (7) seven days or less for both high and low risk patients.

4. Patient 1's medical record was reviewed on February 26, 2013. Patient 1 was admitted on February 12, 2013. An Initial Nutritional Screen was completed on February 12, 2013, with a score of "0." The Adult Initial Nutritional Assessment was completed nine days later, on February 21, 2013.

5. Patient 2's medical record was reviewed on February 26, 2013. Patient 2 was admitted on January 1, 2013. An Initial Nutritional Screen was completed on January 1, 2013, with a score of "0." The Adult Initial Nutritional Assessment was completed nine days later, on January 10, 2013.

6. Patient 4's medical record was reviewed on February 26, 2013. Patient 4 was admitted on January 21, 2013. The Initial Nutritional Screen was completed on January 21, 2013. The nurse scored Patient 4 as a "0" and did not indicate on the nutritional screen that a special diet for diabetes was required. On admission, Patient 4 had a blood sugar level of 200, and was identified as being noncompliant with diabetic diet. Patient 4 experienced a weight gain of 20 pounds in 17 days. The Adult Initial Nutritional Assessment was completed on January 22, 2013. Weekly re-assessments were not found in Patient 4's medical record until approximately a month later, on February 19, 2013.

An interview was conducted with RN 1 and Assistant Director of Nursing on February 26, 2013, at 11 a.m. RN 1 stated Patient 4 was weighed on the same scale and the weight was accurate. RN 1 stated Patient 4 was noncompliant with his diabetic diet and would steal food from his peers during meals and snack times. RN 1 stated they had verbally reported the weight gain to the RD. RN 1 reviewed Patient 4's medical record and was not able to find the weekly RD re-assessments in the medical records.

7. The medical record for Patient 3 was reviewed on February 26, 2013. Patient 3 was admitted to the facility on February 12, 2013, with diagnoses of Dementia secondary to Huntington Disease and Diabetes. According to the Initial Nursing Assessment, on admission, Patient 3 weighed 135 pounds. On February 24, 2013, Patient 3 weighed 151 pounds or sixteen pounds weight gain in twelve days.

An interview was conducted with RN 1 and Assistant Director of Nursing on February 26, 2013, at 10:45 a.m. RN 1 stated Patient 3 was weighed on the same scale and the weight was accurate. RN 1 stated she felt that the weight gain of sixteen pounds was normal because the patient had experienced diarrhea for several days. RN 1 further stated the RD was aware that Patient 3 had diarrhea when admitted. RN 1 stated nursing verbally reported the weight gain to the RD.

Further review of Patient 3's record was conducted with RN 1. There was an Internist Consultation Assessment done on February 16, 2013, because Patient 3 had frequent watery diarrhea for the previous six days. The nutritional re-assessment, dated, February 20, 2013, did not address the episodes of diarrhea. A care plan initiated, on February 20, 2013, by the Nutrition/Dietary Department indicated, "Pt agreed to be weighed weekly, monitor weights, No dietary issues discussed at treatment team today."

The Adult Initial Nutritional Assessment, dated February 13, 2013, did not address Patient 3's episodes of diarrhea for the past several days. There was no nursing care plan initiated for any problems.

The facility s policy and procedure titled, "Assessing & Meeting Patient Care Needs," was reviewed. The policy indicated the purpose of the policy was to provide guidelines for assessing and meeting patients' nutritional needs. "Nutrition services performed by the registered Dietetic Technicians and Registered Dietitians shall be based on the standards of Care...The Registered dietitian will complete the interdisciplinary patient care plan for all patients with high nutrition risk..." The policy further indicated Basic Care would be performed by the Diet Technician and would include a chart review to identify current medical problems related to nutritional risk and patient interview for problem screening related to present appetite, current incidence of diarrhea (how long), recent weight loss or gain, and cause of recent weight change. A Nutritional Assessment/Re-Assessment should be completed when the patient has GI disturbances and current medical problems.





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22384

Based on observations, interviews, and record review, the hospital failed to ensure the food and nutrition staff had access to the hospital's diet manual and were not able to identify and find the diet manuals at the main campus and the Arlington Campus.

Findings:

During an observation and concurrent interview with Food Service Worker (FSW) 5 at the Arlington Campus meal suite on February 26, 2013, at 9:20 a.m., she was asked to retrieve the hospital's diet manual. FSW 5 spent several minutes looking for the diet manual. She then stated she could not seem to find the diet manual.

During a concurrent interview with the Food and Nutrition Service Manager (FNSM), she pointed out the diet manual which was labeled "Nutrition Care Manual". She verified FSW 5 did not know that this was the hospital's diet manual.

During an observation and concurrent interview with Food Service Supervisor (FSS) 2 at the main campus on February 27, 2013, at 10 a.m., when asked to retrieve the diet manual, she opened a notebook labeled "diet manual". When asked how she would use the manual as a reference in preparing the menu for a patient on a low protein diet. She stated that she would use the information from the renal diet (a special diet for patients with kidney insufficiency or failure, not necessarily low protein).

During a concurrent interview with the FNSM, she stated that the notebook FSS 2 was looking at was not the hospital's approved diet manual, even though it was labeled diet manual. She stated that the hospital's diet manual was labeled "Nutrition Care Manual". FNSM verified that FSS 2 did not know this was the hospital's diet manual that contained the hospital's approved diets and was to be used by the dietary staff for preparing patient meals.



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17065

Based on observations, interviews and record reviews, the hospital failed to develop an effective infection control surveillance system for identifying unsafe food handling practices in the dietary department when:
1. refrigerated, previously cooked, potentially hazardous foods (foods that support bacterial growth when not properly stored) were not monitored for safe cool down;
2. the ice machines were not maintained in a sanitary manner and according to manufacturer's directions;
3. the kitchen lacked general cleanliness;
4. there was no splashguard on a handwashing sink adjacent to the clean dish area;
5. the scoops for dry bulk items were stored inside the bins;
6. patient dishes were noted to be stained and unsightly;
7. dietary staff lacked knowledge on proper sanitizer concentration use in the three compartment sink, the appropriate use of the chemical produce wash and appropriate cleaning and sanitizing of food contact surfaces;
8. the shelf life of many foods were not monitored;
9. and, cleaning equipment was inappropriately stored with food and in the clean dish area.

The lack of surveillance of this unsafe food handling practices had the potential to result in a food borne illness outbreak in a highly susceptible patient population in a hospital with a licensed bed capacity of 439.

Findings:

1 a. According to the 2009 US Food and Drug Administration's Food Code, safe cooling of potentially hazardous food (PHF - food capable of supporting bacterial growth) requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of PHF has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, PHF are subject to the growth of a variety of pathogenic microorganisms. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135 °F to 41°F in 6 hours, with cooling from 135 °F to 70 °F in 2 hours.

During a tour of the main campus kitchen on February 25, 2013, at 11:30 a.m., three pans labeled "Spanish rice use by February 27" and four pans labeled "refried beans use by February 27" were noted in the walk-in refrigerator. During a concurrent interview with the Food and Nutrition Services Manager (FNSM), she stated the rice and the refried beans had been previously cooked on February 24, 2013. She stated staff was supposed to log the safe cooling monitoring on the "Cooling Temperature Log".

A review of the "Cooling Temperature Log" dated February 24, 2013, revealed a blank log with the words "Did No Cooling Today" written across it. The form was signed by Food Service Supervisor (FSS) 1.

During an interview with FSS 1, on February 25, 2013, at 4:40 p.m., he verified he filled out the form dated, February 24, 2013. He stated he did not find a log for February 24, 2013, so he filled out a blank form stating no cooling had occurred on that day. FSS 1 stated he did not check the refrigerators to verify if food had been cooked and cooled. He further stated the cook who had prepared the Spanish rice and refried beans on February 24, 2013 came in today (February 25, 2013) and filled out a Cooling Temperature Log for the beans and rice. He provided a copy of the log completed February 25, 2013. He stated the cook said she could not find a form to fill out on February 24, 2013, so she had written the times and temperatures on a piece of paper. FSS 1 verified the cook had not asked him for a log to fill out on February 24, 2013. FSS 1 was unable to state why he did not know that the rice and beans had been cooked and cooled on February 24, 2013, until the surveyor brought it to his attention.

During an additional tour of the main campus on February 25, 2013, at 4:40 p.m., there were individual portions of cooked cream of wheat observed in the trayline area reach-in refrigerator. The tray of dishes was labeled "cream of wheat use by February 28, 2013". During a concurrent interview with the FNSM, she stated the cooked cream of wheat had a three day shelf life so it was cooked that day, February 25, 2013.

A review of the Cooling Temperature Log" dated February 25, 2013, revealed no entry for cream of wheat.

An interview was conducted with the Food Service Worker (FSW) 4, on February 25, 2013, at 4:40 p.m. The GSW 4 stated the cream of wheat had been cooked on February 24, 2013. There was no entry on the Cooling Temperature Log, dated February 24, 2013, for the cream of wheat.

During an interview with the Assistant Dietary Services Manager, on February 25, 2013, at 4:50 p.m., the Assistant Dietary Services Manager stated she worked on February 24, 2013. The Assistant Dietary Services Manager verified she did not check the refrigerators to see if any foods had been cooked that needed to be monitored for safe cooling that day. She also stated the cook who prepared the food on February 24, 2013 did not request a "Cooling Temperature Log" from her.

b. According to the 2009 US Food and Drug Administration's Food Code, potentially hazardous food (PHF) shall be cooled within 4 hours to 41ºF or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna.

During a tour of the main campus kitchen on February 25, 2013, at 12:30 p.m., four pans of tuna salad were noted in the salad prep reach-in refrigerator. The pans were labeled "use by February 26, 2013." One of the pans looked different from the other pans. During a concurrent interview with the FNSM, she stated the hospital received their tuna salad premade, and they do not generally make the in the hospital. She further stated the pan of tuna salad that looked different was made by the dietary staff on February 23, 2013. She did not know why the staff had made the one pan of tuna salad.

A review of the "Cooling Temperature Log," dated February 23, 2013, revealed no entry for the tuna salad. The FNSM verified the tuna salad was not on the log. The FNSM stated since it was not the usual practice to make the tuna salad, it was not the practice to monitor the safe cooling of the tuna. The FNSM also verified the tuna was not kept in the refrigerator, so the tuna salad was likely made from tuna obtained from the storeroom at ambient or room temperature.

A review of the "Cooling Temperature Log" instructions revealed that temperatures were to be recorded at the start of the cooling process, after the first hour, after the second hour, after the fourth hour (if required) and when item was transferred to the refrigerator. It further stated, "If no foods were cooled on any working day, indicate 'No Foods Cooled' in the Food Items column. The Food Service Supervisor or Supervising Cook will verify that the foodservice staff is cooling properly by visual monitoring employees throughout the shift."

2 a. During a tour of the main campus kitchen on February 25, 2013, at 12:40 p.m., a clean paper towel swipe of the ice machine yielded a black smear from the ice maker. The finding was concurrently observed by the Food and Nutrition Services Manager (FNSM). She stated the dietary staff did not clean the ice machine. The Plant Operations department cleaned and maintained the ice machine.

During further observation of the ice machine with Plant Operation Staff (POS) 1, on February 25, 2013, at 1:15 p.m., the ice maker portion of the ice machine was noted to have black specks covering the area where the ice was being made. Also noted were white plastic tubes (water lines) that had a pink tinge color. POS 1 stated that the ice machine was scheduled to be cleaned every six months and the last cleaning was done in September, 2012. It was due to be cleaned again next month. He was unable to state what the black smear was or why the water lines were pink. He did not know why the ice maker had black specks throughout.

A review of the manufacturer's service manual for the main campus ice machine revealed that "maintenance and cleaning should be scheduled at a minimum of twice a year." It further stated that for the ice storage bin, "the interior liner of the bin is in contact with a food product: ice. The storage bin must be cleaned regularly to maintain a sanitary environment. Once a week cleaning with soap and water, a hot rinse and an air dry is a basic procedure."

b. During an observation of the ice machine and interview with POS 2 at the Arlington Campus in the loading dock area, the maintenance of the machine was discussed. POS 2 stated the ice machine was cleaned and sanitized by the POS twice a year.

A review of the manufacturer's manual for this ice machine revealed the "maintenance and cleaning should be scheduled at a minimum of twice a year. Sanitizing of the ice storage bin should be scheduled for a minimum of four times a year."

A review of the hospital's policy titled, "Food & Nutrition Services: Infection Control" dated (revised) January 8, 2013, revealed that "the interior of the ice bin and dispenser shall be emptied and sanitized quarterly, and as needed, with a Nickel-Safe Ice Machine Cleaner."

During an interview with the FNSM on February 27, 2013, at 4:30 p.m., she stated she was not aware of the hospital's policy that the ice storage bin shall be emptied and sanitized quarterly.

During an interview with the Plant Operations Manager, on February 27, 2013, at 1:20 p.m., he stated he missed the directions for the ice storage bins to be sanitized a minimum of four times a year at the Arlington Campus and weekly for the ice machine in the kitchen at the main campus.

3. During a tour of the main campus kitchen on February 25, 2013 between 10:35 a.m. and 12:35 p.m., the following was observed:
a. in the clean area of the dishroom where clean dishes and utensils were stored, the counters and racks had a significant accumulation of dust and debris;
b. in the cook's area, a food storage baker's rack had a significant accumulation of dust and debris;
c. in the catering area, the coffee maker was noted to have an accumulation of dust; and
d. in the food storage shelves adjacent to the timecard area were noted to have an accumulation of dust.

These observations were concurrently verified by the Food and Nutrition Services Manager (FNSM). She stated that the Environmental Services (EVS) staff were responsible for doing a "deep cleaning" of the kitchen every night. The EVS manager was responsible for checking on the job his staff did. She stated the Food Service Supervisors also did a sanitation check daily that included general cleanliness of the department. She was unable to explain how there could be such an accumulation of dust and debris if the deep cleaning was being done nightly and the sanitation checks were being conducted daily.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control" dated (revised January 8, 2013), revealed that "all nonfood-contact surfaces, including floors will be cleaned at a frequency necessary to preclude accumulation of soil residues. Storage areas shall be adequate, cleaned thoroughly weekly and inspected daily by the Food and Nutrition Manager or designee." It further stated that "all kitchen areas shall be clean and free of litter and rubbish. They shall be protected from rodents, roaches, flies and other insects. All utensils, counters, shelves, tables, stoves, hooks and other equipment shall be clean and in good repair."

The FNSM stated the accumulation of dust and debris noted above was not noted in the daily inspections of the department.

During an interview with the Infection Control Preventionist on February 27, 2013, at 3 p.m., she stated she had been conducting weekly sanitation rounds in the kitchen. She did not note the accumulation of dust and debris in her observations. She was unable to state why she did not observe the dust and debris.

4. During a tour of the main campus kitchen on February 25, 2013, at 10:35 a.m., a handwashing sink located in the clean area of the dishroom was noted to be adjacent to clean equipment, dishes and utensils. There was no splashguard on the sink to prevent contamination of the clean area during handwashing. This was verified by the Food and Nutrition Services Manager.

A review of the hospital's policy titled' "Food & Nutrition Services, Infection Control: Sanitation Precautions" dated (revised) January 24, 2012, revealed that "dishwashing and utensil washing equipment and techniques are conveniently located to sanitize all service ware and that prevent recontamination are used."

5. During a tour of the kitchen at the main campus on February 25, 2013, at 5 p.m., two bulk storage bins containing flour were noted with the scoops stored inside the bin with the handles touching the contents.

During a concurrent interview with the Food and Nutrition Services Manager (FNSM), she verified the finding and stated that the scoops should not be stored inside the bins.

A policy regarding the storage of scoops for use in the bulk storage bins was requested and was not provided. During an interview with the FNSM on February 27, 2013, at 5 p.m., she verified there was no policy directing the staff to store the scoops outside the bins.

6. During the tour of the main campus kitchen on February 25, 2013, at 10:50 a.m., the dish machine was observed. The clean patient dishes that were emerging from the dish machine were noted to be stained with brown spots. Some of the spots could be removed by scraping with a fingernail.

During a concurrent interview with the Food Nutrition Services Manager (FNSM), she confirmed the dishes were stained and that they were being used for patient's food service. She further stated the food did not contact the plates because they were served on a separate container that was placed on top of the plates. She agreed they were unsightly. She was unable to state how she could be assured that patients did not use the plates after their food was served to them.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control: Sanitation Precautions" dated (revised) January 24, 2012, revealed that "plastic ware, china and glassware that have lost their glaze or are chipped or cracked are discarded."

7 a. During the tour of the main campus kitchen on February 25, 2013, Food Service Worker (FSW) 3 was observed preparing fresh cauliflower. There was a colander filled with cauliflower in a food preparation sink with water running over the vegetable. It was observed that there was a chemical vegetable wash dispenser mounted on the wall.

During a concurrent interview with FSW 3, she stated the chemical vegetable wash was used to clean the produce. She demonstrated how she used the wash by rinsing the cauliflower with the chemical wash dispenser for approximately 10 seconds. She verified that 10 seconds was how long she typically rinsed fruits and vegetables. FSW 3 stated she also rinsed the produce under running water after she used the vegetable wash. FSW 3 stated she had not received training on how to use the vegetable wash. When she was directed to the posted instructions for the wash on the adjacent wall, she read that the spray must be used for a minimum of 45 seconds to be effective.

A review of the hospital's policy titled, "Food & Nutrition Services, Food Preparation and Service" dated (revised) June, 15, 2012, revealed that raw, unprocessed fruits and vegetables were to be washed under running water in designated preparation sinks. The policy did not have instructions on the use of the chemical vegetable wash.

During an interview with the Food and Nutrition Services Manager on February 27, 2013, at 4:30 p.m., she stated that she did not have a policy on the use of the chemical vegetable wash that was used to clean fruits and vegetables. She was unable to state why the hospital had dispensers in the kitchen when there was no policy on the proper use of the product.

b. During an interview with Food Service Worker (FSW) 6 on February 27, 2013, at 9:35 a.m., he demonstrated the use of the three compartment sink for manual warewashing. FSW 6 stated the first sink was filled with soap and hot water, the second sink with hot water for rinsing, and the third sink was filled with sanitizer. He demonstrated how he would check the concentration of the sanitizer with a test strip. FSW 6 then stated the concentration required was 400 parts per million (ppm). His test strip read 200 ppm and he said he was not sure if 200 ppm was okay. He further stated he had not been trained on the proper concentration for the sanitizer.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control" dated (revised) January 8, 2013, revealed that for the three compartment sink, the sanitizer concentration should be 200 ppm or per manufacturer's recommendations."

A review of the Food and Nutrition Services inservice records showed that FSW 6 had attended two inservices that included the proper use of the three compartment sink for manual warewashing in January 2013. Both inservices included a post test in which one of those tests asked the specific question regarding the proper sanitizer concentration for warewashing. FSW 6's test showed he answered the questions correctly that it should be 200 ppm.

During an interview with the Food and Nutrition Services Manager on February 27, 2013, at 4 p.m., she was unable to state why FSW 6 did not know the proper sanitizer concentration. The Food and Nutrition Services Manager stated she did not conduct a return demonstration to verify that FSW 6 was able to demonstrate the proper procedure.

c. During an interview in the main campus kitchen with FSW 2 on February 25, 2013, at 11:30 a.m., she stated she used the disposable cloths labeled "Wet Task" cloths for cleaning and sanitizing of food contact surfaces. FSW 2 stated she filled the container of dry cloths with sanitizer from the three compartment sink every four hours and checked the concentration of the sanitizer with a test strip. FSW 2 stated the concentration should be 200 ppm.

During an interview with FSW 6, on February 25, 2013, at 12:20 p.m., FSW 6 stated she used the disposable cloths labeled "Wet Task". FSW 6 stated she added the sanitizer solution to the container one time in her eight hour shift. She stated that the concentration of the sanitizer should be 400 ppm.

During a concurrent interview with the Food and Nutrition Services Manager, she stated the concentration should be 200 ppm. She was unable to state what the policy was for how often sanitizer solution needed to be added to the wipes.

During an interview at the Arlington Campus with FSW 5 on February 26, 2013, at 9:45 a.m., FSW 5 stated she used a disposable cloth for cleaning of the food contact surfaces in the meal suite. FSW 5 stated she did not have water, she just used the wipes. She indicated the wipes she used were disposable cloths labeled "CHIX:Pro-Quat Reusable Food Service Towels". FSW 5 stated she got them from the hospital.

During a concurrent interview with the FNSM, she did not know what the cloths were but said she would find out. She later presented a policy regarding the cloths.

A review of the hospital's policy titled, "Food & Nutrition Services, Infection Control: Wiping Cloths and Gloves" dated August 1, 2008, indicate, "disposable wiping cloths that are used for wiping food spills shall be used for no other purpose. Disposable wiping cloths used for wiping food spills shall be: dry and used for wiping food spills from tableware and carry-out containers, or wet and cleaned, stored in chemical sanitizer, and used for wiping spills from food contact and nonfood contact surfaces of equipment. It further stated that "Wet wiping cloths [are] used with a freshly made sanitizing solution..." The policy was not specific as to how often the sanitizer solution should be added to the wipes. It also did not indicate the proper concentration of the solution.

8. During a tour of the main campus kitchen and concurrent interview with the Food and Nutrition Services Manager (FNSM), on February 25, 2013, starting at 11:45 a.m., she stated all foods that did not have a manufacturer's expiration date should be labeled by the staff with a "use by date." She stated most items in the dry storage were given a six month shelf-life from the received date. Multiple items were found in the dry storage room that did not have a manufacturer's expiration date or a use by date label. Undated items included: a #10 (large) can of lemon pudding, a #10 can of dark red kidney beans, a box of turkey gravy mix (received February 4), 3 boxes of ranch dressing (received January 18), 2 cases of #10 cans of spiced tomatoes, 8 cases of hot cocoa mix (received in December), 10 five pound bags of ground coffee, 10 cases of a coffee drink mix and nine 64 ounce bottles of coffee flavoring.

The FNSM stated ensuring that all items without a manufacturer's expiration date were labeled with a use by date was a part of the daily sanitation checks completed by the Food Services Supervisors. She was unable to explain how food that was delivered in December 2012 and January 2013 was never noted that it did not contain a use by date label. She verified that many items did not have a receive date and therefore there was no way to determine how long those items had been sitting on the shelves.

During a tour of the Arlington Campus meal suite on February 26, 2013, at 9 a.m., a case of frozen breakfast sandwiches was noted in the freezer with no manufacturer's expiration date and no use by date label. The FNSM confirmed the finding. The FNSM stated it should be labeled with a use by date.

The facility's policy that directed staff on monitoring the shelf life of dry/canned foods was requested. The FNSM stated there was no written policy that directed the staff to label dry/canned food without a manufacturer's expiration date with a use by date. She stated that was the expectation but there was no policy.

9. During a tour of the main campus kitchen on February 25, 2013, at 10:45 a.m., two brooms and a floor squeegee were observed stored in the dishroom clean dish/equipment storage area. During a concurrent interview with the Food and Nutrition Service Manager (FNSM), she stated that dirty cleaning equipment should not be stored in the clean dish area.

The same day at 12:10 p.m., grill bricks, used for cleaning the grill were observed in the dry storage room. The FNSM verified the finding.

A review of the hospital's policy titled, "Food & Nutrition Services, Food Products Storage" dated August 1, 2008, revealed that non-food items should be stored separately from food items.






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