HospitalInspections.org

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

1. Ensure policies were monitored for day to day clinical and foodservice practices. (Cross Reference A620, A630, A631, A749).

2. Ensure the nutritional needs of patients were met as evidenced by the lack of menu modification in response to inadequate nutrient values on menus used at the facility, lack of the provision of therapeutic diets as prescribed and lack of registered dietitian nutritional intervention/follow-up in accordance with facility policies. (Cross Reference A630).

3. Ensure safe and effective food storage/production practices integrated in the facility's Infection control surveillance system (Cross Reference A749).

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



18918




28135

Based on observation, interview and record review, the facility failed to ensure the Director of Food and Nutrition Service (DFNS) monitored written procedures for foodservice operational processes and clinical nutrition practices.

Failure to monitor standardized policies and procedures could result in patients being exposed to foodborne illness or not receiving appropriate nutritional care which could further compromise medical status.

The facility made the decision to terminate the Food Service Contractor for the Arlington campus effective June 24, 2013. The facility also decided the Moreno Valley campus would prepare and deliver meals to the Arlington campus effective June 25, 2013. The facility secured two refrigerated trucks to deliver meals three times daily to the Arlington campus.

The supervisory staff, appointed by the facility for the Arlington campus, included a dietician and another staff member. There was no evidence to indicate issues such as out of range temperatures were reported to the appropriate supervisory staff and there was no indication that interventions were taken once out of range temperatures were identified.


Findings:

A review of the job description for the Food and Nutrition Services Manager (also known as the Director of Food and Nutrition Services - DFNS) revealed essential duties including:

"Plans, organizes, and directs through subordinate supervisors the work of cooks, and other food services personnel engaged in the procurement, storage, preparation, and serving of food for patients, employee cafeteria, coffee shop and catering for special activities.

Directs through subordinate supervisor the administration of the hospital food and nutrition program services; confers with clinical dietitians; food production, and food preparation and food supervisory personnel in regard to the planning of general and special menus.

Confers with Assistant Hospital Administrator regarding policies of food and nutrition services program as they relate to Hospital policy, recommending changes and improvements as needed.

Reviews and evaluates existing operational methods and procedures of food and nutrition services program for effectiveness and efficiency, initiating changes as necessary to ensure compliance with federal, State, and County laws, rules, and regulations, and the rules and procedures of hospital accrediting bodies."

Lack of monitoring of food and nutrition policies and procedures was reflected in the following findings:

1. On July 1, 2013, beginning at 9:20 a.m., during a tour of the kitchen at the Moreno Valley campus, various deficient practices were noted related to lack of implementation of policies related to proper food handling and storage. (Cross reference A749).

2. On July 2, 2013, starting at 10:30 a.m., at the Arlington Campus, various deficient practices were noted related to monitoring of the safety of the meal delivery system and associated infection control concerns. (Cross Reference A749).


3. During the course of the survey from July 1-3, 2013, deficient practices were noted related to evaluation of the nutritional adequacy of the facility menus, and therapeutic diet definitions, transcription and implementation in comparison to the facility policies and diet manual recommendations. (Cross Reference A630 and A631).

4. During the course of the survey from July 1-3, 2013, deficient practices were noted related to proper evaluation of nutritional needs and timely nutritional follow-ups in accordance with established facility policies. (Cross reference A630).

On July 3, 2013, at 9:30 a.m., in an interview with the DFNS, she stated she had recently taken over the role of DFNS within the last two months and acknowledged some of the food and nutrition policies were still pending review and revision. The DFNS acknowledged monitoring the proper implementation of food and nutrition policies was her responsibility in conjunction with the Supervising Dietitian and other supervisory staff and stated it was a work in progress.



28135





18918

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

1) Standard menus 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, provided adequate amounts for all nutrients on planned menus and addressed the nutritional needs of all subgroups serviced at the facility.

2) Patient meals were served in accordance with prescribed orders and planned menus (Patients 11, 18, 19, and 20).

3) Registered Dietitians (RD) addressed the nutritional status of three patients (Patients 9, 15, 17 and 19 ) in accordance with facility policy and standards of practice.

Findings:

1. 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/resident menus.

On July 3, 2013, at 8:45 a.m., the facility's menu nutrient analysis was reviewed. A "Statement of Nutritional Adequacy" was attached to the menu which documented the majority of the diets served at the facility were deficient in iron, magnesium and potassium. There was no indication the facility modified the planned menus in an attempt to meet the RDAs for these nutrients

Further review of the "Statement of Nutritional Adequacy" revealed the planned menus were analyzed, for the Moreno Valley campus, based on the needs of a female 31-50 years of age. There was no indication of how the facility adjusted menus based on the increased needs of certain nutrients for other age/gender groups.

In an interview on July 3, 2013, at 8:45 a.m., the Director of Food and Nutrition Services (DFNS), stated the Registered Dietitians (RDs) would be responsible for adjusting individual patient menus to meet their needs. She was unable to confirm whether the RDs were aware of the nutritional content of the planned menu, the needs of the various age/gender groups serviced at the facility, and whether adjustments were actually taking place.

Review of the facility policy titled, "Patient Menus - Revised 1/11/13", 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."

2a. On July 2, 2013, at 10:30 a.m., observation of the snack preparation process at the Arlington Campus, revealed foodservice workers utilized a posted "ITF Snack Rotation" menu to prepare snacks for the patients. The snack menu indicated three snacks were to be served to patients at 10 a.m., 2 p.m., and 8 p.m. respectively.

Review of the "Arlington Campus Diet List" revealed two patients were prescribed low fat, low cholesterol diets and seven were prescribed low sodium diets (2 grams sodium per day).

Review of the snack items delineated on the "ITF Snack Rotation" for patients on "Cardiac" diets included cheddar cheese (7 grams of fat, 140 mg (milligrams) sodium), and "Uncrustable PBJ (peanut butter and jelly)" (9 grams of fat, 240 mg sodium).

On July 3, 2013, at 8:45 a.m., in an interview with the DFNS, she acknowledged the "ITF Snack Rotation" menu had not been nutritionally analyzed to determine nutritional content. The DFNS acknowledged the snacks were provided above and beyond the patients' prescribed diets, were provided to all patients, and impacted the provision of therapeutic diets such as low fat and low sodium.

2b. On July 2, 2013, at 12:30 p.m., during an observation of the lunch meal service at the Arlington Campus, two patients (Patients 18 and 19) were noted to be prescribed "Double Portion" diets. Review of the meals served to the patients revealed the patients received the exact food items served on regular diets with the exception of six meatballs served on "Double Portion" trays versus four meatballs served on regular trays.

Review of the Diet Manual guidelines and the "Trayline Production Sheets" revealed no guidance to staff as to how to serve a "Double Portions" diet.

On July 2, 2013, at 2:05 p.m., in an interview with the Supervising Dietitian. She stated a "Double Portions" physician order was served utilizing the "High Protein, High Calorie" menu. The Supervising Dietitian acknowledged this direction was not reflected in the facility Diet Manual or in the "Physician's Guide to Ordering Nutrition Prescriptions."

Review of the "High Protein, High Calorie" menu revealed patients should be served "2x Meatballs" and "2x Tossed Salad with dressing". The regular portion for meatballs was four meatballs. Therefore, "2x Meatballs" would mean the patients would receive eight meatballs. Only one salad was served to the patients prescribed "Double Portions".

2c. On July 3, 2013, at 9:15 a.m., review of the dietary kardex for Patient 20, revealed the patient was prescribed a, "Puree, Renal 100 gram protein diet". In a concurrent interview with the Diet Technician (DT), she stated, in order to serve the patient this prescribed diet, she would utilize a puree menu, change the mashed potato selection to puree rice, and adjust the protein content to 100 grams.

The DFNS, present at the time of the interview, confirmed that preformed puree food products were used for all patients prescribed puree diets (renal and non-renal). She acknowledged these products and the puree menu as a whole had not been evaluated for appropriateness for low sodium (2 grams) and low potassium (2 grams) requirements as set forth on a renal diet.
Review of the puree menu nutritional analysis revealed the menu provided an average of 3136 mg of potassium and 4891 mg of sodium.

2d. On July 1, 2013, at 2:50 p.m., review of the medical record for Patient 11, indicated the patient was admitted on June 27, 2013, with diagnoses that included congestive heart failure, hypertension, diabetes mellitus and renal insuffcency. On June 27, 2013, the physician prescribed a 2200 calorie diabetic diet.

On June 29, 2013, the physician agreed with a Registered Dietitian (RD) recommendation to change the patient's diet to 1800 calorie consistent carbohydrate, cardiac diet.

On June 30, 2013, the physician prescribed a 2200 ADA (American Diabetes Association), low sodium diet. The order form indicated this physician order was noted as input into the computer system at 10 a.m. on 6/30/13.

On July 1, 2013, at 2:50 p.m., review of the patient diet list revealed the patient was receiving an 1800 calorie, cardiac, renal diet. In a concurrent interview with the Nurse Manager, he could not explain the discrepancy between the physician ordered diet and the diet the patient was actually receiving.

On July 3, 2013, at 9:15 a.m., review of the patient's Kardex with the DT revealed Patient 11's diet as 1800 ADA Renal on July 1, 2013, and 2200 ADA, cardiac on 7/2/13.

Review of the facility policy titled, "Diet Orders - Revised 1/19/12" indicated, "All diets should be ordered on the Diet Order List. The nutrition care order is the responsibility of the charge nurse. A nursing representative completes the diet order form listing the patient's name, date of birth, and diet."

Review of the facility policy titled, "Diet List Procedures - Updated 1/20/12" indicated, "The Diet List is completed by the Medical Unit clerk on the Patient Care Unit. When preparing the Diet Order List the Medical Unit clerk refers to the patient's Kardex. Whoever admits a new patient makes out a card for the patient, including all of the physician's orders, and places this card in the Kardex file for reference while the patient is hospitalized."

3. Review of medical records was conducted at the Moreno Valley campus on July 1, 2013, and at the Arlington campus on July 2, 2013. The following findings were made:

a. Patient 9 was admitted to the Moreno Valley campus on June 23, 2013, with diagnoses that included diabetes mellitus and facial cellulitis (inflammation). The Registered Dietitian (RD) completed a nutritional assessment on June 25, 2013, noting the patient reported a 13 pound weight loss in the last month and poor oral intake. The RD documented the patient was at 73% of his ideal body weight. The RD recommended a change in the patient's diet from a puree diet to a 2000 calorie, consistent carbohydrate, mechanically chopped diet and adding a nutritional supplement three times per day. The RD classified Patient 9 as a "Level I".

On June 29, 2013, the physician changed the patient's diet to a soft texture, ADA 2000, lactose-free, renal diet.

Further review of the medical record revealed no further RD notes or nutritional follow-up.

Review of the facility policy titled, "Adult Standards of Care: Assessing & Meeting Patient Care Needs - Revised 6/5/13" revealed, "Nutrition services performed by the Registered Dietitians shall be based on the Standards of Care as follows: .. During the registered dietitian initial assessment, the patient will be assigned a priority level of Level I (high risk), .." The RD follow-up guidelines for Level I patients was 3-4 days from the last RD note.

In an interview on July 1, 2013, at 1:15 p.m., the Supervising Dietitian, could not explain why Patient 9, who was last seen by the RD on June 25, 2013, had not had an RD follow-up as of the time of review of the medical record on July 1, 2013.

3b. Patient 17 was admitted to the Arlington campus on June 20, 2013, with diagnoses that included schizophrenia, diabetes mellitus and hypertension (high blood pressure).

Review of the ETS (Emergency Treatment Service) nursing assessment revealed the patient was identified with decreased weight, decreased appetite for the past three months and diarrhea.

The initial nutrition screen completed as part of the initial nursing assessment indicated the patient had swallowing/chewing difficulties and poor oral intake for more than three days.

The RD completed a nutritional assessment on June 21, 2013, and documented the patient weighed 219 pounds and was at 127% of his ideal body weight. The RD documented under "Nutrition Diagnosis" - Obesity related to excessive intake. The outcome desired for the patient was to consume more than 75% of his meals. The RD recommended changing the patient's diet from a 2000 calorie ADA to a 2200 calorie consistent carbohydrate, 2 gram sodium diet. The RD classified the patient at Level II nutrition risk (to be followed up in 5-6 days). The RD made an entry on the "Master Problem List" related to the patient's poor appetite.

In a concurrent interview with RD 2 and the Supervising Dietitian, at 9:50 a.m., on July 2, 2013, they could not explain why the RD would document the nutrition diagnosis as obesity when the patient's primary problem was poor oral intake. They acknowledged the RD recommendation to provide more calories to the patient in the form of a 2200 calorie diet was probably not very effective considering the patient was reported with poor oral intake of meals.

Review of the patient's weight revealed the following:

6/20/13 219 pounds
6/23/13 217 pounds
6/30/13 208 pounds

Patient 17 lost 11 pounds in ten days.

In the RD follow-up note dated June 26, 2013, the RD documented Patient 17 had poor oral intake, was refusing meals and drinking minimal fluids. Patient 17 was sent that day to the Moreno Valley campus for intravenous hydration treatment. The RD made a recommendation to add Glytrol (nutritional supplement) three times per day with meals. The RD re-classified Patient 17 as a Level I (high nutrition risk) patient.

On June 30, 2013, the RD documented the patient had a nine pound weight loss in the last week and that his intake had improved the day prior (100% breakfast, refused Lunch, 90% dinner). The RD made no additional interventions.

During the interview with RD 2, on July 2, 2013, at 9:50 a.m., she stated the consumption of nutritional supplements was not tracked separately by nursing staff. The percent documented for meals was indicative of the meal and supplement. The RD acknowledged, if nursing documented 50% of a meal, it would be difficult to discern how much of the meal was consumed versus the supplement, and thus the effectiveness of the RD recommendation would be difficult to measure.

On July 2, 2013, at 12:30 p.m., during an observation of the lunch meal service, Patient 17's lunch tray, including the nutritional supplement was noted on the food cart that was returned to the dietary department. In a concurrent interview with the nurse on the unit, she stated Patient 17 had refused his tray.

On July 3, 2013, at 10 a.m., review of Patient 17's Kardex indicated no notations of menu likes or dislikes.

There was no evidence the RD had evaluated how much of the nutrition supplement the patient was consuming and whether he would benefit from other nutritional interventions such as providing high caloric items between meals. There was no evidence the patient was interviewed regarding preferences for food products he is more likely to consume. There was no evidence the patient was considered for an appetite stimulant if appropriate with concurrent prescribed medications.

Review of the facility policy titled, "Adult Standards of Care: Assessing & Meeting Patient Care Needs" indicated, under "Monitoring and Follow-up of High Risk Patients", the RD was to monitor weight status, significant laboratory values, gastrointestinal disturbances, adequacy of treatment and metabolic complications". That portion of the policy did not provide guidance for other nutritional interventions that may be feasible for high nutrition risk patients, as was indicated under "Additional Interventions" for patients with wounds. Those "Additional Interventions" included: "Assessment of Nutrient Intake: Oral, enteral or parenteral, obtain food preferences, ...offer between meal snacks and/or oral supplements, recommend appetite stimulants if appropriate .."



21898

3c. Patient 19 was admitted to the hospital on June 15, 2013, with diagnosis that included schizophrenia. An Internist Consultation Note, dated June 29, 2013, indicated Patient 19 had a low white count (1.9) and severe weight loss in the past six months (80 pounds). The history and physical, dated June 30, 2013, indicated Patient 19 had Leukopenia with associated weight loss due to either HIV/Aids or Leukemia. There was no dietary nutritional consultation completed or requested in the medical record for Patient 19 to address the weight loss and dietary needs.

In an interview with staff, on July 2, 2013, at 10 a.m., staff stated Patient 19 was frequently treated at the facility and was well known by staff. Staff further stated that when admitted on June 15, 2013, it was noted that Patient 19 had lost a significant amount of weight since his last admission.

An interview was conducted with the Supervising Dietitian, on July 2, 2013, at 2 p.m. The Supervising Dietitian reviewed Patient 19's medical records and stated that Patient 19 should have had a nutritional consultation completed by the dietary department.

The facility's policy and procedure titled, "Nutritional Screening, Assessment, Reassessment indicated the purpose of the assessments was to provide patients with timely and appropriate interdisciplinary nutritional care...Priority Level 1 - May include but not limited to...significant weight loss...10% in six months..."

3d. Lunch meal observation was conducted, on July 2, 2013, at approximately 11:30 a.m. It was observed that two Registered Nurse (RN) were involved in passing the trays out to the patients. It appeared the RNs were checking the lunch trays against the diet list. It did not appear that staff was verifying that the food items on the tray were appropriate to the patients' diet order.

Patient 15 was observed sitting at the table eating her lunch. It was noted that Patient 15 had a cup of yogurt on her lunch tray. The tray card indicated that Patient 15 was on a lactose free diet. There was no record that yogurt was tolerated by the patient and that an exception to the lactose free diet was made for the yogurt.

In an interview with the Assistant Director of Nursing (ADN) on July 2, 2013, at 11:45 a.m., the ADN stated the RNs were verifying the diet on the "meal card" which was on the tray matched the diet listed on their "Diet List form." The RN supervisor stated the dietary department was responsible for ensuring that the correct food was placed on the tray based on the patients ' prescribed diet order.

On July 3, 2013, a review of the kitchen's Kardex diet card for Patient 15 was reviewed. The card indicated Patient 15 was on a lactose free diet. The card did not indicate that there were any exceptions to the diet. Yogurt was not listed under "Menu Instructions," as a dairy item that Patient 15 could eat.

Patient 15's food items were not served in accordance with the patient's prescribed physician order.



28135




17065



22384

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

Findings:

On July 1, 2013, at 10 a.m., review of the facility Diet Manual indicated it was the Clinical Diet Manual by Food and Nutrition Management Services, 16th edition, 2009. The manual was approved for use as the facility Diet Manual on June 18, 2013. Documented in the Diet Manual was the following, "This Clinical Diet Manual will become the standard for Food and Nutrition Services Departmental procedure and will supersede all previous Diet Manuals upon approval. Physicians should note that therapeutic diet orders will be complied with according to the standards established in the Clinical Diet Manual unless otherwise specified by Physician's order."

On July 2, 2013, at 10:18 a.m., review of the "Arlington Campus Diet List", indicated two patients with "Low Sodium" prescribed diets. One of the "Low Sodium" orders was further specified as "Low Sodium/3-4 G (grams)/day"

On July 2, 2013, at 2:05 p.m., in an interview with the Supervising Dietitian, and concurrent review of the "Physician's Guide to Ordering Nutrition Prescriptions", an addendum to the facility diet manual, the Supervising Dietitian acknowledged that a "Low Sodium" diet was not an approved facility diet. The Supervising Dietitian stated the "Low Sodium" diet was not part of the facility Diet Manual as the Regular diet provided between 3-4 grams of sodium per day.

Further review of the "Arlington Campus Diet List" revealed two patients were prescribed "Double Portions". Review of the Diet Manual guidelines and the "Trayline Production Sheets" revealed no guidance to staff as to how to serve a "Double Portions" diet.

On July 2, 2013, at 2:05 p.m., in an interview with the Supervising Dietitian. She stated a "Double Portions" physician order was served utilizing the "High Protein, High Calorie" menu. The Supervising Dietitian acknowledged this direction was not reflected in the facility Diet Manual or in the "Physician's Guide to Ordering Nutrition Prescriptions."




28135



17065

Based on observation, interview and record review the hospital failed to ensure effective infection control oversight into food services when staff failed to ensure proper sanitation procedures at the Moreno Valley and Arlington Campuses, related to appropriate storage of food items within manufacturer guidelines, and monitoring of safe food delivery processes.

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

Findings:

1. On July 1, 2013, beginning at 9:20 a.m., during a tour of the kitchen at the Moreno Valley campus, the following observations were made:

a. On a storage shelf in the trayline area, a box containing multiple individual packets of protein powder was noted. There was no expiration date noted on the box or on each individual packet. In a concurrent interview with the Director of Food and Nutrition Services (DFNS), she acknowledged the absence of an expiration date and stated staff must have "cut" the top of the box where the expiration date was documented.

Adjacent to the trayline, multiple individual containers of pudding were noted to be used on patient trays. The pudding containers were not identified with a "Use-by" date. This was confirmed by the DFNS present at the time of the observation.

b. In the walk-in refrigerator number 1, a case (15 dozen) of unpasteurized shell eggs was stored above a case of pasteurized eggs and a container of ready to eat Chicken Romano. In a concurrent interview with the DFNS, she acknowledged the unpasteurized shell eggs should not be stored above ready to eat food products, or pasteurized eggs that may not be fully cooked.

Further inspection of the container of Chicken Romano revealed a hand-written date indicating the product was to be used by July 5, 2013. The DFNS confirmed with facility staff the product had been used over the weekend for patient meal service, and should have been discarded as it was not the facility policy to retain leftovers.

c. In the formula storage room, one case of Pediasure nutritional formula was imprinted with a manufacturer expiration date of June 1, 2013, and two cases of Pediasure nutritional formula were imprinted with a manufacturer expiration date of July 1, 2013. The DFNS, present at the time of the observation, removed the cases from the storage room and stated they should be discarded.

d. In the walk-in refrigerator Number 5, one quart of soymilk was imprinted with a manufacturer "Use-by" date of June 26, 2013, and three half-gallons of manufacturer cream (40% milk) were imprinted with a "Use-by" date of June 30, 2013.

A review of the facility policy titled, "Food Preparation and Service - Revised 4/5/13" indicated, "Foods are to be discarded by the manufacturer's expiration or "use by" date."

A review of the facility policy titled, "Proper Food Handling", noted to be in "DRAFT" form, indicated, "Cross Contamination Precautions: "Raw and potentially hazardous foods must be separated from ready-to-eat food products during storage, preparation and/or service."


2. On July 2, 2013, starting at 10:30 a.m., at the Arlington Campus, the following observations were made:

a. Patient meal trays for the lunch meal were received at 10:46 a.m. The facility utilizes an "A la Carte" menu delivery system that is designed to deliver all food in a chilled status, on refrigerated trucks, after which the meal delivery carts are connected to "chillers" that re-thermalize hot food product to 165 degrees F or above, while maintaining cold food items at appropriate temperatures.

Temperatures of the lunch meal items measured by Foodservice Worker 1 on July 2, 2013, at 10:46 a.m., were as follows:

Meatballs 49 degrees Fahrenheit (F)
Peas 53.9 degrees F
Garden Salad 58.8 degrees F
Peach Cobbler 58.6 degrees F
Juice 65.9 degrees F

The meal carts were then attached to the chillers to re-thermalize. No corrective action was noted to be taken by any facility staff member in response to the measured temperatures.

On July 2, 2013, at 2:05 p.m., in an interview with the Assistant Dietary Service Manager (ADSM), she stated the temperatures of the patient meal items for delivery to the Arlington campus should be as follows:

Temperatures during loading of delivery trucks:
39-41 degrees F
Temperature of delivery truck:
37-41 degrees F
Temperatures upon arrival at Arlington campus:
41 degrees F or below

Re-thermalization temperatures:
Hot Food: >165 degrees F
Cold Food: <41 degrees F

The ADSM stated cold food temperatures took into account both food safety and palatability concerns. The ADSM further stated it was the responsibility of the Supervising Dietitian and Registered Dietitian 2 (RD2) to monitor the process and take corrective action if necessary. The ADSM confirmed there were no problems with the delivery truck reported to her and she was not aware of any temperature variances of food items received at the Arlington campus that required corrective action.

Review of the Refrigerated Truck Delivery temperature log indicated a notation on the form as follows: "Refrigerated Truck temperature Range 34(degrees) F to 41(degrees) F" The documented inside truck temperatures were as follows:

Breakfast Lunch Dinner
6/27/13 40 45 59
6/28/13 59 55 58
6/29/13 54 45 44
6/30/13 60 46.1 52

Under "Comments/Corrective Actions" the following was documented for those dates: "Need to figure out new process."

For July 2013, the recorded temperatures were as follows:

Breakfast Lunch Dinner
7/1/13 54 50 61
7/2/13 52 53 62

Under "Comments/Corrective Actions" the following was documented for those dates: "Need to make sure truck restarted every 15 mins (minutes). Consider timer for driver? If temp (temperature) is over goal hold truck & have driver "drive" the truck to speed up cooling."

From June 27, 2013, to July 2, 2013, of the eighteen documented "Inside Truck" temperatures, only one was in the desired range listed on the monitoring log (36 to 41 degrees F). There was no evidence the facility implemented corrective actions to ensure the refrigerated truck delivered patient meals at the desired temperatures on those dates.

Review of the forms titled, "Arlington's Tray Temperatures" consistently revealed cold food items were not maintained at the desired temperature (41 degrees F or below) during the re-thermalization process. Staff did not consistently implement corrective actions related to these findings. For example, on June 26, 2013, for the dinner meal, the receiving temperature of the milk was 41.8 degrees F. After re-thermalization, the temperature of the milk ranged from 47.2 to 51.6 degrees F (depending on the meal cart). On June 30, 2013, for the dinner meal, the receiving temperature of the cheesecake was 39.4 degrees F. After re-thermalization, the temperature of the cheesecake ranged from 42.7 to 54.3 degrees F (depending on the meal cart).

On July 2, 2013, at 2:05 p.m., in an interview with administrative staff, they stated the process of meal delivery to the Arlington campus was new, having started on June 25, 2013, and was due to be evaluated at the one week mark on July 2, 2013, and that is when corrective action was to be implemented. They confirmed awareness of temperatures that were out of range since the inception of the new process via the documented temperature logs.

Review of the facility policy titled, "Food and Nutrition Services" revealed it was the manager of food service responsibility to, "Maintain proper storage of perishable foods at 41 degrees F or below". The policy also indicated "Cold tables - must be able to keep cold foods below 41 degrees F".

The facility did not have existing policies in place to address the "A la Carte" meal delivery process to the Arlington campus, delineating responsibility for oversight of the process and when/what corrective action should be taken.

b. Meal delivery was noted to begin at noon. Dietary staff was noted to remove patient meal trays from a cart labeled "B/C Overflow" and separate the trays on two uncovered tray delivery units for transportation to Stations B and C respectively. The patient meal trays contained uncovered food items such as peach cobbler. The uncovered tray delivery carts were transported approximately 30-40 feet to the respective stations.

Once on the units, the uncovered tray carts that contained patient meal trays for delivery to patients, were simultaneously used to house "used" patient trays of those patients that were done consuming their lunch meal.

Further observation of trays intended for delivery to the ETS revealed the trays were removed from the enclosed cart and transported on uncovered carts to the ETS.

On July 2, 2013, at 2:05 p.m., in an interview with the Supervising Dietitian and Assistant Hospital Administrator at the Arlington campus, and on July 3, 2013, at 10:40 a.m., in an interview with the Infection Control and Prevention Coordinator, they acknowledged food should be transported in a manner that ensures food items are protected during delivery, and meal delivery carts should not be simultaneously used for clean and dirty patient trays.

Review of the facility policy titled, "Food and Nutrition Services - Revised April 2013" revealed, "Prepared food should be transported to other areas in closed food carts or covered containers."

c. During the meal delivery service, patient meal carts were noted to be placed in the hallway. The enclosed meal carts were noted with the doors open, while a foodservice worker counted the trays, while the open meal delivery carts exposed all patient meal trays. During this process, an environmental services employee was noted to be wheeling a barrel labeled as containing infectious linen, down the same hallway, in between the meal delivery carts.

On July 3, 2013, at 10:40 a.m., in an interview with the Infection Control and Prevention Coordinator, she acknowledged it was not sanitary practice for infectious linen to be transported down the hallway at the same time as meal delivery carts.

d. Arlington Campus Foodservice Workers were observed washing their hands at the handwashing sink in the nourishment area. During handwashing, soapy water was noted to be splashing on the counter next to the handwashing sink. An open box of clean gloves was noted to be stored on the counter, with droplets of soapy water overspray landing on the gloves.

On July 3, 2013, at 10:40 a.m., in an interview with the Infection Control and Prevention Coordinator, she acknowledged the gloves should have been stored elsewhere to prevent contamination or a splash guard should be in place to contain the overspray.

The Infection Control and Prevention Coordinator further stated that the infection control department was involved in conducting departmental rounds two times per year at the Arlington Campus. An Infection Control and Prevention nurse, present at the time of the interview, stated she had conducted rounds at the Arlington campus on June 27, 2013, to evaluate the "A la Carte" process. She stated she monitored temperatures and did not have any concerns. She confirmed she had not observed the meal delivery process or reviewed the temperature logs associated with the process.




28135



18918