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Based on record review and interview, the facility failed to ensure that 6 of 9 sample patients had the right to formulate advance directives in accordance with the facility's policies and procedures (Patient 1, 4, 5, 6, 7 and 8).

Findings:

1. On June 26, 2012 at 5:15 p.m., Patient l's medical record was reviewed with the director of medical record (Employee 1). Patient 1 presented to the emergency department (ED) on June 26, 2012 with bee sting. The demographics form item regarding advance directive indicated "U." During a concurrent interview, Employee 1 stated there was no further documentation regarding advance directive in the medical record.

2. Patient 4's medical record was reviewed on June 27, 2012. Patient 4 was 85 years old and presented to ED on June 25, 2012 with hematuria (blood in the urine). The patient was placed on observation with diagnoses which included urinary tract infection and hyponatremia and was discharged on June 26, 2012 at 7 p.m. The patient stayed in the facility for observation for 23 hours. During an interview on June 27, 2012 at 9:56 a.m., the medical record director stated there was no information about advance directive.

3. A review of the medical for Patient 5 revealed the patient presented to ED with chief complaint of head injury. A review of the demographics indicated "U" for advance directives. During an interview on June 27, 2012 at 10:25 a.m., Employee 1 stated there was no further information regarding advance directives.

4. The medical record for Patient 6 was reviewed on June 27, 2012 at 10:40 a.m. Patient 6 presented to ED on June 26, 2012 with acute bronchitis. The section for advance directive indicated "N". During a concurrent interview, Employee 1 stated there was no other information regarding advance directives.

5. Patient 7's medical record was reviewed with Employee 1 on June 27, 2012. Patient 7 presented to ED on September 13, 2011 at 1:40 p.m., for complaint of abdominal pain. The section for advance directive was blank. During an interview at 11:30 a.m., the same day, Employee 1 stated there was no information regarding advance directive.

6. Patient 8's medical record was reviewed on June 27, 2012 at 3:15 p.m. The patient's face sheet indicated "U" for advance directives. The record indicated the patient was a critical access hospital inpatient and was discharged to "swing bed" on June 24, 2012. On June 27, 2012 at 4:30 p.m., the Chief Patient Care Services (CPCS) was interviewed. CPCS stated they (staff) were supposed to ask the patients and give information on advance directives. CPCS further stated this concern had been identified. The CAH's policy and procedure on advance directives was requested.

On June 28, 2012 at 2 p.m., two facility's policies and procedures were provided. The Advance Directives policy dated January 2001 indicated all adult hospital and clinic patients would be provided with a pamphlet, "Your Right to Make Decisions about Medical Treatment" upon admission, which informs the patient of his or her rights under State law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatments and the right to formulate advance directives. The Resident's Rights policy and procedure dated February 2001 indicated each resident has the right to refuse treatment and to formulate advance directives.

Based on record review and interview, the facility failed to ensure that a pain assessment was performed on 1 of 9 sample patients (Patient 7) at the same time as the vital signs were obtained.

Findings:

Patient 7's medical record was reviewed with Employee 1 on June 27, 2012. Patient 7 presented to the emergency department (ED) on September 13, 2011 at 1:40 p.m., for complaint of abdominal pain. The record indicated a CT (computed tomography) scan of the abdomen showed partial distal small bowel obstruction. The patient was transferred to an inpatient unit at 6:02 p.m., for specialized care.

The medical record indicated a pain scale of 10 out of 10 upon admission to the ED. The patient was given Dilaudid medication for pain.

On June 27, 2012 at 11:20 a.m., when asked to for the vital signs and pain assessment, Employee 1 reviewed the electronic record and stated there was no pain assessment when vital signs were taken upon discharge.

A review of the facility's Pain Assessment! Pain Management policy indicated that all patients admitted to the hospital emergency room or acute care setting would have a pain assessment done as the fifth vital sign. The pain assessment would be documented on the emergency room record along with the vital signs.
According to the Health and safety Code, Section 1254.7 (b) Pain Assessment and Treatment, "Every health facility licensed pursuant to this chapter shall, as a condition of licensure, include pain as an item to be assessed at the same time as vital signs are taken. The health facility shall ensure that pain assessment is performed in a consistent manner that is appropriate to the patient. The pain assessment shall be noted in the in a patient's chart in a manner consistent with other vital signs."

Based on observation, interview and document review, the facility failed to ensure that any construction or alteration of the facility, was in conformance with Title 24, California Administrative Code. The evaluator observed a CT (Computerized Tomography) trailer behind the hospital building. The CT trailer did not have written approval by the authority having jurisdiction.

Finding:

On June 26, 2012 between 11:13 a.m. and 2:39 p.m. accompanied by the maintenance supervisor the evaluator observed a CT trailer behind the hospital building.

The CT trailer was parallel to the hospital 9 feet and 1 inch away from the side of the hospital with a pop-out that was 6 feet 6 inches away from the side of the hospital. The CT trailer received its power from a 3 phase, 300 amp panel in the hospital which ran to a transformer which supplied the CT trailer.

On June 28, 2012 at 10:45 a.m. during an interview the radiologic technologist stated the CT trailer serviced all the sections of the facility but about 90% was for emergency room services.

On June 28, 2012 at 12:35 p.m. during an interview the chief executive officer stated he did not recall any OSHPD (Office of Statewide Health Planning and Development) work as it referred to the CT trailer.

Record review revealed no documented evidence of OSPHD permits or approvals for the CT trailer. A review of the facility license disclosed the service was not included in the license.

According to California Code Regulations, Title 24, Part 1, Sections 7-113 and 7-135, before commencing construction or alteration of any facility, the governing body or authority shall submit an application for plan review to OSPHD and shall obtain the written approval by OSPHD.


19582

On June 26, 2012 at 11:40 a.m., during tour of the emergency department, the Radiology Technician stated they perform CT (Computed Tomography) scan. A review of Patient 7's medical record on June 27, 2012 indicated a CT (computed tomography) scan of the abdomen was performed on the patient on September 13, 2011.

Based on observation and interview, the facility failed to provide a hygrometer or other humidity measurement instrument in the operating room. The facility also failed to provide documented evidence deficiencies listed during the medical gas inspection were corrected.

Findings:

1. On June 27, 2012, between 10:24 a.m. and 10:41 a.m., accompanied by the maintenance supervisor, the evaluator observed there was no hygrometer in the operating room (OR). When asked how the facility knows what the humidity level is in the OR, the maintenance supervisor stated "I don't believe we do."

2. On June 27, 2012, accompanied by the maintenance supervisor, a review of a report from a medical gas inspection made on February 24, 2011 revealed the report indicated "The system is in satisfactory condition as of the date of inspection, with the exception of items listed on the "Comments" page". During an interview, the maintenance supervisor stated that the February 24, 2011 report was the only documentation he had. By the end of the survey the facility failed to provide a corrections page/list, a more current inspection report or other documentation indicating the corrections were made.

The Comments page listed:

a. Some of the oxygen outlets throughout the facility do not meet current minimum flows. It is our opinion that the low flow from these outlets is due to an old style outlet (possibly a 238 or 248 series Chemtron) that uses a ball check type secondary test valve. The design of the secondary check restricts the flow. At present there are no known upgrades for these outlets. Medgas 1 has no suggestions as to increase flow other than to replace these outlets with current generation outlets. A list of low flowing outlets can be found on page A1.

b. The oxygen manifold is equipped with relief valves that are safety devices and will vent excess gas in case of component failure. If a regulator fails, these relief valves will vent into room instead of being piped outdoors as required, causing an oxygen rich environment. These relief valves should be piped outdoors in a manner described in NFPA 99.

c. The vacuum pumps are a dental-type that do not meet NFPA 99 standards regarding medical vacuum systems. Deficient areas include exhaust location, electrical components, and alarm wiring.

d. The oxygen system does not have a high pressure switch for the master alarm panel. (There is a low pressure switch). This high pressure switch is requested by NFPA 99, 2005. If a regulator fails, pressure may increase in the pipeline without warning. A medical gas type oxygen switch and associated wiring should be installed.

e. The oxygen manifold does not have a source valve as required by NFPA 99, 2005.

Outlet Verification Sheet Page A1 dated February 23, 2011 indicated rooms 4, 5 and 6 had low flow. Room 4 had "O2 Low flow 180", room 5 had "Low flow", and room 6 had "Very low flow (< 100)." The comments on the page indicated "Outlets listed above are old style possible Chemetron 238 series converted with 400 series faceplates. This is the cause of low flow. (Secondary check valve restriction.)"

Zone Valve Verification Sheet B2 dated February 23, 2011 indicated the flow shut off located at the reception area could not be checked. The comments on the page indicated "This valve is not a 1/4-turn ball valve." "The valve listed above may leak if used." "We do not recommend using this valve except in an emergency."

Master Alarm Sheet C6A dated February 23, 2011 for the Medical Vac. Line Pres. Low signal had comment "Signal is not functioning at this time."

Page E9 undated for Medical Vacuum Pump had comments "This a dental-type vacuum system. While this pump performs adequately for the hospital's minimal needs, it does not qualify as a medical vacuum system in compliance with NFPA 99 standard."

Based on observation, the facility failed to ensure the premises were clean and orderly.

Findings:

On June 26, 2012, between 11:13 a.m. and 2:39 p.m,. accompanied by the maintenance supervisor, the evaluator observed the following:

1. A blanket like material and duct tape wrapped around a sewer line in the basement.

2. Peeling and chipping paint at the kitchen wall near the water cooler, above and next to the exterior door, and at kitchen cabinets including those next to and over food preparation areas.

3. There was a large cardboard box and an accumulation of lumber under a Computerized Tomography (CT) mobile unit.

4. There were seven torn out rodent proofing mesh screens at the north and east exterior wall vents.

On June 27, 2012, between 10:41 a.m. and 11:36 a.m., accompanied by the maintenance supervisor, the evaluator observed the following:

5. There was ceiling lamp fixture above the medication room at the nurses station was missing the diffuser.

6. There was an accumulation of dust at the fan cover in the Radiology storage room, bathroom of room 3, nurses station and at the fire radio at the nurses station.

7. There was tape peeling from light switch in the operating room.

8. There was tape across the ceiling in the observation room.

Based on review of dietary service policy and procedure manual and staff interview, the facility failed to ensure that the governing body approved the policies and procedure of the hospital's dietary department.

Finding:

Review of the policy and procedure (P/P) manual of the hospital's dietary department revealed that the approval face sheet was last signed on October 8, 2011 by the food service director and not by the governing body. There were no other signatures in the manual for 2012. The consultant dietitian identified that the signatures were missing in her March 2012 report but the policy and procedure manual did not have the necessary signatures as of June 2012.

The reviewed P/P manual contained many blanks that needed to be completed in order that it was customized to the facility. There were policies in the manual that were outdated because procedures had changed due to electronic medical record and delivery of diet orders to the kitchen.

In an interview with the hospital chief executive officer at approximately 12:30 p.m. on June 26, 2012, he stated that the governing had not approved the policies of the dietary department in the six years he had been in the position.

Based on observation, interviews, document reviews and manufacturer's instructions, the hospital failed to ensure the dietetic service department met the needs of all patients as evidenced by the failure to:

1. Provide an organized dietetic service department as evidenced by findings of lack of supervision of the dietary department.

2. Have an effective system to ensure that physicians' orders were followed as evidenced by inaccurate tray cards.

3. Ensure the nutritional needs of all patients were met as evidenced by the failure to prepare all items on the menu and use of correct scoop sizes.

4. Ensure the nutrition screening and assessments were completed timely.

5. Ensure food was prepared in a safe manner, as evidenced by the incorrect consistency of the pureed diet.

6. Ensure the dietary employees were knowledgeable in the activities of the dietetic department as evidenced by the failure to use the correct scoop sizes for meal service, inability to test the chemical concentration of the chemical sanitizer and calibrate food thermometers.

7. Ensure the recommendations of the registered dietitian were followed up as evidenced by the lack of a system to have physicians acknowledge receipt of recommendations.

8. Ensure that the policy and procedure manual were approved by the governing body and updated as evidenced by presence of blanks and policy that do not match current practices.

9. Ensure that gloves were used appropriately as evidenced by the failure to change gloves in between loading of dirty dishes and unloading clean dishes (refer to C 279).

The cumulative effect of these systemic problems resulted in the inability of the hospital's dietetic department to direct staff in a manner to ensure that the nutritional needs of patients were met in accordance with practitioner's orders and acceptable standards of practice.

Based on observations, staff interviews, and record reviews, the facility failed to develop, implement and/or enforce policies for stocking, storage, and handling of drugs in accordance with accepted professional principles.

Findings:

1. On June 26, 2012, during a tour of emergency department, there was a yellow, unmarked, unlocked, 4-drawer crash cart located by inside a room marked "surgery room." The chief executive officer stated the facility did not perform surgery.
The "surgery room" was primarily used for overflow when all the beds in the emergency department were occupied. The "surgery room" was not locked.

At 5:30 p.m., during an inspection of the yellow cart, Nurse 3 confirmed that there was no content list posted anywhere on the unlocked yellow cart. Nurse 3 also stated the cart might have been there for four months and was not sure who stocked the cart. Further inspection revealed the yellow cart contained a fraction of the recommended emergency supplies to treat malignant hyperthermia (MH, a rare but potentially lethal adverse effect of commonly used general anesthetic gases and succinylcholine; succinylcholine is muscle relaxant used by physicians during emergency procedure to insert artificial airways [intubation] into patients with extreme difficulty in breathing). A defined list of supply has been published by the Malignant Hyperthermia Association of the United States (MHAUS) and the Association of Peri-Operative Registered Nurses (AORN), two nationally recognized organizations that set standards of care for this rare but deadly adverse medical outcome.

On June 27, 2012, at 8:40 a.m., the chief of patient care services (CPCS) stated the unmarked, unlocked, yellow cart located in the surgery room of the emergency department was the MH cart. The CPCS agreed the MH cart should have been labeled as such and a content list be included and posted on the outside of the cart as with other emergency carts.

At 4 p.m., during an interview with the facility's pharmacy consultant, the consultant stated the implementation of the MH cart had been discussed in the past P&T committee meetings; however, she stated she was not aware that the facility had already implemented the MH cart.

A review of the facility's plan of correction for a survey conducted on February 23-25, 2011, revealed the facility was to complete the implementation of the MH cart and policy by July 29, 2011.

On June 28, 2012, at 10:15 a.m., the CPCS stated the MH policy & procedure had not been approved by the committee yet. The CPCS further stated the last review of such policy was at a "Medication Safety Committee" meeting that was held in August 2011. The CPCS admitted the above mentioned plan of correction for the previous survey had not been followed through or carried out as planned.

2. On June 26, 2012, at 1:40 p.m., the surveyor observed a medication refrigerator located in the drug storage area of the open nursing station, underneath the back counter and outside of the locked medication room. The medication refrigerator was not locked. During an inventory count with Nurse 1, there were 89 counts of medications stored in the medication refrigerator. The inventory included 25 counts of lorazepam injectable vials (a controlled substance generally used as a tranquillizer).

On June 27, 2012, at 5:16 p.m., surveyor observed the medication refrigerator was left unlocked again.

A review of another facility's policy and procedure, titled "controlled substances," dated April 17, 2007, " ...stored controlled substances are to be kept under lock ... "

A review of the facility's policy and procedure, titled "pharmaceutical storage policy" , dated March 26, 2007, " all drugs must be stored in a secure manner (locked cabinets) with access limited to authorized personnel only ... "

3. On June 26, 2012, at 5:45 p.m., during an inspection of the adult crash cart located in the emergency department with Nurse 3, the content of the sealed tray was compared to the content list posted on the cart. Three counts of medications (2 of lidocaine 2% injectables and 1 of sodium chloride syringe) were missing from the sealed tray. Two counts of medications (aminophylline, used to treat difficulty in breathing) were found to have already expired on "1 JUN 2012."

A review of the facility's policy and procedure, titled " expired medications, " dated April 17, 2007, " ...Drugs that are nearing expiration are removed from stock ... "

4. On June 27, 2012, at 11:30 a.m., during an inspection of the medication cabinets located in the nursing unit with Nurse 4, there was an unsealed portable container labeled as
"Ami Kit" located in the upper right cabinet above the nursing station sink. The container did not have a content list and there were emergency medications inside.

At 12:15 p.m., during an inspection of the medication room, there was an opened, unsealed tray containing 31 counts of various emergency medications. There was no content list. Nurse 1 stated the tray served as one of the two extra emergency medication trays for the crash cart.

At 12:45 p.m., the CPCS confirmed that the "Ami kit" was an emergency transport kit to be used when transferring patient out of the facility to higher level of care. The CPCS agreed that the kit and the tray should be sealed and the contents should be listed on the outside of the container.

At 4 p.m., during a telephone interview, the pharmacist stated she was not aware of the
"Ami kit."

This is contrary to the applicable California Code of Regulations, Title 22, section 70263 (f)(2) " ...the emergency drug supply shall be stored in a clearly marked portable container which is sealed by the pharmacist ...The contents of the container shall be listed on the outside cover ..." Also, according to section 70263 (f)(3) "The supply shall be inspected by a pharmacist ...no less frequently than every 30 days ..."

Based on observation, review of hospital documents, policies and procedures, menus and staff interviews, the hospital failed to ensure that the food and dietetic service was organized in manner that met recognized dietary practices, orders of the physicians and the nutritional needs of the patients. The person in the position of food service director (FSD) was away from the hospital and expectations to be gone for about three weeks. There was no assistant or temporary director hired to manage the department in her absence. Identified deficient practices could be directly tied to the lack of leadership and/or absence of the FSD in this department.

Dietetic staff was not competent or trained in the activities of the department including testing of chemical sanitizer, food thermometer calibration, knowledge of food preparation policy during disaster, improper use of gloves resulting in cross-contamination of clean dishes. In addition, patient food preferences were not being completed, nutrition screening and assessments were not routinely done for as long as two weeks, patient menus was not planned in advance and approved by the dietitian, diet orders were not followed due to tray card errors menu not followed resulting in less food being served to patients.

Finding:

1. In an interview with the hospital's chief executive officer on June 26, 2012 at approximately 12:30 p.m., he stated that the hospital's food service director was away from the hospital and on medical leave with plans to return three weeks later. In an interview with the dietetic staff on June 26 and June 27, 2012 confirmed that there was no assistant director or temporary replacement for the food service director position.

According to interview with the dietetic staff on June 26, 2012 and review of undated hospital policy and procedure, titled "Food Service Policy," "The FSS (food service supervisor/director) will obtain food preferences and will complete page 1 of the nutritional assessment form." This responsibility was not performed on three sampled residents reviewed.

According to an interview with the chief nursing officer on June 26, 2012 at approximately 6:00 p.m., the diet orders are sent to the dietetic service department via the electronic medical record system. The FSD accesses the information to provide food to the patients. The diet order is used to develop tray cards which food service employees use to prepare and dish out food for patients. Review of tray cards of six of six patients in the hospital, revealed that four of the six patients were served the incorrect diets due to errors on the tray cards. The tray cards of one resident had not been updated for over a year and five months. Resident 4's most current diet order is regular diet, ordered on June 24, 2012. Her tray card and diet served is 1800 calories, small portions ordered on January 27, 2011.

Observation in the kitchen on June 26, 2012 revealed the presence of a laptop computer. Dietary staff stated that the orders come to that computer but that they do not have any access to the computer or able to retrieve diet orders in the absence of the foodservice director. Review of the electronic medical record for Resident 4 revealed the status of all the diet orders entered as "incomplete ." According to the undated hospital policy titled "Verify Tray Cards," it is vitally important to have systems intact to assure that every individual receives a meal each time. The procedure states "three separate lists will be made with each individual's name .....the lists will be kept to date by the FSS or appointed staff " . The hospital failed to follow its own policy to ensure that patients receive the correct meal each time.

In an interview with the consultant dietitian on June 27, 2012 at approximately 11:50 a.m., she stated that it was also the responsibility of the FSD to ensure that the tray cards are accurate in order that diet ordered by the physician was what is served to the patients. In an interview was not conducted with the FSD due to her absence from the hospital.

2. Review of the contract showed that the hospital entered into a contract with a consulting dietitian company on March 17, 2011, to provide 16 hours a month of services. Interview with the nursing staff indicated that a registered dietitian visits the hospital about once a month. Review of the consultant dietitian reports from February 2012 to June 2012 showed that the RD visited the hospital once every month for about seven and a half hours a month. These hours were less than what was contracted for and did not meet the nutritional needs of the patients. The RD failed to ensure that recommendations were followed up or acknowledged by the physicians. She failed to identify system failures in the dietetic department. She failed to approve menus in advance. She failed to conduct nutrition assessment on one sampled Patient 8 in a timely manner.

Review of the clinical record of Patient 8 showed that she was admitted to the hospital on June 18, 2012 and transferred to the skilled nursing unit on June 24, 2012 for rehabilitation services. As of June 27, 2012, there had been no nutrition assessment or screening completed on this patient, nine days after admission.

There was no documented evidence of a nutritional screening by the foodservice director or assessment by the registered dietitian. Review of clinical record for Resident 2 revealed that a nutrition assessment was conducted on May 18, 2012. The RD recommended a change in diet to a regular diet. As of June 27, 2012, Resident 2 was on a finely chopped diet. The diet change recommendation was never acknowledged by the physician.

In an interview with the RD on June 27, 2012 at approximately 11:38 a.m. she stated that she leaves her patient referrals and recommendations for physicians with the chief patient care services (CPCS) and the FSD for them to follow up with the physicians on her behalf. She did not indicate when she followed up on the referrals or recommendations to ensure they were acknowledged by the physicians.

In an interview with the CPCS on June 27, 2012 at approximately 4:10 p.m., she acknowledged the presence of a form and system as described by the RD. review of the Nutrition Recommendation Form dated May 18, 2012 indicated that the RD made recommendations for seven patients. There was no evidence that the physicians acknowledged the receipt of the form including recommendation. The DON stated that there was no system in place to check whether the physician received the recommendations. She explained that a clip board is hung outside the door to the office of the physician on it are the recommendations. She does not follow up and neither does the RD.

On June 27, 2012, the dinner menu was non- specific. It read "Resident's Choice for all the items from the main entree to the dessert. Dietary Employee (DE) 1 was asked at approximately 10:00 a.m. what was being planned for dinner. She stated that she was not sure and that she would prepare something for the patients. When pressed further for the specific food, she stated "Macaroni and Cheese, everyone likes it." When she was reminded that the patients ate grilled cheese the night before and cheeseburger for lunch, she stated that she will think of something else, what the residents had not had for a while, "maybe soup." There was no evidence that the items would meet the nutritional needs of the patients. None of the dietary employees suggested calling the consultant RD for guidance. The RD had not approved or planned the menu for the dinner meal on June 27, 2012.

In the interview with the RD on June 27, 2012 at approximately 11:38 a.m., she stated that it was the responsibility of the FSD to identify the resident's choices and plan the meal. She stated that in the absence of the FSD, her responsibilities (including menu planning) will be passed on to other kitchen staff. None of the kitchen staff are qualified or trained in menu planning. She acknowledged she has not approved any of the menus.

3. Three dietary employees were not able to either correctly calibrate a food thermometer, use proper measuring equipment to serve patient meals, use gloves appropriately, test the chemical concentration of the sanitizer in the dish machine, follow the menu and/or correctly prepare menu items for all patients. The lack of competency of these activities placed patients at the risk of food borne illness, inadequate nutrition that could result in weight loss.

During kitchen observations from June 26 to June 27, 2012, several deficient practices were observed. At approximately 10:23 a.m., on June 27, 2012, Dietary Employee 2 (DE 1) was asked to check the chemical (chlorine) concentration of the dish machine. She immersed the test strip in the water in the machine for approximately 45 seconds and then matched the strip to the color strip on the container. She then asked the surveyor whether she had followed the correct procedure.

Review of manufacturer's instructions indicated that DE1 had not followed the correct procedure. The instructions on the label indicated "Immerse the strip in sample and remove immediately. Hold strip level (do not shake off excess). Evaluate the color between 5 and 10 seconds after removing the test strip from sample." She stated in an interview that she did not routinely test the chemical concentration of the dish machine and that it was usually done by the facility engineer.

In an interview with the facility engineer on June 27, 2012 at approximately 4:40 p.m. revealed that he does not test the chemical concentration of the machine. Based on both interviews, it was unclear whether the chemical concentration of dish machine was being monitored.

At approximately 10:40 a.m. on June 27, 2012, Dietary Employee 2 was observed loading dirty dishes and unloading clean dishes without changing gloves. The use of the same gloves she loaded dirty dishes would result in the cross contamination of clean dishes with soiled gloved hands.

At approximately 1:00 p.m. on June 27, 2012, Dietary Employee 2 was asked to calibrate the thermometer prior to testing food, she stated that she did not know how to calibrate the thermometer because that was one of the activities performed by the food service director(FSD).

Two thermometers were tested for accuracy using the ice water method. Both thermometers were out of calibration. Neither was 32 degrees Fahrenheit when immersed in ice water. This implied that all the food temperatures taken with both thermometers were inaccurate. It is unclear how long the thermometers had been out of calibration. The lack of credible temperature readings would give dietary staff a false sense of security that food was being properly held at the proper temperature for meal service. The recommended food storage temperature is below 41 degrees and greater than 140 degrees Fahrenheit. Food improperly held could result in improper food storage temperature that could lead to the growth of microorganism. In addition, food held at the incorrect temperature may become unpalatable due to improper holding temperatures.

Dietary staff did not use the correct scoop size to dish out food. The dinner menu on June 26, 2012 revealed that patients were to be served the following: Grilled Cheese Sandwich (2oz cheese), French Fries (10 fries each), ? cup Cucumber and Onion Salad, ? cup Chilled Peaches, and 8 oz whole milk . The residents were served 5 pieces of French fries, instead of 10 fries and 2.6 oz cucumber and onion salad instead of 4 oz of salad.

On June 27, 2012, the lunch menu was missing a menu item, marinated vegetables. Review of the menu indicated that the vegetable dish was to be prepared with cauliflower, carrots, broccoli, celery, vinegar and onions. This omission resulted in patients not receiving the calories and vitamins especially A & C that are present in vegetables.

Dietary Employee 2, who was responsible for meal preparation, was interviewed on the lack of the salad on patient trays at approximately 3:35 p.m. on June 27, 2012. She stated that she just simply forgot to prepare the vegetables.

Dietary Employee 1 was interviewed on the emergency menu. She was able to plan what she would feed patients in the event of an emergency. Her plans , however, did not match the hospital's emergency plan.

Employee training documentation was not available to be reviewed because the FSD was away from the hospital during the survey and staff training information was not available for review.

The nutritional needs of the patients were not being provided according to community standards of practice and facility policy and procedure. Nutritional screening and assessments were not completed due to the absence of the FSD and the inadequate visits by the consulting RD. These resulted in patients receiving incorrect diets being served.

Menus were not followed as written. Dietary staff did not prepare (eliminated) the menu items, used incorrect scoop sizes to serve patients. Dietary staff also used a set of preconceived rules to serve patients on diabetic diets. In an interview with Dietary Employee 1 on June 26, 2012 at approximately 5:30 p.m., she indicated she gives patients half portions of the starches on the meal. There was no therapeutic diet spreadsheet used in the service of food to patient. She stated she had been taught to prepare the meals that way to prevent blood sugar from rising. The employee's method of food service could result in weight loss due to inadequate calories.

The consistency of puree food was incorrect. During meal observation on June 27, 2012 at approximately 12:30 p.m., random observation of a patient on pureed diet revealed menu items in a divided plate. Each of the items was thin and runny. The consistency of pureed diet should be that of mashed potato. A tray card that read chopped items was observed on June 26, 2012 at approximately 5: 30 p.m. not to be properly chopped. The grilled cheese was cut into two. The nurse stated the diet was appropriate for the patient concerned because the diet had been changed. However, had the patient's diet had not been changed it would have created a choking hazard because dietary staff were not aware that his diet had been changed due to lack of an updated tray cards.

Based on record review and interview, the facility failed to ensure for each patient the record was complete to include a consent form that contains the date and time consent was obtained for 3 of 9 sample patients (Patient 1, 5 and 6).

Findings:

On June 26, 2012 at 5:15 p.m., Patient l's medical record was reviewed with the director of medical record (Employee 1). Patient 1 presented to the emergency department (ED) on June 26, 2012 with bee sting. The consent for medical treatment was signed with no date and time.

A review of the medical record for Patient 5 revealed the patient presented to ED with chief complaint of head injury. The forehead laceration was sutured. The consent for medical treatment was signed with no date and time.

The medical record for Patient 6 was reviewed on June 27, 2012 at 10:40 a.m. Patient 6 presented to ED on June 26, 2012 with acute bronchitis. The consent for medical treatment was signed with no date and time.

During an interview on June 27, 2012 at 10:40 a.m., Employee 1 acknowledged the consent for medical treatment had no date and time. Employee 1 reviewed the electronic medical record (EMR) and stated, not in EMR either.

Based on record review and interview, the facility failed to ensure comprehensive assessment was completed for 2 patients (Patient 7 and 8.)

Findings:

1. Patient 8's medical record including electronic record was reviewed on June 27, 2012 at 3:15 p.m., with Nurse 1. The record indicated the patient was a critical access hospital inpatient and was discharged to "Swing" on June 24, 2012. The patient had a history fall at home and had a right total hip arthroplasty. The Fall and Braden Assessment was blank.

When asked for the initial assessment and care plan, while reviewing the electronic medical record, Nurse 1 stated there was no initial assessment. Nurse 1 also stated, "The care plan was initiated yesterday based on my daily assessment."

At 4:30 p.m., the same day, CPCS was informed of the lack of an initial assessment, fall and Braden assessment for Patient 8. CPCS stated Patient 8 requires an entirely new, complete initial assessment.

2. The closed medical record for Patient 9 was reviewed on June 28, 2012 with Employee 1. The record disclosed the patient was admitted to acute inpatient on June I, 2012 due to pain following a fall and was discharged and transferred to "Swing" on June 3, 2012. The patient was discharged on June 25, 2012. An initial assessment for acute inpatient was in the medical record. Employee 1 was not able to find an initial assessment for the "Swing" admission.

At 9:15 a.m., the same day, CPCS was informed of the lack of initial assessment for Patient 9 when transferred to "Swing", CPCS stated Patient 9 requires an entirely new and complete initial assessment.