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Based on staff interview and administrative document review, the hospital failed to have an organizational structure which took full legal responsibility for determining, implementing, and monitoring policies to ensure the provision of health care in a safe environment when the governing body failed to:

1 Develop and maintain a system to ensure Medical Staff By-Laws, Rules and Regulations were followed and medical staff were professionally qualified for the positions to which they were appointed and for the performance of privileges granted. (Reference C241).

2. Ensure the quality assurance program developed quality programs for nutrition care service and to ensure peer review was conducted prior to reappointment of medical staff. (Reference C330 and C337).

3. Oversee the contract for the registered dietitian who provided nutrition care. (Reference C292).

4. Ensure policies and procedures specifying the professional practices and duties expected of the consultant dietitian were developed and implemented for nutrition care services. (Reference C279).

The cumulative effect of these systemic problems resulted in the Hospital's inability to ensure the provision of quality health care in a safe environment.

Based on staff interview and administrative document review, the Critical Access Hospital (CAH) failed to have a governing body which took full legal responsibility for determining, implementing and monitoring policies when:

1. The Governing Body failed to ensure the Medical Staff leadership complied with the Medical Staff By-Laws, Rules and Regulations and The Medical Staff Peer Review Policy. Members of the Medical Staff who had previously been granted privileges did not have their work peer reviewed on a regular and consistent basis to ensure their competence. Four (4) of eighteen (18) members of the Medical Staff (MD 1, MD 4, MD 5, MD 6), who had previously been granted privileges, were not being peer reviewed on a regular and consistent basis.

2. The Governing Body failed to implement and monitor policies governing the organization of the nutrition care services and develop quality assurance programs to ensure compliance with hospital policy and provide quality health care.

These failures had the potential for all patients seen in the hospital to not receive quality health care.

Findings:

1. On 8/24/15 at 11 a.m., during an interview, CEO 2 stated he was the Chief Executive Officer of the facility and he understood he represented the governing body for the purposes of the interview. CEO 2 stated CC (Credentialing Coordinator) 3 was the Medical Staff credential coordinator of the facility. CEO 2 stated overseeing and managing the Medical Staff credential files was one of CC 3's responsibilities. CEO 2 stated as the Chief Executive Officer of the facility he had been made aware of the numerous problems and issues with the physician credential files including lack of documentation of peer review. CEO 2 stated he knew the peer review process had been instituted for assessing the competence of Medical Staff members previously given privileges, however, it was done on an irregular basis. CEO 2 stated he had made numerous efforts to discuss the Medical Staff issues (including peer review) with the Chief of the Medical Staff of the facility as a means of making him aware that they both had the responsibility for ensuring these duties were performed.

On 8/24/15 at 1:30 p.m., during concurrent interview and review of the credentialing and peer review process, 18 physician credential files were reviewed with CEO 2 and CC 3. CEO 2 and CC 3 agreed the review of the credential files indicated: a.) four (4) out of a total of eighteen (18) members of the medical staff (MD 1, MD 4, MD 5, MD 6), who had previously been granted privileges, were not being peer reviewed on a regular and consistent basis.

On 8/25/15 at 10:00 a.m., during an interview, CC 3 stated she was the Medical Staff credential coordinator. CC 3 stated overseeing and managing the Medical Staff credential files was one of her responsibilities. She stated both Medical Staff leadership and CEO 2 had been made aware of the numerous problems and issues with the physician credential files, including lack of documentation of peer review. She stated the credentialing process had been performed in a casual manner including the process for assessing medical staff members for competence after they were granted privileges. CC 3 stated the peer review process had been instituted for medical staff members previously given privileges and recently reappointed, however, it was done on an irregular and inconsistent basis. CC 3 stated the peer review process did not have the sufficient support, assistance or oversight from the Medical Staff leadership of the facility.

The hospital policy and procedure titled, "Medical Staff By-Laws and Rules and Regulations," dated 4/25/12, indicated "2.03 BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP: Each member of the Medical Staff shall: (b) Abide by the Medical Staff Bylaws and Rules and Regulations and lawful standards, policies, and rules of the Hospital and the Medical Staff; (c) Abide by all applicable laws and regulations of governmental agencies and integrate and utilize, wherever possible, applicable standards of the Joint Commission on Accreditation of Healthcare Organizations; (d) Discharge such Staff, committee, and service functions for which he/she is responsible by appointment, election, or otherwise; ... (g) Actively participate in and regularly cooperate with the Medical Staff in assisting the Hospital to fulfill its obligations related to patient care, including but not limited to patient care audits, peer review, utilization review, quality evaluation and related monitoring activities required of the Medical Staff, and in discharging such other functions as may be required from time to time; ..."

The hospital policy and procedure titled "Medical Staff Peer Review Policy" dated 1/16/13, indicated "Subject: Peer Review Activity: POLICY: Review of circumstances as outlined in this policy will be conducted by a peer physician(s) acting as agent(s) of ... Board of Directors and Medical Staff for purposes of fact finding and forwarded to the medical staff peer review committee for further review and/or action when necessary.
PURPOSE: To assist the medical staff in the development of strategies to continually enhance the safety and quality of patient care and professional conduct at ... I. CIRCUMSTANCES FOR PHYSICIAN & PRACTITIONER PEER REVIEW
A. Any aggregate or individual information derived from generic screens including routine audits, medical staff monitors, adverse or serious adverse events, event notification (incident or occurrence) reports, complaints from patients or staff, third party agencies or other sources of information within the hospital system that suggest possible deviation(s) from accepted standards of patient care, regulatory requirements or other policies that have been approved by the medical staff.
B. Performance of clinical procedures that fall outside the boundaries of documented competencies and approved privileges.
C. Potential clinical quality issue raised by another medical staff member or other clinicians or staff.
D. Disruptive/inappropriate conduct displayed by a physician or other professional practitioner. Examples of such conduct would include, but is not limited to, verbal or physical assaults of staff, patients, visitors, or other medical staff members, impertinent or inappropriate comments written in patient medical records or hospital records, unethical behavior, any suspicion of substance or alcohol use, or refusal to accept appropriate medical staff or committee assignments.
E. In the best interest of patient care and/or the safe and orderly functioning of the hospital, whenever action must be taken immediately to suspend summarily all or any portion of the clinical privileges of a practitioner, such action shall be in accordance with Section 11 of the Corrective Action /Fair Hearing Plan.
F. This Policy shall not be interpreted to replace or supersede any provisions of the Medical Staff Bylaws and Rules and Regulations and the documents associated therewith (e.g., Credentialing Manual, Corrective Action/Fair Hearing Plan). To the extent that there is any conflict between this Policy and the Bylaws, the Bylaws shall control.
II. PROCEDURES FOR PHYSICIAN & PRACTITIONER CASE REVIEW
A. Patient Safety and Quality Improvement (PSQI) Committee will note circumstances requiring review based upon standards developed by the PSQI personnel in conjunction with applicable medical staff committees.
B. PSQI will contact the Medical Director to inform him/her of the need for initial physician analysis, when the circumstances of the case appear to be professional provider-related. The Medical Director will be notified of non-sentinel events and/or unprofessional behavioral issues and requested to review the circumstances of the case or issue. Initial review will be completed in a timeframe that adequately assesses the issues and permits sufficient time to prepare a fair and complete evaluation of the case to the Peer Review Committee. In general, required review of non-sentinel events will be initiated within seven (7) days of notification of the Medical Director either by a verbal or e-mail. This timeframe is waived when the circumstances requiring review represent a series of incidents that only become significant in aggregate over an extended period of time.
Note: If the review involves a serious adverse event, the initial review will be initiated on the same day of recognition of the event.
C. The Medical Director may opt to conduct the review or delegate it to another physician member of the Peer Review Committee. In the event that equity of physician specialty cannot be accomplished with the existing physician members of the committee, the chair may utilize another member of the medical staff or obtain appropriate review from an external peer review physician.
D. A standardized review worksheet sheet [See Appendix A] will be utilized by the physician reviewer to provide consistency in the review process and will complete within 14 days.
E. If the findings from the initial review are to be presented for discussion at the Peer Review Committee, then the individual practitioner will be informed of the general question being investigated at least 72 hours in advance of the scheduled review by email, phone call or letter. The practitioner may provide input to the committee via the Medical Director, but will not be present during this initial discussion in order to facilitate an open dialogue..."

2. On 8/24/15 at 3:30 p.m., during an interview, CEO 2 acknowledged he was responsible for the operation of the hospital and contracted services. CEO 2 stated he had not reevaluated the contract for the Consulting Dietitian Agreement signed on 10/2/14 with the consultant dietitian.

Review of the contract dated October 1, 2014 indicated the Hospital would establish standards for professional practice and duties for the nutrition consultant. The Hospital would have policies and procedures in place for the contracted registered dietitian (RD) to complete nutrition assessments. CEO 2 acknowledged there were no additions to the contract to establish standards of professional practice nor were there policies and procedures developed for completing nutrition assessments for the contracted consulting dietitian services.

Based on observation, interview, clinical and administrative document review the hospital failed to ensure policies were developed and implemented for the provision of services to patients when:

1. There were no policies and procedures to direct patient nutrition care, for acute and swing bed patients, that were approved by the medical staff and governing body resulting in the potential for nutritionally compromised patients to not receive adequate nutritional interventions. (Reference: C279).

2. The infection control program did not adequately monitor cleaning, sanitizing, and maintenance practices for the kitchen ice making machine resulting in the potential to cause food borne illness. (Reference C278).

3. Nutritional services furnished under contract did not enable the hospital to comply with conditions of participation resulting in the potential for nutritional services not being furnished in accordance with nationally recognized standards for nutrional care. (Reference C292).

4. Policies were not adhered to that ensured expired medications were not available for patient use resulting in the potential for patients to suffer harm due to ineffective or unavailable medications. (Reference C276).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, staff interview, administrative document review, manufacturer guidelines, and accepted standards of practice, the hospital failed to ensure policies governing the use of drugs were followed when expired medications were found available for use in patient care areas.

These failures resulted in the potential for patients to suffer harm due to ineffective or unavailable medications.

Findings:

1. On 8/24/15 at 10 a.m., during a concurrent staff interview and observational tour of the inpatient area of the hospital, two opened multi-dose vials (more than one dose of medication in a container) of insulin (a drug used to lower the amount of sugar in the blood.) were observed in a medication refrigerator. One vial was labeled Humalog Lispro. A hospital sticker on the vial indicated an expiration date of 8/3/15. The Director of Nursing (DON) stated, "That should have been pulled [discarded]." The second opened multi-dose vial was Humulin R. There was no facility sticker to indicate the expiration date. The DON stated there should be an expiration sticker on the vial. She stated there was no way to know when the vial was opened or when it should be discarded. This had the potential to cause medication error.

According to the manufacturer's website, ".... In-use Humalog vials... must be used within 28 days or be discarded...."

According to the manufacturer's website, ".... In-use [Humulin-R] vials must be used within 31 days or be discarded...."

According to the Center for Disease Control (CDC), ".... If a multi-dose [vial] has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial ...."

2. On 8/24/15 at 10:23 a.m., during a concurrent interview and observational tour of the hospital Emergency Department, the following medications were present in the medication cabinet:

a. One 10 milliliter (ml) multi-dose vial of folic acid (a B vitamin) injection, 5 milligrams (mg)/ml, opened date of 7/21/15. Registered Nurse (RN) 1 stated, "That should have been pulled four days ago."

b. Eight racepinephrine (used to open restricted breathing passages) inhalation solution packets expiration dated July 2015. The DON stated, "Those should have been pulled July 31, 2015."

c. Acetaminophen (used for fever, pain and swelling) 500 mg, three tablets individually blister packed (individually sealed in plastic), expiration dated 12/2014.

According to the Food and Drug Administration (FDA) article "Don't Be Tempted to Use Expired Medicine," expired medications can be less effective or risky due to a change in chemical composition or decrease in potency.

d. Lomotil (medication used for diarrhea) 2.5 mg pills in a taped envelope. A portion of the envelope was cut off and resealed with tape. The envelope indicated on 8/22/15 the number of pills inside the envelope was six. A review of the narcotic count sheet indicated eight pills should have been in the envelope. The DON stated, "Yes, there's supposed to be eight." Five pills were removed from the envelope by the DON. She stated there were no additional pills in the envelope. There was no legible expiration date on the envelope.

On 8/25/15 at 11 a.m., during an interview, the Consultant Pharmacist (CP) stated, "I haven't checked the drug storage area of the emergency room." When asked why this hadn't been done, the CP stated, "I had checked the refrigerator [in the emergency department]. It's a little new to me still. I was overwhelmed."

The administrative document titled, "Memorandum of Understanding," between the facility and their consulting pharmacist, dated June 19, 2015 indicated, "....The policies and procedures for the hospital, oversight of the medication storage in the emergency department, inpatient unit, and the clinics intend to maintain... services that meets or exceeds all business and industry standards... PHARMACIST services to include... Oversight of the medication storage areas in the emergency department (ED), inpatient unit and clinics..."

The facility policy and procedure titled, "Disposition of Discontinued, Outdated, or Poorly Labeled Medications," dated 3/25/2015, indicated "Nursing or pharmacy will remove all outdated and discontinued medication and all medication containers that have worn, illegible, or missing labels from patient care areas...."

The facility policy and procedure titled, "Monitoring and Accountability," dated 6/4/2015, indicated "All controlled medications, narcotics, hypnotics and other drugs with high abuse potential (Class II, III, IV and V), including [facility] stock and patients' own medications, shall be accounted for at the beginning of each shift..."

According to the Drug Enforcement Agency, Lomotil is a schedule V drug with the potential for abuse.

Based on observation, interview, and administrative document review, the hospital failed to ensure the infection control program included maintenance of the kitchen bin style ice machine in a sanitary condition.

This failure had the potential for the spread of food borne illness to all acute hospital patients who received ice from the food service ice machine.

Findings:

On 8/24/15 at 7:30 a.m., during an concurrent observation and interview, the Dietary Service Supervisor (DSS) stated the ice machine was new and was installed on June 8, 2015. The DSS stated the ice holding bin had been cleaned by the dietary department monthly. Examination of the log for ice machine bin cleaning determined the bin was cleaned in July and August.

The interior of ice machine was observed and wiped with a clean white paper towel above the bin and below the ice harvester (ice maker) bar. The paper towel showed a pink substance had accumulated on the bar. The DSS stated this area was not cleaned by dietary when cleaning the ice bin.

On 8/26/15 at 8:45 a.m., during an interview, the Infection Control Nurse (ICN) stated she was surprised that there was a pink substance found in the new ice machine. The ICN stated she and the DSS were monitoring the ice machine monthly.

Review of email dated 8/25/15, from the ice machine manufacturer to the facility, titled, "pink mold," dated 8/25/15, indicated "it is likely mold or yeast from the air in the machine ...if the machine is exposed to this; it can grow quickly in the warm, moist parts of the ice machine."

According to the Center for Disease Control and Prevention (CDC), Ice and Ice Machines Recommendations, dated 10/2/2011, pathogenic microorganisms (bacteria and viruses that cause sickness) may be present in ice, ice storage chests, and ice-making machines. Some water born bacteria found in ice could potentially be a risk to immunocompromised (immune system is weakened or absent) patients if they consume ice or beverages with ice.

Based on interview and administrative document review, the hospital failed to develop and implement written patient care policies for nutrition care (refer to C400).

This failure placed patients at risk of compromised medical status.

Findings:

Review of Consulting Dietitian Agreement, dated October 1, 2014, indicated standards of professional practice and duties of consulting dietitian shall be established by the hospital and the consultant dietitian shall complete nutritional assessments according to the hospital policies and procedures.

On 8/24/15 at 3:30 p.m., during an interview, the Chief Executive Officer (CEO) 2 confirmed there were no written policies and procedures specifying the professional practices and duties expected of the consultant dietician.

On 8/26/15 at 9:10 a.m., during an interview, the Dietary Services Supervisor (DSS) stated in a meeting on 8/24/15, she, the Nurse Manager of Acute, and the consultant Registered Dietician had reviewed the sending and returning of admission nutrition screen logs. The DSS stated they were working on a policy and procedure for Nutritional Assessment, Intervention, and Monitoring, including dietitian referral, but this was not finished.

Based on interview and administrative document review, the hospital failed to ensure nutrition services, furnished under contract, allowed the Hospital to comply with applicable Conditions of Participation when there was no evaluation of contracted Registered Dietitian (RD) services.

This failure places all patients at risk of compromised nutritional and medical status.

Findings:

On 8/24/15 at 3:30 p.m., during an interview, the Chief Executive Officer (CEO) 2 stated the Consultant Dietitian Agreement, dated October 1, 2014, had not been updated and did not include provisions for evaluation of services provided by consultant dietitian. CEO 2 stated that since the contract had been in effect, he had not implemented any changes to ensure the contracted services provided to patients who received nutrition care met standards of practice. CEO 2 acknowledged he had not established any standards of practice for nutrition care practices.

Review of the contract dated October 1, 2014 indicated the Hospital would establish standards for professional practice and duties for the nutrition consultant. The Hospital would have policies and procedures in place for the contracted RD to complete nutrition assessments. CEO 2 acknowledged there were no additions to the contract to establish standards of professional practice or policies and procedures developed for completing nutrition assessments.

Based on staff interview and administrative document review, the hospital failed to ensure the development and evaluation of quality assurance review when:

1. The Governing Body failed to ensure the Medical Staff leadership complied with the Medical Staff By-Laws, Rules and Regulations and The Medical Staff Peer Review Policy(Reference C337).

2. The hospital failed to develop and implement an ongoing quality program to reflect the scope of the nutrition care program that provided performance improvement based measures. (Reference C337).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, staff interview and administrative document review, the hospital failed to have an effective quality assurance program that evaluated the quality and appropriateness of care provided to patients when:

1. Peer review was not conducted on a regular and consistent basis for Four (4) of eighteen (18) members of the Medical Staff (MD 1, MD 4, MD 5, MD 6) who had previously been granted privileges prior to reappointment to the medical staff.

2. The hospital failed to develop and implement an ongoing quality program to reflect the scope of the nutrition care program that provided performance improvement based measures.

These failures resulted in the potential for patients for receiving inadequate care.

Findings:

1. On 8/24/15 at 11 a.m., during an interview, the Chief Executive Officer (CEO) 2 stated he understood he represented the governing body for the purposes of the interview. CEO 2 stated the Credential Coordinator (CC) 3 was the Medical Staff credential coordinator of the facility. CEO 2 stated overseeing and managing the Medical Staff credential files was one of CC 3's responsibilities. CEO 2 stated as the Chief Executive Officer of the facility he had been made aware of the numerous problems and issues with the physician credential files including lack of documentation of peer review. CEO 2 stated he knew the peer review process had been instituted for assessing the competence of Medical Staff members previously given privileges, however, it was done on an irregular basis. CEO 2 stated he had made numerous efforts to discuss the Medical Staff issues (including peer review) with the Chief of the Medical Staff of the facility as a means of making him aware of the fact that they both had the responsibility for ensuring these duties were performed.

On 8/24/15 at 1:30 p.m., during a concurrent interview and review of the credentialing and peer review process, 18 physician credential files were reviewed with the Chief Executive Officer (CEO 2) and Medical Staff Coordinator (CC 3). The CEO 2 and CC 3 agreed the review of the credential files indicated: a.) four (4) out of a total of eighteen (18) members of the medical staff (MD 1, MD 4, MD 5, MD 7) who had previously been granted privileges were not being peer reviewed on a regular and consistent basis.

On 8/25/15 at 10:00 a.m., during an interview, CC 3 stated she was the Medical Staff credential coordinator of the facility. CC 3 stated overseeing and managing the Medical Staff credential files was one of her responsibilities. She stated both Medical Staff leadership and CEO 2 had been made aware of the numerous problems and issues with the physician credential files, including lack of documentation of peer review. She stated the credentialing process had been performed in a casual manner including the process for assessing medical staff members for competence after they were granted privileges. CC 3 stated the peer review process had been instituted for medical staff members previously given privileges and recently reappointed, however, it was done on an irregular and inconsistent basis. CC 3 stated the peer review process did not have the sufficient support, assistance or oversight from the Medical Staff leadership of the facility.

A signed copy of the Medical Staff By-Laws and Rules and Regulations dated 4/25/12 indicated on page 5, "2.03 BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP Each member of the Medical Staff shall: ... (b) Abide by the Medical Staff Bylaws and Rules and Regulations and lawful standards, policies, and rules of the Hospital and the Medical Staff; (c) Abide by all applicable laws and regulations of governmental agencies and integrate and utilize, wherever possible, applicable standards of the Joint Commission on Accreditation of Healthcare Organizations; (d) Discharge such Staff, committee, and service functions for which he/she is responsible by appointment, election, or otherwise; ... (g) Actively participate in and regularly cooperate with the Medical Staff in assisting the Hospital to fulfill its obligations related to patient care, including but not limited to patient care audits, peer review, utilization review, quality evaluation and related monitoring activities required of the Medical Staff, and in discharging such other functions as may be required from time to time;"

A signed copy of the Medical Staff Peer Review Policy dated 1/16/13 states " Subject: Peer Review Activity POLICY: Review of circumstances as outlined in this policy will be conducted by a peer physician(s) acting as agent(s) of the [the hospital] District Board of Directors and Medical Staff for purposes of fact finding and forwarded to the medical staff peer review committee for further review and/or action when necessary.

PURPOSE: To assist the medical staff in the development of strategies to continually enhance the safety and quality of patient care and professional conduct at [the hospital]. CIRCUMSTANCES FOR PHYSICIAN & PRACTITIONER PEER REVIEW Any aggregate or individual information derived from generic screens including routine audits, medical staff monitors, adverse or serious adverse events, event notification (incident or occurrence) reports, complaints from patients or staff, third party agencies or other sources of information within the hospital system that suggest possible deviation(s) from accepted standards of patient care, regulatory requirements or other policies that have been approved by the medical staff. Performance of clinical procedures that fall outside the boundaries of documented competencies and approved privileges. Potential clinical quality issue raised by another medical staff member or other clinicians or staff. Disruptive/inappropriate conduct displayed by a physician or other professional practitioner. Examples of such conduct would include, but is not limited to, verbal or physical assaults of staff, patients, visitors, or other medical staff members, impertinent or inappropriate comments written in patient medical records or hospital records, unethical behavior, any suspicion of substance or alcohol use, or refusal to accept appropriate medical staff or committee assignments. In the best interest of patient care and/or the safe and orderly functioning of the hospital, whenever action must be taken immediately to suspend summarily all or any portion of the clinical privileges of a practitioner, such action shall be in accordance with Section 11 of the Corrective Action /Fair Hearing Plan. This Policy shall not be interpreted to replace or supersede any provisions of the Medical Staff Bylaws and Rules and Regulations and the documents associated therewith (e.g., Credentialing Manual, Corrective Action/Fair Hearing Plan). To the extent that there is any conflict between this Policy and the Bylaws, the Bylaws shall control. PROCEDURES FOR PHYSICIAN & PRACTITIONER CASE REVIEW Patient Safety and Quality Improvement (PSQI) Committee will note circumstances requiring review based upon standards developed by the PSQI personnel in conjunction with applicable medical staff committees. PSQI will contact the Medical Director to inform him/her of the need for initial physician analysis, when the circumstances of the case appear to be professional provider-related. The Medical Director will be notified of non-sentinel events and/or unprofessional behavioral issues and requested to review the circumstances of the case or issue. Initial review will be completed in a timeframe that adequately assesses the issues and permits sufficient time to prepare a fair and complete evaluation of the case to the Peer Review Committee. In general, required review of non-sentinel events will be initiated within seven (7) days of notification of the Medical Director either by a verbal or e-mail. This timeframe is waived when the circumstances requiring review represent a series of incidents that only become significant in aggregate over an extended period of time.

Note: If the review involves a serious adverse event, the initial review will be initiated on the same day of recognition of the event. The Medical Director may opt to conduct the review or delegate it to another physician member of the Peer Review Committee. In the event that equity of physician specialty cannot be accomplished with the existing physician members of the committee, the chair may utilize another member of the medical staff or obtain appropriate review from an external peer review physician.

A standardized review worksheet sheet [See Appendix A] will be utilized by the physician reviewer to provide consistency in the review process and will complete within 14 days.

If the findings from the initial review are to be presented for discussion at the Peer Review Committee, then the individual practitioner will be informed of the general question being investigated at least 72 hours in advance of the scheduled review by email, phone call or letter. The practitioner may provide input to the committee via the Medical Director, but will not be present during this initial discussion in order to facilitate an open dialogue..."

2. On 8/26/15 at 9:10 a.m., during an interview, the Dietary Services Supervisor (DSS) stated the dietary department had continued two of the quality plans for hair nets and sanitizer. The DSS stated they had added one new quality measure for patient meal tray accuracy for food service. The DSS stated they had added one plan to monitor the nursing nutrition screen sent to the consultant Registered Dietitian (RD) and the return of the screening tool. The DSS stated they had not added any quality plans to monitor the competencies of the consultant RD, the quality of the nutrition assessments process, or timeliness of the nutrition assessments.

On 8/26/15 at 10 a.m., during an interview, the Director of Nursing (DON) stated the quality plan should include evaluation and validation of the nursing admission nutrition screening tool to ensure it accurately identified patients with nutritional needs.

On 8/26/15 at 11 a.m., during an interview, the Director of Quality (DQ) stated there were no quality measures developed and evaluated for patient nutrition care in the acute hospital setting that included developing standards of practice for nutrition care of patients or peer review of nutrition care provided. The DQ acknowledged they were working on plans, but did not know they needed to demonstrate substantial compliance.

Based on interview, clinical record and administrative document review, the hospital failed to ensure nutrition needs of inpatients were met by recognized dietary practices when:

1. One of four patients (Patient 8) reviewed for nutrition services did not have documentation of measurable follow up of moderate nutrition status.

2. One of four patients (Patient 9) was assessed at risk for inadequate fluid intake and poor oral intake. RD made nutrition recommendations, but there was no documentation of a system to review with physician and no implementation of a plan of care.

3. One of four patients (Patient 10) had a recommendation from the RD for a change in fluid restriction but there was no documentation or a system to review with physician and implement the recommendation. Patient 10 had a 4 pound weight loss which was not addressed. Nutrition assessment did not have a measurable follow-up schedule of nutrition status.

This failure had the potential to compromise patients nutritional status and overall recovery.

Findings:

1. According to Patient 8's clinical record, Patient 8 was admitted 8/18/15 with septic (infected) right knee. Patient 8 had an order for a vegetarian diet. Patient 8's albumin level was 1.7 g/dl (normal 3.5 to 5.0 g/dl).

The nutrition assessment dated 8/18/15 indicated Patient 8 was at increased nutrition risk related to low weight: height status with BMI 16.4 (body mass index indicator of nutrition status), poor intake, swallowing difficulty and infection. Nutrition assessment recommendations included a vegetarian diet with 3 small meals and 3 snacks per day, adding high protein, and pureed texture pending swallow evaluation. There was no follow up scheduled to reassess recommendations and nutrition status.

On 8/25/15 at 9:30 a.m., during an interview, the ANM confirmed there was no documentation in the medical record of the physician being notified of RD's recommendations or that Patient 8 was provided with increased protein and small meals with snacks. The ANM confirmed there was no system in place to notify the physician of RD's recommendations.

2. According to Patient 9's clinical record, Patient 9 was admitted 8/19/15 with syncope (short loss of consciousness and muscle weakness). Patient 9 was ordered a Regular diet on 8/25/15. The admission nursing nutrition screen indicated moderate nutrition risk based on nausea, and low albumin level.

The RD's nutrition assessment dated 8/20/15 indicated Patient 9 was at increased nutrition risk related to poor intake, fracture and infection. Fluid intake was inadequate. The assessment indicated fluid requirements were 1600 ml day. Recommendations included Mechanical soft diet with finely chopped meats, small frequent meals, and snacks with nutritional health shakes if meal intake was less than 50 percent. The follow-up on nutrition recommendations were not measurable. The RD indicated he would "remain available" for follow up.

On 8/27/15 at 10 a.m., during an Interview, the Director of Nurses (DON) acknowledged the admission nutrition screening tool used to evaluate patient nutrition status had not been evaluated and validated to ensure patients who were at nutritional risk were identified. The DON acknowledged there was no system in place to notify the physician of RD's recommendation and no system for nursing and RD follow-up of recommendations and hydration (body fluid balance) requirements.

3. According to Patient 10's clinical record, Patient 10 was admitted 8/3/15 with compression fractures. The physician ordered a regular diet with two liter fluid restriction per day. Patient 10's admission weight was 140 pounds and height was 5 feet 5 inches. Patient 10's weight on 8/20/15 was 136 pounds. Patient 10's albumin level on 8/4/15 and 8/25/15 was 2.2 g/dl (normal value 3.5 -5.0 g/dl).

Patient 10's nutrition assessment dated 8/4/15, indicated Patient 10 was at increased nutrition risk related to poor intake, altered electrolytes, and fractures. Patient 10 had compromised visceral (indicator of nutrition status) protein stores related to low albumin level. The recommendations were to consider a 1500 ml fluid restriction, and to offer ensure or other nutritional supplements.

On 8/25/15 at 10:30 a.m., during an interview, the ANM acknowledged she had reviewed the overall plan of nutrition care on 8/24/15. The ANM acknowledged there was no system to ensure the physician was notified of the RD recommendations and implementation of recommendations. There was no ongoing assessment of nutrition status, weight loss, continuing low albumen levels, or assessment of the effectiveness of the nutritional care.