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Based on review of the current QA/PI Plan (Quality Assurance/Performance Improvement) and patient and staff interviews, the hospital failed to identify through the QA/PI process problems related to dietary services and the failure of new admits to receive their prescribed diet in a timely manner. Findings:

In an interview on 1/03/2011 at 8:30 AM S2 ADON (assistant director of nursing) reported patients are informed during admission on ordering meals and that the hospital provides full room dietary services where the patient selects the menu items and meal times and orders their meal per telephone. S2 further stated if a patient is unable to order meals, the nurses automatically places the patient on VIP status which means dietary delivers the meals at a certain time each day. He stated hostesses from dietary services round on the VIP patients each day and assists the patients in choosing the foods allowed on their prescribed diets. S2 added that the phone number to order meals is posted on the wall in each patient room and a reminder flashes on the television screen when the set is on. S2 further stated the nurses do not have anything to do with meals except to enter patient diets into the computer system.

Observations and interviews held on 1/03/2011 between 9:15 AM and 10:00 AM revealed patients #3, #4 and #8 reported to the survey team that when they were admitted, staff did not inform them on how to order their meals. The patients stated they were admitted on the evening shift and did not receive their first meal after admit until midmorning the following day because they did not know how to order the meal.

In an interview on 1/04/2011 at 12:45 PM, S6 PSA (patient services assistant) stated she works the 7AM-7PM shift on the telemetry unit and many patients complain they were not instructed on how to order their meals. S6 said she tells the patients to call the number posted on the wall and to not hang up because it may take a few minutes for dietary services to answer because of the volume of patients placing orders.

On 1/04/2011 at 12:00 PM an interview was held with S7 LPN who stated she hears "lots of complaints" about dietary services and added that many of their elderly patients have difficulty ordering their meals. She added that nurses must determine which patients need VIP status and assistance in obtaining their meals.

On 1/03/2011 at 2:13 PM an interview was held with S4 RD (registered dietitian) Dietary Director who stated the hospital had provided full room dietary services for 8 years and that it worked well for approximately 75% of patients. She explained that approximately 25% of the patients must be made VIP and these patients were identified on admit by the admitting nurse. S4 said the dietary hostesses try to visit all patients within 24 hours of admit at which time they explain the process for ordering meals and identify other patients who need VIP status. S4 further stated she had not received complaints that patients were not informed on how to order their meals and this was not an indicator that dietary services tracked through the QA/PI program.

On 1/04/2011 at 1:00 PM an interview with S5 RN Telemetry Supervisor revealed she was aware that telemetry and other units in the hospital had problems with patients missing their breakfast meal after admit. S5 stated she knew there was a problem with the night staff not informing new patients on how to order their meals and she had discussed this with the nurses. S5 stated many elderly patients do not understand the ordering procedure and their first tray would be missed. S5 further stated she identified the problem but had not taken it through the QA/PI process to gain insight about how the hospital can optimize dietary services and ensure patients are informed and understand how to order their meals.

An interview on 1/05/2011 at 8:25 AM with S9 RN/3rd Floor Charge Nurse revealed she had received complaints that patients call and call before they get through to the dietary department to order their meals. S9 stated sometimes the night nurses do not realize a patient cannot read or has poor vision and when the day shift begins, they identify the patient has special needs and notifies dietary services to make the patient VIP. In an interview on 1/05/2011 at 8:30 AM S10 RN/4th Floor Charge Nurse reported that sometimes family will come to the desk and say their family member needs a meal tray and did not know how to order it.

Review of the hospital's QA/PI Plan (reviewed 4/09) revealed the hospital's commitment was to improve the quality of care they deliver, ensure patient safety, deliver optimal care and achieve patient satisfaction. Further review revealed, "Every department is responsible for implementing quality improvement activities".

I. Based on review of 3 of 6 open medical record (patients #3, #4 and #8) in a total sample of 8, review of policy titled, "Meal Service" (no reference #) and patient and staff interviews, the registered nurse (RN) failed to supervise and evaluate the nursing care for each patient to ensure each patient received their prescribed meals. This was evidenced by the failure of the RN to: 1) ensure each new patient was informed of the process for ordering full room dietary services provided by the hospital and 2) identify patients with special needs that require assistance with meals. Findings:

1. On 1/03/2011 at 9:15 AM patient #3 was observed sitting at bedside with mild shortness of breath noted while speaking. The patient stated she was admitted on 1/01/2011 with complaints of chest pain and was not told about ordering her meals. Patient #3 further stated she had not been hospitalized for several years and was not aware that the hospital offered full room dietary services until her family member told her how to order her meals. The patient stated she did not receive her first meal after admit until midmorning because staff did not tell her how to order it.

2. On 1/03/2011 at 9:48 AM patient #4 was observed in bed clutching her left rib section and reported that she had 5 fractured ribs. Patient #4 stated she was admitted on 12/29/2010 and did not receive a breakfast tray until midmorning on 12/30/2010 because no one informed her on how to order her food.

3. On 1/03/2011 at 10:00 AM patient #8 was observed in bed and reported she had just received an analgesic for pain. Patient #8 reported she was admitted on 1/02/2011 and was not informed on how to order her meals.

In an interview on 1/03/2011 at 8:30 AM S2 ADON (assistant director of nursing) reported patients are informed during admission on ordering meals and that the hospital provides full room dietary services where the patient selects the menu items and meal times and orders their meal per telephone. He further stated if a patient is unable to order meals, the nurses automatically places the patient on VIP status which means dietary services delivers the meals at a certain time each day. He stated hostesses from dietary services rounds on the VIP patients each day and assists the patients in selecting food items allowed on their prescribed diets. S2 added that the phone number to order meals is posted on the wall in each patient room and a reminder flashes on the television screen when the set is on. S2 further stated the nurses do not have anything to do with meals except to enter patient diets into the computer system.

An interview on 1/04/2011 at 12:45 PM with S6 PSA revealed she works the 7:00 AM-7:00 PM shift on the telemetry unit and many patients complain that they were not instructed on how to order their meals. She stated when she begins her shift; it is her routine to ask patients if they ordered their morning meal. S6 said she tells the patients to call the number posted on the wall and to not hang up because it may take a few minutes for dietary to answer because of the volume of patients placing orders.

In an interview on 1/04/2011 at 12:00 PM S7 LPN stated she hears "lots of complaints" about dietary services and added that many of their elderly patients have difficulty ordering their meals. She added that the nurses must determine who needs to be placed on VIP status so that meals are delivered at a set time and for dietary hostesses to daily visit each VIP patient to assist in meal options. S7 said it was difficult for the nurses to know when patients received their meals because dietary services delivers the tray to patient rooms, places the tray on the bedside table and leaves. S7 said if the patient is unable to reach the tray or hearing or cognitively impaired, the tray sits on the table until nursing gets there to assist the patient with the meal.

An interview on 1/03/2011 at 2:13 PM with S4 RD (registered dietitian) Dietary Director revealed the hospital had provided full room dietary services for 8 years and that it worked well for approximately 75% of patients. She explained that approximately 25% of the patients must be made VIP and these patients were identified by the nurse on admit. S4 said the dietary hostesses try to visit all patients within 24 hours of admit at which time they explain the process for ordering meals and identify other patients who need VIP status. S4 further stated she had not received complaints that nurses were not informing patients on how to receive their meals.

On 1/04/2011 at 1:00 PM an interview with S5 RN Telemetry Supervisor revealed she was aware that telemetry and other units in the hospital had problems with patients missing their breakfast meal after admit. S5 stated she knew there was a problem with night staff not informing new patients on how to order their meals. S5 stated many elderly patients do not understand the ordering procedure and their first tray would be missed.

An interview on 1/05/2011 at 8:25 AM with S9 RN/3rd Floor Charge Nurse revealed she received complaints that patients call and call before they get through to the dietary department to order their meals. S9 stated sometimes the night nurses do not realize a patient cannot read or has poor vision and when the day shift begins, they identify patients with special needs and notifies dietary to make the patient VIP. In an interview on 1/05/2011 at 8:30 AM S10 RN/4th Floor Charge Nurse reported that sometimes family will come to the desk and say that their family member needs a meal tray and did not know how to order it.

II. Based on review of 1 of 2 closed medical records of patients who were admitted with diagnoses of chest pain and atrial fibrillation in a total sample of 8, review of policy titled "Peripheral IV (revised 12/05/2010) and staff interviews, the RN failed to supervise and evaluate the nursing care for each patient to ensure policies and procedures were followed for IV site care. This was evidenced by a nurse applying sticky adhesive tape over the IV site of an elderly patient (#1) which created discomfort and a small skin tear when the nurse attempted to remove the tape, when hospital policy indicated the use of hypoallergenic tape for anchoring IV dressings. Findings:

In an interview on 1/04/2011 at 12:00 PM S7 LPN stated she recalled discontinuing the IV for patient #1 who had a "pink tape" anchoring the IV dressing to the patient's skin. S7 further stated they use the pink tape to secure nasogastric tubes to skin and it was often difficult to remove. S7 LPN said when she went to remove the pink tape from patient #1's IV site, it pulled the skin so she used multiple alcohol swabs in an attempt to loosen the tape and prevent skin tearing. S7 stated there was one small skin tear after the process and that she did not remove all the tape for fear of further damage to the skin. S7 said she instructed the patient's daughter to apply warm compresses to the IV site to facilitate further loosing of the pink tape and to prevent another skin tear.

Review of policy titled Peripheral IV revealed hypoallergenic tape should be used for IV sites. In an interview on 1/05/2011 at 8:45 AM the survey team asked S12 RN/Charge Nurse-Telemetry if she used the pink tape on IV sites. S12 responded, "I use it if that's all I have in my pocket".