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Based on observation, interview, and document review, the facility failed to ensure that patient care areas in the Imaging (x-ray) Department and the Nursery were arranged and maintained to ensure patient safety. This had the potential for patients to be exposed to radiation and receive unsafe care.

Findings:

1. During a tour of the Imaging (x-ray) Department on 4/16/12, two x-ray rooms were observed. Both rooms had adjacent bathrooms used by patients. Each bathroom had two doors that could be locked from inside. The first door led from an area used by patients to change their clothes. The second door led directly into the x-ray room. There was no mechanism in place on that second door to prevent a patient from entering the radiology room during an exam, when patients are exposed to radiation for the purpose of creating images of their bones and other body structures.

During an interview on 4/16/12 at 2 pm, the Imaging Services Manager confirmed that there was no means to lock the doors to prevent a patient from entering the x-ray rooms from the adjacent bathrooms. He stated that a patient entering the x-ray room during an exam could be exposed to unnecessary radiation.

2. The Nursery was observed on 4/19/12. There were three spaces designated for infant warmers/cribs. Two of the spaces were occupied with a combination of office furniture medical equipment. The remaining space of the nursery was used as an office. There was only adequate room for one infant warmer/crib to be used safely.

During an interview on 4/19/12 at 8:45 am, the Chief Executive Officer stated that the Nursery served as a "multipurpose room." He stated that the nurses used the room to write in patient records and give report to each other at shift change. He also stated that the physicians used the area to complete paperwork.

During an interview on 4/19/12 at 8:50 am, RN 3 stated that the nursery became very crowded with people and equipment when there were multiple births. Too many staff and pieces of equipment in the room would cause difficulty in providing proper care to the newborns.

Based on food storage observations and dietary staff interview, the hospital failed to store the disaster food supply within the licensed building. Failure to store foods within the hospital's footprint may result in the unavailability of the food supply in the event of a disaster. Failure to ensure a food supply within the certified hospital may compromise patient nutritional and medical status.

Findings:

During review of disaster meal planning on 4/16/12 beginning at 1:40 pm, it was noted that while the hospital had adequate food supplies, not all supplies were stored within the foot print of the hospital.

In a concurrent interview, FSM stated that several years ago the hospital was cited by the county for storing too many boxes within the kitchen as it was a life safety hazard; after which the supplies were moved to a temperature controlled manufactured structure in a back parking area. It would be the expectation that all supplies, including food, required for disaster preparedness would be stored within the approved critical access hospital.

Based on observation, interview, and record review from 4/16/12 through 4/19/12, the facility failed to have an effective organizational structure that included the definition, development, implementation, and maintenance of processes that would have prevented:

1. The hospital's inability to provide infection control services and care in a safe and effective manner accordance with the statutorily-mandated Condition for Coverage for Infection Control Services. (Refer to C 278)

2. The inability of the hospital'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 practitioner orders and acceptable standards of practice. (Refer to C 279)

3. The inability of the hospital's dietary and quality assurance and performance improvement program for food services to ensure a program that evaluated the effectiveness of the services provided through the food and nutrition services department. (Refer to C 336)

Based on observation, interview, and record review, the facility failed to have a governing body legally responsible for the total operation of the facility related to dietary and infection control practices.

Findings:

Observation, interviews, and record review from 4/16/12 through 4/18/12 determined that the facility failed to:

1. Have effective systems in place to provide an environment to avoid sources and transmission of infections and communicable disease. (Refer to C 278)

2. Ensure that dietary services met the needs of all patients. (Refer to C279 and C 336)

Based on observation, interview, and medical record reviews the hospital failed to:

A. Provide an environment to avoid sources and transmission of infections and communicable disease as evidenced by the hospital's failure to have effective systems in place, as evidence by:

1. Endoscopes were not stored in accordance with hospital policy and nationally accepted standards (Refer to C 278).

2. Shared patient equipment was not effectively disinfected between each patient use in accordance with nationally accepted standards (Refer to C 278).

3. Provide a functional and sanitary environment for the provision of surgical services so that the types of surgery conducted can be performed in a manner that protects the lives and assures the physical safety of all individuals in the area, in accordance with hospital policy and nationally accepted standards (Refer to C 278 item 3a and 3b).

4. Participating physicians were not consistently screened for infectious diseases, including blood borne pathogens in accordance with its policy and nationally accepted standard (Refer to C 278, item 4).
The cumulative effects of these systemic problems resulted in the hospital's inability to provide infection control services and care in a safe and effective manner in accordance with the statutorily-mandated Condition for Coverage for Infection Control Services.




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B. Ensure that dietary services met the needs of all patients as evidenced by failure to:

1. Develop comprehensive organizational structure to ensure the nutritional needs of patients were met (Cross Reference C279);

2. Develop performance improvement activities that accurately reflected the scope and nature of the services (Cross Reference C336);

3. Ensure safe and effective food storage/production practices (Cross Reference C279);

4. Ensure maintenance of equipment per manufacturer's instructions (Cross Reference C279);

5. Ensure that patients at nutritional risk received comprehensive nutrition assessments by a Registered Dietitian (Cross Reference C279)

The cumulative effect of these systemic problems resulted in the inability of the hospital'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.

Based on interview and record review, the facility failed to ensure that licensed nurses checked and/or properly documented daily the checks for the defibrillator (defib) and oxygen tanks on five crash carts within the facility. The lack of daily defibrillator and oxygen tank level checks on the crash carts could potentially put patients at risk if either failed to work during an emergency situation (cardiac or respiratory arrest). The daily check of the defibrillator and oxygen tanks assures the user that the equipment was functional within the last 24 hours, and the documentation of the checks provides the information that the checks were actually completed.

Findings:

During a record review on 4/17/12, a facility policy and procedure (P&P) titled, "Crash Cart Check," last reviewed 2/10, indicated a daily check was to be conducted by a licensed nurse. The P&P also indicated the nurse would refer to the crash cart check list and document the presence of all items on the cart as well as the functioning of the monitor/defibrillator daily according to the manufacturer's recommendation.

The crash cart lists kept on each cart had spaces for each date for the day shift or night shift nurse to sign their name, document the defibrillator check, the lock number of each cart, and the oxygen tank check. The instructions printed at the head of the column for the defibrillator and oxygen tank checks indicated a checkmark was to be placed in the dated space if the checks were completed.

During review of the crash cart lists (for the emergency room pediatric [ER-Peds], ER cardiac room [C-Room], ER treatment room [T-Room], and the medical/surgical [M/S] unit adult and pediatric carts) multiple blank spaces were found that indicated the defibrillator and/or oxygen tanks had not been checked for those days.

The following information lists the number of days in each recorded month the checks were not completed or documented for the individual crash carts:

1. ER-PEDS crash cart:
November 2011's defib checks - 27 of 30; oxygen checks - 27 of 30
January 2012's defib checks - 14 of 31; oxygen checks - 8 of 31
February 2012's defib checks - 3 of 29; oxygen checks - 3 of 29

2. ER-C-Room crash cart:
January 2012's defib checks - 7 of 31; oxygen checks - 4 of 31
February 2012's defib checks - 2 of 2; oxygen checks - 4 of 29
March 2012's defib checks - 3 of 31; oxygen checks - 5 of 31

3. ER-T-Room crash cart:
January 2012's defib checks - 1 of 31
February 2012's defib checks - 1 of 29; oxygen checks - 1 of 29
March 2012's defib's checks - 4 of 31; oxygen checks - 7 of 31

4. M/S Adult crash cart:
January 2012's defib checks - 22 of 31; oxygen checks - 4 of 31
February 2012's defib checks - 8 of 29; oxygen checks - 1 of 29
March 2012's defib checks - 3 of 31; oxygen checks - 1 of 31

5. M/S Pediatric crash cart:
January 2012's defib checks - 24 of 31; oxygen checks - 31 of 31
February 2012's defib checks - 22 of 29; oxygen checks - 29 of 29
March 2012's defib checks - 14 of 31; oxygen checks - 23 of 31

During an interview on 4/17/12 at 8:30 am, the registered nurse manager (RNM 1) of the emergency department stated that a checkmark in the spaces where they were required, per the checklist, indicated the checks of the equipment were completed.

During an interview on 4/17/12 at 9:15 am, the Chief Nursing Officer (CNO) stated that since the crash cart checklists instructed the nurses to place checkmarks in the dated spaces, if the spaces were left blank it would mean either the nurses forgot to check the space or the defibrillator and oxygen checks were not completed.

The documented information that the defibrillator checks were done was important to verify the crash cart equipment was functional and ready should an emergency situation arise.

Based on observation, interview, and medical record review, the facility failed to provide an environment to avoid sources and transmission of infections and communicable disease, as evidenced by the hospital's failure to have effective systems in place to ensure a powerful hypnotic drug (a drug that causes sedation) was disposed of in a safe manner.

Findings:

On 4/16/12 at 2:55 pm, multiple syringes with 5 to 15 milliliters of a milky white substance contained in syringes were observed in large blue and white pharmaceutical waste containers in (Operating Rooms 1, 2, and 3). The waste containers had large lids, approximately 6 x 6 inches wide that were flipped half -way back and held an absorbent cloth (to absorb the wasted drugs) that did not cover the entire bottom of the container.

The contents of the pharmaceutical containers were readily accessible and easy to reach in and obtain any used substance. Environmental staff persons as well as nursing staff were observed entering and exiting the operating rooms that held these substances to perform various tasks.

On 4/16/12 at 3 10 pm during an interview in Operating Room 3, ICN and NM 2 identified the syringes containing the milky white substances as Propofol (also known as Diprivan, a powerful hypnotic drug). NM 2 stated it was not the hospital practices to place syringes, that contained medication, in the waste container intact with the medicine inside the syringe. NM 2 acknowledged the medication was and should not be readily accessible to hospital staff person and she indicated immediate action to remedy the situation was required.

Based on food service observations, dietary staff and nursing staff interview, and dietary document review, the hospital failed to

1. Ensure all food production practices were implemented in a manner that would prevent potential foodborne illness.

2. Provide an environment to avoid sources and transmission of infections and communicable disease as evidenced by the hospital's failure to have effective systems in place, as evidence by:

*Endoscopes were not stored in accordance with hospital policy nationally accepted standards. An endoscope can consist of. a rigid or flexible tube; a light delivery system to illuminate the organ or object under inspection.

*Shared patient glucometers were not effectively disinfected between each patient use in accordance with manufacture's recommendations and nationally accepted infection control guidelines.

*Provide a functional and sanitary environment in surgery so that the types of surgery conducted can be performed in a manner that protects the lives and assures the physical safety of all individuals in the area in accordance with hospital policy and nationally accepted standards when:
a. Appropriate surgical attire was not worn in the perioperative areas.
b. Temperature and humidity was not maintained per hospital policy in the hospital operating rooms.

*Participating medical staff was not screened or vaccine preventable diseases in accordance with hospital policy and nationally acceptable infection control standards.

Findings:

1. During general kitchen observations on 4/16/12 beginning at 1:30 pm, it was noted that dietary staff was taking food items from the buffet type salad bar and placing the items back in the walk in refrigerator. In a concurrent interview with FSW2, the surveyor asked to describe the process for breaking down the salad bar. FSW2 stated that at the end of the lunch meal service the items would be covered, dated, and would be used for the ensuing days until the items were gone. In a concurrent interview on 4/17/12, FSM was asked to provide a reference for the observed food handling practice.

In an interview on 4/18/12 at 9 am, the observed practice was discussed with RD 1. The surveyor queried if she had identified this as a practice that might result in cross contaminations. RD 1 stated that she was contracted only for medical nutrition therapy and had no foodservice responsibilities. In a follow up interview on 4/18/12 10:30 am, FSM acknowledged that she was unable to provide a reference. It would be the standard of practice that once foods items such as those on a typical salad bar would be discarded after the meal service rather than held for ensuing days.

In an interview on 4/18/12 beginning at 11 am, CNO stated she was unaware that the RD did not have any foodservice oversight responsibilities. She also stated indicated that these responsibilities might be included in the RD's contract. On 4/18/12 at 1 pm, a review of the hospital's contract with the RD confirmed that the RD's contract was limited to medical nutrition therapy.

In an interview on 4/18/12 beginning at 1:30 pm with RT 1, the position responsible for Environment of Care (EOC) rounds, she stated that rounds in the dietary department, which was considered an ancillary service, would happen on a yearly basis. She further stated that the EOC rounds consisted primarily of departmental safety issues, rather than food handling practices. She also stated that currently the infection control practitioner did not participate in the rounds.

Review of the hospital document titled, "Environment of Care Inspection Checklist," dated 12/12/11, confirmed that the EOC rounds of the department consisted of review of sprinklers, chemical storage, evaluation of fire suppression systems, along with an interview of a staff member regarding personal safety. There was no evaluation of food storage/handling practices. RT 1 also stated that she would rely on the department head to identify issues surrounding food handling practices.


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2. On 4/16/12 at 2:55 pm cabinet containing endoscopes was observed to have approximately ? inch of clear solution in the bottom of the cabinet in an Operating Room 3 in the hospital's perioperative area. The solution smelled like alcohol. In a concurrent interview, ICN acknowledged the solution on the floor of the endoscope cabinet smelled like alcohol. ICN indicated that she was not able to determine if the interior of the endoscopes were dry, and there was no system in place to ensure the scope was dry (internally) before it was next used.

During an interview conducted on 4/16/12 at 3:00 pm, Tech 1 indicated the endoscopes were flushed with alcohol and then hung in the cabinet in the operating room to air dry.

During an interview on 4/17/12 at 7 am, RNM 2 stated, "There was a miscommunication yesterday, our procedure is to flush the endoscopes with 90 mls of air after the alcohol is placed in the endoscopes." RNM 2 acknowledged the floor of the endoscope cabinet was found wet with alcohol solution and; therefore, the process for flushing the endoscope had not been adequate or not done. RNM 2 acknowledged the potential infection and fire hazard of using a scope still wet inside with alcohol in a procedure where there could be a source of ignition, i.e. with cautery.

The Association of Registered Perioperative Nurses (AORN) Standards and Recommended Practices, 2012 edition, under recommendation Vll of the section titled, "Recommended Practices for Cleaning and Processing Flexible Endoscopes and Endoscope Accessories" indicated "After rinsing the endoscope with 70% ethyl alcohol or 90% ethyl alcohol the channels should be dried using low pressure forced air. Using forced air assists with the removal of moisture remaining in the channels. Dry air channels do not support microbial growth."

An AORN Journal article titled, "Surgical Fires, Learn Not to Burn" published I n July 2004, advised "Surgical fires can occur in any setting where invasive procedures are performed and that fires occur in any setting where the three elements that form the fire triad (i.e. fuel, oxygen, heat) come together." The article further advised to minimize ignition, oxidizer, and fuel risks by allowing flammable liquid prep solutions to fully dry. The article emphasized the need to be aware of the flammability of solutions used during surgery and to take steps to avoid igniting their vapors.

The observed incomplete practices conducted by the staff put patients and staff at risk for infections associated with contaminated endoscopes and accidental fire that could result in serious illness, injury and death.

3. During an interview on 4/16/12 at 2 pm in the surgery post anesthesia care unit, RN 5 stated the shared patient LifeScan Sure Step Flexx glucometer (a machine that measures patient blood sugar levels) was cleaned once a day when the quality control check on the machine was done.

During an interview on 4/17/12 at 3:10 pm in the medical surgical patient area, RN 4 stated the shared patient LifeScan Sure Step Flexx glucometer was cleaned each time it was used and when visibly soiled. RN 4 stated she cleaned the glucometer with a cavicide wipe. When questioned, RN 4 indicated the cavicide solution had to remain wet on the machine for half a minute to one minute to kill the organisms.

During an interview in the emergency room on 4/17/12 at 11:30 am, RNM 1 indicated the LifeScan Sure Step Flexx glucometer was cleaned only when it looked soiled. She indicated she cleaned the glucometer a 10% bleach pad. RNM 1 searched the emergency area but was unable to locate the 10% bleach pads.

The hospital's policy for cleaning and disinfecting shared patient glucometers was requested on 4/18/12 at 9 am. ICN indicated the hospital had not developed a policy/procedure(s).

The ONLINE LifeScan web site under Professional Resources, accessed 4//18/12, stipulated "If a single meter is used to treat multiple patients, the meter must be cleaned and disinfected after each use whether or not blood contamination is suspected."

Review of the manufacturer's instructions for Cavicide, an EPA approved (46781-6) disinfectant, stipulated the solution must remain wet on the surface for a minimum of two (2) minutes to kill the following organisms: Clostridium difficile (vegetative cells only), Methicillin Resistant Staphylococcus aureus (MRSA),Vancomycin Resistant Enterococcus faecalis (VRE), Staphylococcus aureus with reduced susceptibility to vancomycin, Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Herpes Simplex Virus Types 1 and 2, Human Immunodeficiency Virus (HIV-1), Human Coronavirus (not associated with Severe Acute Respiratory Syndrome or SARS), and Influenza A2 Virus.

Review of the Centers for Disease Control: Infection Prevention during Blood Glucose Monitoring and Insulin Administration. http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html Accessed 4/12 indicated: "The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. The CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."

4a. On 4/17/12 at 9:20 am, MD 2 and Tech 1 were observed with mask around their necks in a hallway of the perioperative suite. Tech 1 then pulled the mask up to cover his face and entered the operating room.

RNM 2 was observed with a mask around her neck in a hallway of the perioperative suite on 4/17/12 at 9:25 am

Review of the hospital's policy titled, "Perioperative Services: Surgical Attire in Restricted and Semi-Restricted Areas," dated 1/2/11, stipulated, "The mask is changed between cases and immediately upon becoming wet or soiled. The mask should never be worn around the neck (front or in the back)."

4b. On 4/18/12 at 2:10 pm, review of the temperature humidity records for Operating Room 3 for the 2/12 was conducted with Plant OPM and RNM 2. The records showed the humidity was below the recommended minimum parameter of 30% on 18 of the 22 days the room was in use. The temperature was below the recommended minimum temperature of 68 degrees Fahrenheit on 12 of the 22 days the room was in use.

During a concurrent interview, Plant OPM and RNM 2 indicated they did not a have a system to track and record the resolution when work orders were submitted for requested temperature and humidity adjustments in the perioperative areas. Plant OPM indicated the thermostat for the heating and air system was not accurate and it could take a couple of months to get replacement parts for the system. When questioned, Plant OPM indicated the placement of the humidifier system (not mounted according to manufacturer recommendations) could also be a complicating factor in the hospital's maintenance of temperature and humidity in the perioperative areas within the recommended parameters. The humidifier system had been mounted in the ceiling, not mounted according to the manufacturer's instructions.

Review of the undated hospital's Herrtronics AD Series Humidifier Installation and Operations Manual stipulated, "The unit should not be located above (such as false ceilings) ..."
The 2012 edition of Perioperative Standards and Recommended Practices, published by the AORN, made the following recommendations related to Safe Environment of Care, "Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system. Temperature should be maintained between 68? F to 73? F (20? C to 23? C) within the operating room suite and general work areas in sterile processing. Self-regulating, area-specific chiller units may be required because operating rooms are filled with personnel and heat-emitting equipment; therefore, achieving the low end of this range can be difficult. The decontamination area temperature should be maintained between 60? F to 65? F (16? C to 18? C). A temperature > of 70? F to 75? F (21? C to 24? C) should be maintained in recovery areas.

Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas.

Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an enriched environment or when flammable agents are in use and increases the potential for dust. Free-standing humidifiers should not be used because they can harbor microorganisms in fluid reservoirs and aerosolize these microorganisms into the clean environment. Humidity should be monitored and recorded daily using a log format or documentation provided by the HVAC system.

5. A review of 3 medical staff files (CNM, MD 1, and PA) and the hospital's policies on vaccine preventable immunizations was reviewed with MD 3 on 4/18/12 at 11:45 am Three (3) of the 3 medical staff files (CNM, MD 1, and PA) did not contain documentation of screening for varicella, measles, mumps, rubella, or hepatitis B and performance of a one- step TB skin test. During a concurrent interview with the MD 3, he acknowledged the medical staff was only required by the hospital to obtain a current tuberculosis test (one-step) skin test upon hire. The MD 3 acknowledged all physicians were likely to have intimate contact with patients and also potential exposure to blood. The MD 3 acknowledged the medical staff were not being screened to vaccine preventable diseases in accordance with the hospital's policies. The MD 3 stated, "We need to expand to include the medical staff to comply with the existing policies and procedures (referring the hospital's vaccine preventable diseases policies and procedures).


The hospital's policy titled, "Reporting and Prevention of Infection in Health Care Workers," dated 3/15/11, and presented as current was reviewed. The policy defined health care workers as "Banner employees, students, contract personnel, and volunteers working in health care settings who have potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air as they deliver..."

The hospital's policy stipulated "Banner Employees and Volunteers are required to establish current immunity status for measles, rubella, varicella, and mumps prior to work in any healthcare function. Healthcare workers who are not immune to measles, rubella, mumps, and varicella, or who lack proof that they do not have active tuberculosis are not to be recommended to work in Banner hospitals, outpatient settings, home care, and other health care settings with the potential for exposure to patients and/or infectious materials.
The hospital's policy titled, "Employee Health Guidelines," dated 6/1/11, stipulated "All new health care workers will be required to provide immunization documentation for measles, rubella, mumps, and varicella with proof they do not have active tuberculosis. Those who cannot show such documentation will be tested and offered immunization or be tested as outlined. Costs of immunizations will be paid by WMC (Washakie Medical Center). Employees who refuse to submit to the screening or who are not immune or for whom contraindication (e.g. pregnancy) exists will be referred to the Human Resources Department." The hospital's policy listed the Centers for Disease (CDC) as the source of standard for their policy.


The CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis (in a Health-Care Setting, 2005, page 10, indicated "The classification of medium risk should be applied to settings in which the risk assessment has determined that health care workers (HCW) will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. tuberculosis." The recommendations for medium risk included, "All HCWs should receive baseline TB screening (checked to identify presence of the disease) upon hire, using two-step TST (skin test) or a single BAMT (alternate test) to test for infection, and after baseline testing for infection, HCWs should receive TB screening annually."


The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Report (MMWR Volume 46, Number RR-18, December 26, 1997) documented on page 24, "Persons who work within medical facilities should be immune to measles and rubella. Immunity to mumps is highly desirable for all Healthcare Workers. Because any HCW (i.e., medical or nonmedical, paid or volunteer, full time or part time, student or nonstudent, with or without patient-care responsibilities) who is susceptible can, if exposed, contract and transmit measles or rubella, all medical institutions (e.g., inpatient and outpatient, public and private) should ensure that those who work within their facilities are immune to measles and rubella. Likewise, HCWs have a responsibility to avoid causing harm to patients by preventing transmission of these diseases on page 25", the MMWR documented, "All HCWs should ensure that they are immune to varicella."

Based on dietetic services observations, dietary and nursing staff interview, and dietary and medical record review, the hospital failed to ensure that the hospital's nutritional practices met the nutritional needs of patients as evidenced by:

1. Failure to follow the physician ordered diet for 1 of 6 patients reviewed for nutrition care (Patient 12)
2. Lack of development of a non-select patient menu for the hospital's regular and therapeutic diets;
3. Lack of an approved diet manual that described the hospital's regular and therapeutic diets;
4. Lack of a comprehensive nutritional analysis of the hospital menus;
5. Lack of preventive maintenance according to manufacturer's instructions for the hospital's ice machines;
6. Storage of medication in the breast milk refrigerator; and
7. Lack of effective nutrition screening for 2 of 6 patients (Patients 2 and 12) reviewed for nutrition care.
Failure to develop comprehensive systems in dietetic services and nutrition care may result in compromising patients' nutritional and medical status.

Findings:

Dietetic Services

1. On 4/16/12 beginning at 12 pm, the patient trayline was observed. It was noted that a Patient 12 with an admission diagnosis of high blood pressure related to pregnancy had a physician ordered 2000 calorie diet, with a patient preference of a vegetarian diet. It was also noted that dietary staff offered the patient a salad, yogurt, strawberries, ? cheese sandwich and a corn muffin. In an interview on 4/16/12 at 2:30 pm, with FSW 1 she was asked how such a diet would be implemented. She stated that she would use a pattern for a calorie range rather than the specific calorie level that was ordered by the physician.

In an interview on 4/17/12 beginning at 1:30 with Patient 12 she stated that there was a limited selection of items that were offered as vegetarian entrees and was choosing mostly cheese omelets, cheese sandwiches and peanut butter and jelly sandwiches.

In an interview with RD 1 on 4/18/12 beginning at 9 am, the surveyor asked if the hospital had a vegetarian menu. She stated they did not; however did have some vegetarian entrees. An additional review on 4/18/12 at 1 pm, of Patient 12's menu revealed that FSW 1 calculated the menu to utilize 5 carbohydrates for breakfast and lunch and 4 carbohydrates for dinner. She further stated that if the patient did not choose 5 carbohydrates she would add additional items to the meal tray. Concurrent review of Patient 12's tray card beginning at dinner on 4/18/12 through lunch on 4/19/12 confirmed that 3 of 3 meals she selected either a cheese omelet or a cheese sandwich. It was also noted that on the preprinted menu there with the exception of cottage cheese and fruit there were no additional printed vegetarian entrees. It would be the expectation that the hospital developed menus for commonly ordered diets that ensured food items offered met patient nutritional needs.

2. During trayline observation on 4/16/12 beginning at 12 pm, it was noted that the hospital had a patient select menu that had several different categories for each meal such as appetizers, entrees, starches, vegetables and desserts. In a concurrent interview with FSW 1 she was asked what would happen if a patient was unable to select their own foods. She stated that at the time the menus were prepared she would randomly select items from each of the food categories.

On 4/18/12 beginning at 9 am, the hospitals' menus were review with RD 1. She stated that within the past year the hospital went from a non-select menu to a menu that allowed patients to select their own meals. She also stated that at the time of the menu change she had not developed and/or chosen combination of foods that would be offered to patients if they were unwilling and/or unable to select their own menu items. The standard of practice with a room service menu would be to determine a combination of foods throughout out the course of any particular day that would be offered to patients if they were unable to select their own foods. The purpose of pre-determining selected combinations of foods would be to ensure that patients are offered a menu that 1) met the physician ordered diet; 2) met the nutritional needs of patients and 3) ensure that patients who were unable to self-select their menu were offered a variety of foods during the course of hospitalization to maintain and/or improve nutritional status.

Based on dietary staff interviews and review of dietary departmental documents the hospital failed to ensure the patient regular and therapeutic menus were 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. This has the potential for the patients in the hospital to not receive adequate nutrition and to meet the estimated recommended dietary allowances for all nutrients.

3. During meal distribution observation beginning at 12 pm, it was noted that greater than 2 random patients had tray tickets with a physician ordered carbohydrate controlled diet. A carbohydrate controlled diet, indicated as part of the treatment for a diagnosis of diabetes, generally limits the amount of carbohydrate per meal. In addition the number of carbohydrates would be consistent between breakfast, lunch and dinner each day (American Diabetes Association, 2006).

In an interview on 4/18/12 beginning at 9 am, with RD 1 she stated that the hospital had switched from calorie controlled diabetic diets to a carbohydrate controlled diet (CHO controlled). Concurrent comparison of the hospital's document titled "Diet Order Formulary & Interpretation of Diet Orders" dated 12/2010 with the hospital nutrition care manual revealed that the documents were a conceptual description of diets. While the document described the hospitals' most commonly ordered diets neither the formulary nor the diet manual accurately reflected the relationship between the hospitals developed document, the menus served and the nutrition care manual developed by a State affiliated dietetic association. Similarly there was no defined meal pattern for the diets listed; rather noted food selections that may be offered and/or avoided on specific diets.

A diet manual would ensure that the diets offered met the current standards of practice; included a comprehensive description of the therapeutic diets offered by including the purpose of the diet, indications of the diet, nutritional adequacy, sample meal plans consistent with the hospitals' menu and the standard of practice references for the diets. While the hospitals' system for using the evidence based practice guidelines in conjunction with the hospital developed document titled " Diet Order Formulary & Interpretation of Diet Orders" had some of the elements, not all elements were present for each routinely ordered hospital diets that would allow for hospital and/or dietary staff to use the document as a comprehensive resource to order and/or prepare patient diets.

4. On 4/17/12 at 9 am, the hospital's nutrient analysis for the regular and therapeutic diet menus was requested. On 4/17/12 at 4:30 pm, the analysis was submitted. In an interview on 4/18/12 beginning at 9 am, with RD 1 she stated that while she had completed a nutritional analysis of the individual food items she acknowledged that the values used in the analysis for the convenience items was based solely on the consumer nutrition labels. Consumer nutrition labels would be limited to the amount of calories, fat, protein and carbohydrates in a product. She also acknowledged that there was no standardization or nutritional analysis of a non-select menu if patients were unable to make their own food selections. It was also noted the analysis was not comprehensive, rather evaluated 17 of 39 nutrients for which there are recommended intakes. RD 1 also acknowledged that she developed and approved the menus and that with the current format it would not be possible to determine whether the menus met the nutritional needs of patients. It was also noted that the heart healthy diet did not meet the recommended adequate intake for fiber.

Review of the DRI for Macronutrients, dated 2002/2005, indicated total fiber for males nine through 13 years of age is 31 g; 14 through 50 years of age is 38 g; and 50 years through greater than 70 years of age is 30 g; females nine through 18 years of age is 26 g; 19 through 50 years of age is 25 g; 50 through greater than 70 years of age is 21 g. The hospital menus were inadequate in Fiber depending on the age and gender. Analysis for the heart health menu revealed it contained an average of 22 grams of fiber. The menus used were not evaluated for the complete array of macro and micro nutrients specified by the Food and Nutrition Board of the National Research Council.

5. On 4/16/12 beginning at 1 pm, preventive maintenance for the facility ice machines was reviewed with the Food Service Manager (FSM). The FSM stated that the employee responsible for the task was unavailable; however offered that the process was completed per manufacturers' guidance. While the staff responsible for the task was unavailable the FSM was asked to provide the chemicals used as well as the manufacturers' guidance for the different types of ice machines within the hospital. On 4/16/12 at 2:30 pm, the chemicals utilized for the preventive maintenance was reviewed with the FSM. It was noted that the manufacturer of the Hoshizaki ?recommended the use of the manufacturers' product rather than the product that was being used.

6a. During tour of the newborn nursery on 4/16/12 at 1:40 pm, it was noted that nursing staff was storing insulin, for a prenatal patient, in the breast milk refrigerator. In a concurrent interview with RN 2 she acknowledged that these items should not have been stored in this particular refrigerator. She also stated that the newborn nursery did not have its own medication refrigerator. In an interview on 4/16/12 at 2 pm, with the Quality Manager (QM) she stated she asked the pharmacist to evaluate the storage and stated that the medications should have been stored in the medication room adjacent to the nursing station.
Review of the manufacturers' insert for the insulin revealed that opened vials of insulin can be kept unrefrigerated as long as it is kept below 86?F.

6b. It was also noted that the temperature log on the refrigerator door "titled Medication Refrigerator/Freezer Log" was intended for safe storage ranges for medication with an acceptable temperature range of 36-46?F. The hospital policy titled "WIS: Breastfeeding: Expressing, Storing and Handling of Human Milk in the Hospital Setting" dated 1/1/12 guided staff that the breast milk storage temperature range was 32-39.2?F.

Nutrition Care

1. Patient 12 was admitted with diagnosis including gestational high blood pressure and gestational diabetes. Admission diet order dated 4/9/12 was a 2000 calorie diabetic diet with a patient vegetarian preference. Review of comprehensive nursing admission assessment dated 4/9/12 failed to note any nutritional risk. Similarly the electronic medical record failed to note any dietary intake. In an interview on 4/17/12 beginning at 10 am, with RN 3 she stated that labor and delivery patients were on a different electronic medical record (EMR) system than the remainder of the hospital and that there was no nutritional screening as part of that EMR. She also stated that generally dietary intake was not recorded for maternity patients as their length of stay was generally limited. In an interview on 4/18/12 beginning at 2 pm, with offsite IT staff she stated that the EMR for pregnancy women included both a nutrition risk assessment as well as an area to record dietary intake.

In an interview on 4/17/12 beginning at 1:30 with Patient 12 she stated that there was a limited selection of items that were offered as vegetarian entrees and was choosing mostly cheese omelets, cheese sandwiches and peanut butter and jelly sandwiches. She also stated that she had a limited appetite and was not eating very much.

In an interview on 4/18/12 beginning at 10 am, with RD 1 she stated that she was not notified by nursing and or dietary staff that Patient 12, who was experiencing a high risk pregnancy, was an inpatient. She also stated that pregnant women, who were admitted as an inpatient for a diagnosis other than delivery would likely be considered to be at nutritional risk and should have had a nutrition assessment.

2. Patient 2 was a 47 year old male admitted with diagnosis including severe hyponatremia. A history and physical dated 4/11/12 and completed by the admitting physician noted that the patient was fully dependent for all activities of daily living, including feeding. The physician also noted that the patient was fed a pureed diet consisting solely of baby food with no salt. The physician also noted that while it was not possible to obtain the height of Patient 2, he was underweight weighing approximately 70 pounds. A nursing admission screen dated 4/11/23 failed to note any nutritional risk, despite the admission diagnosis of hyponatremia likely related to dietary intake as well as the patients' underweight status. In an interview on 4/18/12 beginning at 10 am, with RD 1 she acknowledged that Patient 2 should have triggered a nutritional consult.

Based on interview and record review, the facility failed to accurately document the adult physical assessments in 5 of 10 medical records. This failure had the potential for the patients to receive inadequate care. (Patients 1, 3, 23, 24, and 26)

Findings:

Patient 1's medical record was reviewed on 4/18/12. She was admitted to the facility on 4/13/12, with diagnoses that included gastroenteritis (inflammation of the stomach and intestines). The adult physical assessments, dated from 4/13/12 through 4/18/12, contained incomplete documentation for 5 of 9 shifts.

Patient 3's medical record was reviewed on 4/19/12. He was admitted to the facility on 4/3/12 with diagnoses that included pneumonia. The adult physical assessment, dated 4/3/12 through 4/7/12, contained incomplete documentation for 3 of 5 shifts.

Patient 23's medical record was reviewed on 4/19/12. She was admitted to the facility on 2/8/12 with diagnoses that included urinary tract infection. The adult physical assessment, dated 2/8/12 through 2/13/12, contained incomplete documentation for 1 of 10 shifts.

Patient 24's medical record was reviewed on 4/19/12. She was admitted to the facility on 12/25/11 with diagnoses that included urinary tract infection. The adult physical assessment, dated 12/25/11 through 12/29/11, contained incomplete documentation for 6 of 8 shifts.

Patient 26's medical record was reviewed on 4/19/12. He was admitted to the facility on 4/17/12 with diagnoses that included seizure (sudden,violent muscle contractions). The adult physical assessment, dated 4/17/12 through 4/19/12, contained incomplete documentation for 2 of 5 shifts.

During an interview on 4/18/12 at 10:05 am, RN 1 stated that she could not think of a reason for the documentation in an adult physical assessment to be incomplete.

During an interview on 4/18/12 at 10:30 am, Chief Nursing Officer confirmed that the documentation in the adult physical assessments was not complete. The facility's expectation was that the adult physical assessment contain complete and accurate documentation about the patient.

The facility policy and procedure titled, "Assessment and Reassessment of Patients Policy," dated 8/9/10, indicated, "The patient is assessed/reassessed based on the following circumstances: ... At designated time frames."

During a separate interview on 4/19/12 at 3:15 pm, Chief Nursing Officer stated that it was the facility's expectation that patients were to be assessed once per shift or more often as needed according to the patient's condition, and the results were to be completely and accurately documented in the patient's adult physical assessment.

Based on dietary and quality management staff interview, the hospital failed to ensure the development of a program that evaluated the effectiveness of the services provided through the food and nutrition services department. Failure to evaluate operational processes relative the departments' scope of services may result in lack of identification of problems within food and nutrition services.

Findings:

On 4/17/12 beginning at 11 am, the performance improvement program for food services was reviewed. In a concurrent interview, the FSM presented samples of reports that were completed by RD1. The reports consisted of a list of inpatients that documented the patient's admission, nutritional risk, diagnosis, gender, height, weight and diet order. While the data was gathered, there was no evaluation of the significant and/or relevance of the data. Similarly, the department was also collecting data that listed the number of number of patients RD 1 saw on a monthly basis. Similarly, there was no evaluation of the data, rather was limited to a statistical listing. While the department was collecting data, there was no analysis of the effectiveness of the services provided.

In an interview on 4/18/12 beginning at 9 am, the QM stated she recently joined the hospital staff. She also stated that (with the exception of the reports provided the department) she was unable to locate any performance measures that demonstrated evaluation of the services for the purpose of the identification of problems and/or analysis of collected data with respect to food services.