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Observations, staff interviews, and review of the cleaning schedules revealed the Critical Access Hospital (CAH) failed to ensure the kitchen was clean and in good repair and failed to comply with the Nebraska Food Code. The CAH is licensed for 17 beds and had a census of 4 acute inpatients and 3 Swingbed patients upon entrance. Findings are:

A. Observation and interviews while on tour of the kitchen on 8/10/10 at 10:00 AM with the dietary cook revealed the following areas had sanitation or equipment maintenance issues. The CAH kitchen provides 3 meals per day plus snacks to the hospital patients. Examples:

1. Exhaust filters located directly above a 6-burner electric, double oven with fry grill had a buildup of grease and a black furry substance along the edges and inner grids. Interview with the cook and maintenance personnel revealed the exhaust vents are cleaned every 3 months and are "taken to the car wash and hosed off." There was some confusion as to when the exhaust vents were last cleaned. Review of CAH documentation indicated maintenance personnel had completed cleaning on 6/8/10.

2. Located in the dry food storage area are numerous white painted wooden shelves. The shelves are heavily marred and chipped, missing large portions of paint and exposing the wood. This does not make for a smooth, cleanable surface.

3. A grey painted steel food prep area, approximately 84 inches by 35 1/2 inches used to prep food for hospital patients, with hanging pots and pans, has a large portion of the grey paint worn and chipped off, exposing the underlying metal. This does not make for a smooth, cleanable surface.

4. Approximately 50 pounds of red potatoes and 25 pounds of red onions are stored in open cardboard boxes in the kitchen by a 3-tub food prepping sink. The open exposure allows for rodent infestation.

5. A wooden enclosed single handwashing sink located in the middle of the kitchen had a basin that was rusted and lacked a large portion of the manufacturer's porcelain finish.

6. There are 6 ceiling double-bulbed lights located in the kitchen. 2 of the reflectors covering the lights are cracked and all 6 of the ceiling lights display dirt on the inner reflectors. Interview with the cook revealed maintenance man is to clean, but does not know when last cleaned. Interview with the maintenance personnel revealed "I do not clean, I make sure the appliances in the kitchen are working."

7. The window air conditioner located in the kitchen has a grate covering and exposes the filter. The filter has a dark brown greasy appearance. Interview with the cook revealed she is unsure when the air conditioner filter was last changed.

8. Observation and interview with the Dietary Manager on 8/8/10/ at 1:00 PM identified 16 various sized pots and pans used to prepare patient meals were heavily dented, scratched and lacked the manufacturer's finish, exposing the underlying metal. This does not allow proper cleaning or sanitation of the pot and pans.

9. Above the main entrance into the kitchen is an air vent measuring approximately 18 inches by 18 inches. The grids on the vent have a rusty appearance.

10. The entire kitchen has numerous areas of various sizes where the walls have been marred and not repaired or painted, exposing the underlay. This does not allow for a smooth, cleanable surface.

Based on staff interviews, a review of the most recent physician reappointments, compared with the documented evidence, revealed the Governing Body failed to follow the medical staff bylaws, rules and regulations, in the reappointment process. In addition, a review of the surgical procedure logs as compared with the privilege list, the Governing Body failed to grant privileges that reflect the hospital's actual practice. Current medical staff consists of 2 family practitioners, 2 mid-level practitioners and a general surgeon. Findings are:

A. The most recent Bylaws of the Medical Staff on page 12 Article VI Clinical Privileges B. Determination of Privileges states: "Determination of initial privileges shall be based upon an applicant's training, experience, and demonstrated competence. The granting of any additional privileges shall be based upon an applicant's training, experience, and demonstrated competence which shall be evaluated by review of the applicant's credentials, direct observation by the active medical staff and review of reports of the medical staff."

B. A review of the initial appointment file of Physician A, who was initially appointed approximately 2 years ago, lacked evidence of direct observation by the medical staff and lacked evidence of review of reports of the medical staff.

C. A review of the clinical privilege list for Physician A included procedures such as splenectomy and thyroidectomy.

D. Interview on 8/11/10 at 2:30 PM conducted with the Director of Nursing (DON), who oversees the reappointment process, confirmed the lack of observational evidence and reports of the medical staff and also confirmed that thyroidectomy and splenectomy procedures were not performed in the facility.

E. On page 12 of the Medical Staff Bylaws Article VI Clinical privileges C. Delineation of Privileges, item 2, states, "The evaluation of such requests shall be based upon the applicant's education, training, experience, demonstrated competence, references, conclusions drawn from quality assessment and improvement activities..."

F. During this same interview, the DON, who also oversees the quality assurance, performance improvement and medical staff peer review activities, confirmed that individual practitioner's quality assessment activities were not taken into consideration at the time of reappointment, as specified in the Medical Staff Bylaws, rules and regulations.

Staff interviews, and observation of the anesthesia cart and a locked cabinet located in the Operating Room, CCU and Emergency Room (ER) crash carts, and general pharmacy with the Director of Nursing (DON) revealed the Critical Access Hospital (CAH) failed to ensure the accountability and distribution of biologicals and lacked accurate records for accountability in accordance with accepted professional practices. The CAH is licensed for 17 beds and had a census of 4 acute inpatients and 3 Swingbed patients upon entrance. Findings are:

A. Interview and observations of the anesthesia cart and locked medication cabinet located in the Operating Room, the CCU and ER crash carts on 8/11/10 at 2:35 PM revealed the CAH has a Registered Pharmacist (RP) that is contracted with the CAH and provides services intermittently throughout the week. The CAH pharmacy also provides drugs to the clinic and "if the clinic needs something, cause they don't know where things are, then those medications are signed out so the clinic can bill the patient, the RP keeps track of all the narcotics and it takes 2 signatures to check out a narcotic from the pharmacy." The DON is responsible to keep track and order all the CAH's biologicals. After the medications arrive they are checked in by the DON and distributed to the anesthesia cart/locked cabinet in the OR, ER and CCU crash carts, or stored in the pharmacy for future use. Further interview with the DON described the pharmacy as an "open pharmacy." Although the pharmacy is locked and allows licensed professionals access 24 hours a day/7 days a week, there is no current inventory system for the removal of non-narcotic medications in place to track the distrubution or inventory of the pharmacy, anesthesia cart or locked cabinet located in the OR, ED or CCU crash carts. It was also acknowledged the medication storage areas do not have current medication formularies with maximum medication distribution, and "there is no way to track if someone takes other medications out of the carts or OR that they should not have."

Observation with the DON of the biological inventory of the anesthesia cart and the locked medication cabinet stored in the OR revealed the biological medications used to perform surgical procedures were identified by the DON as "significant medications and could be harmful if not used in a professional manner by properly trained professions" and revealed the formulary/count did not match what was actually stored in the anesthesia cart or locked medication cabinet. Examples include:

1. Diprivan (Propofol) 10 mg/ml - 20 ml vial to have a count limit of 4 - had a count of 69 vials - Diprivan is used to sedate patients for surgical procedures;
2. Vecuronium Bromide 10 mg/ml had a count of 7 - but is not listed on the anesthesia cart/supply list - Vecuronium Bromide is used for rapid sequence intubation and used for surgical procedures;
3. Anectine 20 mg/ml -10 ml vial to have a count limit of 10 - actual count is 2 - Anectine is a neuromuscular blocking agent and used for surgical procedures;
4. Robinul (Glycopyrrolate) 0.2 mg/ml - 2 ml vial to have a count limit of 4 (10 on hand) - had a count of 22 vials - Robinul is an antimuscarinic and used for surgical procedures.

Based on staff interviews, review of personnel files, review of infection prevention surveillance data and direct observation, the Critical Access Hospital (CAH) failed to ensure newly hired individuals received orientation to infection prevention specific to their job duties regarding hand hygiene and failed to document observed hand hygiene practices. The facility reports an average daily census of 1.23. Findings are:

A. A review of personnel files of 2 newly-hired individuals (nursing assistant and dietary employee) within the past year, lacked evidence of orientation to hand hygiene specific to their job duties.

B. At 3:00 PM on 8/11/10, interview with the Dietary Manager confirmed the lack of education for newly-hired dietary employees. During this interview the newly-hired dietary employee was observed moving from the soiled dishwashing area to the clean area without handwashing between the 2 areas, as required.

C. An interview with the Infection Control Practitioner on 8/12/10 at 11:30 AM revealed that the current surveillance system lacked any documented evidence of hand hygiene practices in the facility by direct care staff or surgical staff to identify sources of potential infections.

Based on staff interview and a lack of documented evidence, the Critical Access Hospital Radiology Department personnel failed to ensure patients and staff were protected from radiation hazards. The facility is licensed for 17 beds and reported an average daily census of 1.23 patients. Findings are:

A. An interview conducted with the department manager on 8/10/10 at 3:00 PM confirmed the lead aprons, gonad shields, gloves and thyroid shields used to protect patients and staff during procedures exposing them to radiation, had not been evaluated for cracks and structural integrity.

B. The department manager stated that these protective devices had not been evaluated for at least 2 years.

Record review, staff interviews, review of contracted services for dietary, and review of the policies and procedures for dietary services revealed the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment was completed by a Registered Dietitian within the 3-day time frame as allotted by the dietary policies and procedures ensuring acceptable parameters of nutritional status for 1 of 3 Swingbed patients reviewed (Patient 7). The CAH is licensed for 17 beds and had a census of 4 acute inpatients and 3 Swingbed patients upon entrance. Findings are:

A. Record review on 8/11/10 at 8:00 AM for Patient 7 revealed an admission date of 7/20/10 at 1620 (4:20 PM) with pertinent diagnoses of tracheo-esophageal fistula, pressure sore over coccyx, COPD, and ongoing anemia. Prior medical history shows that Patient 7 was admitted for Swingbed services after a stay at an acute care hospital resulting in surgery and placement of a jejunostomy tube (J-tube). Patient 7 was started on tube feedings of Jevity 1.0 at 60 ml/hour for weight of 57.9 kilograms with the energy requirement of 1470 kilocalories and protein needs of 49-64 grams, adding Juven for wound healing, 1 packet per J-Tube BID (twice a day) and placed on strict NPO (nothing by mouth). Patient 7 was then admitted to the CAH from the acute care hospital with the prior physician recommendations noted and identified as needing support, including continued dietary support from the Jevity and to remain NPO. The admission plan addresses weekly lab testing, NPO status, pressure sore to coccyx, medication and Jevity 1.0 at 60 ml/hour per J-tube continuous.

Patient 7's medical record lacked physician admission orders on 7/20/10 indicating how often Patient 7 should be weighed. Admission weight documented at 129.9 pounds. Orders included Juven 1 packet 24 gm in 80 mg water. On 7/23/10 weight was 127 pounds, down 2.9 pounds. Physician order reads "increase tube feeding to 65 ml/hour." Record shows weight recordings and order changes on the following dates:
- 7/30/10--124.7 pounds, down 5.2 pounds since admission
- 8/2/10--125.9 pounds, down 4 pounds since admission
- 8/6/10--125.4 pounds, down 4.5 pounds since admission, losing approximately 3% of admission weight in 17 days; physician's order indicated to increase "the tube feeding to 70 ml/hour
- 8/7/10-- physician order reads to increase tube feedings to 80 ml/hour with Juven 1 can per J-Tube TID (3 times a day).

Upon discharge on 8/11/10 Patient 7's pressure sore on coccyx was assessed as Stage IV.
Documentation indicates the DM did an informal assessment for Patient 7 on 7/23/10. Registered Dietitian did not complete a dietary assessment for Patient 7 until 1 week later on 7/27/10. The medical record lacks documentation from the RD pertaining to a nutritional followup assessment or evaluation of Patient 7's identified nutritional status until the required 2-week initial assessment was completed on 8/3/10 by a Registered Nurse (RN).

B. Review of the policies and procedures for Dietary Services and Supervision for Swingbed patients reads: The consulting dietitian will complete the nutritional assessment of the patient within 3 days of admission. The food service supervisor will do routine documentation on all residents. The food service supervisor will notify the consulting dietitian of any problems for followup and documentation. #3 reads: food supervisor will notify the consulting dietitian of any problems for the followup documentation:
- Significant weight loss/gain
- Change in status ie. Acute care
- Changes in appetite or food intake
- Diet change to a therapeutic diet, tube feedings or pureed consistency
- Decubitus ulcer/skin problems
- Food intake of less than 50% or more in 3 days
- Chronic diarrhea or constipation
- Abnormal lab values such as albumin, hemoglobin
- New diagnosis affecting nutrition
- Refusal to eat all or majority of foods from a major food group

C. Interview with the Director of Nursing (DON) and Dietary Manager throughout the survey revealed the CAH has a contracted Registered Dietitian available to the CAH 24-hrs a day/7 days a week. Further interviews revealed the DM does not have the dietary skill level to complete a comprehensive dietary assessment, and does not feel comfortable doing 1 and that the dietitian was notified immediately of Patient 7's admission on 7/20/10. Interview with DM revealed that she was not sure what to assess because Patient 7 was NPO.

D. Review of the comprehensive care plan for Patient 7 lacks documentation as to acceptable weight loss and followup documentation as to the effectiveness of the dietary plan. Interview with the DON on 8/11/10 revealed the care plan should have been more comprehensive, considering all the issues this patient had with nutrition and pressure sore. Upon admission on 7/20/10 and discharge on 8/11/10 Patient 7 required approximately 17 different physician orders for medical interventions pertaining to the coccyx ulcer and the MRSA at the J-Tube site.

Observations, staff interviews, and review of the cleaning schedules revealed the Critical Access Hospital (CAH) failed to ensure the kitchen was clean and in good repair and failed to comply with the Nebraska Food Code. The CAH is licensed for 17 beds and had a census of 4 acute inpatients and 3 Swingbed patients upon entrance. Findings are:

A. Observation and interviews while on tour of the kitchen on 8/10/10 at 10:00 AM with the dietary cook revealed the following areas had sanitation or equipment maintenance issues. The CAH kitchen provides 3 meals per day plus snacks to the hospital patients. Examples:

1. Exhaust filters located directly above a 6-burner electric, double oven with fry grill had a buildup of grease and a black furry substance along the edges and inner grids. Interview with the cook and maintenance personnel revealed the exhaust vents are cleaned every 3 months and are "taken to the car wash and hosed off." There was some confusion as to when the exhaust vents were last cleaned. Review of CAH documentation indicated maintenance personnel had completed cleaning on 6/8/10.

2. Located in the dry food storage area are numerous white painted wooden shelves. The shelves are heavily marred and chipped, missing large portions of paint and exposing the wood. This does not make for a smooth, cleanable surface.

3. A grey painted steel food prep area, approximately 84 inches by 35 1/2 inches used to prep food for hospital patients, with hanging pots and pans, has a large portion of the grey paint worn and chipped off, exposing the underlying metal. This does not make for a smooth, cleanable surface.

4. Approximately 50 pounds of red potatoes and 25 pounds of red onions are stored in open cardboard boxes in the kitchen by a 3-tub food prepping sink. The open exposure allows for rodent infestation.

5. A wooden enclosed single handwashing sink located in the middle of the kitchen had a basin that was rusted and lacked a large portion of the manufacturer's porcelain finish.

6. There are 6 ceiling double-bulbed lights located in the kitchen. 2 of the reflectors covering the lights are cracked and all 6 of the ceiling lights display dirt on the inner reflectors. Interview with the cook revealed maintenance man is to clean, but does not know when last cleaned. Interview with the maintenance personnel revealed "I do not clean, I make sure the appliances in the kitchen are working."

7. The window air conditioner located in the kitchen has a grate covering and exposes the filter. The filter has a dark brown greasy appearance. Interview with the cook revealed she is unsure when the air conditioner filter was last changed.

8. Observation and interview with the Dietary Manager on 8/8/10/ at 1:00 PM identified 16 various sized pots and pans used to prepare patient meals were heavily dented, scratched and lacked the manufacturer's finish, exposing the underlying metal. This does not allow proper cleaning or sanitation of the pot and pans.

9. Above the main entrance into the kitchen is an air vent measuring approximately 18 inches by 18 inches. The grids on the vent have a rusty appearance.

10. The entire kitchen has numerous areas of various sizes where the walls have been marred and not repaired or painted, exposing the underlay. This does not allow for a smooth, cleanable surface.

Based on staff interviews, a review of the most recent physician reappointments, compared with the documented evidence, revealed the Governing Body failed to follow the medical staff bylaws, rules and regulations, in the reappointment process. In addition, a review of the surgical procedure logs as compared with the privilege list, the Governing Body failed to grant privileges that reflect the hospital's actual practice. Current medical staff consists of 2 family practitioners, 2 mid-level practitioners and a general surgeon. Findings are:

A. The most recent Bylaws of the Medical Staff on page 12 Article VI Clinical Privileges B. Determination of Privileges states: "Determination of initial privileges shall be based upon an applicant's training, experience, and demonstrated competence. The granting of any additional privileges shall be based upon an applicant's training, experience, and demonstrated competence which shall be evaluated by review of the applicant's credentials, direct observation by the active medical staff and review of reports of the medical staff."

B. A review of the initial appointment file of Physician A, who was initially appointed approximately 2 years ago, lacked evidence of direct observation by the medical staff and lacked evidence of review of reports of the medical staff.

C. A review of the clinical privilege list for Physician A included procedures such as splenectomy and thyroidectomy.

D. Interview on 8/11/10 at 2:30 PM conducted with the Director of Nursing (DON), who oversees the reappointment process, confirmed the lack of observational evidence and reports of the medical staff and also confirmed that thyroidectomy and splenectomy procedures were not performed in the facility.

E. On page 12 of the Medical Staff Bylaws Article VI Clinical privileges C. Delineation of Privileges, item 2, states, "The evaluation of such requests shall be based upon the applicant's education, training, experience, demonstrated competence, references, conclusions drawn from quality assessment and improvement activities..."

F. During this same interview, the DON, who also oversees the quality assurance, performance improvement and medical staff peer review activities, confirmed that individual practitioner's quality assessment activities were not taken into consideration at the time of reappointment, as specified in the Medical Staff Bylaws, rules and regulations.

Staff interviews, and observation of the anesthesia cart and a locked cabinet located in the Operating Room, CCU and Emergency Room (ER) crash carts, and general pharmacy with the Director of Nursing (DON) revealed the Critical Access Hospital (CAH) failed to ensure the accountability and distribution of biologicals and lacked accurate records for accountability in accordance with accepted professional practices. The CAH is licensed for 17 beds and had a census of 4 acute inpatients and 3 Swingbed patients upon entrance. Findings are:

A. Interview and observations of the anesthesia cart and locked medication cabinet located in the Operating Room, the CCU and ER crash carts on 8/11/10 at 2:35 PM revealed the CAH has a Registered Pharmacist (RP) that is contracted with the CAH and provides services intermittently throughout the week. The CAH pharmacy also provides drugs to the clinic and "if the clinic needs something, cause they don't know where things are, then those medications are signed out so the clinic can bill the patient, the RP keeps track of all the narcotics and it takes 2 signatures to check out a narcotic from the pharmacy." The DON is responsible to keep track and order all the CAH's biologicals. After the medications arrive they are checked in by the DON and distributed to the anesthesia cart/locked cabinet in the OR, ER and CCU crash carts, or stored in the pharmacy for future use. Further interview with the DON described the pharmacy as an "open pharmacy." Although the pharmacy is locked and allows licensed professionals access 24 hours a day/7 days a week, there is no current inventory system for the removal of non-narcotic medications in place to track the distrubution or inventory of the pharmacy, anesthesia cart or locked cabinet located in the OR, ED or CCU crash carts. It was also acknowledged the medication storage areas do not have current medication formularies with maximum medication distribution, and "there is no way to track if someone takes other medications out of the carts or OR that they should not have."

Observation with the DON of the biological inventory of the anesthesia cart and the locked medication cabinet stored in the OR revealed the biological medications used to perform surgical procedures were identified by the DON as "significant medications and could be harmful if not used in a professional manner by properly trained professions" and revealed the formulary/count did not match what was actually stored in the anesthesia cart or locked medication cabinet. Examples include:

1. Diprivan (Propofol) 10 mg/ml - 20 ml vial to have a count limit of 4 - had a count of 69 vials - Diprivan is used to sedate patients for surgical procedures;
2. Vecuronium Bromide 10 mg/ml had a count of 7 - but is not listed on the anesthesia cart/supply list - Vecuronium Bromide is used for rapid sequence intubation and used for surgical procedures;
3. Anectine 20 mg/ml -10 ml vial to have a count limit of 10 - actual count is 2 - Anectine is a neuromuscular blocking agent and used for surgical procedures;
4. Robinul (Glycopyrrolate) 0.2 mg/ml - 2 ml vial to have a count limit of 4 (10 on hand) - had a count of 22 vials - Robinul is an antimuscarinic and used for surgical procedures.

Based on staff interviews, review of personnel files, review of infection prevention surveillance data and direct observation, the Critical Access Hospital (CAH) failed to ensure newly hired individuals received orientation to infection prevention specific to their job duties regarding hand hygiene and failed to document observed hand hygiene practices. The facility reports an average daily census of 1.23. Findings are:

A. A review of personnel files of 2 newly-hired individuals (nursing assistant and dietary employee) within the past year, lacked evidence of orientation to hand hygiene specific to their job duties.

B. At 3:00 PM on 8/11/10, interview with the Dietary Manager confirmed the lack of education for newly-hired dietary employees. During this interview the newly-hired dietary employee was observed moving from the soiled dishwashing area to the clean area without handwashing between the 2 areas, as required.

C. An interview with the Infection Control Practitioner on 8/12/10 at 11:30 AM revealed that the current surveillance system lacked any documented evidence of hand hygiene practices in the facility by direct care staff or surgical staff to identify sources of potential infections.

Based on staff interview and a lack of documented evidence, the Critical Access Hospital Radiology Department personnel failed to ensure patients and staff were protected from radiation hazards. The facility is licensed for 17 beds and reported an average daily census of 1.23 patients. Findings are:

A. An interview conducted with the department manager on 8/10/10 at 3:00 PM confirmed the lead aprons, gonad shields, gloves and thyroid shields used to protect patients and staff during procedures exposing them to radiation, had not been evaluated for cracks and structural integrity.

B. The department manager stated that these protective devices had not been evaluated for at least 2 years.

Record review, staff interviews, review of contracted services for dietary, and review of the policies and procedures for dietary services revealed the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment was completed by a Registered Dietitian within the 3-day time frame as allotted by the dietary policies and procedures ensuring acceptable parameters of nutritional status for 1 of 3 Swingbed patients reviewed (Patient 7). The CAH is licensed for 17 beds and had a census of 4 acute inpatients and 3 Swingbed patients upon entrance. Findings are:

A. Record review on 8/11/10 at 8:00 AM for Patient 7 revealed an admission date of 7/20/10 at 1620 (4:20 PM) with pertinent diagnoses of tracheo-esophageal fistula, pressure sore over coccyx, COPD, and ongoing anemia. Prior medical history shows that Patient 7 was admitted for Swingbed services after a stay at an acute care hospital resulting in surgery and placement of a jejunostomy tube (J-tube). Patient 7 was started on tube feedings of Jevity 1.0 at 60 ml/hour for weight of 57.9 kilograms with the energy requirement of 1470 kilocalories and protein needs of 49-64 grams, adding Juven for wound healing, 1 packet per J-Tube BID (twice a day) and placed on strict NPO (nothing by mouth). Patient 7 was then admitted to the CAH from the acute care hospital with the prior physician recommendations noted and identified as needing support, including continued dietary support from the Jevity and to remain NPO. The admission plan addresses weekly lab testing, NPO status, pressure sore to coccyx, medication and Jevity 1.0 at 60 ml/hour per J-tube continuous.

Patient 7's medical record lacked physician admission orders on 7/20/10 indicating how often Patient 7 should be weighed. Admission weight documented at 129.9 pounds. Orders included Juven 1 packet 24 gm in 80 mg water. On 7/23/10 weight was 127 pounds, down 2.9 pounds. Physician order reads "increase tube feeding to 65 ml/hour." Record shows weight recordings and order changes on the following dates:
- 7/30/10--124.7 pounds, down 5.2 pounds since admission
- 8/2/10--125.9 pounds, down 4 pounds since admission
- 8/6/10--125.4 pounds, down 4.5 pounds since admission, losing approximately 3% of admission weight in 17 days; physician's order indicated to increase "the tube feeding to 70 ml/hour
- 8/7/10-- physician order reads to increase tube feedings to 80 ml/hour with Juven 1 can per J-Tube TID (3 times a day).

Upon discharge on 8/11/10 Patient 7's pressure sore on coccyx was assessed as Stage IV.
Documentation indicates the DM did an informal assessment for Patient 7 on 7/23/10. Registered Dietitian did not complete a dietary assessment for Patient 7 until 1 week later on 7/27/10. The medical record lacks documentation from the RD pertaining to a nutritional followup assessment or evaluation of Patient 7's identified nutritional status until the required 2-week initial assessment was completed on 8/3/10 by a Registered Nurse (RN).

B. Review of the policies and procedures for Dietary Services and Supervision for Swingbed patients reads: The consulting dietitian will complete the nutritional assessment of the patient within 3 days of admission. The food service supervisor will do routine documentation on all residents. The food service supervisor will notify the consulting dietitian of any problems for followup and documentation. #3 reads: food supervisor will notify the consulting dietitian of any problems for the followup documentation:
- Significant weight loss/gain
- Change in status ie. Acute care
- Changes in appetite or food intake
- Diet change to a therapeutic diet, tube feedings or pureed consistency
- Decubitus ulcer/skin problems
- Food intake of less than 50% or more in 3 days
- Chronic diarrhea or constipation
- Abnormal lab values such as albumin, hemoglobin
- New diagnosis affecting nutrition
- Refusal to eat all or majority of foods from a major food group

C. Interview with the Director of Nursing (DON) and Dietary Manager throughout the survey revealed the CAH has a contracted Registered Dietitian available to the CAH 24-hrs a day/7 days a week. Further interviews revealed the DM does not have the dietary skill level to complete a comprehensive dietary assessment, and does not feel comfortable doing 1 and that the dietitian was notified immediately of Patient 7's admission on 7/20/10. Interview with DM revealed that she was not sure what to assess because Patient 7 was NPO.

D. Review of the comprehensive care plan for Patient 7 lacks documentation as to acceptable weight loss and followup documentation as to the effectiveness of the dietary plan. Interview with the DON on 8/11/10 revealed the care plan should have been more comprehensive, considering all the issues this patient had with nutrition and pressure sore. Upon admission on 7/20/10 and discharge on 8/11/10 Patient 7 required approximately 17 different physician orders for medical interventions pertaining to the coccyx ulcer and the MRSA at the J-Tube site.