HospitalInspections.org

17065


Based on medical record review and dietary and administrative staff interview, the hospital failed to ensure the development of nursing care plans for 2 of 7 (Patients 103 and 114) reviewed for nutritional care. Failure to develop comprehensive care plans may result in lack of assessment and development of patient care interventions of identified patient problems.

Findings:

1. Patient 103 was admitted with diagnosis including depression. An admission nutrition screening dated 7/14/11 noted no nutritional risk factors. Admission height dated 7/14/11 was 5 foot 3 inches, weight was 207 pounds. A follow up weight dated 7/16/11 noted a weight of 205 pounds, a loss of 2 pounds in 2 days. Admission diet order dated 7/14/11 was a regular diet. A follow up diet order dated 7/15/11 was for a low fat diet.

A nutrition assessment dated 7/15/11 noted that the patient had poor dietary intake. The assessment also noted decreased needs for weight loss and that weight loss was desired. There was no documentation that Patient 103 agreed to a weight loss plan. There was no assessment of the effects that the admission diagnosis of depression may have on Patient 103's dietary intake. The assessment also recommended a nutritional supplement three times/day to increase caloric intake. It would be the standard of practice to ensure that the nutritional need of hospitalized patients was met (American Dietetic Association, 2011); while weight loss may be a long term goal for some patients, weight lost through refusal to eat during hospitalization would not meet nutritional needs.

Review of dietary intake beginning on 7/14/11 noted that nursing staff failed to record intake 11 of 21 meals. It was also noted that the average documented intake for 10 meals from 7/14-7/20/11 was 55%. There was no documentation for the amount of supplement that was consumed. Review of patient 103's treatment plan #8, dated 7/18/11 (4 days after admission) documented a poor dietary intake. The interventions of the care plan were to assess and monitor intake; obtain initial weight; obtain ongoing weight; observe for food pocketing; offer frequent small amounts; observe for swallowing difficulties; determine food preferences and cue patient for swallowing after each bite. While the care plan was placed in the chart there was no evidence that the standardized care plan was modified to meet Patient 103's needs. Additionally the care plan did not contain any measurable goals, rather the goal was to " maintain appropriate intake to support nutritional goals during hospitalization. " As of 7/21/11 there was no indication that the care plan was reviewed for effectiveness.

In an interview on 7/21/11 at 11 am, with DMS I and AS L they acknowledged that weight loss during hospitalization may not be in the best interest of patients who are likely nutritionally compromised at the time of admission.

2. Patient 114 was admitted with diagnosis including depression. Admission height dated 7/14/11 was 6 feet 5 inches and weight was 233 pounds. A nutrition screening dated 7/14/11, completed by nursing staff, failed to note any nutritional risk factors. Admission diet order dated 7/14/11 was a regular diet with a 4 gram sodium restriction. A nutrition assessment dated 7/18/11 noted that Patient 114 lost 65 pounds within the previous 14 months. The assessment also noted an average intake of 33% over the previous 3 days. There were no documented interventions despite poor dietary intake. A follow up Registered Dietician assessment dated 7/20/11 noted a weight loss of 5 pounds over the previous 2 days with a dietary intake of 78% for the previous day. Review of Patient 114 ' s treatment plans, beginning 7/14/11 revealed that while 5 care plans were developed, there were none developed that assessed Patient 114 ' s weight loss and poor dietary intake.



21156

Based on food service observations and dietary staff interview, the hospital failed to ensure competency of 1 staff member (Dietary Staff J) in assessing the effectiveness of the sanitizer solution. Failure to ensure competency of staff in this task may result in inaccurate results exposing patients to risk of foodborne illness from unsanitized equipment and surfaces.

Findings:

On 7/20/11 beginning at 4:20 pm, the surveyor asked DS J to describe how food production surfaces were cleaned. She stated that she utilized a sanitizer solution that was dispensed from a pump station located above the sink. The surveyor also asked DS J to describe how she ensured that the station delivered adequate chemicals. She demonstrated the testing using the existing sanitizer solution. She proceeded to immerse the chemical test strip in the water for 1 minute and stated that this was her normal process.

Review of the manufacturers ' guidance printed on the side of the test strips guided staff to immerse the strip for 10 seconds and immediately read the results.

Based on interview and hospital document review, the hospital failed to ensure the completion of a comprehensive, daily, nutritional analysis for patient menus. Lack of nutritional analysis of foods offered to patients may result in menus/food selections that do not meet the nutritional needs of inpatients, resulting in weight loss and further compromise of clinical condition.

Findings:

On 7/20/11 beginning at 3:30 pm, the hospitals ' menus were reviewed. It was noted that while a nutritional analysis existed it was not comprehensive. The menu analysis was an average for one cycle of a menu that consisted of multiple cycles. It was also noted that the nutrient analysis consisted only of the main menu items only. The analysis did not include the alternate selection that was printed on patient tray tickets.

In an interview on 7/21/11 beginning at 10:30 am, with DMS I she stated that the menu was developed by their food vendor based on the menu cycles. She also acknowledged that the nutrient report lacked an analysis of the alternate entree. The standard of practice would be to ensure that a daily comprehensive menu analysis was available that included the regular, pediatric, adolescent and therapeutic diets which include all food selections that patients ' would be offered (American Dietetic Association, 2011)

Based on food service observations, dietary staff interview and dietary document review, the hospital failed to ensure menus were followed as evidenced by 1) inaccurate portions and 2) alternate meal selections that did not have equal nutritive value. Failure to ensure menus were followed and substitutes were of equal nutritive value may result in weight loss and further compromise clinical status.

Findings:

1. During trayline observation on 7/20/11 beginning at 11:30 am, the following was noted:
a. Patient 115 had a physician ordered diabetic diet. It was noted that for the entree the patient received 4 ounces of the pasta primavera entree. In a concurrent interview with DS K, the surveyor asked how he determined portion size. He stated that portion sizes were printed on the recipe.

Review of the standardized recipe for the pasta revealed that the portion should have been a ? cup serving.

b. Patient 110 had a vegetarian physician ordered diet. It was noted that the patient received a ? cup serving of pasta with mushrooms and peas for the entree.

In an interview on 7/20/11 beginning at 12:30 pm, with DMS I, the surveyor asked her to describe the selection for alternate menu items. She stated that each meal had an entree with meat as well as a vegetarian option. The surveyor also asked how the hospital ensured the selected alternates were of equal nutritive value to the main entree. DMS I acknowledged that she had not evaluated whether all of the alternates were equal in nutritive value to the main entree.

Concurrent review of the alternate menu revealed that in addition to the pasta primavera, alternate entrees included broccoli/mushroom crepes as well as a bean/cheese burrito. Review on 7/20/11 at 1 pm, of the menu revealed that the main entree was 3 ounces of meat, which was equal to approximately 21 grams of protein. Review of the nutritional analysis of the pasta primavera revealed it contained 5.7 grams of protein. It was also noted that the broccoli/mushroom crepe contained 10 grams of protein and the bean/cheese burrito contained 11 grams of protein, all of which were less than the regular entree.

17065


Based on dietary document review and dietary staff interview, the hospital failed to ensure the development and approval of a diet manual that was consisted with the patient menu. Lack of a comprehensive system of menu planning may result in physicians ' ordering diets that would not meet the clinical and nutritional status of patients, further compromising clinical status.

Findings:

During review of patient diets on 7/20/11 beginning at 11:30 am, it was noted that patient therapeutic diets included consistent carbohydrate diets and fat restricted diets. In a concurrent interview with DMS I she stated that patients with physician ordered low fat diets would receive a cardiac diet. Review of the hospitals ' undated document titled " Diets Available at CBH " revealed that a cardiac diet would consist of a 2 gram sodium, low cholesterol and less than 50 grams of fat. Concurrent review of the diet manual dated 4/11 revealed that a cardiac diet consisted of 2 grams of sodium and 55-70 grams of fat, there was no specified cholesterol level documented. Similarly Patient 115 had a physician ordered consistent carbohydrate diet; however the menu provided three levels of this diet. DMS I stated that unless otherwise specified nursing staff would enter an 1800 calorie diet into the electronic medical record with further clarification from the physician.

In an interview on 7/21/11 at 10:30 am, with DMS I and Administrative Staff (AS) L they stated that the hospital purchased a diet manual from one vendor and the menus from a second vendor. They also stated and acknowledged that they had not identified that there may be discrepancies between the sources of information and that the guidance in the diet manual and the therapeutic spreadsheets that guided staff on serving diets may not be consistent.

17065


Based on dietary observations, dietary staff interview and dietary document review, the hospital failed to ensure effective sanitizer concentrations. Failure to ensure sanitizer concentrations are effective may result in bacterial contamination during food production activities exposing patients to the risk of foodborne illness.

Findings:

On 7/20/11 beginning at 4:20 pm, the surveyor asked DS J to describe how food production surfaces were cleaned. She stated that she utilized a sanitizer solution that was dispensed from a pump station located above the sink. The surveyor also asked DS J to describe how she ensured that the station delivered adequate chemicals. She demonstrated testing using the existing sanitizer solution. It was noted that the color of the strip did not react. As a comparison, in the presence of hospital staff, the surveyor immersed the strip in clear water. It was noted there was no color difference between the strip that was immersed in the sanitizer and that which was immersed in the sanitizer.

Review of staff guidance for chemical testing, which was posted above the sanitizer pump station revealed that the desired concentration of the sanitizer was 200 parts/million.