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Based on staff interview and administrative document review, the governing body failed to ensure that there was safe and effective implementation of the patient food service when the hospital failed to have an organized dietary service (Cross Reference A618, A621, A630 and A631). Failed to implement an effective quality appraisal and performance program for Food and Dietetic Services (Cross Reference A 276). Failed to implement nursing care plans developed multidisciplinary plans (Cross Reference A396).
There were planned improvements of deficient practices cited of full validation survey 5/13/13 and in the plan of correction submitted dated 6/14/13 that were not implemented and deficient practices continued. These management system problems resulted in the hospital's inability to meet the Condition of Participation for Quality Appraisal and Performance Improvement Program (QAPI) and Condition of Participation for Food and Dietetic Services.
Findings:
Administrative records were reviewed starting 7/10/13 at 9:00 a.m., including the QAPI program, policies and procedures for hospital diets and some diet nutritional analysis.
The Administrator stated on 7/11/13 at 2:40 p.m., that she was the responsible person and spoke for the governing body. The Administrator stated that she was disappointed that the progress to meet the Condition of Participation for Food and Food and Dietary Services and QAPI was not in better shape and the plan of correction had not been completed as outlined. The Administrator stated that they needed additional help and resources to ensure the conditions were met following this revisit and they planned to implement ongoing monitoring and management reviews.

Based on staff interviews and document review the hospital's governing body failed to ensure a quality assessment and performance improvement (QAPI) program that reflected the complexity of the hospital services that focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors as evidenced by:

1. Ensure an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes when the Quality Appraisal and Performance Improvement (QAPI) program implemented an ongoing data based measurable indicators or show evidence of improving health outcomes for the program developed. (Cross Reference A 273)

The cumulative effect of these systemic problems resulted in the inability for the hospital's quality program to monitor QAPI in such a manner as to ensure that the nutritional needs of the patients were met in accordance with physicians' orders and acceptable standards of practice. There were planned improvements of deficient practices cited of full validation survey 5/13/13, and in the plan of correction dated 6/14/13, that were not implemented and deficient practices continued. These system problems resulted in the hospital's inability to meet the Condition of Participation for Quality Appraisal and Performance Improvement Program.





27533

Based on observation, staff interview and document review, the hospital failed to ensure an ongoing quality program that showed measurable improvement in indicators for which there is evidence that it will improve health outcomes with the Quality Appraisal and Performance Improvement Program (QAPI). The failure to measure, analyze and track the deficient practices and develop a robust QAPI program in Food and Dietetic Services would allow the failures to continue and compromise patient care. Identified failing from the full recertification survey on 5/13/13 and Plan of Care continued on the revisit 7/10/13.

Findings:
Review of the Food and Dietetic Services Quality Appraisal and Performance Improvement plan starting on 7/11/13 at 10:00 a.m., showed they had revamped the quality program to include, correctly serving patient meal trays and monitoring kitchen sanitary conditions including handwashing, timeliness of dietitian initial nutrition assessments, nutrition analysis available.

Discussion with the Registered Dietitian (RD) and Quality Director concurrently on 7/11/13 starting at 1:00 p.m., stated that they had not completed the hospital menu analysis and had not integrated the diet manual information specific to the hospital into the Academy Care Manual they have on line. The RD acknowledged the hospital diets pages were in a policy and not integrated into the manual that was accessible to all staff.

The Quality Director acknowledged that the quality program should have measured and analyzed the nutrition care planning and nutritional assessment practices cited in the previous survey. The quality staff acknowledged the quality program was not effective in the hospital evaluating and correcting identified problems related to the effective nutrition care of the patients and developing measurable care plans.

The RD and Quality Director stated 2:00 p.m., 7/10/13 that the quality program did not address the quality of the nutritional assessments only the timeliness of those patient admitted with diagnosis requiring nutrition consults. There was no quality program to address the accuracy of the nutrition assessments. There was not data or analysis of the nutrition program for patient during their hospital stay.






27533

Based on observation, interview, and review of medical records the hospital failed to ensure multidisciplinary care plans was developed to include individual and measurable goals for 4 of 7 patients (Patients 100, 101, 103, and 106) reviewed for nutritional assessment and care planning. This failure has the potential to compromise the medical care of the patients.
Findings:

1. Patient 100 was admitted 7/2/2013 with diagnosis of intermittent explosive disorder. Medical referral dated 7/2/13 stated patient has a diagnosis of Prader-Willi Syndrome (genetic syndrome with characteristic of muscle weakness, insatiable appetite, obesity if food intake is uncontrolled, and mental retardation). Diet was prescribed as calorie controlled 1200 calories- strict diet plan. Patient weigh on admission was 36.2 kilograms (80.5 pounds), height 143.5 centimeters (57 inches). The nurse admitting nutrition screen stated no nutritional risk.
Initial nutrition assessment dated 7/2/13 stated patient on calorie controlled diet and recommended plan for regular diet and education to patient. The nutrition assessment did not include the diagnosis of Prader Willi Syndrome or question the diet order for calorie controlled diet for an adolescent patient.
Review of the care plans showed there was no care plan developed for the Prader-Willi Syndrome and diet restrictions.
Interview with Registered Dietitian (RD) and Quality Director on 2:25 p.m., stated the initial nutritional assessment should have included the diagnosis of Prader- Willi Syndrome since there are significant nutritional implications and the RD who wrote the recommendation should have investigated the medical history to ensure the patient nutrition in accurately and completely assessed. The RD acknowledged there should have been a care plan developed to ensure the individual need of the patient diet and restrictions were provided.
2. Patient 101 was admitted 6/19/13 with diagnosis of major depression. Medical diagnoses included hypertension, constipation. Diet order was sodium restricted no added salt (3 to 4 grams sodium). Weight was 62.1 kilogram (136.6 pounds), and 83.9 kilograms (184.58 pounds) on 7/2/13 (both standing scale). Constipation medications were Colace and miralax pharmaceuticals.
1. Review of the initial nutrition assessment 6/24/13 stated albumin (measure of serum protein and nutritional status) low 3.1 g/dl (3.4 to 5.4 g/dl normal range). Registered Dietitian (RD) recommenced 2 gram sodium diet. Appetite was fair and noted constipation but did not recommend any dietary interventions.
Nutrition follow up note dated 7/2/13 noted poor appetite at 47 percent average meal intake . There was no assessment of the constipation or the previous recommendation for 2 gram sodium diet.
Nutrition follow up note dated 7/6/13 stated weight 62.1 kilograms (136.6 pounds). RD stated the 6/19 weigh of 83.9 kilograms likely inaccurate. There was no albumin lab noted.
Labs dated 7/3/13 albumin 3.1 mg/dl (3.4 to 5.4 g/dl normal range).
Review of the paper chart on 7/10/13 also showed a post it note on the continued stay physician progress note dated 7/2/13 stated "Recommend: add small portions with meals per patient request," signature was RD.
Review of diet orders and physician notes did not show any diet change or physician acknowledgement of the recommendation for small portions with meals.
Review of care plan dated 6/21/13 and 7/2/13 showed plans for HTN, gives away food, and constipation addressed the nursing concerns but there was no documentation that the RD had attended the care plan meeting or been involved in developing nutrition care plans for the patient at nutritional risk with poor intake, giving away food, constipation, and hypertension.
Interview with the Registered Dietitian (RD) and Quality Manager on 7/10/13 approximately 2:00 p.m., reviewed the nutrition care for Patient 101. RD stated that she was only attending the care meeting for nutritional high risk patients. Quality Director acknowledged the weigh discrepancy should have been addressed at admission to ensure accurate weight was recorded. Quality director acknowledged the nutrition assessment should have addressed all of the nutrition concerns of HTN, poor intake, weigh and albumin. Quality director acknowledged the diet recommendations should have been addresses.
3. Patient 103 was admitted on 7/2/13 with diet of low cholesterol and 50 gram of fat. This was an adolescent male. History and Physical dated 7/2/13 stated decreased appetite and lost 10 pounds in last month.
Nutrition assessment dated 7/6/13 recommended education for the therapeutic diet. The nutrition assessment did not address the comments in the H&P regarding the poor intake or weight loss.
Review of the care plans on 7/11/12 at 11:00 a.m. showed three psychiatric plans and no nutritional care plans to address the low fat low cholesterol diet restrictions and the need for patient education. There was no care plan for the history of poor appetite or weight loss.
Quality Director acknowledged on 7/11/13 at 2:00 p.m., there should have been care plan developed and the RD would be part of the care team to address the nutritional concerns.
4. Patient 106 was admitted 7/5/13 with diagnosis of Diabetes Mellitus, GERD (gastrointestinal esophageal reflux disease) (chronic condition with the stomach acid content wash up into the throat causing irritation and damage), hyperlipidemia (elevated blood fats) and developmental delay. Physician diet order was consistent carbohydrate with mechanical soft.
Review of the medical record showed no nutritional assessment for the GERD or the hyperlipidemia.
Review of the care plans showed nursing had initiated care plans for: #2 patient eating at least 75 percent of meal, #3 diabetes on metformin and proper diet as prescribed, and #9 patient has no teeth and assist with meals with no choking There was no RD input or review of the care plans to ensure all nutritional aspects of care were addressed for patient care.







27533

Based on observation, interview and document review the hospital failed to ensure that dietary services met the needs of all patients as evidenced by failure to:
1. Ensure the qualified dietitian met the needs of 4 of 7 patients (Patients 100, 101, 103 and 106) reviewed for nutrition care and multidisciplinary nutrition care planning (Cross reference A621 and A396).
2. Ensure the regular and therapeutic menus met the nutritional components to meet the current national standards including the RDA (Recommended Dietary Allowances) and DRI (dietary recommended intakes) of the Food and Nutrition Board of the National Research Council (Cross Reference A630).
3. Ensue a therapeutic diet manual that accurately reflected physician ordered diets and current standards of practice (Cross Reference A631).
4. Monitor performance improvement activities that reflected the scope and nature of the services and that identified opportunities for improvement (Cross Reference A276).
The cumulative effect of these systemic problems resulted in the inability of the hospitals' Food and Dietetic Services to ensure that food was served and met the nutritional needs of the patients in accordance with practitioners' orders and acceptable standards of practice. The system problems resulted in the hospital's inability to meet the Condition of Participation for Food and Dietetic Services.






27533

Based on staff interview and medical record review the hospital failed to ensure the qualified dietitian met the needs of 3 of 7 patients (Patients 100, 101, and 106) reviewed for nutrition care and multidisciplinary nutrition care planning.
Findings:
1. Patient 100 was admitted 7/2/13 with diagnosis of intermittent explosive disorder. Medical referral dated 7/2/13 stated patient has a diagnosis of Prader-Willi Syndrome (genetic syndrome with characteristic of muscle weakness, insatiable appetite, obesity if food intake is uncontrolled, and mental retardation). Diet was prescribed as calorie controlled 1200 calories-strict diet plan. Patient weigh on admission was 36.2 kilograms (80.5 pounds, height 143.5 centimeters (57 inches). The nurse admitting nutrition screen stated no nutritional risk.
Initial nutrition assessment dated 7/2/13 stated on calorie controlled diet and recommended plan for regular diet and education to patient. The nutrition assessment did not include the diagnosis of Prader Willi Syndrome.
Review of the care plans showed there was no care plan developed for the Prader-Willi Syndrome.
Interview with Registered Dietitian (RD) and Quality Director on 2:25 p.m., stated the initial nutritional assessment should have included the diagnosis of Prader- Willi Syndrome since there are significant nutritional implications and the RD who wrote the recommendation should have investigated the medical history to ensure the patient nutrition in accurately and completely assessed. The RD acknowledged there should have been a care plan developed to ensure the individual need of the patient diet and restrictions were provided.
2. Patient 101 was admitted 6/19/13 with diagnosis of major depression. Patient 101 was en elderly female. Medical diagnoses included hypertension, constipation. Diet order was sodium restricted no added salt (3 to 4 grams sodium). Weight was 62.1 kilogram and 83.9 kilograms on 7/2/13 (both standing scale). Constipation medications were Colace and miralax pharmaceuticals.
Review of the initial nutrition assessment 6/24/13 stated albumin (measure of serum protein and nutritional status) low 3.1 g/dl (3.4 to 5.4 g/dl normal range). Registered Dietitian (RD) recommenced 2 gram sodium diet. Appetite was fair and noted constipation but did not recommend any dietary interventions. There were no interventions for the below normal albumin.
Nutrition follow up note dated 7/2/13 noted poor appetite at 47 percent average meal intake . There was no assessment of the constipation or the previous recommendation for 2 gram sodium diet.
Nutrition follow up note dated 7/6/13 stated weight 62.1 kilograms. Stated the 6/19 weigh of 83.9 kilograms likely inaccurate. There was no albumin lab noted.
Labs dated 7/3/13 albumin 3.1 mg/dl (3.4 to 5.4 g/dl normal range).
Review of the paper chart on 7/10/13 also showed a post it note on the continued stay physician progress note dated 7/2/13 stated, "Recommend: add small portions with meals per patient request," signature was RD.
Review of diet orders and physician notes did not show any diet change or physician acknowledgement of the recommendation for small portions with meals or 2 gram sodium diet.
Interview with the Registered Dietitian (RD) and Quality Manager on 7/10/13 approximately 2:00 p.m., reviewed the nutrition care for Patient 101. RD could not explain why Patient 101 nutrition assessments did not assess for the low albumin levels, or dietary interventions for constipation. RD could not state why the diet recommendations for 2 gram sodium and small portion diets were not followed up on in a timely manner. The 2 gram sodium diet was recommended on 6/24/13 and 16 days of hospital stay. The RD was not able to address the weight discrepancy and why it was stated to be inaccurate 21 days after the admission and documentation of the two weights at 61.2 kilograms and 83.9 kilograms. The RD could not address why there was no nutrition assessment of the 7/2/13 assessment of appetite poor at 47 percent meal intake.
3. Patient 103 was admitted on 7/2/13 with diet of low cholesterol and 50 gram of fat. This was an adolescent male. History and physical dated 7/2/13 stated decreased appetite and lost 10 pounds in last month.
Nutrition assessment dated 7/6/13 recommended education for the therapeutic diet. The nutrition assessment did not address the comments in the H&P regarding the poor intake or weight loss.
4. Patient 106 was admitted 7/5/13 with diagnosis of Diabetes Mellitus, GERD (gastrointestinal esophageal reflux disease) (chronic condition with the stomach acid content wash up into the throat causing irritation and damage), hyperlipidemia (elevated blood fats) and developmental delay. Physician diet order was consistent carbohydrate with mechanical soft.
Review of the medical record showed no nutritional assessment for the GERD or the hyperlipidemia.
Review of the care plans showed nursing had initiated care plans for: #2 patient eating at least 75 percent of meal, #3 diabetes on metformin and proper diet as prescribed, and #9 patient has no teeth and assist with meals with no choking There was no RD input or review of the care plans to ensure all nutritional aspects of care were addressed for patient care.

The RD and Quality Director stated 2:00 p.m., 7/10/13 that the quality program did not address the quality of the nutritional assessments only the timeliness of those patient admitted with diagnosis requiring nutrition consults. There was no quality program to address the accuracy of the nutrition assessments There was not data or analysis of the nutrition program for patient during their hospital stay.
Review of the Assessment and reassessment of patient policy dated revised 2010 stated under General Guidelines: 11. Initiate appropriate patient care treatment plans based on assessment. Ongoing evaluation and reassessment continues based on observation of outcomes of interventions. For Nutrition Services the assessment process is initiated for other patients (if not triggered or ordered) by a routine review based on length of stay of patient request. Patient assessment if at risk 3-4 days and in not at risk 5-7 days.
The initial nursing screen was not identifying all patients or all nutrition the nutrition of patient was compromised and there was no management system (a framework of processes, policies, and quality evaluation to ensure objectives and maintaining requirements.





27533

Based on staff interview and document review the hospital failed to ensure the nutritional needs of the patients were met in accordance with recognized dietary practices. The menus were not analyzed to ensure they met the nutritional components to meet the current national standards including the RDA (Recommended Dietary Allowances) and DRI (Dietary Required Intake) of the Food and Nutrition Board of the National Research Council. Lack of nutrient analysis of patient menus could potentially place patients at risk of not receiving required nutrients and compromising medical care
Findings:

Document review on 7/10/13 starting at 9:00 a.m., of facility provided documents related to nutrient analysis showed a nutrient analysis of some of the diets including regular and low sodium, low cholesterol, consistent carbohydrate (modifications of normal diet used to improve specific health conditions).The menu analysis was not evaluated for the average of three week cycles or for gender and age served and for all modified and therapeutic diets.

The provision of the DRI which include the RDA's Adequate Intake and Acceptable Macronutrient Distribution Range developed by the Food and Nutrition Board under the aegis of the Institute of Medicine, are used to evaluate nutritional adequacy of patient menus. Menus for all diets can then be improved when deficient analysis shows deficiencies in essential nutrients or medical staff is aware of limitations to diets and medical needs can be addressed and planned.

Interview with the Registered Dietitian (RD) on 7/10/13 at 9:00 a.m., stated that had not completed the nutrient analysis of the patient menus for all diets including the therapeutic diets for all age and gender. The RD stated that they were working on the analysis but this was not completed as planned in the Plan of Correction (POC) submitted to the Department following the recertification survey dated 5/13/13 with a POC completion date of June 10, 2013. The RD stated they had not completed the complete nutritional analysis, and menu revisions based on the nutrient analysis.

The menus used were not evaluated to ensure they met the required nutrients or were deficiencies noted in the diet manual when not possible to meet the DRI/RDA since there was no nutrient analysis.








27533

Based on observation, interview, and document review, the hospital failed to have a therapeutic manual including the diets offered met the current standard of practice and included a comprehensive description of the therapeutic diets offered by including the purpose of the diet, indications or the diet, nutritional adequacy or the diet, sample menu plans and standard of practice references. This comprehensive diet manual would be available to medical and dietary service staff for reference.

Lack of comprehensive diet manual that reflected hospital-developed diets may result in inaccurate guidance to dietary and hospital staff when following physician ordered diets to meet the nutritional need of the patient and further compromising medical status.

Findings:

Review of the reference titled: Diet Manual stated the Academy of Nutrition and Dietetics Nutrition Care Manual was the diet manual used by the hospital. The policy showed a revised date of 2010.

The RD on 7/10/13 starting at 9:00 a.m., stated that the hospital used the Academy of Nutrition and Dietetics Care Manual, an online reference for medical and dietary staff. She acknowledged the Care Manual was a general reference for staff and did not include the hospital specific diets and all the element of a hospital specific diet manual. The RD stared that she had developed a policy to include the some of the elements including the purpose of the diet, indications or the diet, sample menu plans but this was separate and not integrated for the staff to access.

The RD acknowledged that since these elements were in a policy and separate from the on line Care Manual it did not meet the intent of the integrated diet manual specific to the hospital diets. The RD acknowledged they did not have the adequacy for the diets and population served completed and available to put in the diet manual.

Review of the hospital menus and daily spread sheets showed designated diets as "Carbohydrate Controlled diet," "Liberal House Renal," "Chronic Renal diet,"
and large and small portions. The Diet Manual diet terminology was "Consistent Carbohydrate diet," "Modified Renal diet," "high nutrient diet," and did not contain information for the large portion diets. The diet manual did not contain the specific diet nutrient analysis of the hospital menus and thus would not reflect current nutrients for each diet. The diet manual did not specify calories or protein components of the small portion diet.

The Registered Dietitian (RD) stated on 4/30/13 at 1:00 p.m. that the different terminology for the diets would be confusing for the nursing staff. She further acknowledged that the current Diet Manual was not consistent with the menus they planned on using and they would be unable to add the nutrient analysis to this diet manual to reflect the nutrient analysis of their menus.

The diet manual should ensure the diets offered met the current standard of practice and included a comprehensive description of the therapeutic diets offered by including the purpose of the diet, the indication for the diet, nutritional adequacy of the diet, and sample menu plans consistent with the hospital's menu and current standard of practice references and be available to all staff involved in the care of the patient.

The Plan of correction (POC) dated 5/13/2013 recertification survey showed a June 10, 2013 completion date.









27533

Based on record review and interview, the facility failed to assess patient memory for 1 of 8 active sample patients (A2). This deficiency makes it impossible to follow the changes of this parameter and adjust treatment accordingly. Furthermore, the lack of description makes it impossible to duplicate the evaluation since the mechanisms used to test memory was not documented.

Findings include:

A. Record Review

The psychiatric evaluation for patient A2 dated 7/27/2013 had no memory described. It stated, "Sensory and Cognition: Patient is alert and oriented x 3."

B. Interview

In an interview on 8/7/2013 at 1 p.m. the Medical Director, who did that evaluation, agreed that there was no testing of patient's memory described in the psychiatric evaluation.

Based on record review and interviews, the facility failed to assure that the Medical Director and the Director of Nursing (DON) adequately protected the rights of patients who were placed in seclusion and/or restraint. Specifically the Directors failed to ensure the proper use of Seclusion and Restraints (S&R) for 1 non-sample patient (N2) added for review of S&R. The facility failed to follow proper release criteria for S&R for patient N2, thereby keeping patient restrained longer than necessary. The facility also failed to ensure the use of the least restrictive methods for external control of aggressive and agitated behavior based on individual patient findings/needs for 1 active sample patient (A2) and 2 of 3 non-sample patients added for review (N2 and N3). The facility had used chemical restraint for episodes of patient agitation, and had no policy and procedure in place to support the use of chemical restraints. No evaluation of patients in restraint was done, because the facility did not consider the choice of medications and dosages to be chemical restraint. Facility staff did acknowledge that the medications would have a "sedating" effect, and the medication combination used was one usually used as a regular order set for Emergency Medications for any patient given the medications when agitated. This failure exposed patients to potential harm from unnecessary chemical restraint and jeopardized patients' rights to safe treatment in the least restrictive manner possible. (Refer to B144 and B148)