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Based on trayline observations, dietary management staff interview and dietary document review the hospital failed to ensure an effective system to ensure 1) the nutritional needs of inpatients were met as evidenced by an incomplete nutritional analysis and 2) ensure that the menu for Calorie-Controlled-Consistent Carbohydrate Controlled Diets met the hospitals' guidance for the dietary management of diabetes.

Findings:

1. Diabetes nutrition recommendations for health care institutions, published by the American Diabetes Association (Diabetes Care, Volume 27, Supplement 1, January 2004) describes a consistent carbohydrate diabetes meal plan without specific calorie levels; rather incorporating a consistent carbohydrate content. The recommendations also further clarify that "the carbohydrate content would be comparable from day to day at breakfast, each day, at lunch, and each day at dinner, as well as snacks

During trayline observations on 3/29/12 beginning at 11:30 am, it was noted there were greater than 2 patients who had physician ordered carbohydrate controlled diets. In an interview on 3/29/12 at 1:15 pm, with Dietary Management Staff A she stated that recently the hospital converted their calorie controlled diabetic diets to a "Calorie Controlled-CCD (1800-2000 cal/day" plan. She also stated that prior to the conversion the department conducted multiple in-services with physicians' regarding the change. DMS A also presented an undated document titled "Section D: Dietary Management of Diabetes Mellitus." The document described the philosophy of the diet as allowing more flexibility in health care facilities by incorporating consistent carbohydrate intake with consistency in timing of meals and snacks. The document also describes that the goal of carbohydrate counting is to "1. Distribute the total carbohydrate servings equally throughout the day." Additionally the document noted that an institution "may opt to combine CHO [carbohydrate] counting and consistent CHO methods.

On 3/29/12 at 1:30 pm, the surveyor requested a meal by meal analysis of the CC-CCD diet for days 8, 19 and 14. DMS A stated that she recently received the menu analysis from the corporate office and placed them in a spreadsheet; however the CC-CCD diet appeared incorrect.

On 4/2/12 at 4:39 pm, the surveyor received the analysis. It was noted that the analysis consisted of 1 day, rather than 3 requested days. The submission of 1 day did not provide the requested information to ensure the hospitals' meal planning guidelines were followed. Current review of the submitted day revealed that the carbohydrate content for the day was listed as a total of 242 grams of carbohydrate (67 grams for breakfast; 92 grams for lunch and 82 grams for dinner), noting that the carbohydrate distribution did not meet the intent of the diet per the submitted hospital document.

2a. The Dietary Reference Intakes (DRI), developed by the Food and Nutrition Board of the National Academies' Institute of Medicine were developed as a replacement for the Recommended Dietary Allowances (RDA's). The DRI's released in multiple publications titled the Dietary Reference Intakes (DRI's). The intent of the DRI publications are to "provide health professionals ...references for planning for the nutrient needs of individuals and groups of people" (Institute of Medicine of the National Academies, 2006). The DRI's consist of recommendations for macronutrient intakes such as energy, fiber, dietary fat and cholesterol as well as recommendations for intake of vitamins and minerals.

On 3/29/12 beginning at 1:30 pm, the hospitals' menu analysis was reviewed with DMS A for the 3-week cycle. It was noted that while the analysis consisted of a daily total for the hospitals' nine most commonly ordered diets the nutritional analysis did not include all of the nutrients for which there were DRI's. The analysis consisted of 17 of 32 nutrients for which there were recommended intakes. In a concurrent interview with DMS A she stated that the information was provided to her by the corporate entity. In a follow up correspondence dated 4/2/12, submitted at 4:39 pm, noted that the vendors and/or manufacturers' of food products purchased by the facility did not provide additional information. It also noted a recommendation to access other data bases for comparable recipes/products in an effort to obtain a comprehensive analysis. There was no indication that this recommendation was carried out.

*b. It was also noted that while there was a nutritional analysis of the dietary fiber content of the diets it was noted that across the therapeutic diets the fiber content ranged from 26-20 grams of fiber, which according to the hospitals' nutritional analysis was less than 60% of the recommended intake. The DRI for fiber for total fiber intake ranges depending on age and gender. Adequate intake for females from ages 9-70 ranges from 21-16 grams of fiber. Similarly the range for males in the same age group is 30-38 grams.

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Based on observation, staff interview, and document review, the hospital failed to ensure that the environmental services staff performed weekly cleaning of the exterior of the ice machines per hospital policy.

Findings:

During a tour on 3/29/12 at 10:30 a.m., the ice machines in the hospital were viewed. Administrative Staff A and Administrative Staff B were interviewed concurrently regarding the cleaning procedures for the ice machines.

Administrative Staff A stated that the exterior of the ice machines was supposed to be cleaned daily by environmental services staff and documented on a log sheets that were hanging on the side of each machine.

Observation of the ice machine on the 2N medical surgical nursing unit revealed that there was a white residue on the stainless steel lip above the drain pan and in the drain pan. Administrative Staff A stated that it was calcium build up from the hard water. There was no documentation on the log sheet that the exterior of the machines had been cleaned on the following dates of 2012:
January 1, 4, 6, 7, 10-23, 26, 27, 28, and 30.
February 1, 2, 6, 7, 9-29.
March 1-28.

Observation of the ice machine on the 2S medical surgical nursing unit revealed that it also had a white residue on the stainless steel lip of the drain pan and in the drain pan. Administrative Staff A stated that the machine was a new one that had been installed on February 29, 2012. There was no environmental services cleaning log sheet posted on the side of the machine.

Administrative Staff B stated that environmental services staff were given a daily assignment sheet to direct them in the cleaning procedures they were to perform. Review of the daily assignment sheet revealed that it was coded to direct staff on specific procedures. There was no code for cleaning the ice machines. When asked what staff was using to clean the exterior of the ice machines, Administrative Staff B did not know.

Review of hospital policy titled, "Ice Machine Maintenance" dated 6/25/11 indicated that, "Environmental Services is responsible for daily cleaning of the ice machines ..." There was no specific procedure provided for with what and how the exterior of the ice machines was to be cleaned.