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Based on dietetic services observations, dietary document review and dietary and administrative staff interview, the hospital failed to ensure measurable improvements and timely interventions for patient food temperatures that were not within acceptable hospital developed parameters.

Findings:

During meal distribution observation and concurrent interview with Dietary Staff (DS) Q, on 3/21/16 beginning at 12 p.m. a test tray was conducted. DS Q stated that she was the person responsible for completing weekly test trays. DS Q selected a different unit each week and evaluated meals for temperature, palatability and appearance as well as several other elements. The tray was evaluated at the time the last patient received their meal. She stated that since the hospitals' dishwasher was non-functional maintaining food temperatures problematic. DS Q described that the hospital changed to plastic plates from Styrofoam several weeks earlier; however after the change temperature regulation seemed to be more problematic. There was no current plan to go back to the Styrofoam despite better results.

In an interview on 3/24/16 beginning at 9 a.m., with Administrative Staffs (AS) A and H they were aware that the change to plastic plates did not maintain temperatures. While they were in the process of developing a proposal for administrative staff to place an external dishwashing trailer on the hospital campus, the document was still in the formulation and approval stages, it would require an unspecified timeframe for approvals and implementation. There were no intermittent plans developed. Administrative Staffs A and H also stated education was provided to nursing staff to ensure patient readiness prior to meal service; however there was no monitoring for the effectiveness of this intervention and whether or not patient readiness was a contributing factor of suboptimal food temperatures.

Weekly facility documents titled "Patient/Resident Tray Assessment" from 2/28 to 3/21/16 revealed that 8 of 8 meal evaluations did not meet expected parameters with relationship to food temperatures. Each tray had the possibility of receiving a maximum of 18 points. The results of the temperature evaluation ranged from 0 to 7 points, with the majority of the meal trays receiving 2-5 points.

Review of hospital document titled "Performance Improvement/Risk Management/Patient Safety Plan 2016" noted that the scope of the plan is organization wide and applies to all departments to provide a framework of optimal patient care.

Review of facility document titled "Statement of Deficiencies" dated 12/30/15 noted that hospitals' program will "...measure, analyze and track quality indicators for Food and Nutrition Services ...Such data will be reviewed on a routine basis ...implement appropriate corrective and improvement activities ..."

Based on medical record review, nursing and administrative staff interview, the hospital failed to ensure effective procedures to ensure that verbal orders were not used as part of routine day to day operations in 3 (Patients 29, 30 and 31) records reviewed for clinical nutrition care. The use of verbal orders as routine communication may result in increased errors during order implementation with the potential to further compromise patient medical status.

Findings:

Verbal orders are those which are communicated in the presence of the physician, are intended to be used infrequently in emergent situations where it is impossible or impractical for the ordering physician to enter their own order without delaying the treatment of the patient (Code of Federal Regulations Section 482.23 (c)(3)(i)).

Patient 29 was admitted on 3/20/16 with diagnosis that included swelling, weakness and difficulty walking. Medical record review was conducted on 3/23/16 beginning at 11 a.m. Admission diet order for 3/20/16 was NPO (nothing by mouth). Follow up order dated 3/21/16 was for initiation of tube feeding (liquid feeding through a tube placed through the nose into the stomach). A comprehensive nutrition assessment was conducted on 3/21/16 at 8:19 a.m. The assessment resulted in recommendation for Novosource Renal at 50 cc/hour. The order was entered into the electronic medical record by the Registered Dietitian on 3/21/16 at 11:33 a.m. as a verbal order. The physician authenticated the order on 3/22/16 at 7:13 a.m. In a concurrent interview with Registered Nurse (RN) V she stated that based on the timing of the order it was likely that the order was finalized as part of the daily rounds in the intensive care unit. In a concurrent interview with Administrative Staff (AS) H she stated that she developed the verbal order guidance in accordance with language in the State Business and Professions code for Registered Dietitian. She was unaware of Federal regulatory guidance in relationship to verbal orders.

Food and Nutrition Policy titled "Telephone and Verbal Orders" dated 9/14 guided staff that all nutrition related orders would be entered into the electronic medical record and supported the use of verbal order terminology. The policy did not incorporate Federal regulatory guidance. Similarly the hospital policy titled "Medication Orders-Required Elements" dated 10/13 described the elements required for a valid medication order as well as guidance to " ...minimize the use of verbal and telephone orders ..." The policy did not describe situations in which verbal orders may be used; provide a mechanism to verify the identity and authority of the issuing practitioner; describe the elements required for inclusion of a verbal order or establish procedures for effective communication and authentication of verbal orders.

Additional medical record review on 3/23/16 at beginning at 2 p.m. revealed that verbal orders were also utilized in providing nutrition care for Patients 30 and 31.