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Based on review of the Interdisciplinary Plan of Care (IDPOC), review of physician's orders, and review of the Acute Hemodialysis Flow Sheets, it was determined the plan of care for the hemodialysis treatment was not followed by the acute hemodialysis nurse for five of five (#1-#4 and #16) current patients and one of one (#11) discharged patient; the acute hemodialysis failed to assess the patient to address why the physician's order for treatment was altered for five of five (#1-#4 and #16) current patients and one of one (#11) discharged patient; there was no evidence the IDPOC addressed the coordination of dialysis needs between the nursing unit staff and the acute dialysis staff for five of five (#1-#4 and #16) current patients and one of one (#11) discharged patient. The failed practices did not assure Patients #1-#4, #11 and #16 were free of potential complications of dialysis. The findings had the likelihood to affect any patient admitted who would receive hemodialysis. The findings were:

A. Patient #1:
1) Admitted on 03/01/19.
2) Physician's hemodialysis orders dated 03/04/19 were:
a) Dialysis every Monday-Wednesday-Friday;
b) Dialyze for 3 hours;
c) The order did not identify the 160 as the dialyzer, size or brand;
d) BFR (blood flow rate) of 400 milliliters/minute (ml/min)
e) DFR (dialysate flow rate) of 800 ml/min
f) A dialysis bath of 3K (potassium) mEq (milliEquivalent), 3Ca (calcium) mEq, 139 Na+ (sodium) and 35 HCO3 (bicarbonate) mEq, 36-37-there was no evidence what the 36-37 stood for.
g) Fluid removal 3L (liters)
h) Heparin 2000 units IV (intravenous) push as indicated PRN (as necessary) dialysis. The order did not give any instructions on what as indicated meant.
i) Heparin 500 units IV push as indicated PRN dialysis. The order did not give any instructions on what as indicated meant.
j) Normal Saline 1000 ml, 1000 ml/hr IV piggyback as indicated PRN (hypotension (low blood pressure), medication flushes and rinseback), use with hemodialysis. Give parameters for BP (blood pressure) and ml max (maximum) for IV bolus. The order did not give any instructions for BP parameters or the maximum IV fluid boluses.
3) Review of three of three (03/04, 06 and 08/19) Acute Hemodialysis Flow Sheets showed:
a) 03/04/19 (Monday):
1. The hemodialysis orders were a 3K 2.5Ca dialysis bath which did not meet the physician's order of 3K 3Ca bath. The UFG (ultrafiltration goal) for fluid removal was 1 liter (1,000 ml).
2. The pre-treatment dialysis data showed the UF (ultrafiltration) calculation was to remove 1000-2000 ml with 400 ml for the prime/rinseback for a total of 1400-2400 ml of fluid to remove which did meet the 3 liters as ordered by the physician on 03/14/19.
3. The end of treatment fluid loss was recorded as 1,400 ml. There was no assessment by the Registered Nurse (RN) at what point during the treatment it was decided to only remove 1,400 ml versus 2,400 ml.
4. There was no assessment by the RN that the patient could not tolerate the removal of 3L. There was no evidence the physician was contacted that the UFG of 3L was not achieved.
5. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
b) 03/06/19 (Wednesday):
1. The hemodialysis orders were for a 3K 2.5Ca dialysis bath which did not meet the physician's order of 3K 3Ca bath. The UFG (ultrafiltration goal) for fluid removal was 3 liters (3,000 ml).
2. The pre-treatment data showed the patient had edema in both lower extremities.
3. The pre-treatment dialysis data showed the UF calculation was to remove 2400-3400 ml, plus 560 ml of IV medications/fluids, plus 400 ml for the prime/rinseback for a total of 2-3000 ml of fluid to remove. The actual fluid removal would have been 3360-4360 ml by adding the numbers together. There was no evidence RN assessed that the patient was going to receive more fluids than what was calculated to remove.
4. The end of treatment fluid loss was recorded as 2,400 ml. There was no assessment by the RN why the patient could not tolerate removing the fluid as ordered.
5. The post treatment RN assessment showed the patient still had edema in both lower extremities.
6. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
7. There was no evidence the physician was notified post treatment that the patient did not achieve the ordered 3L and the patient still had edema after treatment.
c) 03/08/19 (Friday):
1. The first page of the flow sheet was dated 03/09/19 while the second page was dated 03/08/19.
2. The hemodialysis orders were for a 3K 2.5Ca dialysis bath and UFG for fluid removal was 2-3 liters (2,000-3,000 ml).
3. The UF Calculation was to remove 2,000 ml, plus 400 ml for the prime/rinseback for a total of 2,400 ml to remove which did not meet the 3 liters as ordered by the physician.
4. The end of treatment fluid loss was recorded as 2,400 ml. There was no assessment by the RN why the patient could not tolerate removing the fluid as ordered.
5. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
6. There was no evidence the physician was notified post treatment that the patient did not achieve the ordered 3L.
4) Review of the IDPOC for dialysis dated 03/01/19 showed:
a) The goals were:
1. Maintain adequate fluid volume. This goal was not measurable to determine if the patient maintained an adequate fluid volume.
2. Remains free of infection. This goal does not identify what would be observed (i.e. arteriovenous dialysis access) for infection.
3. Patient/caregiver demonstrate understanding of food/drug interaction education. This goal does not identify what medications would be assessed for food/drug interaction related to dialysis.
4. Verbalizes understanding of adequate nutrition. This goal does not identify what adequate nutrition would be for a dialysis patient.
5. Patient would be able to tolerate therapy schedule without shortness of breath or undue fatigue. There was no evidence how this goal relates to dialysis.
6. Patient/caregiver would demonstrate knowledge of skin care measures-pressure reduction and skin care. There was no evidence how this goal relates to dialysis.
7. Patient would experience stable SBP (systolic blood pressure) throughout dialysis treatment. There was no evidence what was considered a stable SBP.
b) The only intervention was to discuss patient education. There were no interventions identified to assure the goals at 4a1-7 were met. There was no evidence of the coordination of care between the nursing unit staff and dialysis staff.
5) During an interview on 03/08/19 at 1:59, the Acute Dialysis Manager, Chief Nursing Officer (CNO) and Director of Quality/Risk Management confirmed the findings for A1-4.

B. Patient #2
1) Admitted on 03/08/19.
2) Physician's hemodialysis orders dated 03/06/19 were:
a) Dialysis every Monday-Wednesday-Friday;
b) Dialyze for 3 hours;
c) The order did not identify the 160 as the dialyzer, size or brand;
d) BFR of 400 ml/min.
e) DFR of 400 ml/min.
f) A dialysis bath of 3K 2.5Ca, 139 Na+ and HCO3 mEq 36.
g) Ultrafiltration 3L. Under comments it was stated UF 0-3L as tolerated. There was no guidance for the nurses to follow for determining the fluid removal of 0-3L.
g) Heparin 2000 units IV push as indicated PRN dialysis. The order did not give any instructions on what as indicated meant.
h) Heparin 500 units IV push as indicated PRN dialysis. The order did not give any instructions on what as indicated meant.
i) Normal Saline 1000 ml, 1000 ml/hr IV piggyback as indicated PRN (hypotension, medication flushes and rinseback), use with hemodialysis. Give parameters for BP (blood pressure) and ml max (maximum) for IV bolus. The order did not give any instructions for BP parameters or the maximum IV fluid boluses.
3) Review of one of one (03/08/19) Acute Hemodialysis Flow Sheet showed:
a) The hemodialysis orders was UFG of 1-3L which did not match the order of 0-3L.
b) The patient had pitting to one plus edema in both upper and lower extremities.
c) The calculated UFG was 1-3L plus 400 ml prime/rinseback for a total of 1400-3400. The recorded treatment showed the UFR (ultrafiltration rate) ranged from 330 ml/hour to 800. The calculated UFR based on the UFG would be 467 ml/hr for 1,400 ml or 1,133 ml/hr for 3,400 ml. There was no evidence the RN had assessed the patient to reflect why the UFR was changed throughout the treatment. The orders did not include a UF Profile.
d) During the treatment, the DFR was set at 800 ml/min but the physician order was 400 ml/min. There was no evidence the RN clarified the order for the DFR.
d) The recorded fluid removal at the end of treatment was 2,000 ml. The post treatment RN assessment showed the patient still had edema in both upper and lower extremities.
e) There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
f) There was no evidence the physician was notified post treatment that the patient did not achieve the ordered 3 L. and the patient still had edema after treatment.
4) Review of the IDPOC showed dialysis was not addressed.
5) During an interview on 03/08/19 at 2:15 PM, the Acute Dialysis Manager, CNO and Director of Quality/Risk Management confirmed the findings B1-4.

C. Patient #3:
1) Admitted on 02/26/19.
2) Physician's hemodialysis orders dated 02/27/19 were:
a) Dialysis every Monday-Wednesday-Friday;
b) Dialyze for 3 hours;
c) The order did not identify the 160 as the dialyzer, size or brand;
d) BFR of 400 ml/min
e) DFR of 800 ml/min
f) A dialysis bath of 2 K+ mEq, 3 Ca+++mEq, 139 Na+ and 35 HCO3 mEq, 36-37-there was no evidence what the 36-37 stood for..
g) Fluid removal 2L
h) Heparin 2000 units IV push as indicated PRN dialysis. The order did not give any instructions on what as indicated meant.
j) Normal Saline 1000 ml, 1000 ml/hr IV piggyback as indicated PRN (hypotension, medication flushes and rinseback), use with hemodialysis.
3) The physician's orders did not include an order to transfer the patient to an outpatient unit for dialysis in order to receive sodium thiosulfate.
4) There was no evidence of ongoing communication between the facility and the outpatient dialysis facility of the patient's status during and after dialysis treatment.
5) Review of the (IDPOC) for dialysis dated 02/28/19 showed:
a) The goals were:
1. Maintain adequate fluid volume. This goal was not measurable to determine if the patient maintained an adequate fluid volume.
2. Remains free of infection. This goal did not identify what would be observed (i.e. arteriovenous dialysis access) for infection.
3. Patient/caregiver demonstrate understanding of food/drug interaction education. This goal did not identify what medications would be assessed for food/drug interaction related to dialysis.
4. Verbalizes understanding of adequate nutrition. This goal did not identify what adequate nutrition would be for a dialysis patient.
5. Patient would be able to tolerate therapy schedule without shortness of breath or undue fatigue. There was no evidence how this goal related to dialysis.
6. Patient/caregiver would demonstrate knowledge of skin care measures-pressure reduction and skin care. There was no evidence how this goal related to dialysis.
7. Patient would experience stable SBP (systolic blood pressure) throughout dialysis treatment. There was no evidence what was considered a stable SBP.
b) The only intervention was to discuss patient education. There were no interventions identified to assure the goals at 4a1-7 were met. There was no evidence of the coordination of care between the nursing unit staff and dialysis staff.
6) During an interview on 03/11/19 at 10:18 AM, the CNO and Director of Quality/Risk Management stated that on 02/27 or 28th/19 the patient had gone to the outpatient dialysis facility for treatment. When the facility called the outpatient dialysis facility to determine pick-up time, it was learned the patient had been transferred to (Named Facility) emergency department for evaluation/treatment for continued bleeding from the hemodialysis access site. The CNO and Director of Quality/Risk Management confirmed the findings for Patient #3 at C1-5.

D. Patient #11:
1) Admitted on 02/12/19 and discharged on 02/19/19.
2) Physician's hemodialysis orders dated 02/13/19 at 0823 (8:23 AM) were:
a) Dialysis every Monday-Wednesday-Friday;
b) Dialyze for 3 hours;
c) The order did not identify the 160 as the dialyzer, size or brand;
d) BFR of 400 ml/min
e) DFR of 800 ml/min
f) A dialysis bath of 2 K 3Ca, 139 Na and 35 HCO3 mEq, 67-there was no evidence what the 67 stood for.
g) Fluid removal 3L (liters)
h) Heparin 2000 units IV (intravenous) push as indicated PRN (as necessary) dialysis. The order did not give any instructions on what as indicated meant.
i) Normal Saline 1000 ml, 1000 ml/hr IV piggyback as indicated PRN (hypotension, medication flushes and rinseback), use with hemodialysis.
3) Physician's hemodialysis orders dated 02/13/19 at 0948 (9:48 AM) were:
a) Dialysis every Monday-Wednesday-Friday;
b) Dialyze for 3.5 hours;
c) The order did not identify the 180 as the dialyzer size or brand;
d) BFR of 400 ml/min
e) DFR of 800 ml/min
f) A dialysis bath of 2 K 3Ca, 139 Na and 35 HCO3 mEq, 67-there was no evidence what the 67 stood for.
g) Fluid removal 2L.
4) Physician's hemodialysis orders dated 02/15/19 at 1642 (4:42 PM) showed:
a) Dialysis every Monday-Wednesday-Friday;
b) Dialyze for 3 hours;
c) The order did not identify the 160 as the dialyzer size or brand;
d) BFR of 400 ml/min
e) DFR of 800 ml/min
f) A dialysis bath of 2 K 2.5Ca, 140 Na and 35 HCO3 mEq, 36-37-there was no evidence what the 67 stood for.
g) Fluid removal 2L (liters)
h) Normal Saline 1000 ml, 1000 ml/hr IV piggyback as indicated PRN (hypotension, medication flushes and rinseback), use with hemodialysis. There was no evidence of parameters for hypotension
5) Review of two of two (02/13 and 15/19) Acute Hemodialysis Flow Sheets showed:
a) 02/13/19 (Wednesday):
1. Hemodialysis orders was for a UFG of 2L
2. The pre-treatment assessment showed the patient had generalized edema.
3. UF calculations were 2,000 ml plus 400 prime/rinseback for a total of 2400 ml. The recorded treatment showed the UFR (ultrafiltration rate) ranged from 570-1000 ml/hr. The calculated UFR based on the UFG would be 685.7 (686). There was no evidence the RN had assessed the patient to reflect why UFR was changed throughout the treatment. The orders did not include a UF Profile.
4. The recorded fluid removal was 1,208 ml which was less than the set UFG. The post treatment assessment by the RN showed the patient had generalized edema. There was no assessment by a RN to address why the patient did not achieve the set UFG.
5. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
6. There was no evidence the physician was notified post treatment of the patients fluid volume loss of 2L was not achieved and the patient still had edema after treatment.
b) 02/15/19 (Friday):
1. Hemodialysis orders was for a UFG of 2L
2. The pre-treatment assessment showed the patient had generalized edema.
3. UF calculations was 2,000 ml plus 400 prime/rinseback for a total of 2400 ml. The recorded treatment showed the UFR (ultrafiltration rate) ranged from 660-1000 ml/hr. The calculated UFR based on the UFG would be 686. There was no evidence the RN had assessed the patient to reflect why UFR was changed throughout the treatment. The orders did not include a UF Profile.
4. The recorded fluid removal was 1,208 ml which was less than the set UFG of 2,400 ml. The post treatment assessment by the RN showed the patient had generalized edema. There was no assessment by a RN to address why the patient did not achieve the set UFG.
5. The treatment began at 1805 (6:05 PM) and ended at 1920 (7:20 PM). At 1920, the physician (Named) was notified that the system had clotted 2 times and was advised to have patient scheduled for AVF (arteriovenous fistula-dialysis access) declot on Monday. There was no clarification with physician that it was the extracorpreal circuit (dialyzer and blood lines) that had clotted and not the AVF.
6. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
6) Review of the IDPOC for dialysis dated 02/13/19 showed:
a) The goals were:
1. Maintain adequate fluid volume. This goal was not measurable to determine if the patient maintained an adequate fluid volume.
2. Remains free of infection. This goal did not identify what would be observed (i.e. arteriovenous dialysis access) for infection.
3. Patient/caregiver demonstrate understanding of food/drug interaction education. This goal did not identify what medications would be assessed for food/drug interaction related to dialysis.
4. Verbalizes understanding of adequate nutrition. This goal did not identify what adequate nutrition would be for a dialysis patient.
5. Patient would be able to tolerate therapy schedule without shortness of breath or undue fatigue. There was no evidence how this goal related to dialysis.
6. Patient/caregiver would demonstrate knowledge of skin care measures-pressure reduction and skin care. There was no evidence how this goal related to dialysis.
7. Patient would experience stable SBP (systolic blood pressure) throughout dialysis treatment. There was no evidence what was considered a stable SBP.
b) The only intervention was to discuss patient education. There was no interventions identified to assure the goals at 4a1-7 were met. There was no evidence of the coordination of care between the nursing unit staff and dialysis staff.
c) There was no evidence of coordination of care between the nursing unit staff and the acute dialysis staff.
7. During an interview on 03/08/19 at 3:00 PM, the Acute Dialysis Manger, CNO and Director of Quality/Risk Management confirmed the findings in D1-6.

E. Patient #16:
1) Admitted on 02/28/19:
2) Physician's hemodialysis orders dated 03/01/19 were:
a) Dialysis every Monday-Wednesday-Friday;
b) Dialyze for 3 hours;
c) The order did not identify the 160 as the dialyzer, size or brand;
d) BFR of 400 ml/min.
e) DFR of 800 ml/min .
f) A dialysis bath of 3K 3Ca, 139 Na and 35 HCO3 mEq, 36-37-there was no evidence what the 36-37 stood for.
g) Fluid removal 3L (liters)
h) Heparin 2000 units IV push as indicated PRN dialysis. The order did not give any instructions on what as indicated meant.
i) Heparin 1,000 units IV push as indicated PRN dialysis; stop one hour before treatment ends. The order did not give any instructions on what as indicated meant.
j) Normal Saline 1,000 ml/hr IV piggyback as indicated PRN dialysis.
k) Normal Saline 1,000 ml/hr IV piggyback as indicated PRN (hypotension (low blood pressure), medication flushes and rinseback), use with hemodialysis. Give parameters for BP (blood pressure) and ml max (maximum) for IV bolus. The order did not give any instructions for BP parameters or the maximum IV fluid boluses.
3) Review of four of four (03/01, 04, 06 and 08/19) Acute Hemodialysis Flow Sheets showed:
a) 03/01/19 (Friday):
1. UF calculations was 3,000 ml plus 400 prime/rinseback for a total of 3400 ml. The recorded treatment showed the UFR (ultrafiltration rate) ranged from 452 to 1,870 ml/hr. The calculated UFR based on the UFG would be 1,133 ml/hr. There was no evidence the RN had assessed the patient to reflect why UFR was changed throughout the treatment. The orders did not include a UF Profile.
2. The pre and post treatment RN assessment showed the patient had generalized edema. There was no evidence to determine if enough fluid was removed.
3. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
4. There was no evidence the physician was notified post treatment the UFG of 3L was not achieved and the patient still had edema after treatment.
b) 03/04/19 (Monday):
1. The hemodialysis order was a 3K 2.5Ca which was in conflict with the order of 3K 3Ca bath. The UFG was 2,000 ml.
2. The pre-treatment RN assessment showed the patient had edema in both the upper and lower extremities.
3. The calculated UF was 2,000 to 3,000 ml plus 400 ml for prime/rinseback for a total of 2,400-3,400 ml.
4. The post treatment assessment showed the patient had edema in both the upper and lower extremities.
5. There was no evidence the RN assessed the patients fluid removal needs as the patient still edema after treatment.
6. There was no evidence the physician was notified post treatment the patient still had edema after treatment.
7. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
c) 03/06/19 (Wednesday):
1. The hemodialysis order was a 3K 2.5Ca which was in conflict with the order of 3K 3Ca bath.
2. The pre-treatment RN assessment showed the patient had edema in both the upper and lower extremities.
3. The calculated UF was 1,000 to 2,000 ml plus 400 ml for prime/rinseback for a total of 1,400-2,400 ml which was in conflict with the physicians order.
4. The recorded fluid volume loss was 2,400 ml.
5. The post treatment assessment showed the patient had edema in both the upper and lower extremities.
6. There was no evidence the RN assessed the patients fluid removal needs as the patient still had edema after treatment.
7. There was no evidence the physician was notified post treatment the patient did not achieve the 3L and still had edema after treatment.
8. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
d) 03/08/19 (Friday):
1. The hemodialysis order was a 3K 2.5Ca which was in conflict with the order of 3K 3Ca bath. The UFG was 1-2L which was in conflict with the order of 3L.
2. The pre-treatment RN assessment showed the patient had edema in both the upper and lower extremities.
3. The calculated UF was 1,000 to 2,000 ml plus 400 ml for prime/rinseback for a total of 1,400-2,400 ml which was in conflict with the physicians order.
4. The recorded fluid volume loss was 1,400 ml. The was no RN assessment on why the decision was made to only remove 1,400 ml versus 2,400 ml.
5. The post treatment assessment showed the patient had edema in both the upper and lower extremities.
6. There was no evidence the RN assessed the patients fluid removal needs as the patient still had edema after treatment.
7. There was no evidence the physician was notified post treatment the patient did not achieve the 3L and still had edema after treatment
8. There was no pre or post treatment weight to assist in determining the patient's fluid loss during treatment.
4) Review of the IDPOC showed there was no evidence the patients dialysis needs were addressed.
5) During an interview on 04/18/19 at 3:14 PM, the CNO and Director of Quality/Risk Management confirmed the findings in E1-4.

Based on clinical record review and interview, it was determined there was no evidence the physician's order to remove anti-embolism stockings for one hour each shift was followed by the nursing staff for five of five (#5, #8, #9, #14 and #20) patients selected for review. The failed practice did not assure a Registered Nurse (RN) assessed the patients to assure there were no complications from wearing the compression stockings. The failed practice affected Patient #5, #8, #9, #14 and #20 and any patient who wore anti-embolism stockings. The findings were:

Review of physician's orders for Patient #5, #8, #9, #14 and #20 showed they had an order for a constant below the knee graduated compression stocking (anti-embolism stocking) with removal every shift for one hour. There was no evidence the stockings remained constant and were removed for one hour as follows:
A. Patient #5:
1) Admitted on 03/06/19.
2) Physician order dated 03/06/19 showed to apply below the knee graduated compression stockings (anti-embolism stocking), to wear constantly and remove one hour each shift.
3) Review of the electronic IView record showed the compression stockings were either addressed or they were not removed for one hour each shift for 6 of 6 (03/06-11/19) days. During a telephone interview on 04/10/19 at 1:00 PM, the Director of Quality/Risk Management confirmed the findings in A1-3.
B. Patient #8:
1) Admitted on 02/14/19.
2) Physician order dated 02/14/19 showed to apply below the knee graduated compression stockings to wear constantly and remove one hour each shift.
3) Review of the electronic IView record showed the compression stockings were either not addressed or they were not removed for one hour each shift for 24 of 24 (02/14-03/09/19) days. During a telephone interview on 04/18/19 at 2:55 PM, the Director of Quality/Risk Management and CNO confirmed the findings in B1-3.
C. Patient #9:
1) Admitted on 02/22/19.
2) Physician order dated 02/22/19 showed to apply below the knee graduated compression stockings to wear constantly and remove one hour each shift.
3) Review of the electronic IView record showed the compression stockings were either not addressed or they were not removed for one hour each shift for 16 of 16 days (02/22/19 to 03/07/9). During a telephone interview on 04/18/19 at 2:57 PM, the Director of Quality/Risk Management and CNO confirmed the findings in C1-3.
D. Patient #14:
1) Admitted on 08/22/18 and discharged on 09/06/18.
2) Physician order dated 08/22/18 showed to apply below the knee graduated compression stockings to wear constantly, and remove one hour each shift.
3) Review of the electronic IView record showed the compression stockings were either not addressed or they were not removed for one hour each shift for 15 of 15 days (08/22/18 to 09/06/18). During a telephone interview on 04/18/19 at 3:22 PM, the Director of Quality/Risk Management and CNO confirmed the findings in C1-3.
E. Patient #20:
1) Admitted on 03/03/19.
2) Physician order dated 03/04/19 showed to apply below the knee graduated compression stockings to wear constantly, and remove one hour each shift.
3) Review of the electronic IView record showed the compression stockings were either not addressed or they were not removed for one hour each shift for 9 of 9 days (03/03-10/19) During a telephone interview on 04/18/19 at 3:22 PM, the Director of Quality/Risk Management and CNO confirmed the findings in E1-3.

Based on review of the IDPOC (Interdisciplinary Plan of Care) and interview, it was determined the nursing staff failed to develop a care plan that had measurable goals with interventions to meet each goal for 16 of 16 (#1-#10 and #15-#20) current records and four of four (#11-#14) closed records. The practice of no measureable goals did not assure the nursing staff could determine the effectiveness of the IDPOC for potential revisions to improve patient outcomes. The failed practice of no interventions did not assure the nursing staff were aware of what care was required to meet the established goals to resolve the identified problem. The findings were:

A. Review of the IDPOC for Patient #1-#10, #11-#14 and #15-#20 showed the identified nursing problems goals were not measureable with no interventions to direct the nursing staff on the care to provide to resolve the identified problem. For example:
1) Problem Integumentary (skin); Goals: Exhibit no redness of bony prominences, Verbalizes understanding of skin impairment prevention and skill would remain intact without evidence of breakdown, rash, infection or pruritis; and there were no identified interventions to coincide with each goal to assure the nursing staff were aware of what care was required to assure the goals for the problem were resolved or maintained.
2) Problem Pain; Goals: Pain does not impact daily functions, acceptable pain at rest, pain associated behavior reduced, unable to self report; and there were no identified interventions to to coincide with each goal to assure the nursing staff were aware of what care was required to assure the goals for the problem were resolved or maintained.
B. During interviews the CNO and Director of Quality confirmed findings as follows: Patient #1 on 03/08/19 at 1:59 PM; Patient #2 on 03/08/19 at 2:15 PM; Patient #3 on 03/11/19 at 10:18 AM; Patient #4 on 04/18/19 at 2:41 PM; Patient #5 on 04/18/19 at 2:08 PM; Patient #6 on 04/18/19 at 2:36 PM; Patient #7 on 04/18/19 at 2:47 PM; Patient #8 on 04/18/19 at 2:55 PM; Patient #9 on 04/18/19 at 2:57 PM; Patient #10 on 04/18/19 at 3:12 PM; Patient #11 on 03/08/19 at 3:00 PM; Patient #12 on 04/18/19 at 3:23 PM; Patient #13 on 04/18/19 at 3:23 PM; Patient #14 on 04/18/19 at 3:22 PM; Patient #15 on 04/18/19 at 3:25 PM; Patient #16 on 04/18/19 at 3:14 PM; Patient #17, #18, #19 on 04/18/19 at 3:25 PM; and Patient #20 on 04/18/19 at 3:22 PM.

Based on review of policies, review of cleaning logs, observation and interview, it was determined the Certified Dietary Manager (CDM) failed to assure policies for scheduled cleaning were adhered to by the kitchen staff for 28 of 28 days for February 2019; the CDM failed to keep the cleaning schedules for six months for one of one (January 2019) month requested; and the CDM failed to maintain a clean environment (Bread Racks, Drying Rack, floor, handwashing sink, fryer, cooks oven, etc) in the kitchen. The failed practices affected all patients admitted to the facility and all staff who work in the kitchen. The findings were:

A. Review of policy titled, "Cleaning Schedule," effective 06/22/18, showed:
1) The Nutrition Manager/Director and Management Team were responsible to assure regular and proper sanitation of all areas and facilities of the Nutrition Department.
2) The Nutrition Department would post cleaning schedules on a routine basis for each kitchen area.
3) Cleaning schedules were completed for all staff by the supervisors.
4) The cleaning schedules were done on a daily, weekly and monthly basis as designated.
5) Individual employees were assigned cleaning tasks which they initial upon completion.
6) The supervisor was to check to assure that each task was completed and done correctly.
7) The schedules were filed for a period of six months and include all areas of equipment and storage utensils or facilities.
B. Review of operational standard titled, "Sanitation Program," showed:
1) The Sodexo General Manager/Food Services Director monitors sanitizing schedules and procedures.
2) Equipment, walls, floors and storage areas were to be routinely cleaned with appropriate sanitizing compounds.
3) A copy of the Areas Assigned on Sanitation/Cleaning Schedule and the Cleaning Frequencies were attached and showed clean up of the kitchen areas were hot production, bakery, cold production, patient tray assembly, storeroom, pots and pans, dishroom and hand sinks.
C. Observation of the kitchen on 03/07/19 from 11:21 AM to 11:50 AM with the Chef, Registered Dietitian and the Director of Quality/Risk Management showed the kitchen was not clean or maintained (missing floor tiles) as follows:
1) In the Dry Storage area, there were two carts. One of two carts had a brown sticky substance on top of the cart.
2) Two of three Bread Racks had dried food particles on the rails. One of the two Bread Racks had trays of food on the rack.
3) One of one Bread Rack in the tray assembly area had greasy/sticky residue.
4) At the end of the tray assembly counter, the floor had a brown stain.
5) On the outside of the fryer has a heavy build-up of grease/grime. The floor covering in front of the fryer was missing exposing the wood beneath.
6) The grill had been down and was not being used but the back splash had a build-up of grease/grime.
7) The Drying Rack had a build-up of grimy/sticky substance. There were 22 lids in the rack. The wheel casters were rusted.
8) In the Dish Catching Room, the Dryer Rack was sticky and a build-up of dust.
9) One of one handwashing sink had a grimy residue. The paper towel dispenser had a shelf under where the paper towels were pulled out. The shelf a had build-up dirt and grime. The eye wash station was beneath the paper towel dispenser. The bowl of the eye wash station was dusty.
10) In Cooks Prep Area, the outside of the oven had build-up of grease and grime which was brown in color.
11) The flooring throughout the kitchen had missing tiles and were discolored.
D. Review of the Daily Cleaning Assignments Patient Cook, Daily Cleaning Assignments Cafeteria, Patient Cook, Daily Cleaning Assignments Hostess 1 (630-300), Daily Cleaning Assignments Hostess 1 Evening, Daily Cleaning Assignments Hostess 2 (630-300), Daily Cleaning Assignments Hostess 2 Evening, Daily Cleaning Assignments Coldfood Area Morning, Coldfood Area Evening, Daily Cleaning Assignments Utility Morning, Daily Cleaning Assignments Utility Evening Shift, and Storeroom Position showed the forms were not initialed by the person(s) responsible for the tasks nor was there evidence the Supervisor had reviewed for completion. During an interview on 03/07/19 at 11:50 AM, the Chef was questioned about cleaning schedules for the kitchen. The Chef showed the Surveyor a binder with cleaning schedules. The Chef stated that the staff were to initial the logs when they were done. Review of the logs in the binder for February 2019 showed there were no initials on any sheet for 28 of 28 days. The Chef stated that the Shift Supervisor was responsible to monitor to assure completion. The Chef and the Director of Quality/Risk Management confirmed the logs for February 2019 had not been initialed to show completion of the task. The Chef and Quality Director/Risk Management confirmed there were no logs in the binder for January 2019 (31 days) for March 2019 (6 days).
E. During an interview on 03/08/19 at 8:54 AM to 9:04 AM with Certified Dietary Manager (CDM), the following was discussed:
1) The CDM confirmed there were no cleaning logs available for review in the binder or filed for January 2019.
2) The CDM stated that they were only required to keep the logs for 30 days. There were no past logs available for review.
3) The CDM stated that the day and evening shift supervisors should have checked forms for completion and sign the forms.


Based on review of policy, review meal tray temperatures and interview, it was determined the Certified Dietary Manager (CDM) failed to assure temperatures of the hot and cold foods were recorded at the beginning and end of meal service lasting longer than 15 minutes for 28 of 28 (02/01-28/19) days for February 2019 as required by the Rules and Regulations for Hospitals and Related Institutions In Arkansas 2016. The failed practice did not assure the temperature of the hot and cold foods would be maintained at a temperature greater than or equal to 160 degrees Fahrenheit and reach the patient at 140 degrees Fahrenheit to prevent a foodborne illness. The failed practices had the likelihood to affect all 69 patients on census as of 03/07/19 and all patients admitted to the facility. The findings were:

A. Review of policy titled, "Food And Nutrition Services: Infection Control," showed:
1) Food & (and) Nutrition Services would maintain temperature records (food, dish machine, refrigerators, freezers).
2) Facilities provides for on-going maintenance of the food service area and equipment.
B. Review of operational standard titled, "Food Safety (HACCP - Hazard Analysis Critical Control Points)," showed:
1) Food Safety self-inspections were to be conducted monthly and documented.
2) Action plans with documented follow-up were to be developed and implemented for any areas not meeting standards.
3) Temperature records for Critical Control Points for all patient and cafeteria meals served were to be monitored and retained for one year.
C. Review of policy titled, "Principles of Food Handling, Preparation and Service," showed:
1) The Nutrition Manager/Director/Management Team were responsible to monitor and enforce the standards and procedures of food service in the manual.
2) All foods were to be prepared, stored, held, or served in accordance with proper temperature standards to ensure quality and safety.
3) All cooked foods were to be prepared and held, served and stored at specifically defined temperatures.
D. Review of policies showed there was no evidence the requirement by the Rules and Regulations for Hospitals and Related Institutions in Arkansas 2016 for hot and cold potentially hazardous foods would be recorded at least at the end of meal services that continued for more than 15 minutes.
E. Review of the Rules and Regulations For Hospitals and Related Institutions In Arkansas 2016 showed the temperature of hot and cold potentially hazardous foods shall be recorded at least at the beginning and end of meal service that continued for more than 15 minutes.
F. Review of the CHI SVN and Rehab Tray Assembly, Delivery and Pickup Schedule showed the meal service lasted for more than 15 minutes. The rehabilitation hospital tray assembly for breakfast was 6:15 AM to 7:00 AM; lunch was 11:40 AM to 12:15 PM; and dinner was 4:40 PM to 4:50 PM. The meal delivery tray assembly for the sister hospital for breakfast was 7:00 AM to 7:15 AM; lunch was 11:10 AM to 11:25 AM; and dinner was 4:15 PM to 4:25 PM.
G. Review of the Daily Service & HACCP Record from 02/01-28/19 showed there were no temperatures recorded at the beginning and end of meal service. During a telephone interview on 04/17/19 at 1:40 PM, the Director of Quality/Risk Management and the Certified Dietary Manager confirmed the findings that temperatures were not recorded at the beginning and end of meal service.
H. During an interview on 03/07/19 at 2:15 PM, the Chef was questioned about the temperatures not taken at the end of trayline. The Chef stated that it was not required because the trayline service was less than two hours. The Chef was questioned regarding the food temperature ranges not on the food temperature logs. The Chef stated that the temperatures were posted on the wall and staff were trained on food temperature ranges so they were not required to be on the log. The Chef stated that only the Supervisors would initial when the temperatures were checked.
I. During an interview on 03/07/19 at 2:30 PM, the Chief Nursing Officer (CNO) and Director of Quality/Risk Management were asked when trays were delivered to the nursing units. Both stated that breakfast was at 7:30 AM; Lunch at 12:00 Noon; and Dinner at 5:00 PM. The CNO stated that the kitchen also delivered meals to the sister hospital next to the facility.
J. During an interview on 03/08/19 at 8:54 AM to 9:04 AM with Certified Dietary Manager (CDM), the following was discussed:
1) The CDM stated that temperature requirements were posted above the sink in the cooks preparation area and were not required to be listed on the logs.
2) The CDM stated that the trayline was set up 30 minutes before serving time. Breakfast 6:15-6:30 AM; Lunch 11:15 AM; and Dinner 4:15 PM.
3) The CDM stated that the trayline normally lasted only one hour so the temperature at the end of trayline was not required. The CDM stated that they used to do temperatures at the end of trayline but were told they did not have to do it anymore.
H. During an interview on 03/08/19 at 11:12 AM, Food Service Employee #1 was questioned about taking temperatures at the end of trayline services. Food Service Employee #1 stated that at one time they were required to take the temperature and the Supervisor signed off after them on the logs.
K. During an interview on 03/08/19 at 11:15 AM, Food Services Employee #2 was questioned about taking food temperatures. Food Service Employee #2 stated that she took the temperatures as the food was being cooked but did not record the temperature. Food Services Employee #2 stated that temperatures were taken when put on the trayline.