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The hospital failed to meet the regulatory compliance for §482.12 Condition of Participation for Governing Body. The Governing Body was responsible for the conduct of the hospital operations, and carried out the responsibilities and the functions specific to the governing body as evidenced by:

1. Based on interview and record review, the governing body failed to exercise quality oversight responsibility to safeguard one of one sampled patient (Patient 2) with history of kidney transplant (replacing a diseased kidney or injured kidney with a healthy kidney from a donor) from complications resulting from injection of intravenous (IV-within the vein) contrast (iodine-based material injected into a vein to enhance x-ray and CT images) when the Nephrologist (MD 1- medical doctor who specializes in kidney care and treating diseases of the kidneys) was not consulted for medical care. (Refer to A-0053).

2. Based on interview and record review, the hospital failed to ensure the Registered Nurse (RN) 1 performed a nursing assessment for one of one sampled patient (Patient 3) follow a change in condition. (Refer to (A-0395).

3. Based on interview and record review, the hospital failed to ensure the Magnetic Resonance Imaging Technician (MRIT) activated the emergency system for one of one patient (Patient 1) who deteriorated during the MRI (a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) procedure. (Refer to A-0547).

4. Based on interview and record review, the hospital failed to document and keep a record of the MRI Screening Form for one of one sampled patient (Patient 1) who had an MRI of the Brain without contrast. (Refer to A-0553)

5. Ensure the Director of Food & Nutrition Service (DFNS) effectively directed and provided oversight related to safe food handling and sanitary environment within the foodservice operation related to prompt elimination of harborage conditions that attract rodents. (Refer to A-0620, A-0622)

6. Ensure integration of the food and dietetic service into the hospital-wide QAPI (Quality Assessment and Performance Improvement) and Infection Control program related to on-going rodent problem in the kitchen. (Refer to A-0618, A-0620)

7. Ensure aspects of nutritional care were incorporated into the hospital's structure for provision of nutrition care services to patients in accordance with standards of practice. (Refer to A-0621)

a. Implement a system to order Registered Dietitian (RD) consults to provide Medical Nutrition Therapy (MNT) for patients with food allergies for one of five sampled patients (Patient 26). (Refer to A-0621)

b. Ensure RD's offered or provided therapeutic diet education to meet patient's individualized nutritional needs in accordance with the hospital's RD job description and standards of practice for one of five sampled patients (Patient 27).
(Refer to A-0621)

c. Ensure effective monitoring of oral nutrition supplement (ONS) for two of five sampled patients (Patient 26, Patient 21). (Refer to A-0629)

d. Ensure an RD provided nutrition recommendations to one of five sampled patients (Patient 26) to ensure nutritional needs were met in accordance with standards of practice. (Refer A-0629)

e. Ensure RD's assessed and evaluated therapeutic diets for two of five sampled patients (Patient 27, Patient 29). who had multiple variations to select from, to determine whether nutrition recommendations to a patient's physician were in order. (Refer to A-0629)

8. Based on observation, interview, and record review, the facility failed to implement nationally recognized organization Center for Disease Control (CDC-federal government agency that protects public health by preventing and controlling disease, injury, and disability) infection prevention and control practices) infection prevention and control practices when one of three sampled patients (Patient 4), who was diagnosed with Herpes Zoster (also known as Shingles, a painful rash caused by herpes virus), was not placed on Transmission-Based Precaution (used as second tier of basic infection control and are to be used in addition to Standard Precautions [includes hand hygiene and use of personal protective equipment such as gloves, masks, gowns, face shields, or goggles]). (Refer to A-0750).

9. Ensure the MRI technologist (MRIT) and Emergency Department Registered Nurse (EDRN) 1 activated the emergency response system and initiate cardiopulmonary resuscitation for one of one patient (Patient 1) during a life threatening event. (Refer to A1112).

10. Ensure EDRN 1 documented nursing assessment, placed one of one sampled patient (Patient 1) suffering from a life-threatening condition on the cardiac (heart) monitor, vital signs (includes temperature, heart rate, respiratory rate, blood pressure) machine, and pulse oximetry (measures oxygenation in one's blood), and continued to monitor care upon return to the ED from Radiology Department (RD).
(Refer to A1112).

The cumulative effects of these systemic failures had the potential to negatively impact health and safety of all hospital patients and those patients seeking emergency care at the facility, in compliance with the Condition of Participation for Governing Body, Food and Dietetic Services, and Emergency Services.

Based on observation, interview, and record review, the hospital did not meet the requirements for Condition of Participation, CFR (Code of Federal Regulations) 482.28 Food and Dietetic Services when the hospital failed to:

1. Ensure the Director of Food & Nutrition Service (DFNS) effectively directed and provided oversight related to safe food handling and sanitary environment within the foodservice operation, and ensure prompt elimination of harborage conditions that attract rodents to avoid potential transmission of infection when there was a known rodent problem in the kitchen. (Cross Refer A-0620, A-0622)

2. Ensure integration of the food and dietetic service into the hospital-wide QAPI (Quality Assessment and Performance Improvement) and Infection Control program related to on-going rodent problem in the kitchen that had not been reported to the Infection Program Manager (IPM) nor to the Quality Committee responsible for organizational performance improvement for a multidisciplinary approach to promptly put in place effective measures to eliminate rodents presence within the foodservice operation, and provide awareness of the situation to medical staff responsible for care of the patients, as rodents are capable of transmitting disease to humans by contaminating
food and food-contact surfaces. (Cross Refer A-0618, A-0620)

3. Ensure aspects of nutritional care were incorporated into the hospital's structure for provision of nutrition care services to patients in accordance with standards of practice related to:

a. Implement a system to order Registered Dietitian (RD) consults to provide Medical Nutrition Therapy (MNT) for patients with food allergies for one of five sampled patients (Patient 26). This failure placed patients at an increased risk of experiencing allergic symptoms ranging from mild to life-threatening. (Cross Refer A-0621)

b. Ensure RD's offered or provided therapeutic diet education to patients, patients families or caregivers to meet patient's individualized nutritional needs in accordance with the hospital's RD job description and standards of practice for one of five sampled patients (Patient 27). This failure had the potential to not fully utilize RD's skill sets and expertise for therapeutic diet counseling which could impede a patient's ability to minimize risks imposed by disease and/or comorbidities, decrease a patient's quality of life and prevent a method toward reducing rates of re-admission of hospitalization. (Cross Refer A-0621)

c. Effectively monitor of an oral nutrition supplement (ONS) when there lacked documentation of quantity consumed of ONS and failed to develop, update and/or revise an individualized nutrition plan of care with alternative nutrition approaches when two of five sampled patients (Patient 26, Patient 21) nutritional needs were not met.
(Cross Refer A-0629)

d. Ensure a RD provided nutrition recommendations to one of five sampled patients (Patient 26) physician regarding a discrepancy between Patient 26's renal diet order in comparison with Patient 26's individual assessed daily protein needs. This failure had the potential for Patient 26's nutritional needs to not be met in accordance with standards of practice. (Cross Refer A-0629)

e. Ensure the hospital's overall system included RD's to assess and evaluate therapeutic diets, such as consistent carbohydrate diet (for treatment of diabetes) that had multiple variations to select from, same for the variety of renal diets (for treatment of kidney disease), to determine whether nutrition recommendations to a patient's physician were in order to ensure a patient's individualized nutritional needs were met for two of five sampled patients (Patient 27, Patient 29). (Cross Refer A-0629)

The cumulative effect of these systemic problems resulted in the inability of the hospital's food and nutrition services to ensure the needs of the patients was met as required by the mandated Condition of Participation for Food and Dietetic Services. This had the potential to affect the hospital census of 494 highly susceptible patients.

According to the FDA (Food and Drug Administration) Food Code 2022, "A "Highly susceptible population" means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; ... or older adults; and (2) Obtaining food at a facility that provides services such as...health care...hospital."

The hospital failed to meet the regulatory compliance §482.55 Condition of Participation Emergency Services as evidenced by:

1. Ensure the Emergency Department Registered Nurse (EDRN) 1 and MRI technologist (MRIT), activated emergency response system or initiated cardiopulmonary resuscitation for one of one patient (Patient 1) exhibiting a life threatening event during a Magnetic Resonance Imaging (MRI- [a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body]) procedure.

This failure resulted in the delay of treatment in the management of a life-threatening condition. (Refer to A1112).

2. Ensure EDRN 1 documented nursing assessment, placed one of one sampled patient (Patient 1) suffering from a life-threatening condition on the cardiac (heart) monitor, vital signs (includes temperature, heart rate, respiratory rate, blood pressure) machine, and pulse oximetry (measures oxygenation in one's blood), and continued to monitor care upon return to the ED from Radiology Department (RD).

This failure decreased the patient's chances of survival. favorable outcome, and had the potential to contribute to Patient 1's death. (Refer to A1112).

Based on interview and record review, the governing body failed to provide quality oversight responsibility to safeguard one of one sampled patient (Patient 2) with history of kidney transplant (replacing a diseased kidney or injured kidney with a healthy kidney from a donor) from complications resulting from injection of intravenous (IV-within the vein) contrast (iodine-based material injected into a vein to enhance x-ray and CT images) when the Nephrologist (MD 1- medical doctor who specializes in kidney care and treating diseases of the kidneys) was not consulted for medical care.

This failure resulted in Patient 2's MD 1 to not be informed of the plan to send Patient 2 for Computerized Tomography Scan (CT scan-diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) with IV Contrast of the chest, abdomen, and pelvis and resulted in a serious kidney complication of contrast-induced nephropathy (CIN- one of the major causes of hospital-acquired acute kidney injury [AKI], which led to Patient 2 undergoing Hemodialysis (a life-saving treatment for kidney failure that removes waste and extra fluids from the blood using a dialyzer [artificial kidney] when the kidneys can no longer work adequately).

Findings:

During a review of Patient 2's "History & Physical (H&P) on 2/25/25 at 9:23 a.m. with Registered Nurse Clinical Informaticist (RNCI) and Patient Safety Manager (PSM), Patient 2's "History & Physical (H&P)," dated 12/8/24, was reviewed. The H&P indicated, "Patient 2 was brought to the Emergency Department with complaints of pain to the right ribs and pelvis after a slip and fall at 4 a.m. Patient 2 has a history of kidney transplant in 2017 and no longer on dialysis. Patient 2 has diabetes mellitus (condition of high blood sugar) and a history of deep vein thrombosis (blood clot formation) of upper extremity in May 2024, for which she takes Eliquis, an anticoagulant (blood thinner).

During a review of Patient 2's "Emergency Documentation-ED Note Physician (ENP)," dated 12/8/24, the ENP indicated, "Primary survey indicated intact airway with bilateral breath sounds. Secondary survey indicated there was no obvious trauma to head. Chest was stable. No obvious signs of trauma along the right wall and no palpable deformities. No acute injuries noted. The CT of the chest, abdomen and pelvis with IV contrast indicated negative findings except for minimally non-displaced right rib fractures involving the 5th to the 10th ribs.

During an interview on 2/26/25 at 8 p.m. with MD 1, MD 1 stated, "Nobody called me to notify me about my patient having a full body scan with IV contrast. I was notified five days later. I did not appreciate that, and I was not happy. Why did this patient have to get IV contrast with kidney transplant? They (the Resident and the attending physician) need to call me. Was the patient presented to the attending by the Resident? We do not treat by protocol medicine (a set of instructions which describe a process to be followed). I don't think that is safe. I protested that decision. My patient [Patient 2] became anuric (no urine output). She had fluid overload. She became short of breath. Once she became anuric, no urine output, that became a good indication hemodialysis was necessary. The attending physician or the resident physician could have called me, and we could have developed a plan of care for the patient."

During a review of Patient 2's "Intake and Output Record (IOR)," dated 12/8/24 to 12/16/24, the IOR indicated the following:
12/8/24 to 12/9/24: Urine voided: 800 ml
12/9/24 to 12/10/24: Urine voided:0 (zero)
12/10/24 to 12/11/24: Urine voided: 0
12/11/24 to 12/12/24: Urine voided: 450 ml
12/12/24 to 12/13/24: Urine Voided: 9 ml
12/13/24 to 12/14/24: Urine Voided: 0
12/14/24 to 12/15/24: Urine Voided: 0
12/15/24 to 12/16/24: Urine Voided: 0
12/16/24 to 12/17/24: Urine Voided: 0

During a review of Patient 2's "Serum Creatinine Level (SCrL determines normal kidney function. The normal range of SCrL for female adult is 0.6 milligram per deciliter (mg/dl) to 1.1 mg/dl." SCrL dated 12/8/24 to 12/21/24 were reviewed. The SCrL indicated the following:
12/8/24: 1.74 mg/dl
12/10/24: 1.8 mg/dl
12/11/24: 2.28 mg/dl
12/12/24: 2.68 mg/dl
12/13/24: 3.69 mg/dl
12/14/24: 3.02 mg/dl
12/15/24: 3.08 mg/dl
12/16/24: 3.11 mg/dl
12/17/24: 2.3 mg/dl
12/18/24: 3.51 mg/dl
12/19/24: 3.02 mg/dl
12/20/24: 3.98 mg/dl
12/21/24: 4.6 mg/dl

During an interview on 2/27/25 at 10:27 a.m. with Surgery Program Director,also the Vice Chair of Surgery Services, SPD stated if a Resident Physician (RP) is assigned to see a patient, it is expected the supervising physician also sees the patient and depending upon the level of supervision of the resident physician. SPD stated RP's judgment has limitations and so the RP must escalate the patient evaluation to the attending and make decisions together regarding the care of the patient. SPD stated if a patient with a history of kidney transplant is given an IV contrast, there is a potential to kill the kidney. SPD stated the patient should be hydrated prior to IV contrast injection and physicians should take extra precautions to prevent life-long dialysis.

During a concurrent interview and record review on 2/27/25 at 1:50 p.m. with RP 1, Patient 2's "Surgery Consultation Note, (SCN)," dated 12/8/24, was reviewed. The SCN indicated "History of deceased donor renal transplant on immunosuppressant therapy (treatment that reduces its ability to fight infections and other diseases. Injuries: non-displaced fx (fracture-break in the bone) R (right) 5th to 10th ribs. Recommend medicine admission for management of complex medical management. ACTS (surgical services) will follow for management of rib fractures. RP 1 stated he assumed he presented the case to his attending physician. RP stated he sees the patient, makes assessment, and have a verbal conversation with the attending /supervising physician. RP 1 stated he did not notify [Patient 2]'s nephrologist after he spoke with Patient 2's daughter.

During a review of the hospital's "Governing Bylaws," dated 12/21/23, the Bylaws indicated, "A. Quality Performance Responsibilities: This Board has the final moral, legal, and regulatory responsibility for everything that goes on in the organization, including the quality services provided by all individuals who perform their duties in the organization's facilities pr under the Board sponsorship: 1. Understand and accept responsibility for the actions of all physicians, nurses, and other individuals who perform their duties in the organizations' facilities ...11. Monitor programs and services to ensure they comply with policies and standards relating to quality."

During a review of the hospital's "Medical Staff Rules and Regulations (MSRR)," dated 7/24/24, the MSRR indicated, "2.2 Responsibilities of Attending Physician: (a) the attending physician will be responsible for the following while in the District: (1) the medical care and treatment of the patient while in the District, including appropriate communication among the individuals involved in patient care (including personal communication with other physicians where possible. 5.1 Requesting Consultation: (a) The attending physician shall be responsible for requesting a consultation when indicated for contacting a qualified consultant. (b) Requests for consultation shall be entered in the patient's medical record. In addition to documenting the reasons for the consultation request in the medical record, the attending practitioner will make reasonable attempts to personally contact the consulting practitioner to discuss the consultation request."

Based on observation, interview, and record review, the facility failed to ensure:

1. The Director of Food & Nutrition Services and Food Service Manager followed the hospital's "Quality Improvement Plan" when an on-going rodent problem in the kitchen was not reported to QAPI (Quality Assessment and Performance Improvement) program, nor Infection Prevention Manager (IPM), per the hospital's "Quality Improvement Plan" to institute a PI project for prompt resolution of the rodent problem that was high risk, high volume and problem prone. (Cross Refer A-0620)

2. There was data collected to evaluate and review the hospital's established time frames for Registered Dietitian (RD) follow-up for high nutrition risk patient's to ensure provision of dietetic services to improve, and/or prevent or minimize nutritional decline, in a timely manner for one of five sampled patients (Patient 26), that had potential to affect other in- patients and/or future patients. (Cross Refer A-0629)

3. The hospital's QAPI had not identified and ensured the RD's assessed and evaluated the special therapeutic dietary needs of those patients requiring a therapeutic diet (ordered as part of a patient's treatment for a disease or clinical condition) to determine if nutrition recommendations to a patient's physician were in order pertaining to individualized nutrition needs for two of five sampled patients (Patient 27, Patient 29), that had potential to affect other in-patients and/or future patients. In addition, RD's were not offering and providing therapeutic diet education to patients, patient's families/caregivers in accordance with hospital's RD job description and standards of practice for quality of care. (Cross Refer A-0629, A-0621)

These failures had a potential for transmission of infection to patients, staff, and visitors and a decline in patient's nutritional and medical status.

Findings:

1. During an interview on 3/3/25 at 11:50 a.m. with Food Service Manager (FSM) and Director of Food & Nutrition Services (DFNS), FSM stated she had not reported the rodent problem in the kitchen and retail kitchen to anyone other than DFNS, Facilities staff, and EVS (environmental services/housekeeping). DFNS stated he had not reported the rodent problem in the kitchen and retail kitchen to the hospital-wide infection control program committee/IPM or to QAPI/Quality Committee (QComm).

During an interview on 3/3/25 at 2:45 p.m. with Director of Quality & Patient Safety (DQPS), DQPS stated she was a part of the Quality Committee that had responsibility for oversight of organizational performance improvement. DQPS stated absolutely IPM and QComm should have been informed about rodents in the kitchen and we (both IPM and QComm) were not aware of that. DQPS stated rodents in the kitchen certainly qualified for a high risk, high volume, and problem prone performance improvement (PI) project. DQPS stated QComm could have ensured appropriate measures were in place for prompt resolution of the rodent problem.

During a review of the facility's P&P titled, "Quality Improvement Plan (QIP)," dated 1/26/22, the "QIP" indicated, "The Quality Council requires the. . .organization's staff to implement and report on the activities for identifying and evaluating opportunities to improve patient care and services throughout the organization."

2. During a review of Patient 26's "Nutrition Note (NN)", dated 2/2/25, the "NN" indicated, "Nutrition Risk Level: High (2/2/25), Assessment: RD consult for low Braden score (a tool used to assess a patient's risk for developing pressure injury to the skin). Pt [patient] admitted for management of TB [Tuberculosis; a contagious bacterial infection that primarily affects the lungs]. Pt currently on Diabetic diet, eating limited amount. . .Pt had physical assessment completed previously given low bodyweight, though no malnutrition found. Pt previously reported early satiety (feeling of fullness), may benefit from snacks, supplements (products to provide additional calories and/or protein). Pt not fully meeting nutrition needs at this time. Nutrition Diagnosis: Inadequate nutrient intake. . .Nutrition Recommendations: Current order for Diabetic diet - BG [blood sugar] well controlled. Monitor phosphorous [a mineral]/potassium [an electrolyte] for possible Renal [kidney disease] diet restriction as needed. Trial Nepro [oral liquid supplement to add nutrients designed for kidney disease] 1/ [per] day and snacks 1/day - Proposed to MD. Continue renal multivitamin."

During a concurrent interview and record review on 2/28/25 at 12:00 p.m. with Clinical Nutrition Services Manager (CNSM), and DFNS, Patient 26's "Orders," dated 2/2/25 was reviewed. The order indicated, "Order: RDN [Registered Dietitian Nutritionist] F/U [follow up] Assessment, End-state Date/Time: 2/7/25 16:12 PST [Pacific Standard Time], entered and electronically signed by: [name of RD 1]." CNSM stated RD 1 assessed Patient 26 at nutritional high risk and not meeting nutrient needs, recommended nutrition interventions, and documented the RD follow up would occur five days later on 2/7/25. CNSM stated the hospital's policy and procedure allowed patients identified as high nutrition risk to have a follow up RD evaluation up to five days later. CNSM stated, "I thought we just had to follow our policy."

During a concurrent interview and record review on 2/28/25 at 12:05 p.m. with CNSM and DFNS, CNSM was asked if the hospital's system of allowing up to five days for an RD to follow up on a patient assessed as high risk for nutrition deficits had been meeting patient's nutritional needs in a timely manner. CNSM and DFNS stated the hospital's average length of patient hospital stay was 4.5 days. CNSM stated she had not collected data to track and analyze whether the RD follow up time frame up to five days for a high risk nutrition patient was meeting patient's individualized nutritional needs, in a timely manner. CNSM stated she used ASPEN (American Society for Parenteral and Enteral Nutrition) and/or NCM (Academy of Nutrition & Dietetics [AND] Nutrition Care Manual[NCM]) as sources for nutrition care standards of practice to guide development of the hospital's policies and procedures related to nutrition care of patients.

During a review of the Hospital's policy and procedure (P&P) titled, "Diet Manual and Approval Acute Care," dated 7/22/24, the P&P indicated, "The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM) is the standard guide and reference for nutrition care."

During a review of ASPEN's standards of care guidance titled "ASPEN Adult Nutrition Care Pathway (Age 18+ years) (ANCP)", dated 9/14/22, the "ANCP" indicated once inadequate nutrient intake had been identified "Monitoring & Evaluation: Follow-up within 3 days, monitor parameters; tolerance of nutrient intake, oral intake including supplements, vitamins, minerals, anthropometric data (weight trends), functional status."

During a review of the facility's P&P titled, "Adult and Pediatric Assessment (APA)," dated 6/12/24, the "APA" indicated, "Nutrition screening identifies patients who may have a nutrition diagnosis and may benefit from nutrition assessment and intervention by a Registered Dietitian. . .The Registered Dietitian will screen each patient for whom a notification is received. A comprehensive nutritional assessment will be completed if the patient is screened at moderate or high nutritional risk. If a patient is assessed at low risk, the screen and risk identification is documented. .Adult Nutritional Screening criteria; constipation, diarrhea, eating disorder, enteral [tube] feedings, loss of appetite/poor intake, lactation, nausea, skin breakdown or pressure injury, TPN [total parenteral nutrition; nutrition through a large vein], unplanned weight loss, vomiting, tube feeding [nutrition through a tube], stroke, length of stay of (5th day of hospital stay RD will receive a consult, and patient would be seen between the 5th and 7th day of hospital stay for a nutrition screen by RD per CNSM), BMI [body mass index; a tool to assess underweight, normal weight, overweight, obesity] <19 [underweight], Pressure injury stage II [partial-thickness skin loss] or higher, dysphagia [difficulty swallowing] alert, via malnutrition tracker via a software, and NPO [not eating or drinking through the mouth] x [for] 3 days."

3a. During a concurrent interview and record review on 2/28/25 at 10:24 a.m. with CNSM and DFNS, Patient 27's "Admission History Adult (AHA)," dated 2/26/25 was reviewed. The AHA indicated and CNSM stated the "AHA" included admission nutrition screening questions completed by nursing in which Patient 27 was determined not to meet facility's criteria for nutrition risk that would have triggered an RD consult for further nutrition screening by an RD

During an interview on 2/28/25 at 10:36 a.m. with CNSM, CNSM stated Patient 27's therapeutic diet order was diabetic CC 60 g [consistent carbohydrate dispersed evenly over three meals with limit of a total of 60 grams of carbohydrate per day] and low potassium. CNSM stated the diabetic diet orders available to the physician's to select from a drop down menu in the electronic health record (EHR) were 45 g CC [limit of 45 grams of consistent carbohydrate], 60 g CC or 75 g CC that corresponded with different total daily calories provided depending on the amount of CC ordered. In addition, CNSM stated the hospital had various renal diets as a drop down menu physicians selected from as follows: "Renal with an 80 g pro [protein]/d", "High Protein Renal with 100 g pro/d", "Low Protein- 60 g pro/d 2 gm [gram] Sodium [limit of salt intake]", and a "Low Protein Renal- 60 g pro/d." CNSM stated within the hospital's nutrition care structure, if the hospital's nutrition screening did not drive an RD to conduct a nutrition assessment for a patient, the hospital RD's would not perform nutrition assessments for those patients that had specialized therapeutic dietary needs, simply due to a therapeutic diet in and of itself, to evaluate if the diet order was aligned with the patient's daily calorie and protein needs, or if not, to provide nutrition recommendations to the physician regarding a patient's therapeutic diet.

3b. During a concurrent interview and record review on 2/28/25 at 3:26 p.m. with CNSM, Patient 29's "Inpatient" form, undated was reviewed. The Inpatient form indicated Patient 29 was 59 years old. Patient 29's "Admission History Adult (AHA)," dated 2/21/25 was reviewed. The AHA indicated and CNSM stated the "AHA" included admission nutrition screening questions completed by nursing in which Patient 29 was determined not to have any of the facility's criteria for nutrition risk to trigger an RD consult for RD to conduct further nutrition screening and/or complete a nutrition assessment. The "AHA" included a notation of "Home Diet: Diabetic, Renal."

During a review of Patient 29's "Progress Note (PN)," dated 2/27/25, completed by RD 4, the "PN" indicated, "Nutrition Screen: Consult received as part of length of stay, pt meets criteria for low acuity (condition with low probability of progression); admitted with PD catheter (PD; Peritoneal [thin tissue that lines the abdominal cavity] dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] catheter dysfunction [malfunction of the tube used to access patient's blood for dialysis], provided a renal, diabetic diet-po intake average of 72% [percent] x 9 meals, no trouble chewing or swallowing, BMI [body mass index] 27.2, skin intact, Braden score 20. Will monitor per policy, RD available sooner, prn [as needed]."

During an interview on 2/28/25 at 3:30 p.m. with CNSM, CNSM stated within the hospital's system RD's were not required to perform a nutrition assessment for chronic diseases with comorbidities (a disease or medical condition that is simultaneously present with another) that required specialized dietary needs with a therapeutic renal, diabetic diet. CNSM stated it would require Patient 29 to have an RD complete a nutrition assessment to determine Patient 29's daily calorie and protein needs in order to evaluate whether Patient 29 was prescribed the correct grams of carbohydrate diabetic diet and correct grams of protein renal diet to meet Patient 29's individual nutritional needs.
However, Patient 29 was screened by RD 4 to be low acuity after six days in the hospital with comorbidities of renal disease and diabetes and was assessed as continuing to be at low nutrition risk, per hospital P&P titled "Adult and Pediatric Assessment (APA)", dated 6/12/24, the "APA" indicated "Low Risk. . .follow-up completed within 10 days." CNSM stated RD 4 did not document an RD follow up date for monitoring as the hospital had established screening criteria during the hospital stay in which nursing screens for low appetite/poor po intake would trigger an RD consult, if that occurred.

During an interview on 2/28/25 at 3:45 p.m. with CNSM, CNSM stated Patient 29 had not seen an RD since admission as she was assessed to be low nutrition risk, the RD's do not evaluate whether the ordered therapeutic diet meets Patient 29's specialized dietary needs due to comorbidities of diabetes and renal disease, and the hospital's RD's do not offer and conduct therapeutic diet education to in-patient's, patient's families or caregivers, nor do the RD's review, update or revise interdisciplinary plans of care related to any type of diet education or readiness for therapeutic diet education.

During a review of NCM, dated 2025, NCM indicated, "Registered dietitian nutritionists (RDN) must also receive referrals for nutrition problems other than malnutrition, such as the following: Knowledge deficits; For example, education focused on modification of sodium and fluid intake, in order to mitigate heart failure symptoms and reduce readmission rates."

During a review of The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM indicated, ". . .education handouts in the Nutrition Care Manual® (NCM®) are not intended to substitute for nutrition counseling with a registered dietitian nutritionist (RDN). The information is meant to serve as a general guideline and may not meet the unique nutritional needs of individual clients or patients. All medical professionals should consult with a RDN before providing handouts to clients or patients."

During a review of the facility's job description (JD) titled, "Registered Dietitian," dated 4/6/2017, the JD indicated, "Job Responsibilities Essential: Performs assessment and screening for patients designated as a high risk for optimal nutrition. Develops nutritional treatment plans in coordination with the interdisciplinary team and in collaboration with the patients and families as able. Follows up such patients to evaluate progress towards goals. . .Provides nutrition information and recommendations to physicians regarding patient's nutritional status in a timely manner. . .Performs or coordinates nutrition education for patients and/or patient's caregivers, and chart's appropriately to the medical record. Tailors nutrition education to the needs of the patient and their family (ex: medical needs, cultural preferences, patient readiness, etc). . .Continuously looks for ways to improve nutritional care to patients. Acts with others to monitor current levels of service, plan new or improved services, implement the plan, and reassess, educate, and make changes necessary for excellent care of patients."

During a review of the Hospital's P&P titled, "Quality Improvement Plan (QIP)," dated 1/26/22, the "QIP" indicated, "Purpose: The purpose of [name of hospital] Quality Improvement Plan is to have an effective, data-driven Quality Assessment Performance Improvement program that delivers high-quality, excellent clinical services and enhances patient safety."

During a review of the Hospital's job description (JD) titled "Clinical Nutrition Manager," dated 6/23/2020, the JD indicated, "In coordination with the Food and Nutrition Services Director establishes, enforces, and evaluates levels of productivity and performance standards for areas under the supervision of this position. This includes standards on recommendations for diet orders, documentation in the medical record system, nutritional assessments, patient follow-up and patient/family education and counseling. Identifies, reviews, and evaluates nutrition services through quality assurance and monitoring techniques to improve quality of care."

During a review of the Hospital's job description (JD) titled "Director of Food & Nutrition Services," dated 6/18/21, the JD indicated, "Provides oversight of the clinical nutrition program. Provides guidance and direction to the Clinical Nutrition Manager. . .Improve the Quality of Their Services; Responsible for quality and performance improvement activities in their department(s) and as they may affect other areas of [name of hospital]. . .Identifies, reviews, reports, and maintains indicators of sound clinical, service, and high quality practice. . .Researches industry 'best practices' for possible implementation in department(s)."

Based on interview and record review, the hospital failed to ensure the Registered Nurse (RN) 1 performed a nursing assessment for one of one sampled patient (Patient 3) follow a change in condition. This failure had the potential to result in delayed or inadequate care and had the potential to result in serious health consequences.

Findings:

During a concurrent interview and record review on 2/26/25 at 1:10 p.m. with Director of Trauma (DOT), Patient 3's "Pain" dated 12/12/25 was reviewed. The "Pain" indicated, pain assessment completed on 12/12/24 at 3:36 a.m., Patient 3 complained of sudden chest pressure. Patient 3 reported a 10 out of 10 pain level which indicated worst pain possible on the numerical pain scale (a widely used tool to assess pain intensity. It consists of a 0-10 point scale, where: 0: No pain, 1-3: Mild pain, 4-6: Moderate pain, 7-9: Severe pain,10: Worst possible pain). DOT was unable to provide documentation RN 1 performed a focused assessment following Patient 3's report of chest pressure. DOT stated RN 1 should have completed a focused assessment on Patient 3.

During a concurrent interview and record review on 2/26/25 at 2:03 p.m. with RN 1, Patient 1's "Patient 3's "Pain" dated 12/12/25 was reviewed. RN 1 stated when a patient complain of chest pain or chest pressure, a registered nurse is expected to perform a focused assessment (detailed assessment of specific body systems or areas related to presenting problem or current concern). RN 1 stated he complete a focused assessment for Patient 3 following the new complaint of chest pressure.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Documentation, Nursing: Acute Patient Care," dated 3/20/23, the P&P indicated, "Focused assessments (assessments focused on a specific body system or systems) are performed with changes in patient condition or as a follow up to any unusual findings from a previous assessment. . . Nursing documentation reflects communications, observations, decisions, actions and outcomes related to patient-centered care. . .To record nursing actions and individual responses as soon after they occur. . .Changes in condition and follow up actions/responses to symptoms or condition changes. . .Nursing documentation reflects assessment findings and depicts both clinically significant normal findings as well as abnormal findings per the clinician's clinical judgment. . . Documentation includes the status of the identified problems until they are resolved in the medical record or become inactive."

Based on interview and record review, the hospital failed to ensure the Magnetic Resonance Imaging Technician (MRIT) activated the emergency system for one of one patient (Patient 1) who deteriorated during the MRI (a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body) procedure. This failure resulted in the delay of emergency intervention provided Patient 1 during a life-threatening condition.

Findings:

During a concurrent interview and record review on 2/24/25 at 1:59 p.m. with Director of Radiology (DR) and Imaging Service Manager (ISM), Patient 1's MRI scan, dated 1/12/25, was reviewed. DR stated Patient 1 had an order for MRI of the brain without contrast on 1/12/25 at 10:48 p.m. DR stated Patient 1's MRI scan was started but was aborted on 1/13 25 at 1:42 a.m. due to Patient 1's change in condition during the MRI procedure. DR reviewed the documentation of the MRI technician (MRIT) which indicated, "Attempted exam. Patient became unstable towards the end of the exam. Unable to finish. Patient's condition deteriorated." DR was unable to find documentation the Rapid Response Team [RRT-hospital team that responds to patients who are deteriorating or have an emergency] or a Code Blue [designation for someone experiencing a life threatening medical emergency in need of immediate resuscitation to preserve life]) was called in MRI. ISM stated the staff had been educated and trained to call RRT or Code Blue when an emergency arise in MRI. ISM stated MRITs were trained to "Call RRT Alert Ext 44, Give Room Number, Call Primary Care Physician."

During an interview on 2/24/25 at 6:54 p.m. with MRIT, MRIT stated the emergency department registered nurse (EDRN 1), who was monitoring Patient 1 during the MRI scan, stated the scan needed to be stopped. MRIT stated EDRN 1 went inside the MRI room to check on the patient. MRIT stated the nurse informed him the patient did not look good and that the procedure could not be continued. MRIT stated EDRN 1 stated the patient needed to be taken back to the ED. MRIT stated there was no cardiopulmonary resuscitation performed on Patient 1 in MRI room. MRIT stated he did not call RRT or a Code Blue because EDRN 1 was in the room, and she took control of the situation.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response Team," dated 11/22/24, the P&P indicated, "The system is designed to recognize at-risk adult and adolescent (age 14-17) non-critical care patients earlier in their course of deterioration and to rapidly mobilize appropriate institutional resources including but not limited to the Primary Care Practitioner and RRT. . . PROCEDURE: 1. RRT Activation and 10 SOV [signs of vitality] Assessment. . . D. Activation of the RRT alert and notification of the managing practitioner will occur simultaneously 1. If 2 or more of the weighted 10 SOV criteria are present and or any patient the staff is seriously concerned about. . . Call RRT Alert Ext 44, Give Room Number, Call Primary Care Physician."

During a review of the hospital's P&P titled, "Code Blue," dated 9/28/22, the P&P indicated, " Procedure: I. First Responder A. Any district staff member witnessing an individual who is experiencing cardiac and/or respiratory arrest will immediately call for help either verbally and/or by dialing "44" within the main campus or "9-911" in
satellite areas using any in-house telephone. The operator will page the code team."

Based on interview and record review, the hospital failed to document and keep a record of the MRI Screening Form for one of one sampled patient (Patient 1) who had an MRI of the Brain without contrast. This failure had the potential to result in adverse consequences from not having accurate information for Patient 1, which could negatively affect safe patient care.

Findings:

During an interview on 2/24/25 at 3:06 p.m. with Imaging Service Manager (ISM), ISM stated she was unable to find the final review of the MRI Screening by the MRI Technologist (MRIT). ISM stated the MRIT should review the MRI screening before the study.

During an interview on 2/24/25 at 7:15 p.m. with MRIT, MRIT stated when an order for an MRI is received, an MRI screening form is filled out, first by the nurse obtaining information from the patient's family. MRIT stated he reviewed [Patient 1]'s screening form, but he did not sign it. MRIT stated he normally completes the form once the MRI study is finished; unfortunately, the scan was stopped almost at the end of the procedure because the patient deteriorated. MRIT stated our policy states we review the screening tool, talk to the patient, and sign the form before the scan is started. MRIT stated if the scan was not completed, as in this case, the form does not get sent over to PACS (picture archiving and communication system. It stores, uploads, and transfers images to a secure network database). MRIT stated the MRI Screening was not completed and uploaded onto the PACS system; therefore, there was no record the MRI screening was done.

During a review of the hospital's policy and procedure titled, "MRI Patient Screening," dated 6/11/24, the P&P indicated, "Policy: To assure patient safety, all patients will be screened twice prior to Magnetic Resonance Imaging (MRI). Procedure: B. The licensed MRI technologist will not start the MRI exam until the screening form is completed, reviewed, and the required signatures are obtained ...K. The licensed MRI technologist will perform a second review of the screening form with the patient as condition allows or a licensed nurse before the patient is taken into the MRI suite ...N. The screening form will be signed by a licensed MRI technologist and scanned into picture archiving communication system (PACS)."

Based on observation, interview, and record review, the hospital failed to ensure the Director of Food & Nutrition Service Director (DFNS) provided effective daily oversight related to the management of the foodservice operation, develop and implement policies and procedures to maintain safe food handling and a sanitary environment within the kitchen to avoid sources and potential transmission of infection when:

1. There was excessive moisture and condensation located in the dishmachine room due to a vent hood in disrepair where clean dishes were stored on drying racks. This failure had the potential for contaminating food equipment and the surrounding environment as excessive condensation could drip onto food equipment and create an environment to promote mold growth, and attract pests, such as rodents that could carry disease.

2. There were unsanitary conditions in the kitchen related to extensive build up of debris and grime along the baseboards, floors, walls, drains and lacked an air gap for a hose adjacent to a reach-in refrigerator, and did not repair holes in the wall promptly, especially with a known rodent problem in the kitchen.

3. Uncooked rice was not stored in a sanitary manner when the dry rice was located in an ingredient bin with extensive black colored scratches and was in disrepair.

4. Cold food was not maintained at 41 degrees F (Fahrenheit) or less while holding during the lunch trayline meal service. Failure to ensure cold food was not held within the temperature danger zone (42 degrees F to 134 degrees F) impeded the tracking of time to ensure the cold food was not in the danger zone for four or more hours, to include transportation, distribution, and potential for delay of consumption of food by patient at bedside, that could result in foodborne illness.

5. The dry food storage room had an open crevice in the wall, and extensive food debris underneath the shelving and milk crates with sugar granules on top of a food storage lid in which the lid contained a thick yellow colored substance.

6. The foodservice operation in the main kitchen had a known rodent problem for at least ten months during which time harborage conditions and unsanitary conditions remained.

7. The DFNS failed to report the extensive, on-going rodent problem to the hospital-wide infection control program and to the hospital-wide QAPI (Quality Assessment and Performance Improvement) program for a multidisciplinary approach and strategic planning to take effective measures to eliminate the rodents that are vectors of disease-causing microorganisms which may be transmitted to patient, staff or visitors by contamination of food and food-contact surfaces.

These failures had the potential for growth of microorganisms and cross contamination which placed the patients at an increased risk for foodborne illness, and potential for rodent related infections in patients, staff and visitors.

Findings:

1. During a concurrent observation and interview on 2/27/25 at 10:32 a.m. with DFNS and Director of Facilities Planning (DF) in the kitchen, there was an excessive amount of steam and condensation filling the large dishmachine room while the dishmachine was in use. Large drying racks stored clean dishes in the dishmachine room during the presence of excessive steam and condensation. DF stated the dishmachine was installed by an outside vendor per the dishmachine rental agreement about a year ago. DF stated although the dishmachine was newer the vent hood attached to the dishmachine was not. DF stated he observed the steam escaping form underneath the vent hood and filling the dishmachine room with excessive steam and condensation which was indicative of a improperly sized vent hood for that particular dishmachine. DF stated the improperly sized dishmachine vent hood caused the excessive steam and heat creating an unsafe and unsanitary environment as the moisture/condensation had the potential to support mold growth, attract rodents, and caused an uncomfortable work environment for staff.

During a concurrent interview and record review on 2/27/25 at 2:41 p.m. with DFNS, DFNS stated the excessive moisture and condensation from the dishmachine was reported via a work order "a while ago."

During a review of "Work Order (WO)," dated 5/23/24, the "WO" indicated, "Problem: Please see if the vent hood in the kitchen dish room is operational. It is very hot. Can we put in a small swamp cooler? Building: Main campus, Location: Kitchen, Action: Repair - Completed."

During a concurrent interview and record review on 2/27/25 at 4:30 p.m. with DF, DF reviewed the "WO", dated 5/23/24, DFP stated the repair was ineffective as the condition still exists.

During a review of the Food and Drug Administration Food Code (FDAFC), dated 2022, the "FDAFC" indicated, "Exhaust ventilation hood systems in warewashing areas including components such as hoods, fans, guards, and ducting shall be designed to prevent. . .condensation from draining or dripping onto equipment."

During a review of the FDAFC Annex (FDAFCA), dated 2022, the FDAFCA indicated, "If a ventilation system is inadequate. . .condensate may build up on the floors, walls and ceilings of the food establishment, causing an unsanitary condition and possible deterioration of the surfaces of walls and ceilings. The accumulation of. . .condensate may contaminate. . .food-contact surfaces."

2. During a concurrent observation and interview on 2/27/25 at 11:00 a.m. with DFNS and Director of DF in the kitchen, to the far back wall and right outside of the dish machine room, there was a large white fiber reinforced plastic (FRP) hanging up isolating an area behind the FRP from the rest of the kitchen. DFNS stated there used to be an old wooden type cabinet with a food contact surface counter top that was removed due to not able to clean it effectively and could harbor rodents. DF stated when the old cabinet was removed it accidentally caused part of the wall to come along with it leaving a hole in the wall which could be a harborage source for rodents. DF stated he placed the FRP to prevent entry of rodents into the food preparation area of the kitchen. DF stated he was still meeting with leadership to formulate a plan on how extensive of a project they want to do with that space, therefore, no notification to regulatory agencies had occurred yet.

During a review of FDA Food Code (FDAFC), dated 2022, the FDAFC indicated, "Physical facilities shall be maintained in good repair."

During a concurrent observation and interview on 2/27/25 at 11:09 a.m. with DFNS and DF, in the kitchen, the rim of a floor sink drain was extensively covered with black and brown colored debris with brown and black round debris on the floor next to the rim of the floor sink drain that was adjacent to a reach-in refrigerator unit.
There was a tube that was covered in black colored substance located directly on the bottom of the floor sink drain. DFNS stated the black colored substance was located on the outside of the tube. DFNS and DF stated the tube was not the waste water outlet for the reach-in refrigerator and they were unsure what the tube was for. DFP and DFNS verified the tube should not be located on the floor of the floor sink drain and had potential for cross-contamination from backflow should the drain back up. DFNS stated the drains, surrounding area of the floors and baseboards and lack of an air gap regarding the tube was unsanitary conditions in the kitchen.

During a concurrent observation and interview on 2/27/25 at 11:14 a.m. with DFNS and DF, in the kitchen, the floors, baseboard and wall located behind, underneath and near the 3-compartment pot and pan sink had very thick build up of black grime in the corner of the wall along a raised baseboard, along the baseboard and up onto the wall. In addition, there was water dropping from a small gray colored hose in close proximity to a bottle of blue colored chemical at the 3-compartment pot and pan sink. The dripping water was pooling causing a small puddle of water on the floor.

During a review of the FDA Food Code Annex (FDAA), dated 2022, FDAA indicated liquid wastes need to be quickly carried away to prevent pooling which could attract pests such as insects and rodents."

During a review of "FDA Food Code" (FDAFC), dated 2022, FDAFC indicated, "Non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues."

During a review of "FDAFCA", dated 2022, FDAFCA indicated, "The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic [capable of causing disease] microorganisms will not be allowed to accumulate and insects and rodents will not be attracted."

During a review of the facility's "WO (Work Order)," dated 9/1/24 at 4:41 a.m., the "WO" indicated, "Pest removal from underneath pots and pans sink, repair completed 9/1/24 at 6:04 a.m."

During a review of the facility's "WO," dated 9/26/24 at 8:22 a.m., the WO indicated, "Mouse been caught on mouse trap needs to be picked up on the pots and pans station, repair completed on 9/26/24 at 9:20 a.m."

3. During a concurrent observation and interview on 2/27/25 at 11:24 a.m. with DFNS and DF, in the kitchen, uncooked, white rice was stored directly in a food ingredient bin in which the inside of the bin had extensive black colored scratches and was in poor condition. DFNS stated the rice was not stored in a sanitary manner and that the ingredient bin needed to be replaced. DFNS stated the Food Services Manager (FSM) had not informed him about that.

During a review of the facility's policy and procedure (P&P) titled, "Chipped, Cracked, and Crazed China," dated 5/21/24, the P&P indicated, "Policy: The use of cracked, crazed or damaged meal service equipment a safety hazard and is prohibited. . .Damaged items are immediately taken out of service. . .Procedure: Staff to notify management if/when replacement of equipment is needed."

4. During a concurrent observation and interview on 2/27/25 at 12:15 p.m. with DFNS in the kitchen, lunch trayline meal service for patients was observed in which there were two reach-in refrigerators next to trayline with their doors propped opened. DFNS stated the lunch trayline service takes about two hours, sometimes more depending on the census (the number of in-patients). DFNS was asked if staff checked the cold food holding temperatures used for lunch meal service, and DFNS stated, yes, they do. DFNS was observed asking staff where the binder was for the trayline cold and hot holding temperatures, and staff replied that they only check the temperature of hot foods from the steamtable with a thermometer immediately prior to starting trayline, not the cold holding foods.

During a concurrent observation and interview on 2/27/25 at 12:17 p.m. with DFNS in the kitchen, DFNS observed a food service worker (FSW)1 use a digital thermometer and inserted the thermometer into the middle of an eight ounce carton of milk obtained from one of the reach-in refrigerators used for trayline, and FSW 1 stated it's 45. 1 degrees F (Fahrenheit). FSW 1 stated they were about 50% (percent) done plating patient lunches for meal service.

During an interview on 2/27/25 at 12:25 p.m. with FSM, FSM stated they had not been checking the internal temperature of the cold foods being held for trayline meal service and the temperature should have been checked.

During a review of the facility's P&P titled, "Food Safety HACCP [Hazard Analysis of Critical Control Points]," dated 9/13/24, the P&P indicated, "Procedure: The HACCP monitoring system is in place throughout the food cycle including receiving, storage, production, holding, & serving process. Cold food must be maintained at 40 degrees F or below while holding and serving. Product temperature must be recorded on a specified log at 2 hour intervals during holding and serving. If a product is held and served for less than 2 hours, the product temperature must be recorded at the beginning and end of service. Cold food holding equipment (i.e., refrigerators, ice beds) must be kept clean, sanitized and in good working order (correctly calibrated)."

5. During a concurrent observation and interview on 2/27/25 at 3:10 p.m. with DFNS, FSM, and Dietary Stockroom Clerk (DSC) in the dry food storage room (DFSR) in the kitchen, DSC was using a mop on the floor toward the entrance of the dry food storage room. DSC stated he just finished cleaning the floors in the DFSR.

During a review of the facility's job description (JD) titled, "Dietary Stockroom Clerk", dated 2/8/16, the "JD" indicated, "Maintains cleanliness of storage areas including the storeroom, walk-in coolers, and freezers."

During a concurrent observation and interview on 2/27/25 at 3:12 p.m. with DFNS and FSM in the DFSR, an opened crevice in the wall was observed that could allow entry of pests, with surrounding food debris on the floor. Upon further observation of the floor that was just cleaned by DSC, there was extensive food and food debris all along the baseboards and surface floor, and located under shelves and milk crates.

During a concurrent observation and interview on 2/27/25 at 3:24 p.m. with DFNS in the DFSR, a food storage bin labeled "Granulated Sugar Prep 2/22/25; Must Use By 2/21/26" was observed to have an extensive amount of sugar granules on the top of the lid facing up with thick yellow colored substance along the corner of the lid. DFNS stated he did not know what the yellow colored substance was. DFNS stated the lid should have been washed and sanitized. In addition, there were multiple unused floor drains that had a cover to help prevent entry of pests into the kitchen. Surrounding the floor drains was a black colored substance and DFNS stated he thought that was some type of glue substance maintenance used to secure the drains flat so they could not be pushed up potentially by rodents, however, the thick amount of blackish colored glue could impede effective cleaning as it was not a smooth surface.

During an interview on 2/27/25 at 3:29 p.m. with FSD, FSD stated he did not think it was necessary to remove the dry food stored in manufacturer packaging, such as plastic, and cardboard boxes and place into impermeable food grade containers with tight fitting lids despite knowing a there was a rodent problem in the kitchen for at least the past ten months.

6. During a review of the facility's "WO (Work Order)," dated 8/7/24 at 5:24 a.m., the WO indicated, "Please reach out to [name of contracted pest control company]. We are in need of pest traps for the kitchen, vendor service 8/7/24 at 8:36 a.m."

During a review of the facility's "WO (Work Order)," dated 8/14/24 at 5:55 a.m., the WO indicated, "Please reach out to [name of contracted pest control company]. We need our traps. . .in kitchen rest, vendor service 8/15/24 at 7:50 a.m."

During a review of the facility's "kitchen (Work Order)," dated 8/23/24 at 2:26 p.m., the WO indicated, "Please remove dead rat from the trap in the utility closet. Repair completed 8/26/24 at 7:11 a.m."

During a review of the facility's "WO (Work Order)," dated 9/1/24 at 4:41 a.m., the WO indicated, "Pest removal from underneath pots and pans sink, repair completed 9/1/24 at 6:04 a.m."

During a review of the facility's "WO," dated 9/26/24 at 8:22 a.m., the WO indicated, "Mouse been caught on mouse trap needs to be picked up on the pots and pans station, repair completed on 9/26/24 at 9:20 a.m."

During a review of the facility's "WO (Work Order)," dated 10/08/24 at 7:31 a.m., the WO indicated, "There is a little mouse underneath trash cans in the main cafeteria, minor repair 10/8/24 at 12:51 p.m."

During a review of the facility's "WO (Work Order)," dated 10/08/24 at 12:31 p.m., the WO indicated, "Can we get mouse traps put in underneath the trash cans, minor repair 10/08/24 at 3:48 p.m."

During a review of the facility's "WO (Work Order)," dated 10/10/24 at 7:05 a.m., the WO indicated, "There is a mouse in the diet office. Repair completed 10/10/24 at 9:50 a.m."

During a review of the facility's "WO (Work Order)," dated 10/21/24 at 4:32 p.m., the WO indicated, "Pest removal needed in cold food area, repair completed 10/22/24 at 3:02 p.m."

During a review of the facility's "WO (Work Order)," dated 10/31/24 at 5:08 a.m., the WO indicated, "Please reach out to [name of contracted pest control company] to re-bait and reset traps, vendor service 10/31/24 at 8:21 a.m."

During a review of the facility's "WO (Work Order)," dated 1/21/25 at 11:24 a.m., the WO indicated, "Multiple holes in walls, cracks in doors that need sealing to prevent pest entry."

During a review of the facility's "WO (Work Order)," dated 1/23/25 at 3:15 p.m., the WO indicated, "Counter/cabinet and replace with our own worktables. Removed from service 2/12/25 at 11:49 a.m."

During a review of the facility's "WO (Work Order)," dated 2/12/25 at 12:47 p.m., the WO indicated, "Rat underneath supplements need to be disposed of, minor repair 2/12/25 at 3:14 p.m."

During a review of the facility's "WO (Work Order)," dated 2/17/25 at 8:12 a.m., the WO indicated, "Rat underneath sink in dish room. If we can get it removed, removed from service 2/17/25 at 1:13 p.m."

During a review of the facility's "WO (Work Order)," dated 2/24/25 at 11:12 a.m., the WO indicated, "[Name of DFNS] is requesting a door seal on the walk in 1 [refrigerator] and outside double doors to prevent pest entry, incident evaluation 2/25/25 at 8:46 a.m."

During a review of the facility's "WO," dated 2/25/25 at 5:12 a.m., the WO indicated, "We have pests that are caught in traps if we can get them discarded, 2 in dish room and 1 in the cold food demo area, repair completed 2/25/25 at 7:46 a.m.

During a review of the FDAFC, dated 2022, the FDAFC indicated, "The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices. . .and (D) Eliminating harborage conditions."

During a review of the FDAFC, dated 2022, the FDAFC indicated, "Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. . .dead or trapped. . .rodents, and other pests shall be removed from control devices and removed from the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests. . .dead rodents. . .must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests."

During an interview on 2/27/25 at 3:03 p.m. with FSM and DFNS, FSM stated facilities department manages the contracted pest control vendor. FSM stated the pest control vendor leaves a carbon copy of their report after each visit in her in-box which she reviews and then gives it to DFNS.

During an interview on 3/3/25 at 11:50 a.m. with FSM and DFNS, FSM stated she had not reported the rodent problem in the kitchen and retail kitchen to anyone other than DFNS, facilities staff and EVS (environmental services/housekeeping). DFNS stated he had not reported the rodent problem in the kitchen and retail kitchen to the hospital-wide infection control program/committee/Infection Prevention Manager (IPM) or to the QAPI program/Quality Committee.

During an interview on 3/3/25 at 2:45 p.m. with Director of Quality & Patient Safety (DQPS), DQPS stated she was a part of the Quality Committee (QComm) that had responsibility for oversight of organizational performance improvement. DQPS stated absolutely IPM and the Quality Committee (QComm) should have been informed about rodents in the kitchen and we (both IPM and QComm) were not aware of that. DQPS stated rodents in the kitchen certainly qualified for the criteria of high risk, high volume and problem prone for a performance improvement (PI) project. DQPS stated the QComm could have assisted DFNS by ensuring appropriate measures and allocation of resources were put in place to ensure resolution of the rodent problem.

During a review of the facility's P&P titled, "Quality Improvement Plan (QIP)," dated 1/26/22, the "QIP" indicated, "The Quality Council requires the. . .organization's staff to implement and report on the activities for identifying and evaluating opportunities to improve patient care and services throughout the organization."

During an interview on 3/3/25 at 11:55 a.m. with a Cook (Cook 1), Cook 1 stated she started her shift on 3/3/25 at 4:45 a.m. Cook 1 stated when she arrived she turned on the foodservice equipment and then goes to the refrigerator and gets her cart to begin food preparation. Cook 1 stated she did not clean and sanitize when she arrived in the morning since that was done the night before. Cook 1 stated trayline (assembly to plate food) for breakfast meal service started at 6:00 a.m.

During an interview on 3/3/25 at 12:01 p.m., with FSM and DFNS, FSM stated she had not modified the schedule for the a.m. opening cook position, or any other morning position, to provide extra time to clean and sanitize foodservice counter tops, and foodservice equipment including the steamtable used for breakfast trayline service, for example, during the known rodent problem in the kitchen that had been going on for at least ten months per FSM and DFNS.

During an interview on 3/3/25 at 12:05 p.m. with DFNS, DFNS stated he was aware rodents were nocturnal and active at night and in the kitchen. DFNS stated he had not directed FSM to modify the morning crew's schedule or tasks to accommodate cleaning and sanitizing of foodservice equipment in the mornings prior to food preparation, after being aware rodents are nocturnal and highly likely contaminating food contact surfaces during the night. DFNS stated when we see rodent droppings the staff sweep them up.

During a review of Centers for Disease Control and Prevention (CDC) education material titled, "How to Clean Up After Rodents (CUR)," dated 4/8/24, the "CUR" document indicated, "Diseases are mainly spread to people from rodents when they [humans] breathe in contaminated air. Don't vacuum or sweep rodent urine, droppings, or nesting materials. This can cause tiny droplets containing viruses to get into the air."

During a review of information (info.) provided by California Department of Public Health - Food and Drug Branch (CDPHFDB) titled "Vermin", dated 5/7/24, the CDPHFDB info. indicated, "Diseases from rats and mice can spread to people directly through: handling of rodents, contact with rodent feces, urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste), rodent bites, rodents can also spread disease indirectly by ticks, mites, lice, or fleas that can act as vectors to spread diseases between rodents and people. Foodborne illness and mouse-borne allergens are among the most common rodent-related human health hazards in urban environments."

During a review of the facility's P&P titled, "Sanitation Program," dated 9/13/24, the P&P indicated, "Policy: It is the policy of the Food and Nutrition Service Department to maintain a clean department through a comprehensive cleaning and sanitation program. The Food Service Director and/or designee monitors cleaning and sanitizing schedules and procedures. Equipment, walls, floors and storage areas are routinely cleaned with the appropriate cleaning and sanitizing solution."

During a review of the facility's job description (JD) titled, "Food Service Manager," dated 2/8/21, the "JD" indicated, "Oversees daily duties in the kitchen production: . . .Establishes and monitors cleaning schedule for proper sanitation, production and all food storage areas."

During a review of the facility's job description (JD) titled, "Director of Food & Nutrition Services," dated 6/18/21, the "JD" indicated, "Supervision of all production, food service and sanitation for patients, cafeteria and catering. . .Puts safety first, including speaking up respectfully when concerned or uncomfortable about a potential safety issue that is noticed or identified; steps in and works to correct this safety concern. Proactively address problems or defects; investigates, reports and corrects. Keep patients safe by preventing infections. . ., participates in meetings and carries out meeting responsibilities as assigned. . .Responsible for quality and performance improvement activities in their department(s) and as they may affect other areas of [name of hospital].

Based on observation, interview, and record review, the facility failed to ensure nutritional aspects were implemented and supervised by a Registered Dietitian (RD) when:

1a. One of one sampled patient (Patient 26) with a latex allergy had potential for cross-reactivity (when an antibody reacts with a molecule that is similar to another molecule) with certain foods did not receive Medical Nutrition Therapy (MNT) in accordance with standards of practice. This failure had the potential for Patient 26's latex allergy that may be associated with allergies to certain foods to go unrecognized and care plan needs unmet.

1b. The hospital's system did not ensure RD's provided MNT based on established standards of practice to patients, patient's families or caretakers for those patients with food allergies. This failure placed patients at an increased risk of experiencing allergic symptoms ranging from mild to life-threatening.

2. RD 2 did not ensure dry weights were used for meaningful evaluation of weight changes for one of five sampled patients (Patient 26) who received hemodialysis (a medical procedure that filters waste products and excess fluid from the blood when the kidneys are unable to do so) three times a week, in accordance with nutrition assessment standards of practice. Clinical Nutrition Services Manager (CNSM) stated the pre dialysis weights and post dialysis weights were not available to the RD's for patients receiving dialysis treatments. Failure to implement nutrition standards of care when assessing weight changes for patient's receiving dialysis treatments could lead to unrecognized unplanned weight loss or weight gain with care plan needs not met.

3. A diet clerk interpreted a therapeutic low potassium diet order for one of five patient's (Patient 27) without supervision from an RD to ensure the low potassium diet order was clarified with the physician to ensure Patient 27's nutritional and safety needs were met.

4. The hospital's structure did not ensure RDs provided individualized therapeutic diet education to patients and/or patient's families or caregivers in accordance with the hospital's RD job description for one of five sampled patient's (Patient 27). Failure to fully utilize RDs skill sets and expertise for patient care could impede minimizing risks imposed by disease, comorbidities and/or not maximizing the impact of personalized patient therapeutic diet education in reducing rates of re-admission.

Findings:

1a. During a concurrent interview and record review on 2/28/25 at 11:32 a.m. with CNSM and Director of Food and Nutrition Services (DFNS), Patient 26's "Nutrition Note (NN)," dated 2/2/25 was reviewed. The NN indicated, "Allergies. . .Latex (Rash)." CNSM stated the NN was Patient 26's admission nutrition assessment and the latex allergy listed was automatically populated from other areas of Patient 26's electronic health record (EHR). CNSM stated the NN, dated 2/2/25, did not contain documentation by RD (Registered Dietitian) 1 addressing the latex allergy as it was listed as a drug allergy and did not have anything to do with nutritional care of Patient 26. DFNS stated latex allergy was listed as a drug allergy and FANS staff already used latex free gloves, otherwise the latex allergy did not have anything to do with food and nutrition services.

During a review of Allergy & (and) Asthma Network on-line information titled, "Latex Allergy and Foods (LAF)," dated 2025, LAF indicated, "If you have a latex allergy, you can sometimes have reactions to certain fruits and vegetables. These reactions occur in 30-50% of people with latex allergy. Latex reactions to certain fruits and vegetables can happen because these foods share similarly structured proteins that the body mistakenly recognizes as latex. This, in turn, causes allergic reactions in latex-sensitive people. These allergic reactions can occur not only after eating these foods but also after touching or smelling them." (https://allergyasthmanetwork.org/allergies/latex-allergy/latex-allergy-foods/)

During a review of the facility's policy and procedure (P&P) titled, "Adult and Pediatric Assessment," dated 6/12/24, the P&P indicated, "Nutritional Assessment: To obtain, verify, and interpret data needed to identify nutrition-related problems, their causes, and significance. A Registered Dietitian (RD) conducts an in-depth assessment using comprehensive data, as well as interpretation of the data, to determine the presence and the degree of nutritional risk. Information on. . .food allergies will also be reviewed."

During a review of the facility's P&P titled, "Diet Manual and Approval Acute Care," dated 7/22/24, the P&P indicated, "Purpose: To provide a reference for nutrition care, which will be used as a guideline for diet related information. The facility specific diet manual outlines all regular and therapeutic diets available for patients in the facility. The Nutrition Care Manual is the standard guide and reference for nutrition assessment and care. Policy: The facility specific diet manual is updated at least annually and reflects the current meals and therapeutic diet options available for providers to order for their patients. The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM) is the standard guide and reference for nutrition care. The NCM is online and available to all healthcare providers at [name of hospital]. Procedure: The NCM is consistent with AND's Evidence Analysis Library, AND's position papers, and the Nutrition Care Process."

During a concurrent interview and record review on 2/28/25 at 11:38 a.m. with CNSM, the on-line NCM, dated 2025 was reviewed. The NCM indicated, "A nutrition consult should be ordered when a patient with latex allergy. . .is admitted to the hospital. Patients with latex allergy may need an allergen (a substance that causes an allergic reaction) free prescription." CNSM stated RD 1 did not assess and evaluate nutritional aspects of care for Patient 26 latex allergy in accordance with standards of practice.

1b. During a concurrent interview and record review on 2/28/25 at 12:22 p.m. with CNSM, in the presence of DFNS, CNSM stated the hospital's nutrition screening that should identify high risk nutrition patients who may benefit from a nutrition assessment and intervention by an RD did not capture patients with a food allergy. CNSM stated she used the NCM as established standards of care for guidance when developing the hospital's diet manual.

During a review of The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM indicated, "Food allergy: A nutrition consult should be ordered when a person with a food allergy is admitted to the hospital. Patients with food allergies must adhere to an allergen-free nutrition prescription, by avoiding their diagnosed allergens, during their entire hospital stay. A nutrition consult is indicated for all patients with food allergy to ensure the following: Successful elimination of the allergen, ensure adequate intake of nutrients that would normally be provided by foods that are eliminated. . . education handouts in the Nutrition Care Manual® (NCM®) are not intended to substitute for nutrition counseling with a registered dietitian nutritionist (RDN). The information is meant to serve as a general guideline and may not meet the unique nutritional needs of individual clients or patients. All medical professionals should consult with a RDN before providing handouts to clients or patients." The NCM further indicated, "A cascade of symptoms, which usually occur within minutes after eating the offending food, involve the cutaneous (skin), respiratory (lungs), gastrointestinal (stomach and intestines), and/or cardiovascular (heart) systems. In the most severe cases, the airway closes off and the blood pressure drops rapidly, which could result in death. Once an anaphylactic reaction begins, there is no way to predict how serious it can become. Food-induced anaphylaxis is the most common cause of anaphylaxis in emergency rooms in the United States."

During an interview on 3/3/25 at 11:25 a.m. with CNSM, CNSM stated she needed to institute RD consult orders for food allergies into the hospital's structure, including providing various food allergy guidance and sample menus into the hospital specific diet manual as it was currently excluded, to ensure patients with food allergies received MNT in accordance with standards of practice.

During a review of the facility's P&P titled, "Adult and Pediatric Assessment," dated 6/12/24, the P&P indicated, "Nutrition Screening: Identifies patients who may have a nutrition diagnosis and may benefit from nutrition assessment and intervention by a Registered Dietitian. . .Nutritional Assessment: To obtain, verify, and interpret data needed to identify nutrition-related problems, their causes, and significance. A Registered Dietitian (RD) conducts an in-depth assessment using comprehensive data. . .information on. . .food preferences. . .and food allergies will also be reviewed."

2. During a concurrent interview and record review on 2/28/25 at 12:22 p.m. with CNSM, Patient 26's "Nutrition Follow-up (NFU)", dated 2/7/25, completed by RD 2 was reviewed. The NFU indicated, "High nutrition risk follow up. . .Pt [patient] remains on a Renal diet (diet for kidney disease) with a PO [by mouth] intake averaging < [less than]25% last 9 documented meals. Pt has been consuming snacks that have been order. However, pt is likely not meeting estimated nutrition needs at this time. . .Weight trend within admission appears to show a weight gain from 52.8 to 53.5 to 55.5 kg [kilogram]--pt is at a negative fluid balance this admit, wt [weight] questionable but monitoring." CNSM stated Patient 26 received hemodialysis three times a week due to ESRD [end stage renal disease]. CNSM showed Patient 26's weights listed in the EHR under "Measurements" indicated, "1/31/25- 53.5 kg, 2/2/25- 53.5 kg, 2/3/25- 55.5 kg, and CNSM stated that was the only location where patients weights were recorded. CNSM stated comparing dry weight to dry weight post dialysis was the standards of practice when evaluating weight loss or weight gain for a patient with ESRD on HD (hemodialysis). CNSM stated the weights in the EHR under "Measurements" was not the dry weight post dialysis. CNSM stated she would need to work on ensuring RD's have available, and use, dry weights pre and post dialysis treatment when conducting nutrition assessments for patients receiving dialysis for a meaningful evaluation of weight changes that may lead to an RD recommending nutrition interventions.

During a review of the facility's P&P titled, "Adult and Pediatric Assessment," dated 6/12/24, the P&P indicated, "Nutritional Assessment: To obtain, verify, and interpret data needed to identify nutrition-related problems, their causes, and significance.

During a review of The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM indicated, "In adults undergoing dialysis, assessments are best obtained after treatment when body fluid compartment levels are more likely to be balanced." The NCM referenced "KDOQI Clinical Practice Guideline for Nutrition in CKD (CPG)", dated 2020, the CPG indicated, ". . .percent change in usual
body weight (dry weight in maintenance dialysis patients) may be a more reliable measure."

During a review of the facility's job description (JD) titled, "Registered Dietitian," dated 4/6/2017, the JD indicated, "Continuously looks for ways to improve nutritional care to patients. Acts with others to monitor current levels of service, plan new or improved services, implement the plan, and reassess, educate, and make changes necessary for excellent care of patients."

3. During a concurrent observation and interview on 2/27/25 at 11:30 a.m. with DFNS in the kitchen, Patient 27's lunch meal tray card indicated diet order was diabetic 60 g CC and 2 gm potassium with milk and broccoli observed on Patient 27's meal tray. DFNS stated patients therapeutic diet select menus are screened by Diet Clerks.

During a concurrent interview and record review on 2/28/25 at 10:36 a.m. with CNSM, CNSM stated Patient 27's diet order in the EHR indicated 60 g CC, low potassium diet upon admission on 2/25/25 and remained that way as of 2/28/25. CNSM stated a "low potassium diet" was not a recognized diet order, as the hospital had 2 gm or 3 gm potassium diet orders readily available with menus and corresponding nutrient analysis to ensure patient's received the diet order as intended, and defined in the hospital's diet manual.

During a concurrent interview and record review on 2/28/25 at 11:16 a.m. with CNSM, CNSM reviewed a software program (Computrition) the Diet Clerks utilized that contained pertinent patient specific dietary needs which generated individualized meal tray cards that provided direction to kitchen staff when assembling a patient's meal tray, such as food allergies, and food preferences. CNSM reviewed Computrition for Patient 27 that listed, "Diet Order Restrictions: Consistent Carb (CC) 60 Diabetic, K 2000 mg." Computrition had a tab titled "Diet Order History (DOH)", dated 2/26/25 8:47 a.m., the DOH indicated, "Start Meal: 2/26/25- Breakfast, "Who" name of Diet Clerk listed (DC 1), "Menu Type" Renal, "Order Details" DB, 60g CC, K2gm." CNSM stated DC 1 cannot write diet orders and cannot interpret what the correct low potassium diet order was for Patient 27, whether 2 gm K or 3 gm K. CNSM stated DC 1 should have communicated with an RD or RN (Registered Nurse) to clarify the diet order with the physician for Patient 27's nutritional and safety needs.

During an interview on 3/3/25 at 11:28 a.m. with CNSM, CNSM she did not find a 2 gm potassium diet, nor a 3 gm potassium diet in the hospital's approved diet manual. CNSM stated those 2 gm K+ and 3 gm K+ diets are used by the hospital's physician's and she did provide directions and recipes to the kitchen staff on how to prepare patient meal trays to meet those diet orders.

During a review of the facility's policy and procedure (P&P) titled, "Diet Manual and Approval Acute Care," dated 7/22/24, the P&P indicated, "Purpose: To provide a reference for nutrition care, which will be used as a guideline for diet related information. The facility specific diet manual outlines all regular and therapeutic diets available for patients in the facility. The Nutrition Care Manual is the standard guide and reference for nutrition assessment and care. Policy: The facility specific diet manual is updated at least annually and reflects the current meals and therapeutic diet options available for providers to order for their patients.

During a review of the facility's job description (JD) titled, "Diet Clerk," dated 1/31/20, the JD indicated, "Job Responsibilities Essential: Receives diet orders from the electronic medical record and maintains current diet order in the automated diet office system (Computrition). Consults with patients, nurses, dietitians, and dietary personnel as needed concerning patient diets."

4. During a concurrent interview and record review on 2/28/25 at 10:36 a.m. with CNSM, CNSM stated Patient 27's diet order in the EHR indicated 60 g CC, low potassium diet upon admission on 2/25/25 and remained that way as of 2/28/25.

During an interview on 2/28/25 at 10:55 a.m. with CNSM and DFNS, CNSM stated Patient 27's therapeutic 60 g CC diet was prescribed for diabetes management and low potassium diet order was for renal disease and did not meet the facility's nutrition screening criteria to warrant a RD to complete a nutrition assessment and/or provide therapeutic diet order education at anytime during the hospital stay based on diagnosis of chronic disease, chronic co-morbidities or therapeutic diet order in and of itself. CNSM stated teaching of therapeutic diets to patient's was important and within the scope and expertise of a RD but "we have to manage the resources we have."

During a concurrent interview and record review on 2/28/25 at 11:25 a.m. with Director of Medical Surgical Services (DMSS), CNSM and DFNS, DMSS stated nursing staff have access to therapeutic diet education handouts located in Cerner (A software program) that a nurse could provide to a patient upon discharge "depending on the patient situation", it was not automatic. DMSS stated nursing was responsible for initiating, updating and revising nutrition plans of care (Interdisciplinary/IDT nutrition care plans) that could include "Diet/Nutrition" with specifications such as "needs further teaching", or "verbalizes understanding." DMSS reviewed Patient 27's Plans of Care and stated there was not a nutrition plan of care initiated for Patient 27. CNSM stated the hospital's RDs do not access the plans of care for patients and therefore do not initiate, update or revise a patient's IDT nutrition plans of care. CNSM stated she saw discharge orders for today for Patient 27.

During an interview on 2/28/25 at 12:3 p.m. with Discharge Case Management (DCM), DCM stated she did not have anything to do with diets or therapeutic diet education for patients. DCM stated she did discharge planning for identified patient's that needed case management but did not discuss or provide diet education, even in the form of therapeutic diet education handouts.

During a review of the facility's job description (JD) titled, "Registered Dietitian," dated 4/6/2017, the JD indicated, "Job Responsibilities Essential: Performs assessment and screening for patients designated as a high risk for optimal nutrition. Develops nutritional treatment plans in coordination with the interdisciplinary team and in collaboration with the patients and families as able. . .Performs or coordinates nutrition education for patients and/or patient's caregivers, and chart's appropriately to the medical record. Tailors nutrition education to the needs of the patient and their family (ex: medical needs, cultural preferences, patient readiness, etc). . .Continuously looks for ways to improve nutritional care to patients. Acts with others to monitor current levels of service, plan new or improved services, implement the plan, and reassess, educate, and make changes necessary for excellent care of patients."

During a review of NCM, dated 2025, NCM indicated, "Registered dietitian nutritionists (RDN) must also receive referrals for nutrition problems other than malnutrition, such as the following: Vitamin intake; For example, ensuring consistent vitamin K intake for patients treated with vitamin K antagonists, Obesity; For example, diagnosis and documentation of obesity to support additional reimbursement to compensate for the increased costs of caring for morbidly obese patients; Knowledge deficits; For example, education focused on modification of sodium and fluid intake, in order to mitigate heart failure symptoms and reduce readmission rates."

During a review of the facility's job description (JD) titled "Clinical Nutrition Manager", dated 6/23/2020, the JD indicated, "In coordination with the Food and Nutrition Services Director establishes, enforces, and evaluates levels of productivity and performance standards for areas under the supervision of this position. This includes standards on recommendations for diet orders, documentation in the medical record system, nutritional assessments, patient follow-up and patient/family education and counseling. Identifies, reviews, and evaluates nutrition services through quality assurance and monitoring techniques to improve quality of care."

Based on observation, interview, and record review, the facility failed to ensure two of eight food service workers (Dietary Stockroom Clerk [DSC], Food Service Worker [FSW] 2) were competent in assigned duties related to:

1. DSC left extensive quantities of food debris alongside the walls and underneath shelving and crates after DSC just completed the task. Failure to adequately clean the floors in the dry food storage room allowed an environment to attract pests.

2. FSW 2 failed to immerse a chemistry (chem) test strip into a sanitizing solution located in a red bucket in accordance with manufacturer's guidelines (MG) when determining if the sanitizing solution was at the correct concentration to effectively sanitize. Failure to use the chem test strip in accordance with manufacturer's guidelines had the potential to give an inaccurate PPM (parts per million; a unit used to express the concentration of a substance in a solution) reading (color on chem strip that gets compared to a color coded graph with PPM labeled) and impede effective sanitizing of food contact surfaces.

Findings:

1. During a concurrent observation and interview on 2/27/25 at 3:10 p.m. with Director of Food & Nutrition Services (DFNS), Food Service Manager (FSM), and Dietary Stockroom Clerk (DSC) in the dry food storage room (DFSR) in the kitchen, DSC was walking out of the "DFSR"with a mop as he had just finished mopping the floor in the DFSR.

During a concurrent observation and interview on 2/27/25 at 3:12 p.m. with DFNS and FSM in the DFSR, an opened crevice in the wall was observed that could allow entry of pests, with surrounding food debris on the floor. Upon further observation of the floor that was just mopped by DSC, there was extensive food, such as individual size pack of crackers, and food debris all along the edge of the baseboards and the floor surface, as well as under shelves and milk crates. DFNS stated DSC did not demonstrate competency of assigned task of mopping the floors in the DFSR..

During a review of the facility's job description (JD) titled, "Dietary Stockroom Clerk", dated 2/8/16, the "JD" indicated, "Maintains cleanliness of storage areas including the storeroom, walk-in coolers, and freezers."

2. During a concurrent observation and interview on 2/27/25 at 11:26 a.m. with Food Service Worker (FSW) 2, in the presence of DFNS and DFP in the kitchen, FSW 2 was standing at a food preparation counter with a red bucket filled with solution on the lower shelf underneath the counter top. FSW 2 stated he used a cloth from the red bucket filled with a sanitizer solution to sanitize the food preparation counter about thirty minutes earlier, and the sanitizer solution was still readily available for use. FSW 2 placed a large piece of chem test strip against the inside of the bucket while the lower part of the chem strip was immersed into the sanitizing solution located in the red bucket and left it there for approximately 30 to 60 seconds. FSW 2 then removed the chem test strip, compared the color to the color coded graph, and FSW 2 stated it was 400 PPM. FSW 2 stated he was supposed to immerse the chem test strip into the sanitizing solution for 30 seconds.

During a concurrent interview and record review on 2/27/25 at 12:27 p.m. with DFNS, a poster with MG's for the chem test strip and sanitizing solution, located on the wall above the 3-compartment pot and pan sink, was reviewed. The MG's for the chem test strip indicated, "Withdraw and tear off approximately 2 inches of test paper from dispenser. Dip test paper for 10 seconds in sanitizing solution. Don't shake. Compare colors immediately with colors on the test paper package to determine PPM."

During a review of the Food and Drug Administration Food Code (FDAFC), dated 2022, the "FDAFC" indicated a test kit or other device that accurately measures the concentration of sanitizing solutions shall be provided and used in accordance with the manufacturer's label instructions.

Based on interview, and record review, the facility failed to:

1. Effectively monitor nutrition intervention(s) when the quantity consumed of an oral nutrition supplement (ONS) was not documented and failed to develop, update and/or revise anindividualized nutrition plan of care with potential alternative nutrition approaches when two of five sampled patients (Patient 26, Patient 21) nutritional needs were not met.

2. A Registered Dietitian (RD) did not provide nutrition recommendations to the physician for one of five sampled (Patient 26) regarding a discrepancy between Patient 26's renal diet order in comparison with Patient 26's assessed daily protein needs to ensure individualized nutritional needs were met in accordance with standards of practice.

3. The hospital's overall system did not ensure RD's assessed and evaluated the appropriateness of prescribed therapeutic diets in which variations were available for a physician to select from to determine whether nutrition recommendations to a patient's physician were in order to ensure the therapeutic diet met a patient's individualized nutrition needs for two of five sampled patients (Patient 27, Patient 29). (Cross Refer A-0283)

Failure to ensure patients nutritional needs are met in a timely manner could negatively impact the health status of medically fragile patients.

Findings:

1a. During a review of Patient 26's "Nutrition Note (NN)," dated 2/2/25, the NN indicated, "Nutrition Risk Level: High (2/2/25). . .Pt not fully meeting nutrition needs at this time. Nutrition Diagnosis: Inadequate nutrient intake. . .Trial Nepro 1/day and snacks 1/day - Proposed to MD [medical doctor]. Continue renal [kidney] multivitamin."

During a review of Patient 26's "Orders", dated 2/2/25, an order indicated, "Nepro 1 carton daily" and another order for a "snack" dated 2/2/25 were both electronically signed by a physician.

During a review of Patient 26's "Orders", dated 2/2/25, an order indicated, "Order: RDN F/U [follow up] Assessment, End-state Date/Time: 2/7/25 16:12 PST, entered and electronically signed by: [name of RD 1]."

During an interview on 2/28/25 at 12:00 p.m. with CNSM, CNSM stated RD 1 assessed Patient 26 at nutritional high risk and not meeting nutrient needs, recommended nutrition interventions, and documented the RD follow up would not occur until five days later on 2/7/25.

During a concurrent interview and record review on 2/28/25 at 12:22 p.m. with CNSM, Patient 26's "Nutrition Follow-up (NFU)", dated 2/7/25 completed by RD 2 was reviewed. The NFU indicated, "High nutrition risk follow up. . .Pt remains on a Renal diet with a PO intake averaging <25% [less than 25 percent] last 9 documented meals. Pt has been consuming snacks that have been order. However, pt is likely not meeting estimated nutrition needs at this time. If pt's PO intake remains poor within the next 2-3 days, pt may benefit from artificial nutrition support given it will be 7 days with a decreased PO intake." CNSM stated there was no documentation by RD2 evaluating the effectiveness of the trial of Nepro 1 time a day. CNSM stated there was no documentation as to whether RD 2 spoke with Patient 26 related to acceptability and to encourage and discuss benefits of drinking the supplement, along with eating meals and the potential nutritional consequences on her health if she did not consume adequate nutrition. CNSM stated it was her expecation for the RD to document follow up on the previous nutrition recommendation related to the ONS.

During a review of Patient 26's "NN" completed by RD 3, dated 2/10/25, the NN indicated, "Recommendations: Continue with Nepro QD to document intake please. . .No documentation of supplement intake." There was no documentation to indicate RD 3 had tried to speak with Patient 26 nor tried to speak with Patient 26's family to collaborate with the patient and family to get input on potential new alternative nutrition approaches, as the care plan had remained the same since 2/2/25.

During a concurrent interview and record review on 2/28/25 at 12:26 p.m. with CNSM and Director of Medical Surgical Services (DMSS), Patient 26's "Nutrition ADLs (Activities of Daily Living)," dated 2/3/25 through 2/10/25 was reviewed. DMSS stated there was no documentation of the Nepro order for one time a day to show it was offered and/or consumed since ordered, and it should have been. CNSM stated the software program that the food and nutrition services staff used showed the Nepro supplement was scheduled to be provided to Patient 26 between lunch and dinner time. CNSM stated it was necessary to document quantity consumed of a nutrition supplement ordered as an intervention to monitor for effectiveness, compare to a patient's daily nutritional needs in order to update and revise a patient's nutrition plan of care in a timely manner, and or re-evaluate when to offer an alternative nutrition approach in a timely manner.

1b. During a concurrent interview and record review on 2/28/25 at 2:17 p.m. with CNSM and DMSS, CNSM stated Patient 21 was admitted to the facility on 2/19/25. Patient 21's "Admission History Adult (AHA)," dated 2/19/25 was reviewed. The AHA indicated and CNSM stated the "AHA" included admission nutrition screening questions completed by nursing in which Patient 21 triggered for an RD consult within 48 hours due to loss of appetite/poor po intake prior to admission.

During a review of Patient 21's "Orders," dated 2/20/25 at 1:12 p.m., the orders indicated, "Ensure Plus High Protein (EPHP) TID [three times a day] w[with]/Meals, Pt [patient] prefers Strawberry."

During a concurrent interview and record review on 2/28/25 at 2:25 p.m. with CNSM and DMSS, DMSS stated there was no documentation under "Intake and Output" located in Patient 21's EHR (electronic health record) that "EPHP" was provided with the dinner meal on 2/20/25. DMSS stated the nursing staff were to document consumption of the EPHP on a line titled "Oral Supplement Amount", and if there is not an "Oral Supplement Amount" line visible, or was left blank, then that meant there was no EPHP offered because nurses were trained to document refused or not available on the same "Oral Supplement Amount" line. During a review of the "Oral Supplement Amount" from 2/21/25 through 2/25/25 the EPHP was documented three out of 15 times. EPHP should have been offered and the consumption documented were 237 ml (mililiters-unit of measure), 160 ml and 300 ml. CNSM stated the EPHP came in a 8 oz (ounce-unit of measure) serving size which was 240 ml. DMSS stated the nurses' needed more training and oversight over to ensure correct and consistent documentation of oral nutrition supplements for monitoring of acceptability by the patient. DMSS stated it may be time to revise the nutrition plan of care and offer an alternative nutrition intervention to meet nutritional needs of the patient.

During a review of the facility's job description (JD) titled, "Registered Dietitian," dated 4/6/2017, the JD indicated, "Performs assessment and screening for patients designated as a high risk for optimal nutrition. Develops nutritional treatment plans in coordination with the interdisciplinary team and in collaboration with the patients and families as able. Follows up such patients to evaluate progress towards goals."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs, Intake & Output, Weights: (Adult)," dated 3/20/23, the P&P indicated, "All patients' vital signs, weight, and dietary intake & output will be consistently measured and documented. . .Procedure: Diet: Confirm physician order for diet and other supplements. . .Document percent consumed for every meal, snack and nutritional supplement. . .Do not leave documentation blank."

During a review of the facility's policy and procedure (P&P) titled, "Adult and Pediatric Assessment," dated 6/12/24, the P&P indicated, "Procedure: A comprehensive nutritional assessment will be completed if the patient is screened at moderate or high nutritional risk. If a patient is assessed at low risk, the screen and risk identification is documented. . .Follow up is assigned based on risk status as determined and documented by the RD. a. Follow up or rescreening is due as follows: i. High Risk - within 5 days, ii. Moderate Risk - within 7 days, iii. Low Risk -rescreen every 10 days."

During a review of the facility's policy and procedure (P&P) titled, "Diet Manual and Approval Acute Care," dated 7/22/24, the P&P indicated, "The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM) is the standard guide and reference for nutrition care."

During a review of ASPEN's standards of care guidance titled "ASPEN Adult Nutrition Care Pathway (Age 18+ years) (ANCP)", dated 9/14/22, the "ANCP" indicated once inadequate nutrient intake had been identified "Monitoring & Evaluation: Follow-up within 3 days, monitor parameters; tolerance of nutrient intake, oral intake including supplements, vitamins, minerals, anthropometric data (weight trends), functional status."

During a review of the facility's job description (JD) titled "Clinical Nutrition Manager", dated 6/23/2020, the JD indicated, "In coordination with the Food and Nutrition Services Director establishes, enforces, and evaluates levels of productivity and performance standards for areas under the supervision of this position. This includes standards on recommendations for diet orders, documentation in the medical record system, nutritional assessments, patient follow-up and patient/family education and counseling. Identifies, reviews, and evaluates nutrition services through quality assurance and monitoring techniques to improve quality of care."

2. During a review of Patient 26's NN, dated 2/2/25, the NN indicated, "Nutrition Risk Level: High (2/2/25). . .Pt not fully meeting nutrition needs at this time. Nutrition Diagnosis: Inadequate nutrient intake. . .Nutrition Recommendations: Current order for Diabetic diet - BG [blood glucose] well controlled. Monitor phosphorous[a mineral]/potassium [an electrolyte] for possible Renal diet [diet for kidney disease] restriction as needed. . .ESRD [end stage renal disease] on hemodialysis [a medical procedure that filters waste products and excess fluid from the blood when the kidneys are unable to do so] Process:. . . .Trial Nepro (ONS to add calories) 1/[per]day and snacks 1/day - Proposed to MD. Continue renal multivitamin."

During a review of Patient 26's "Nutrition Assessment Information (NA)", dated 2/2/25, located under "Nutritional" located in the EHR, the "NA" indicated, "Estimated Protein Needs Low g [grams]/day = 54, Estimated Protein Needs High g/day = 64 g."

During a review of patient 26's "Orders", dated 2/6/25, an order indicated, "Renal Diet" that was "entered and electronically signed" by a physician.

During an interview on 2/28/25 at 3:04 p.m. with CNSM, CNSM stated RD 1 should have provided recommendations to the physician to address the discrepancy between the renal diet order that provided 80 grams of pro/day as compared to Patient 26's assessed daily pro needs between 54 - 64 g pro/day (1-1.2 gm pro/kg [kilogram]) by recommending the renal diet be changed to a 60 g pro/d renal diet.

During a review of the facility's job description (JD) titled, "Registered Dietitian," dated 4/6/2017, the JD indicated, "Job Responsibilities Essential: Performs assessment and screening for patients designated as a high risk for optimal nutrition. Develops nutritional treatment plans in coordination with the interdisciplinary team. . . Provides nutrition information and recommendations to Physicians regarding patient's nutritional status in a timely manner."

During a review of the facility's policy and procedure (P&P) titled, "Diet Manual and Approval Acute Care," dated 7/22/24, the P&P indicated, "Purpose: To provide a reference for nutrition care, which will be used as a guideline for diet related information. The facility specific diet manual outlines all regular and therapeutic diets available for patients in the facility. The Nutrition Care Manual is the standard guide and reference for nutrition assessment and care. Policy: The facility specific diet manual is updated at least annually and reflects the current meals and therapeutic diet options available for providers to order for their patients. The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM) is the standard guide and reference for nutrition care. The NCM is online and available to all healthcare providers at [name of hospital]. Procedure: The NCM is consistent with AND's Evidence Analysis Library, AND's position papers, and the Nutrition Care Process."

During a review of the facility's "Diet Manual and Approval Acute Care (DM)," dated 7/22/24, the DM indicated the facility had menus with corresponding nutrient analysis for renal diets providing 60 g pro/d, 80 g pro/d or 100 g pro/d.

3a.During a concurrent interview and record review on 2/28/25 at 10:24 a.m. with CNSM and DFNS, Patient 27's "Admission History Adult (AHA)", dated 2/26/25 was reviewed. CNSM stated the "AHA" included admission nutrition screening questions completed by nursing in which Patient 27 was determined not to have any of the facility's criteria for nutrition risk that would in turn trigger an RD consult for further nutrition screening by an RD to determine if a nutrition assessment would be completed for Patient 27.

During an interview on 2/28/25 at 10:36 a.m. with CNSM, CNSM stated Patient 27's therapeutic diet order was diabetic CC 60 g [consistent carbohydrate dispersed evenly over three meals with limit of a total of 60 grams of carbohydrate per day] and low potassium. CNSM stated the diabetic diet orders available to the physician's to select from a drop down menu in the electronic health record (EHR) were 45 g CC [limit of 45 grams of consistent carbohydrate], 60 g CC or 75 g CC that corresponded with different total daily calories provided depending on the amount of CC ordered. In addition, CNSM stated the hospital had various renal diets as a drop down menu physicians selected from as follows: "Renal with an 80 g pro [protein]/d", "High Protein Renal with 100 g pro/d", "Low Protein- 60 g pro/d 2 gm [gram] Sodium [limit of salt intake]", and a "Low Protein Renal- 60 g pro/d." CNSM stated within the hospital's nutrition care structure, if the hospital's nutrition screening did not drive an RD to conduct a nutrition assessment for a patient, the hospital RD's would not perform nutrition assessments for those patients that had specialized therapeutic dietary needs, simply due to a therapeutic diet in and of itself, to evaluate if the diet order was aligned with the patient's daily calorie and protein needs, or if not, to provide nutrition recommendations to the physician regarding a patient's therapeutic diet.

3b.During a concurrent interview and record review on 2/28/25 at 3:26 p.m. with CNSM, Patient 29's "Inpatient" form indicated she was 59 years old. Patient 29's "Admission History Adult (AHA)", dated 2/21/25 was reviewed. CNSM stated the "AHA" included admission nutrition screening questions completed by nursing in which Patient 29 was determined not to have any of the facility's criteria for nutrition risk to trigger an RD consult for RD to conduct further nutrition screening and/or complete a nutrition assessment. The "AHA", dated 2/21/25, included a notation of "Home Diet: Diabetic, Renal."

During a review of Patient 29's "Progress Note (PN)", dated 2/27/25, completed by RD 4, the "PN" indicated, "Nutrition Screen: Consult received as part of length of stay, pt meets criteria for low acuity (condition with low probability of progression); admitted with PD catheter (PD; Peritoneal [thin tissue that lines the abdominal cavity] dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] catheter dysfunction [malfunction of the tube used to access patient's blood for dialysis], provided a renal, diabetic diet-po intake average of 72% [percent] x 9 meals, no trouble chewing or swallowing, BMI 27.2, skin intact, Braden score 20. Will monitor per policy, RD available sooner, prn [as needed]."

During an interview on 2/28/25 at 3:30 p.m. with CNSM, CNSM stated within the hospital's system RD's were not required to perform a nutrition assessment for chronic diseases with comorbidities (a disease or medical condition that is simultaneously present with another) that required specialized dietary needs with a therapeutic renal, diabetic diet. CNSM stated it would require Patient 29 to have an RD complete a nutrition assessment to determine Patient 29's daily calorie and protein needs in order to evaluate whether Patient 29 was prescribed the correct grams of carbohydrate diabetic diet and correct grams of protein renal diet to meet Patient 29's individual nutritional needs.
However, Patient 29 was screened by RD 4 to be low acuity after six days in the hospital with comorbidities of renal disease and diabetes and was assessed as continuing to be at low nutrition risk, per hospital P&P titled "Adult and Pediatric Assessment (APA)", dated 6/12/24, the "APA" indicated "Low Risk. . .follow-up completed within 10 days." CNSM stated RD 4 did not document an RD f/u date for monitoring as the hospital had established screening criteria during the hospital stay in which nursing screens for low appetite/poor po intake would trigger an RD consult, if that occurred.

During an interview on 2/28/25 at 3:45 p.m. with CNSM, CNSM stated Patient 29 had not seen an RD since admission as she was assessed to be low nutrition risk, the RD's do not evaluate whether the ordered therapeutic diet meets Patient 29's specialized dietary needs due to comorbidities of diabetes and renal disease, and the hospital's RD's do not offer and conduct therapeutic diet education to in-patient's, patient's families or caregivers, nor do the RD's review, update or revise interdisciplinary plans of care related to any type of diet education or readiness for therapeutic diet education.

During a review of NCM, dated 2025, NCM indicated, "Registered dietitian nutritionists (RDN) must also receive referrals for nutrition problems other than malnutrition, such as the following: Knowledge deficits; For example, education focused on modification of sodium and fluid intake, in order to mitigate heart failure symptoms and reduce readmission rates."

During a review of The Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM indicated, ". . .education handouts in the Nutrition Care Manual® (NCM®) are not intended to substitute for nutrition counseling with a registered dietitian nutritionist (RDN). The information is meant to serve as a general guideline and may not meet the unique nutritional needs of individual clients or patients. All medical professionals should consult with a RDN before providing handouts to clients or patients."

During a review of the facility's job description (JD) titled, "Registered Dietitian," dated 4/6/2017, the JD indicated, "Job Responsibilities Essential: Performs assessment and screening for patients designated as a high risk for optimal nutrition. Develops nutritional treatment plans in coordination with the interdisciplinary team and in collaboration with the patients and families as able. Follows up such patients to evaluate progress towards goals. . .Provides nutrition information and recommendations to physicians regarding patient's nutritional status in a timely manner. . .Performs or coordinates nutrition education for patients and/or patient's caregivers, and chart's appropriately to the medical record. Tailors nutrition education to the needs of the patient and their family (ex: medical needs, cultural preferences, patient readiness, etc). . .Continuously looks for ways to improve nutritional care to patients. Acts with others to monitor current levels of service, plan new or improved services, implement the plan, and reassess, educate, and make changes necessary for excellent care of patients."

During a review of the facility's job description (JD) titled "Clinical Nutrition Manager", dated 6/23/2020, the JD indicated, "In coordination with the Food and Nutrition Services Director establishes, enforces, and evaluates levels of productivity and performance standards for areas under the supervision of this position. This includes standards on recommendations for diet orders, documentation in the medical record system, nutritional assessments, patient follow-up and patient/family education and counseling. Identifies, reviews, and evaluates nutrition services through quality assurance and monitoring techniques to improve quality of care."

During a review of the facility's job description (JD) titled "Director of Food & Nutrition Services," dated 6/18/21, the JD indicated, "Provides oversight of the clinical nutrition program. Provides guidance and direction to the Clinical Nutrition Manager."

Based on observation, interview, and record review, the facility failed to implement nationally recognized organization Center for Disease Control (CDC-federal government agency that protest public health by preventing and controlling disease, injury, and disability) infection prevention and control practices when:) infection prevention and control practices when one of three sampled patients (Patient 4), who was diagnosed with Herpes Zoster (also known as Shingles, a painful rash caused by herpes virus), was not placed on Transmission-Based Precaution (used as second tier of basic infection control and are to be used in addition to Standard Precautions [includes hand hygiene and use of personal protective equipment such as gloves, masks, gowns, face shields, or goggles]). This failure had the potential to transmit infection to patients, staff and visitors.

Findings:

During an interview on 2/26/25 at 11:05 a.m. with Assistant Emergency Department Nurse Manager, (AEDNM), AEDNM stated patient in room 52 was on isolation.

During an observation on 2/26/25 at 11:10 a.m. in Emergency Department (ED) room 52, there was no infection control signage posted on the door, and there was no isolation caddy (contains personal protective equipment) outside the door.

During a concurrent observation and interview on 2/26/25 at 11:16 a.m. with ED Technician (EDT) in front of ED room 52, EDT was posting the signage outside the door of room 52 for Contact Precaution (infection control measures used to prevent the spread of infectious diseases transmitted through direct or indirect contact with patients or their environment). EDT stated AEDNM asked her to post the Contact Precaution sign up in ED room 52's door.

During an interview on 2/26/26 at 11:25 a.m. with AEDNM, AEDNM stated, "If a patient is on isolation, there should be a sign with Stop Sign and the type of isolation the patient is on."

During an interview on 2/26/25 at 11:30 a.m. with Registered Nurse (RN) 2, RN 2 stated at shift change at 6 a.m. RN 2 was informed Patient 4 in room 52 has shingles. RN 2 stated Patient 4 should be on contact precaution and there should be signage on the door and there should be caddy front of the door with supplies. RN 2 stated Patient should have a contact precaution signage on the door, and there should be a caddy with isolation supplies outside Patient 4's room.

During a concurrent interview and record review on 2/26/25 at 3 p.m. with Director of Trauma (DOT), Patent 4's "Physician Orders (PO)," 2/25/25 was reviewed. The PO indicated, Patient 4 was on Acyclovir (viral treatment) 800 mg (milligram) started on 2/25/25 for viral treatment. DOT stated Patient 4 was diagnosed with herpes zoster on 2/25/25.

During a review of the facility's policy and procedure (P&P) titled, "Standard and Transmission-Based Precautions," dated 4/26/24, the P&P indicated, "To prevent the transmission of infection within the hospital by patients receiving care, staff and visitors. . .Contact Precautions: You must at a minimum wear gloves when entering the room. . .Place the caddy and appropriate transmission-based precautions signage in the caddy pocket. . .Some examples of illness requiring contact precaution include: herpes zoster (disseminated or in the Immunocompromised [having an impaired immune system]). RN initiates transmission-based precaution by placing the isolation caddy with appropriate PPE at the door to the patient's room and enters an order for the type isolation in use into the electronic medical record."

Based on interview and record review, the hospital failed to:

1.Ensure Emergency Department Registered Nurse (EDRN) 1) activated emergency response system or initiated cardiopulmonary resuscitation for one of one patient (Patient 1) exhibiting a life threatening event during a Magnetic Resonance Imaging (MRI- [a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body]) procedure.

2. Ensure EDRN 1 documented nursing assessment, placed one of one sampled patient (Patient 1) suffering from a life-threatening condition on the cardiac (heart) monitor, vital signs (includes temperature, heart rate, respiratory rate, blood pressure) machine, and pulse oximetry (measures oxygenation in one's blood), and continued to monitor care upon return to the ED from Radiology Department (RD).

These failures decreased the patient's chances of survival. favorable outcome, and had the potential to contribute to Patient 1's death.

Findings:

During a review of Patient 1's "History & Physical (H&P)," dated 1/12/25, the H&P indicated, Patient 1 was brought to the hospital ED after a fall while getting off the toilet, fell on his side, and hit his head. Patient 1 had a past medical history of coronary artery disease (CAD-occurs when the arteries of the heart cannot deliver enough oxygen-rich blood to the heart due to narrowing or blockage) s/p (status post) coronary artery bypass graft (CABG- surgical procedure to treat a blockage or narrowing of one or more of the coronary arteries [blood vessels of the heart] to improve blood flow to the heart) and atrial fibrillation (irregular heart beat not anticoagulated [not on blood thinner]). Patient 1's computerized tomography (CT-an imaging technique to obtain detailed image of the body) scan of the brain indicated subdural hematoma (blood collected in between the skull and the brain) following head injury.

During a review of Patient 1's "Neurosurgery Consultation Notes (NCN)," on 2/24/25 at 10:23 a.m. with Registered Nurse Clinical Informaticist (RNCI), the NCN, dated 1/12/25, indicated, "MRI of the brain to r/o (rule out) stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures)."

During a concurrent interview and record review on 2/24/25 at 1:59 p.m. with Director of Radiology (DR) and Imaging Service Manager (ISM), Patient 1's MRI scan, dated 1/12/25, was reviewed. DR stated Patient 1 had an order for MRI of the brain without contrast on 1/12/25 at 10:48 p.m. DR stated Patient 1's MRI scan was started but was aborted on 1/13 25 at 1:42 a.m. due to Patient 1's change in condition during the MRI procedure. DR and ISM were unable to locate the results of the partial MRI scan for Patient 1. DR reviewed the documentation of the MRI technician (MRIT) which indicated, "Attempted exam. Patient became unstable towards the end of the exam. Unable to finish. Patient's condition deteriorated." DR was unable to find documentation the Rapid Response Team [RRT-hospital team that responds to patients who are deteriorating or have an emergency] or a Code Blue [alert that someone is experiencing a life threatening medical emergency]) was called in MRI. ISM stated the staff had been educated and trained to call RRT or Code Blue when an emergency arise in MRI. ISM stated MRITs were trained to "Call RRT Alert Ext 44, Give Room Number, Call Primary Care Physician."

During an interview on 2/24/25 at 4:53 p.m. with Director of Critical Care Services (DCCS) who was the Interim Director of Emergency Services at the time of the incident, DCCS stated she was notified Patient 1 had concerns, coded, and died by way of MIDAS (hospital incident reporting system). DCCS stated she interviewed EDRN 1 and according to EDRN 1, Patient 1's heart rate became bradycardic (slow heart rate) and that Patient 1 did not have a pulse. DCCS stated according to EDRN 1 Patient 1 was pulled out of the MRI scanner in the room and EDRN 1 was unable to obtain vital signs. DCCS stated according to EDRN 1, EDRN 1 made the decision to return Patient 1 to the ED instead of calling RRT or calling a Code Blue. DCCS stated there was no advanced cardiac life support implemented, thus a delay in the implementation of emergency intervention. During a review of the ED Documentation, dated 1/12/25 and 1/13/25, DCCS confirmed there was no EDRN 1 documentation of what transpired in MRI and upon return of Patient 1 to the ED until 2:27 a.m. DCCS stated the expectation was for the EDRN 1 to provide emergency intervention and call the RRT when Patient 1's condition deteriorated in MRI and before moving the patient back to the ED.

During an interview on 2/24/25 at 6:54 p.m. with MRIT, MRIT stated EDRN 1 came with the patient to MRI. Patient 1 was transported to MRI by the MRI aide via gurney accompanied by EDRN 1. MRIT stated Patient 1 was transferred to the MRI table for the procedure. MRIT stated the patient was on the portable monitor and was connected to the vital signs machine. MRIT stated when MRI scan was started the nurse, the MRI aide, and himself had to go to the control room (immediately outside the magnet room where the operator console, keyboard, communication devices, computer equipment that controls the scanner were located) for safety reasons. MRIT stated the nurse, the MRI aide, and himself could see the Patient 1 from the window. MRIT stated the patient's vital signs and heart monitor wave form was visible from the window. MRIT stated near the end of the MRI scan, EDRN 1 stated the scan needed to be stopped. MRIT stated EDRN 1 went inside the MRI room to check on the patient. MRIT stated the nurse informed him the patient did not look good and that the procedure could not be continued. MRIT stated EDRN 1 stated the patient needed to be taken back to the ED. MRIT stated there was no cardiopulmonary resuscitation performed on Patient 1 in MRI room. MRIT stated he did not call RRT because the EDRN 1 was in the room, and she took control of the situation.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response Team," dated 11/22/24, the P&P indicated, "The system is designed to recognize at-risk adult and adolescent (age 14-17) non-critical care patients earlier in their course of deterioration and to rapidly mobilize appropriate institutional resources including but not limited to the Primary Care Practitioner and RRT. . . PROCEDURE: 1. RRT Activation and 10 SOV [signs of vitality] Assessment. . . D. Activation of the RRT alert and notification of the managing practitioner will occur simultaneously 1. If 2 or more of the weighted 10 SOV criteria are present and or any patient the staff is seriously concerned about. . . Call RRT Alert Ext 44, Give Room Number, Call Primary Care Physician."


2. During a concurrent interview and record review on 2/24/25 at 3:50 p.m. with RNCI, Patient 1's ED Progress Notes, dated 1/12/25 and 1/13/25, were reviewed. RNCI was unable to find nursing documentation of when Patient 1 returned to the ED, nursing assessment of Patient 1 upon return to the ED, records of cardiac rhythm (record of one's electrical activity), vital signs (includes temperature, heart rate, respiratory rate, blood pressure, pain) and pulse oximetry (measures blood oxygenation). RNCI stated there were no additional documentation until a Code Blue was called at 2:27 a.m. in the ED. RNCI stated Patient 1's oxygen saturation was at 44% and Patient 1 was intubated, and placed on a ventilator at 2:59 a.m.

During a review of Patient 1's "Critical Care Progress Notes (CCPN)," dated 1/13/25 at 2:27 a.m., the CCPN documented by the Nurse Practitioner (NP) indicated, "I was across the patient's room [Patient 1's room in the ED] and noticed that patient [Patient 1] was pale and had a nasal cannula [a device that delivers extra oxygen through a tube and into one's nose] and not connected to the cardiac monitor [a device that records the electrical activity of the heart]. We connected the patient to the cardiac monitor, rhythm was asystole [no movement or electrical activity in the heart)], no pulse, started CPR [cardiopulmonary resuscitation-emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped] called Code Blue."

During a review of Patient 1's "Cardiopulmonary Resuscitation (CRR) Report," dated 1/13/25, the CRR indicated," Time code began: 2:27 a.m. Time code ended: 2:43 a.m. Rhythm: PEA (Pulseless Electrical Activity) Asystole 2:27 a.m. until 2:42 a.m. Ventricular Tachycardia (a heart rate higher than 120 beats per minute, major cause of sudden cardiac death) at 2:43 a.m. (responded to synchronized cardioversion (application of low-energy delivered between two consecutively conducted impulses of a cardiac cycle] at 200 joules (a unit of energy). At 1:10 a.m. return of spontaneous circulation (ROSC-resumption of a sustained heart rhythm that perfuses the body after cardiac arrest) was achieved and patient was transferred to Cardiovascular Intensive Care Unit (CVICU).

During a review of the hospital's P&P titled, "Assessment and Documentation, Nursing: Acute Patient Care," dated 3/20/23, the P&P indicated, "PROCEDURE: 1 Nursing Assessment: A. A licensed nurse (within their scope of practice) assesses the patient's needs for nursing care from admission through discharge in all settings where nursing care is provided. Assessments include both subjective and objective findings based on a body system (basic head-to-toe). . .II. Documentation Elements: Nursing documentation reflects the nursing care that occurs in a timely and ongoing basis. A. Nursing documentation reflects assessment findings and depicts both clinically significant normal findings as well as abnormal findings per the clinician's clinical judgment. B. Documentation includes the status of the identified problems until they are resolved in the medical record or become inactive. . . Focused assessments (assessments focused on a specific body system or systems) are performed with changes in patient condition or as a follow up to any unusual findings from a previous assessment."

During a review of the hospital's P&P titled, "Code Blue," dated 9/28/22, the P&P indicated, " Procedure: I. First Responder A. Any district staff member witnessing an individual who is experiencing cardiac and/or respiratory arrest will immediately call for help either verbally and/or by dialing "44" within the main campus or "9-911" in
satellite areas using any in-house telephone. The operator will page the code team."