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Based on record review and interview the hospital failed to follow their policy and procedure for staffing as evidenced by having inadequate numbers of nurses and mental health techs to meet the needs of the patients for 16 of 28 shifts during the time period of 12/01/10 through 12/14/10. Findings:


Review of the "Staffing Protocol" submitted as the one currently in use by hospital, revealed the following staffing patterns required for the corresponding census which does not include patients requiring 1:1 observation:
Day Shift
1 RN for up to 23 patients
1 LPN for up to 23 patients
4 MHT for up to 24 patients

Night Shift
1 RN for up to 23 patients
1 LPN for up to 23 patients
3 MHT for up to 23 patients

24 or more patients (Hospital capacity is 28 patients)
Day Shift Night Shift
2 RN 1 RN
1 LPN 2 LPN
5 MHT 4 MHT

Review of the Nurse Staffing Pattern for the dates of 12/01/10 through 12/14/10 revealed the following dates and shifts with inadequate staff according to the staffing protocol: 12/02/10 7P shift; 12/03/10 7A and 7P shifts; 12/04/10 7A and 7P shifts; 12/05/10 7P shift; 12/06/10 7A shift; 12/07/10 7A and 7Pshifts; 12/08/10 7A shift; 12/09/10 7A shift; 12/10/10 7A shift; 12/11/10 7A shift; 12/12/10 7A shift; 12/13/10 7A shift; and 12/14/10 7A shift.

Review of the Staff Personnel Roster submitted by the hospital as accurate and currently in use revealed the hospital is staffed for patient care on a 24/7 basis with a patient capacity of 28 with the following: Registered Nurses (RN) 2 - Full-time, 1 Part-time, and 7 prns (as needed);
Licensed Practical Nurses (LPNs) 4 - Full-time and 6 prns; Mental Health Technicians (MHTs) 13- Full-time and 13 Part-time.

The DON could not submit the data for 12/01/10 through 12/14/10 to substantiate how the hospital arrived at the staffing needed because the information is not kept.

In a face to face interview on 02/11/10 at 11:00am RN S2 verfied the hospital was short-staffed during the time period of 12/01/10 - 12/14/10. Further he indicated that the prn staff listed on the roster are employed at other hospitals so it is a challenge to keep the hospital staffed with so few full-time employees. S2 indicated the hospital has admit criteria in an effort to take only patients with stable medical conditions; however information is gathered for admission by the marketers who are not medical personnel. Further he indicated patients are not assessed before admit and therefore medical stability must sometimes be determined via documentation only.

Based on record review and interview the hospital failed to ensure the RN (Registered Nurse) 1) assessed and monitored a patient with a high sodium lab value who continued to refuse nutrition and fluid for signs and symptoms of dehydration resulting in the patient being transfered five days later to the Emergency Department of Hospital "A" with a critical Sodium value of 160 and admitted for additional care (#3); and a patient with a history of Congestive Heart Failure (CHF) who, upon admit, had shortness of breath and edema to the extremeties, continued with signs and symptoms of CHF and was prescribed Lasix Therapy, breathing treatments and 1500cc Fluid restriction without continued assessment of fluid restriction, weight or dietary intake (#5) for 2 of 2 patients not assessed for change in condition out of a total of six sampled patients. FIndings:

1) performed a comprehensive physical assessment on all patients in order to assess care needs and implement appropriate interventions
Patient #3
Review of the History & Physical for Patient #3 revealed an 84 year old woman admitted to the hospital on 11/15/10 from a nursing home with the diagnosis of Dementia with behavioral disturbance and psychosis. Further review revealed #3 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 2 to 3+ edema of the lower extremities upon admit.

Review of the medical record revealed no documented evidence the patient had been weighed upon admit or at anytime during her hospital stay.

Review of the nursing notes dated 10/15/10 through 11/22/10 revealed no documented evidence Patient #3's lower extremities had been assessed for edema.

Review of the Graphic Sheet for Patient #3 revealed no documented evidence nutritional intake was assessed on 11/16/10 or 11/22/10. Further review revealed #3 had the following documented intake: 11/17/10 - 30% of dinner; 11/18/10 - 50% of breakfast; 11/19/10 - 50% of breakfast, 10% of lunch, 20% of dinner and 50% of supplement; 11/20/10 - 5% of lunch, 50% of supplement; and 11/21/10 - 75% of dinner.

Review of the abnormal lab results dated 11/17/10 (WBC) White Blood Count of 13.2 H (Reference Range 4.0-11.0); RBC (Red Blood Cells) of 3.22 H (Reference Range 3.80-5.30);
Hgb (Hemoglobin) of 10.0 L (Reference Range 12.0-16.0); Hct (Hematocrit) of 30.4 L (Reference Range 37.0-47.0); Na (Sodium) 149 H (Reference Range 135-145); K (Potassium) 5.3 H (Reference Range 3.5-5.1); Cl (Chloride) 117 H (Reference Range 100-109); CO2 (Carbon Dioxide) 19 L (Reference Range 22-33); Glucose 118 H (Reference Range 70-100); BUN Level 52 H (Reference Range 5-25); Creatinine Level 2.45 H (Reference Range 0.57-1.25); and 11/22/10 Na (Sodium) 160 CRITICAL (Reference Range 135-145).

Patient #5
Review of the History & Physical for Patient #5 revealed an 88 year old woman admitted to the hospital on 02/01/11from a nursing home with the diagnosis of Alzheimers and Dementia with psychosis. Further review revealed #5 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 1+ edema of the lower extremities upon admit.

Review of the medical record revealed no documented evidence the patient had been weighed upon admit. Further review revealed Patient #5 weighed 185 pounds on 02/03/11; however, because there was no documented baseline weight, the effectiveness of the Lasix therapy on the patient's weight was not assessed. The surveyor requested #5 be weighed on 02/11/10 at which time she weighed 172 pounds reflecting a 13 pound weight loss in 8 days.

Review of the Medical Physician's Progress Notes revealed the following: 02/03/11 - Patient indicates shortness of breath better, 1+ edema noted, diminished breath sounds bilaterally and occasional rhonchi heard.

Review of the nursing notes dated 02/01/10 through 02/10/11 revealed no documented evidence Patient #5's lower extremities had been assessed for edema or the lung field assessed when the patient complained of shortness of breath .

In a face to face interview on 02/10/11 at S2, DON indicated physical assessments had not been performed on patients previously to the last DHH survey. S2 indicated a new assessment form was implemented which included a review of systems.

Review of Policy 2.1 titled "Patient Centered Interdisciplinary Assessment" (last reviewed 12/10) and submitted by the hospital as the one currently in use, revealed......II. Patient Centered Interdisciplinary Assessment: A. Nursing (Sections I and II) 2. General information is obtained in Section I. It includes some of the following data: education, employment, home environment, previous treatment, legal status, functional status, vital signs, allergies/reactions. Either a licensed or non-licensed staff can complete Section I. 3. Section II, Biopsychosocial is completed by the Registered Nurse within 8 hours of admission......". Further review of the policy revealed no documented evidence daily assessments were addressed.


2) a urinalysis was obtained as ordered by the licensed practitioner
Patient #6:
Medical record review revealed that Patient #6 was admitted to the hospital on 1/28/11. Review of the psychiatric evaluation revealed that Patient #6 was a 77 year old female with dementia and admitted for a recent decline in her behavior. Review of the history & physical revealed that Patient #6's medical history includes hypothyroidism, dementia, rhinitis, arthritis, depression, and chronic urinary tract infections. Review of the physicians orders revealed an order dated 1/28/11 at 12:00 noon for a urinalysis to be obtained on Patient #6. Review of the medical record revealed that the urinalysis was not obtained until 2/05/11 (8 days after being ordered by the practitioner). Documentation in the physician progress notes revealed that the urinalysis was pending on 1/30/11 and 1/31/11. Documentation in the physician progress notes revealed an entry by the nurse practitioner on 2/02/11 documenting "We do need to get urinalysis". Review of the physicians orders revealed an order dated 2/05/11 at 12:00 noon for an in and out catheter to obtain the urinalysis.

The attending Physicians' Assistant (PA) S11 was interviewed on 2/10/11 at 10:45 a.m. PA, S11 reviewed the medical record of Patient #6 and confirmed that there was a delay in obtaining the ordered urinalysis and that he needed the results of the urinalysis in order to determine if the patient had a urinary tract infection. PA, S11 reported that he wrote an order for an in and out catheterization of Patient #6 on 2/05/11 in order to obtain the urinalysis because the nursing staff had not obtained the urinalysis prior to the date and time of ordering the in and out catheter. PA, S11 reported that the results indicated no urinary tract infection and had the results been positive for a urinary tract infection, it could have affected treatment decisions and the patient's response to treatment.

RN S3, Clinical Coordinator and LPN S9, Assistant Director of Nursing were interviewed on 2/10/11 at 11:15 a.m. S3 and LPN S9 reviewed the medical record of Patient #6 and confirmed that there was an 8 day delay in obtaining the ordered urinalysis and determining if the patient had a urinary infection. RN S3 and LPN 9 reviewed the results of the urinalysis collected on 2/05/11 (8 days after being ordered) and reported that the results indicated no urinary tract infection. When asked if nursing administration had identified or were made aware of the delay in obtaining the urinalysis on Patient #6, LPN S9 reported that an incident report had been filled out relating to the nursing staff's inability to obtain the urine sample due to not having the needed equipment . LPN S9 presented the Incident Report regarding the delay in obtaining the urinalysis on Patient #6. Review of the Incident Report dated 2/01/11 revealed "Unable to collect urine specimens ordered by MD on these 2 patients d/t lack of needed equipment (NUN'S CAPS). Doctor was notified and no order given to perform invasive urine catheterization to obtain urine specimen" and "Request for Nun's Caps Submitted 2 weeks ago & equipment still not available". When asked about the process for obtaining equipment needed to provide care for patients, RN S3 confirmed that there was a breakdown in obtaining the needed equipment for Patient #6 and confirmed that an invasive procedure (in & out catheterization) performed on Patient #6 on 2/05/11 could have been prevented if the hospital had implemented an effective system to ensure the timely delivery of patient care supplies and/or equipment.

Based on record review and interview the hospital failed to: 1) ensure the plan of care was developed and implemented to include medical interventions related to medical conditions (#3, #5); 2) implemented according to physicians' orders related to weights (#3, #5) and fluid restriction (#5); 3) updated for changes in condition related to level of consciousness and abnormal lab values (#5); and 4) obtain a urinalysis as ordered by the licensed practitioner (#6) for 3 of 6 sampled patients. Findings:


1) ensure the plan of care was developed and implemented to include medical interventions related to medical conditions
Patient #3
Review of the History & Physical for Patient #3 revealed an 84 year old woman admitted to the hospital on 11/15/10 from a nursing home with the diagnosis of Dementia with behavioral disturbance and psychosis. Further review revealed #3 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 2 to 3+ edema of the lower extremities upon admit.

Review of the medical record revealed no documented evidence the patient had been weighed upon admit or at anytime during her hospital stay.

Review of the nursing notes dated 10/15/10 through 11/22/10 revealed no documented evidence Patient #3's lower extremities had been assessed for edema.

Review of the Graphic Sheet for Patient #3 revealed no documented evidence nutritional intake was assessed on 11/16/10 or 11/22/10. Further review revealed #3 had the following documented intake: 11/17/10 - 30% of dinner; 11/18/10 - 50% of breakfast; 11/19/10 - 50% of breakfast, 10% of lunch, 20% of dinner and 50% of supplement; 11/20/10 - 5% of lunch, 50% of supplement; and 11/21/10 - 75% of dinner.

Review of the abnormal lab results dated 11/17/10 (WBC) White Blood Count of 13.2 H (Reference Range 4.0-11.0); RBC (Red Blood Cells) of 3.22 H (Reference Range 3.80-5.30);
Hgb (Hemoglobin) of 10.0 L (Reference Range 12.0-16.0); Hct (Hematocrit) of 30.4 L (Reference Range 37.0-47.0); Na (Sodium) 149 H (Reference Range 135-145); K (Potassium) 5.3 H (Reference Range 3.5-5.1); Cl (Chloride) 117 H (Reference Range 100-109); CO2 (Carbon Dioxide) 19 L (Reference Range 22-33); Glucose 118 H (Reference Range 70-100); BUN Level 52 H (Reference Range 5-25); Creatinine Level 2.45 H (Reference Range 0.57-1.25); and 11/22/10 Na (Sodium) 160 CRITICAL (Reference Range 135-145).

Review of the Care Plan for Patient #3 dated 11/15/10 through 11/18/10 revealed no documented evidence the patient's medical problems of nutrition, weight, edema, or abnormal lab values had been identified or interventions implemented.


2) implemented according to physicians' orders related to weights (#3, #5) and fluid restriction (#5);
Patient #3
Review of the History & Physical for Patient #3 revealed an 84 year old woman admitted to the hospital on 11/15/10 from a nursing home with the diagnosis of Dementia with behavioral disturbance and psychosis. Further review revealed #3 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 2 to 3+ edema of the lower extremities upon admit.

Review of the Physician's Orders dated 11/15/10 revealed an order for a weight on admit and then every Thursday.

Review of the medical record revealed no documented evidence the patient had been weighed upon admit or at anytime during her hospital stay.

Patient #5
Review of the History & Physical for Patient #5 revealed an 88 year old woman admitted to the hospital on 02/01/11 from a nursing home with the diagnosis of Alzheimer's and Dementia with psychosis. Further review revealed #5 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 1+ edema of the lower extremities upon admit.

Review of the Physicians' Orders dated 02/01/11 revealed an order for a weight on admit and then every Thursday.

Review of the medical record revealed no documented evidence the patient had been weighed upon admit. Further review revealed Patient #5 weighed 185 pounds on 02/03/11; however, because there was no documented baseline weight, the effectiveness of the Lasix therapy on the patient's weight was not assessed. The surveyor requested #5 be weighed on 02/11/10 at which time she weighed 172 pounds reflecting a 13 pound weight loss in 8 days.

Review of the Physician's Orders dated 02/06/11 at 11:00am revealed an order for a 1500cc fluid restriction.

Review of the medication record including the Graphic Sheet and Nurses' Notes for Patient #5 dated 02/06/11 through 02/10/11 revealed no documented evidence 1500cc fluid restriction had been implemented as ordered. Further review revealed no documented evidence Intake and Output was being assessed.

3) updated for changes in condition (#3)
Patient #3
Review of the History & Physical for Patient #3 revealed an 84 year old woman admitted to the hospital on 11/15/10 from a nursing home with the diagnosis of Dementia with behavioral disturbance and psychosis. Further review revealed #3 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 2 to 3+ edema of the lower extremities upon admit.

Review of the Graphic Sheet for Patient #3 revealed no documented evidence nutritional intake was assessed on 11/16/10 or 11/22/10. Further review revealed #3 had the following documented intake: 11/17/10 - 30% of dinner; 11/18/10 - 50% of breakfast; 11/19/10 - 50% of breakfast, 10% of lunch, 20% of dinner and 50% of supplement; 11/20/10 - 5% of lunch, 50% of supplement; and 11/21/10 - 75% of dinner.

Review of the abnormal lab results dated 11/17/10 revealed (WBC) White Blood Count of 13.2 H (Reference Range 4.0-11.0); Na (Sodium) 149 H (Reference Range 135-145); K (Potassium) 5.3 H (Reference Range 3.5-5.1); BUN Level 52 H (Reference Range 5-25); and Creatinine Level 2.45 H (Reference Range 0.57-1.25).

Review of the Care Plan for Patient #3 dated 11/17/10 through 11/18/10 revealed no documented evidence the patient's plan of care was updated to reflect the change in condition related to abnormal lab values.

4) Failing to ensure the plan of care was implemented by failing to obtain a urinalysis as ordered by the licensed practitioner(#6) being exposed to an invasive procedure (in & out catheterization) that could have been prevented had the equipment been available.

Patient #6:
Medical record review revealed that Patient #6 was admitted to the hospital on 1/28/11. Review of the psychiatric evaluation revealed that Patient #6 was a 77 year old female with dementia and admitted for a recent decline in her behavior. Review of the history & physical revealed that Patient #6's medical history includes hypothyroidism, dementia, rhinitis, arthritis, depression, and chronic urinary tract infections. Review of the physicians orders revealed an order dated 1/28/11 at 12:00 noon for a urinalysis to be obtained on Patient #6. Review of the medical record revealed that the urinalysis was not obtained until 2/05/11 (8 days after being ordered by the practitioner). Documentation in the physician progress notes revealed that the urinalysis was pending on 1/30/11 and 1/31/11. Documentation in the physician progress notes revealed an entry by the nurse practitioner on 2/02/11 documenting "We do need to get urinalysis". Review of the physicians orders revealed an order dated 2/05/11 at 12:00 noon for an in and out catheter to obtain the urinalysis.

The attending Physicians' Assistant (PA) S11 was interviewed on 2/10/11 at 10:45 a.m. PA, S11 reviewed the medical record of Patient #6 and confirmed that there was a delay in obtaining the ordered urinalysis and that he needed the results of the urinalysis in order to determine if the patient had a urinary tract infection. PA, S11 reported that he wrote an order for an in and out catheterization of Patient #6 on 2/05/11 in order to obtain the urinalysis because the nursing staff had not obtained the urinalysis prior to the date and time of ordering the in and out catheter. PA, S11 reported that the results indicated no urinary tract infection and had the results been positive for a urinary tract infection, it could have affected treatment decisions and the patient's response to treatment.

RN S3, Clinical Coordinator and LPN S9, Assistant Director of Nursing were interviewed on 2/10/11 at 11:15 a.m. S3 and LPN S9 reviewed the medical record of Patient #6 and confirmed that there was an 8 day delay in obtaining the ordered urinalysis and determining if the patient had a urinary infection. RN S3 and LPN 9 reviewed the results of the urinalysis collected on 2/05/11 (8 days after being ordered) and reported that the results indicated no urinary tract infection. When asked if nursing administration had identified or were made aware of the delay in obtaining the urinalysis on Patient #6, LPN S9 reported that an incident report had been filled out relating to the nursing staff's inability to obtain the urine sample due to not having the needed equipment . LPN S9 presented the Incident Report regarding the delay in obtaining the urinalysis on Patient #6. Review of the Incident Report dated 2/01/11 revealed "Unable to collect urine specimens ordered by MD on these 2 patients d/t lack of needed equipment (NUN'S CAPS). Doctor was notified and no order given to perform invasive urine catheterization to obtain urine specimen" and "Request for Nun's Caps Submitted 2 weeks ago & equipment still not available". When asked about the process for obtaining equipment needed to provide care for patients, RN S3 confirmed that there was a breakdown in obtaining the needed equipment for Patient #6 and confirmed that an invasive procedure (in & out catheterization) performed on Patient #6 on 2/05/11 could have been prevented if the hospital had implemented an effective system to ensure the timely delivery of patient care supplies and/or equipment.

Based on record review and interview the hospital failed to ensure all staff were assessed for competency for the assessment of medical and psychological conditions before being assigned to patient care for 1 of 1 sampled staff personnel files (S4). Findings:

Review of the personnel record for RN S4 revealed he performed a self-assessment of his knowledge and skills of the following: policies and procedures, quality service, nursing process, equipment, patient teaching, Code Blue, Communication (Shift Report), and Psychiatric Disorders on 11/07/10. Further review revealed S4 assessed himself as a (1) indicating he could perform the skill independently. The Nursing Competency Checklist was signed off by an RN no longer employed by the hospital. Further review revealed no documented evidence respiratory assessment was a skill assessed on the competency checklist or medical conditions had been included in the competency assessment.

Review of the 90 Day Evaluation for S4 dated 03/23/10 revealed he scored a "2" indication "Satisfactory Performance". Further explanation revealed....."performance was acceptable most of the time. Employee's performance needs periodic supervisory intervention or follow-up". Supervisory Comments made on the evaluation revealed S4 needed to perform additional CEUs to increase psychiatric knowledge and improve documentation especially on the Master Treatment Plan". Further review revealed no documented evidence S4 obtained any additional psychiatric education or S4 was monitored for improvement in chart documentation.

In a face to face interview on 02/11/11 at 9:30am S3, RN Clinical Coordinator, indicated she was aware the orientation process needed improvement. Further S3 indicated the hospital accepted both adult and geriatric patients who may have co-morbid diagnoses which need assessment and treatment while hospitalized for a primary psychiatric condition. After review of RN S4's personnel file verified he had not been assessed for competency in assessment of medical conditions.

Based on record review and interview, the hospital failed to have a full-time employee who serves as Director of the Food and Dietetic Services; have a full-time employee who is responsible for daily management of the dietary services; have a full-time employee who is qualified by experience or training; and failed to develop policies/procedures that address safety practices for food handling, emergency food supplies, and/or employee orientation and supervision of work for employees working in food services. Findings:

The Administrator was interviewed on 2/09/11 at 10:50 a.m. The Administrator reported that St. James Behavioral Health Hospital is a 28 bed hospital. The Administrator reported that S9 is the hospital's Dietary Manager. The Administrator indicated that S9 functions as the hospital's Assistant Director of Nursing or Clinical Services Assistant and the hospital's Dietary Manager or Director of Food and Dietetic Services.

The Dietary Manager (S9) was interviewed on 2/09/11 at 2:30 p.m. S9 reported that she is a LPN (Licensed Practical Nurse) and indicated that her primary role is serving as the hospital's Assistant Director of Nursing or Clinical Services Assistant. S9 reported that her duties include assisting with staffing and scheduling of the hospital which she reports takes up a large portion of her time and supervising the mental health technicians. When asked if she functions as the hospital's Director of Food and Dietetic Services, S9 reported yes. When asked to report the average number of hours per week spent as the Dietary Manager or Director of Food and Dietetic Services, S9 reported that she spends less than 5 hours per week in the role of Dietary Manager or Director of Food and Dietetic Services. S9 confirmed that the hospital does not have a full time Dietary Manager or Director of Food and Dietetic Services. When asked to provide all policies/procedures relating to dietary services, S9 presented a one (1) page policy/procedure titled "Dietary Services" and reported that this was the hospital's only policy/procedure for Dietary Services. The hospital's policy/procedure titled "Dietary Services" was reviewed. The policy/procedure documents "It is the policy of the Hospital to provide nutritionally sound diets for all patients as well as dietary consultations for those patients with special dietary needs". When asked about policies/procedures that address safety practices for food handling and emergency food supplies, S9 reported that she was not aware of the hospital having any policies/procedures addressing food handling or emergency food supplies. When asked about policies/procedures that address employee orientation and supervision of work for employees working in food services, S9 reported that she was not aware of the hospital having any policies/procedures addressing employee orientation and supervision of work for employees working in food services. When asked about her training in relation to dietary services, S9 reported that she obtained a "ServSafe Food Protection Manager Certification" offered by the Louisiana Restaurant Association and attended a "Food Nutrition and Diet Therapy" inservice training offered by the hospital's Registered Dietician. S9 reported that other than the "ServSafe" certification and the inservice provided by the Registered Dietician, she has had no additional training.

Based on observation, record review and interview, the hospital failed to ensure that personnel assigned to perform duties relating to food and dietary services were knowledgeable and deemed competent in their assigned roles prior to the performance of dietary related assignments. Findings:

Observations in the dining area were made on 2/09/11 between 11:50 a.m. and 12:05 p.m. S10 (Mental Health Technician) was noted to be preparing the table for the lunch meal. Temperatures were obtained of the hot foods prior to serving the meals to patients. The chopped broccoli was noted to be at 110 degrees Fahrenheit and the rice was noted to be at 105 degrees Fahrenheit. These food temperatures were confirmed by the Dietary Manager (S9). When asked about the required temperatures of hot foods and cold foods at the point of serving patients, the Dietary Manager reported that she was not aware of the required temperatures at the point of delivery to patients. (State Licensure Regulations documents that delivery temperatures are maintained at 120 degrees F or above for hot foods and 50 degrees F or below for cold items, except for milk which is stored at 41 degrees F). The Dietary Manager and the Mental Health Technician (S10) preparing the table for the hospitalized patients reported that they were not aware of the temperature requirements of foods at the point of delivery to patients in a hospital.

The Registered Dietician (S8) was interviewed on 2/09/11 at 1:30 p.m. S8 reported that meals are prepared by "Batemans" prior to being transported to St. James Behavioral Health Hospital. S8 indicated that breakfast meal trays are delivered before 7:00 a.m. and lunch and dinner trays are delivered before 12 noon on Mondays through Fridays. S8 reported that breakfast and lunch trays are delivered hot and maintained at a temperature of greater than 140 degrees while in the food services area. S8 confirmed that dinner trays and weekend trays are delivered frozen and placed in a freezer where they remain until approximately 2 hours before the scheduled meal times at which time the trays are placed in the warming device where they will be brought to a temperature of greater than 140 degrees. When asked about the process for ensuring that foods are served to patients (point of delivery) at the acceptable temperatures, S8 reported that the Dietary Manager (S9) could better answer questions relating to process and systems utilized by hospital personnel.

The Dietary Manager (S9) was interviewed on 2/09/11 at 2:30 p.m. When asked about the hospital's policy/procedure relating to food temperatures, S9 reported that she was not aware of a hospital policy/procedure relating to food temperatures. When asked to provide all policies/procedures relating to dietary services, S9 presented a one (1) page policy/procedure titled "Dietary Services" and reported that this was the hospital's only policy/procedure for Dietary Services. The hospital's policy/procedure titled "Dietary Services" was reviewed. The policy/procedure documents "It is the policy of the Hospital to provide nutritionally sound diets for all patients as well as dietary consultations for those patients with special dietary needs". When asked about policies/procedures that address safety practices for food handling and emergency food supplies, S9 reported that she was not aware of the hospital having any policies/procedures addressing food handling or emergency food supplies. When asked about policies/procedures that address employee orientation and supervision of work for employees working in food services, S9 reported that she was not aware of the hospital having any policies/procedures addressing employee orientation and supervision of work for employees working in food services. When asked about her training in relation to dietary services, S9 reported that she obtained a "ServSafe Food Protection Manager Certification" offered by the Louisiana Restaurant Association and attended a "Food Nutrition and Diet Therapy" inservice training offered by the hospital's Registered Dietician. S9 reported that other than the "ServSafe" certification and the inservice provided by the Registered Dietician, she has had no additional training.

Based on record review and interview, the hospital failed to ensure the nutritional needs of patients hospitalized on the acute care psychiatric unit were met in accordance with recognized dietary practices as evidenced by failing to monitor the dietary intake and nutritional status for 3 of 6 sampled patients (#3, #4, #5). Findings:



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Patient #3
Review of the History & Physical for Patient #3 revealed an 84 year old woman admitted to the hospital on 11/15/10 from a nursing home with the diagnosis of Dementia with behavioral disturbance and psychosis. Further review revealed #3 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 2 to 3+ edema of the lower extremities upon admit.

Review of the Graphic Sheet for Patient #3 revealed no documented evidence nutritional intake was assessed on 11/16/10 or 11/22/10. Further review revealed #3 had the following documented intake: 11/17/10 - 30% of dinner; 11/18/10 - 50% of breakfast; 11/19/10 - 50% of breakfast, 10% of lunch, 20% of dinner and 50% of supplement; 11/20/10 - 5% of lunch, 50% of supplement; and 11/21/10 - 75% of dinner. Further review of the medical record revealed no documented evidence the poor nutritional intake had been reported to the dietitian or the physician.

Patient #4
Review of the Psychiatric Evaluation for Patient #4 revealed an 80 year old man admitted from a nursing home on 12/02/10 for increased agitation during the late afternoon and early evening hours. His primary diagnosis was documented as dementia with behavioral disturbance.

Review of the Graphic Flowsheet for Patient #4 dated 12/05/10 revealed he had consumed 100% of his lunch. Further review revealed no documented evidence of any intake or output after this time 12/06/10 - 12/08/10. Further review of the medical record revealed no documented evidence the poor nutritional intake had been reported to the dietitian or the physician.

Patient #5
Review of the History & Physical for Patient #5 revealed an 88 year old woman admitted to the hospital on 02/01/11 from a nursing home with the diagnosis of Alzheimer's and Dementia with psychosis. Further review revealed #5 had a history of CHF (Congestive Heart Failure) and HTN (Hypertension) with 1+ edema of the lower extremities upon admit.

Review of the Graphic Sheet for Patient #5 revealed no documented evidence nutritional intake was assessed on 02/05/11, 02/06/11 or 02/09/11.

In a face to face interview on 02/09/10 at 2:30pm LPN (Licensed Practical Nurse) S9 indicated her position is Assistant Director of Nursing. Further LPN S9 indicated her duties included assisting with staffing and scheduling of the hospital which takes up a large portion of her time, supervising the mental health technicians and Director of Dietary Services. S9 indicated she spends an average of less than five (5) hours per week in her role as Director of Food and Dietary Services.