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Based on record review, staff interview and observation, it was determined that the facility staff failed to have an effective system in place to ensure that menus provided were in accordance with physicians' orders and established standards of practice. The findings include:

On 04/07/10, 04/08/10, and 04/12/10, an in-depth review of the the hospital's dietetic services department was conducted. During this time, multiple concerns were identified with regards to menu-planning and the provision of therapeutic diets. Based on the findings, it was determined that the facility staff failed to maintain the minimum standards with regards to the provision of common therapeutic diets. Details of these findings are described under A0628 (482.28(b)) and A0630 (482.28(b)(2)).

Facility staff must ensure that the nutritional needs of the patients are met in accordance with practitioners' orders and acceptable standards of practice.

Based on the findings of the staff of the Office of the State Fire Marshall during the survey of March 31, 2010 to April 2, 2010, the hospital was not maintained in manner to provide for the safety of the patients as evidenced by:

A tour of the facility conducted by the staff of the Office of the State Fire Marshall found the hospital was not in compliance with the Life Safety Code. The hospital failed to appropriate hardaware on doors to staorgae areas for liquid oxygen and 150 "H" cylinders of oxygen (K29) ; failed to install and maintainfire deterction in the smoking room (K53); failed to maintain the sprinkler system in the itchen frree of corrosion (K62) ; failed to provide an approved receptacle for ashes in the smoking area ( K66); and failed to provide an anunciator panel for the emergency generator in an area where it could be monitored 24 hours a day seven days a week (K106).

Based on review of the medical record, staff interviews, and policies and procedures, the staff failed to provide interpretive services for one patient who speaks Arabic and does not understand English. The hospital failed to consistently use interpretive services and language line to communicate with the patient to assess her needs, thought process,and explain her treatment.

Patient #4 is a 67 year old with a history of several admissions since October 2007. Patient #4 is from Egypt, speaks only Arabic, and does not understand English. The patient's past medical history includes status post middle cerebral artery stroke, paroxysmal atrial tachycardia, and hypertension. Other diagnoses include hyperlipidemia, bradycardia with third degree heart block leading to pacemaker placement, status post GI bleed, and a history of depression. Review of the medical record has notes written by the social worker that an interpreter is scheduled on an as needed basis and that a telephone interpreter is available 24 hours a day. There is documentation in the record that physical therapy and psychiatry consistently used interpreter services to communicate and assess the patient. Nursing service generally uses translator services for specific procedures like placement of the pacemaker. When the patient is upset, the boyfriend is called to assist in calming the patient. The daily assessment of the patient by physicians and nursing is performed without an interpreter.

On 8/25/08, Patient #4 was readmitted to the University Specialty Hospital after being treated at another facility for respiratory distress. Upon her return to the hospital, the history and physical performed by her attending physician noted, "we are unable to assess her orientation to time, place, and person." Later the same physician documents "unable to assess her sensory because of her language barrier." No further notations were found in the record to indicate this patient was reassessed with the use of a translator or the language line.

This patient requires use of a pelvic restraint device to maintain safety due to a high fall risk. The procedure for use of restraint requires that the process of restraint be explained to the patient and an alternative be offered. Communication is required to assess the patient's ability to comply with and understand the the process. Patient # 4 needs a translator for communication to take place. The nurse assigned to Patient #1 on 4/8/10 stated she was not aware that the hospital had a language line.

The hospital failed to meet the needs and protect the rights of this non-English speaking patient in a consistent manner. Patient #4 has the right to have procedures and treatments explained in a language or manner that she understands. Accurate assessments of the patient cannot be made if a language barrier exists.

Based on record review, staff interview and observation, it was determined that the facility staff failed to evaluate a patient's trend of continued weight gain. The findings include:

Patient # 2 is an 83 year old male who was admitted to the hospital on 02/19/10. Review of the patient's medical record revealed the following weights (documented on the weight flow sheet):

02/19/10 - 186.2 lbs.
03/3/10 - 186.8 lbs.

Review of the patient's weights documented in the weight book revealed the following weights (documented in pounds):

02/19/10 - 186.2
02/26/10 - 192.5
03/02/10 - 186.8
03/03/10 - 186.8
03/05/10 - 191.5
03/08/10 - 189.5
03/10/10 - 190.0
03/12/10 - 190.4
03/17/10 - 206.0
03/19/10 - 205.5
03/24/10 - 201.5
03/26/10 - 216.5
03/31/10 - 221.0
04/07/10 - 225.5

From 02/19/10 through 04/07/10, the patient exhibited a 39.3 lb. weight gain, equivalent to a 21.1 % change in body weight in less than 2 months. Per hospital policy, the weights from the weight book were supposed to be transcribed into the patient's medical record, however, this transcription did not occur. The weight trend was overlooked, and as a result, no assessment was conducted to evaluate the patient's continued weight gain.

Based kitchen observations, record review and staff interview, it was determined that the facility staff failed to: 1) ensure that food was fresh and safe for consumption; and 2) maintain a system in place for ensuring that pots, pans and serving utensils were effectively sanitized to prevent cross-contamination and minimize the risk of foodborne illness outbreaks. The findings include:

1) The facility staff failed to ensure that food was fresh and safe for consumption.

On 04/07/10 at 9:45AM, an announced kitchen inspection was conducted. During this time, the surveyor observed 13 undated 32-ounce containers of Egg Beaters and 8 undated 5-pound containers of Wholesome Farms liquid egg product in the dairy walk-in refrigerator. The FSD (Foodservice Director) upon initial interview was unable to state the shelf-life of these products once thawed, and upon completion of the survey on 04/12/10, was still unable to provide this information for the Wholesome Farms product. Both products have a limited shelf-life, and must be dated upon thawing to ensure freshness.

Subsequent observation of the dry storage area revealed 5 cases (consisting of 8 1-Liter containers per case) of Optimental Ready-to-Hang enteral feeding formula with an expiration date of 08/01/09 (8 months old). This product is a liquid nutritional supplement for patients on tube feedings, and must be used by the expiration date.

2) The facility staff failed to maintain a system in place for ensuring that pots, pans and serving utensils were effectively sanitized to prevent cross-contamination and minimize the risk of foodborne illness outbreaks.

On 04/07/10 at 10:10AM, the surveyor observed the 3-compartment sink in use. A 3-compartment sink (or pot sink) is used for washing, rinsing and sanitizing pots, pans, serving utensils, etc. Placed above the sanitizer compartment were chlorine test strips. The sanitizer being used was noted to be a quaternary solution. The surveyor asked the FSD to measure the sanitizer concentration (which is done by using the appropriate test strips). The FSD proceeded to measure the quaternary sanitizer using the chlorine test strips. Because these were not the correct strips, the concentration could not be measured. The FSD continued to attempt to check the concentration without results. The surveyor then asked if there were any quaternary test strips, and pointed out the that the FSD was using the wrong test strips. No quaternary strips were in-house.

Review of the April 2010 pot sink sanitizer concentration logs revealed that staff were documenting a reading of 200 ppm (parts per million), though this was without the appropriate test strips available to them. This included documentation of a reading of 200 ppm for that morning. After surveyor intervention, the appropriate test strips were ordered and obtained later that day.

Facility staff must have available (and use) appropriate test strips to ensure that dishes are properly sanitized. This is to minimize the risk of cross-contamination and foodborne illness outbreaks. Monitoring logs must be accurate and reliable to maintain patient safety.

Based on record review, staff interview and observation, it was determined that the facility staff failed to: 1) provide a diet as prescribed by the physician; 2) follow accepted standards of practice with regards to the provision of fluids to a patient with kidney failure; and 3) appropriately monitor a patient's nutritional status while ensuring that she received a nutritionally-adequate vegetarian diet. The findings include:

1) The facility staff failed to provide a diet as prescribed by the physician.

Patient # 1 is a 45 year old morbidly obese female with end-stage renal failure. She has a physician's order for a renal diabetic diet. Review of the patient's meal tickets for 04/08/10 - 04/10/10 revealed that she was only being sent a renal diet. No diabetic diet provisions were being made. Facility staff must provide diets as ordered by the physician.

2) The facility staff failed to follow accepted standards of practice with regards to the provision of fluids to a patient with kidney failure.

Patient # 1 is a 45 year old morbidly obese female with end-stage kidney failure. She requires dialysis 3 times per week. Review of the patient's meal tickets for 04/09/10 revealed that she was being sent 1,140 mL (milliliters) of fluid at breakfast, 1,500 mL of fluid at lunch, and 1,260 mL of fluid at dinner. This equates to a total of 4,900 mL of fluid (or over 20 cups) provided on her meal trays alone over a 24-hour period.

Patients with kidney failure often require limitations to how much fluid is consumed. This is because the kidneys are not functioning properly. Excessive fluid intake, such as the amounts provided to this patient, can cause swelling of the ankles and feet, fluid in the lungs, shortness of breath, and other serious complications. Attention must be paid to the total amount of fluid being provided to patients with end-stage renal disease.

3) The facility staff failed to appropriately monitor a patient's nutritional status while ensuring that she received a nutritionally-adequate vegetarian diet.

Patient # 3 is 54 year old female with a diagnosis of severe protein deficiency. She requests a vegetarian diet. Review of the facility's pre-planned menus failed to reveal a vegetarian diet plan. Review of the patient's meal tickets from 04/08/10 - 04/14/10 revealed numerous meals where no protein-based entree was being provided in place of the meat. Interview with the FSD revealed that there was no plan in place to ensure that the patient would receive a balanced diet sufficient in protein. Because there were no vegetarian menus, the patient's menus were frequently insufficient in protein and subject to repetition (for example, the 3 times when she did receive an alternate, it was egg salad).

Review of the patient's medical record revealed prealbumin levels that were low. Serum prealbumin levels are often indicators of protein malnutrition. On 03/31/10, the patient's prealbumin was 15 mg/dL (milligrams per deciliter), and on 04/08/10, the patient's prealbumin level was 14 mg/dL. Both of these values are low.

On 03/26/10, the patient was admitted with a weight of 240.5 lbs. On 04/05/10, her weight was documented as 235 lbs., indicating a 5.5 lb. loss in weight (or 2.3 % loss in body weight over a 10-day period). Per hospital policy, patients are to be reweighed when there is a 5 lb. or greater change in weight. As confirmed upon staff interview, no reweigh was obtained.

According to the patient's initial nutritional assessment dated 03/30/10, the plan was to "monitor prealbumin levels to ensure pt (patient) has enough calories and protein for healing". However, additional record review on 04/08/10 failed to reveal that a nutritional assessment evaluating the patient's low prealbumin levels had been conducted. There was also no evaluation of the patient's weight loss.

Facility staff must monitor the nutritional care of each patient while ensuring that menus meet individual needs.

Based on kitchen and meal service observations, in addition to record review and staff interview, it was determined that the facility staff failed to: 1) provide diet-appropriate menus for several therapeutic diet extensions; 2) have pre-planned menus for two diets (one of which was a patient-requested diet, and one of which was physician-prescribed); and
3) ensure that patients on pureed diets received varied, nutritionally-balanced meals. The findings include:

1) The facility staff failed to provide diet-appropriate menus for several therapeutic diet extensions.

On 04/07/10, the surveyor requested a copy of the current week's menus, including all therapeutic diet extensions. Therapeutic diet extensions are pre-planned menu spreadsheets that determine what foods are provided (and in what amounts) for each diet served. These menus must be approved by a Registered Dietitian (RD), and be in accordance with the facility's approved diet manual (which, according to the Foodservice Director, was the diet manual published by the American Dietetic Association).

Initially, the surveyor was provided with a set of menus from the hospital's contractual food management company. The surveyor was told that these were the correct menus. Upon inspection of the noon meal on 04/07/10, discrepancies were noted between the menu and the food being served. At that point, the surveyor was told that the menus provided were not correct, and that the menus were contained in a computerized menu management program, i.e. GeriMenu. No hardcopies (signed off by a dietitian) were on hand. The surveyor was told that the FSD (Foodservice Director) - who was also a RD - was responsible for entering the various therapeutic diets into GeriMenu.

On 04/07/10, after the hardcopies were printed out (and signed by the RD), numerous diet-related concerns were noted by the surveyor. These concerns include, but are not limited to the following:
a) Inappropriate food items were included on the pureed diet spreadsheets. These food items were not in accordance with current standards of practice nor the approved diet manual:

- On week 2 day 3 "pot roast" was listed as the dinner entree.
- On week 2 day 4 "rice" was listed for lunch.
- On week 2 day 1 "carrots" were listed for lunch.
- On week 2 day 4 "bread dressing" was listed for dinner.
- On week 2 day 5 "garlic bread sticks" were listed for dinner.
- On week 2 day 3 "peas and mushrooms" were listed for dinner.

These items are contraindicated on a pureed diet unless they are in a pureed form. It was also noted that based on the approved diet manual, oatmeal was not to be served on a pureed diet, yet it was being served at breakfast 3 times each week.

Patients often require pureed diets due to chewing and/or swallowing impairments. Foods on a pureed diet must be blenderized until smooth, and similar in consistency to that of whipped potatoes, applesauce or baby food.

b) Inappropriate food items were included on the 2 gram sodium diet. These food items were not in accordance with current standards of practice nor the approved diet manual:

- On week 1 day 4 a "salt" packet was listed for breakfast.
- On week 2 day 3 a "salt" packet was listed for dinner.
- On week 2 day 4 a "salt" packet was listed for dinner.

Numerous other items that would typically not be in accordance with a very low sodium diet (such as a 2 gram sodium diet) were also being provided. These items include beef stew, tater tots, macaroni and cheese, country style pot roast, beef fried rice, turkey pot pie, etc. Lower sodium versions of these food items would need to be provided to stay within the daily guidelines of a 2 gram sodium diet.

c) Inappropriate food items were included on the 3-4 gram sodium, low cholesterol diet. These food items were not in accordance with current standards of practice nor the approved diet manual:

- On week 1 day 4 a "salt" packet was listed for breakfast.
- On week 2 day 3 a "salt" packet was listed for dinner.

d) Inappropriate food items were included on the renal (kidney disease) diet. These food items were not in accordance with current standards of practice nor the approved diet manual:

- On week 1 day 4 a "salt" packet was listed for breakfast.
- On week 2 day 3 a "salt" packet was listed for dinner.
- On week 1 day 4 "baked ziti casserole" was listed for lunch.
- On week 1 day 2 "vegetable lasagna" was listed for dinner.
- On week 2 day 1 Half & half, cream cheese and milk were listed for breakfast.
- On week 2 day 2 "chocolate chip" cookies were listed for lunch.
- On week 2 day 7 a "brownie" was listed for lunch.
- On week 2 day 6 "chocolate" cake was listed for dinner.
- On week 3 day 5 "vegetable lasagna" was listed for lunch.
- On week 3 day 5 "Devil's food cake" was listed for dinner.
- On week 1 day 5 "beef stew" was listed for lunch.
- On week 2 day 6 "beef stew" was listed for lunch.

These items are typically omitted from a renal diet due to their high potassium, sodium and/or phosphorus content. Interview with the FSD confirmed that these items were being given in error.

e) Fluctuations in the number of carbohydrate servings were observed on the carbohydrate-controlled diabetic diets. Upon interview with the FSD, the surveyor was told that the diet was supposed to follow a 5/5/5 carbohydrate meal pattern. This means that 5 servings of carbohydrates should be provided at breakfast, lunch and dinner to maintain a consistent carbohydrate load throughout the day for patients with diabetes.

Review of the cycle menus revealed that the number of carbohydrate servings varied between 4-6 servings per meal. For example, on week 2 day 3, at least 6 carbohydrate servings are provided (orange juice, oatmeal listed twice, hash browns, biscuit, and skim milk). On week 2 day 1 lunch, approximately 4 carbohydrate servings are listed (noodles, roll, and strawberry shortcake). On week 2 day 4 lunch, both chicken noodle soup with crackers and vegetable soup with crackers are listed. On week 1 day 4 lunch, the main meal consists of approximately 3-4 carbohydrate exchanges (bean soup with crackers, baked ziti casserole, and garlic bread stick), and the alternate meal provides 2 carbohydrate exchanges (mashed potatoes and bean soup with crackers).

These variances are not consistent with the intent of a carbohydrate-controlled diet. Carbohydrate controlled diets are designed to keep a patient's blood sugars at a consistent level throughout the day. This helps to minimize blood sugar fluctuations.

f) Review of the dysphagia 2 mechanically altered diet revealed that the vast majority of items provided were in the pureed form. For example, on week 1 day 1 lunch, patients receive pureed cream of broccoli soup, pureed fish, and pureed peas, with pureed carrots as the vegetable alternate. On week 1 day 1 dinner, patients receive pureed cream of chicken soup, pureed pot roast, and pureed carrots, with pureed green beans as the vegetable alternate. This pattern of pureed meals continues throughout the remaining 3-week cycle menu.

The intent of a dysphagia 2 diet is to transition patients with dysphagia (difficulty swallowing) from pureed textures to more solid textures. There are 3 levels to the dysphagia diets. The goal is to advance the patient as tolerated in an effort to liberalize the diet. By pureeing the majority of food items served on this diet, the patients are subjected to a more restrictive diet than necessary.

Facility staff must provide menus that meet the needs of the patients.

2) The facility staff failed to have pre-planned menus for two diets (one of which was a patient-requested diet, and one of which was physician-prescribed).

a) Patient # 1 is a 45 year old morbidly obese female with end-stage renal failure. She has a physician's order for a renal diabetic diet.

Review of the hospital's pre-planned menus failed to reveal a therapeutic diet extension (spreadsheets) for patients on a renal diabetic diet combination. Pre-planned, RD-approved menu extensions must be in place to ensure that menus are both nutritionally-adequate and consistent with all dietary restrictions associated with a complex diet order such as this.

b) Patient # 3 is 54 year old female with a diagnosis of severe protein deficiency. She requested a vegetarian diet.

Review of the facility's pre-planned menus failed to reveal a vegetarian diet plan. Review of the patient's meal tickets from 04/08/10 - 04/14/10 revealed numerous meals where no protein-based entree was being provided in place of the meat. Interview with the FSD revealed that there was no plan in place to ensure that the patient would receive a varied diet sufficient in protein. Because there were no vegetarian menus, the patient's menus were frequently insufficient in protein and subject to repetition (for example, the 3 times when she did receive an alternate, it was egg salad).

Facility staff must have pre-planned menus in place to meet patient needs and ensure that nutritionally balanced meals are provided.

3) The facility staff failed to ensure that patients on pureed diets received varied, nutritionally-balanced meals.
On 04/08/10, the surveyor reviewed the hospital's pureed menu cycle. Numerous repetitions were noted, including but not limited to the following:

On week 1 of the pureed menu cycle, pureed peas were being offered at lunch on day 1, lunch on day 3, dinner on day 4, and dinner on day 6. Pureed green beans were being offered at lunch on day 2, lunch on day 4, and lunch on day 5. Pureed corn was being offered at dinner on day 2, lunch on day 6, and dinner on day 7. Mashed potatoes were being offered at lunch and dinner on days 1, 3, 4, 5, 6, and lunch on day 7. Pureed chicken with gravy was being offered at lunch on days 1, 2, and 7 and dinner on days 4 and 6. No meat or protein-based entree was noted at lunch on day 5. It was also noted that these menus were not consistent with the regular menus.

Facility staff must provide varied, nutritionally-balanced diets to meet the needs of the patients. Furthermore, the pureed menu should mimic the regular diet as much as possible, with modifications to adjust texture and consistency. This enables patients on pureed diets to receive the same menu as individuals on regular diets.