HospitalInspections.org

The hospital failed to ensure Food and Nutrition Services (FANS) was sufficiently integrated into the hospital-wide Quality Assurance Performance Improvement (QAPI) program. This failure resulted in hospital staff not knowledgeable on, or implementing, a routinely prescribed therapeutic diet order "Soft and Bite-Sized (SB6) in accordance with the hospital's diet manual and standards of care and the potential for patient's prescribed an SB6 diet to not have nutritional needs met or the potential for patients to choke due to too large of pieces of food. (Refer A-0618, A-0631)

Findings:

During an interview on 8/12/24 at 12:25 p.m. with (Chief Nursing Officer) CNO, CNO was unable to state what the food size should be with a SB6 diet order. CNO stated, "Can I look and get back to you?" CNO stated she could not recall if or when the hospital provided IDDSI (International Dysphagia Diet Standardization Initiative) training. CNO stated IDDSI was implemented a while back. CNO was asked to let the hospital's Quality Risk Manager (QRM) know that a copy of the IDDSI training and date implemented was requested.

During an interview on 8/12/24 at 3:58 p.m. with Registered Dietitian (RD), RD stated IDDSI diets had been implemented at the hospital since at least 2021. RD stated she could not recall about hospital training on IDDSI. IDDSI training records were requested.

During an interview on 8/13/24 at 2:58 p.m. with RD, in the presence of CNO, RD stated she attended quality council (QC) meetings. RD stated she currently had two qualitative items that are being tracked via "QC" related to her role as the clinical nutrition Dietitian. RD stated those are tracking timeliness of RD nutrition assessments and follow ups and completing nutrition assessments and patient education for those patients taking Warfarin (a medication used to treat and prevent blood clots) that were started in 2021. RD was asked if she currently had any other performance improvement (PI) projects she was working on, and RD stated, "Not right now." RD was asked if she had adequate time to address PI projects, and RD stated, "If I identified one, I would make the time."

During an interview on 8/14/24 at 9:40 a.m. with Quality Risk Manager (QRM), RD, Food & Nutrition Service Director (FNSD) and CNO, it was discussed that SB6 diet was not followed and IDT and dietary staff not knowledgeable on SB6 diet had been identified by the survey team and was of concern. In addition, it was discussed that not only was the meat size not followed but other aspects of SB6 were not followed as well per the diet manual and standards of practice. It was communicated it was the hospital's responsibility to identify gaps in nutritional care with not only SB6 but to further investigate all IDDSI diets, their operations related to IDDSI and address their training needs.

The hospital had not provided any evidence of hospital wide training on IDDSI diets prior to exit.

Based on observation, interview, and record review, the hospital failed to ensure the Food and Nutrition Services (FANS) department was organized and managed effectively when:

The hospital did not ensure the organization structure of Food & Nutrition Services department (FANS) was implemented as evidenced by one of one sampled Registered Dietitian (RD) job description and/or functions and one of one sampled Food and Nutrition Services Director (FNSD) was not aligned with the hospital's organization chart.

One of one sampled FNSD job description, titled "Nutrition Services Director", was not written in a manner that complied with federal and/or state requirements for the position, and was not fully implemented.

One of one sampled RD job description and functions carried out by the RD at the hospital were not aligned with the hospital's organization (org) chart, not sufficient in providing a monitoring/oversight role over FANS department as evidenced by lack of development of written policies and procedures (P&Ps) that reflected the depth and breadth of the FANS department, unsanitary practices within the foodservice operation, and lack of identified training needs in order to implement the Soft & Bite Sized (SB6) diet in accordance with physician orders and hospital's diet manual.

This failure had the potential for cross contamination, unsafe food handling practices and growth of microorganisms which placed the patients at an increased risk for foodborne illness. This had the potential to affect the hospital census of 59 highly susceptible patients.

Further, lack of accurate implementation of the SB6 diet placed patient's at an increased risk for choking. This failure resulted in the hospital not serving the SB6 diet as prescribed to two of six sampled patient's (Patient 1, Patient 2), and there were four additional patients with a physician ordered SB6 diet (Patient 3, Patient 4, Patient 5, Patient 6) which had the potential to affect the patient's nutritional needs and place at an increased risk of choking.

(Refer to A-0618, A-0620, A-0621, A-0622, A-0631)

Findings:

1a. During a review of the hospital's "Organizational Structure; Controller/Food & Nutrition (FANS org chart)", [undated], the FANS org chart depicted the FNSD under the controller/ as reporting to the Controller. The FNSD was depicted below the RD with a solid line from the FNSD up to the RD.

1b. During a review of the hospital's job description (JD), [undated], for FNSD position, the JD was titled "Nutrition Services Director (FNSD)." The FNSD JD indicated, "The Nutrition Services Director plans, directs and coordinates the activities of the Nutrition Service Department for multiple hospitals, departments. . ." The FNSD JD was not formally structured to ensure compliance with CMS (Centers for Medicare & Medicaid Services) federal regulations that required a full-time Director of Food and Dietetic Services, and required state food service standards, laws and regulations to be followed, when the JD was written to allow the FNSD to direct more than one hospital. During a review of Center for Health Care Quality, California (CA) Code of Regulations (CCR), Title 22, Division 5, Chapter 1, Section 70275 (b), and CA Health and Safety Code 1265.4, required the qualified person running the day to day foodservice operation to be full-time to the hospital.

During a review of the hospital's JD for FNSD, the FNSD JD indicated, "The position implements and supports policies and procedures to provide administrative direction for cafeteria management, food preparation, distribution, service, budgeting, purchasing, sanitation standards, safety practices, staffing and staffing development and all other areas/departments of direct supervision and management. In addition, this position will provide administrative direction for therapeutic diets and assures that standard of care is met in accordance with all associate regulatory agencies. . ."

During an interview on multiple occasions from 8/12/24- 8/14/24, the Quality Risk Manager (QRM) and FNSD stated the hospital did not have a P&P for the dishmachine, 3 compartment sink (manual system to wash large utensils, pots, pans, includes a disinfecting rinse) nor for sanitizing food contact surfaces in which all three of those areas had either a wrong and incomplete monitoring log, staff were not clear on required temperatures for the dish machine (dishwasher), and/or staff were unfamiliar with the manufacturer's guidelines of a cleaning product and/or sanitizer which had the potential to impact the health and safety of patients. Staff utilized different dating methods that were unclear to dietary staff and there was no P&P available to provide consistent expectations for dietary staff to utilize. The hospital's FNSD JD in this regard was not carried out and the FANS department was not effectively organized to meet both federal and state regulations that required written P&Ps to include guidelines for kitchen sanitation. (Refer to A-0618)

During a review of California Code of Regulations (CCR), Title 22, Division 5, Chapter 1, Section 70273(b), the state regulation indicated, "Policies and procedures shall be developed and maintained in consultation with representatives of the medical staff, nursing staff and administration to govern the provision of dietetic services. Policies shall be approved by the medical staff, administration and governing body. Procedures shall be approved by the medical staff and administration." (Refer to A-0618, A-0620, A-0621).

During a concurrent observation and interview on 8/12/24 at 9:24 a.m., in the kitchen, the Controller (C) was in the kitchen and stated he was in charge of the food and nutrition services while the FNSD was in another state due to personal reasons, and FNSD was called back and would be there the next day. The Controller repeated that he was in charge of the department that day but relied on Cook 1, during which time the hospital had a full time RD on site but she remained in her role as the clinical RD.

During a review of the hospital's JD titled "Dietitian (RD)", [undated], the RD JD indicated, "Position Purpose: The Dietitian plans therapeutic diets and confers with patients, doctors, nursing staff and patient family members concerning these diets. The position monitors Nutrition Services provided to patients to ensure that standards of care are met in accordance with all associated regulatory agencies and the administrative policies of the hospital. The dietitian instructs patients in diets for home use prior to discharge and as outpatients. . .To ensure the accuracy of food production as related to modified diets, the Dietitian acts in a supervisory capacity, as needed and performs other project assignments, Responsibilities and Tasks:. . .Ensures updated diet manuals are current/available in Nutrition Services Department, nursing units. Conducts in-service on Nutrition/modified diets to Nutrition Services staff and other disciplines."

During a concurrent interview and record review on 8/13/24 at 10:30 a.m. with RD, RD reviewed a Food Safety and Sanitation Audit form (FSSA), dated 8/8/24, completed by the RD. The FSSA indicated 100% [percent] compliance within the foodservice operation as indicated by all categories marked "Yes" for in compliance next to items that included, "Procedures are in place to prevent cross-contamination, knives and other utensils are appropriately maintained and sanitized before each use, food service utensils are sanitized prior to use. . ., Dishwashing machine is filled and used according to manufacturer recommendations, Dishwashing machine chemicals used are monitored for proper dispensing on a routine basis. Documentation is maintained for such monitoring, three compartment sinks are filled at temperatures required for chemicals to provide optimal cleaning and sanitation." RD stated her primary role over the foodservice operation was to complete the FSSA on a quarterly basis. RD was asked if she was aware that the foodservice operation did not have P&P's for the dishmachine to ensure the required temperatures were met per manufacturer guidelines. RD stated, "There is no requirement for temperature for the dishmachine, only for sanitation." RD was asked if she were aware the wrong log for monitoring sanitation was currently in use for the dish machine for August 2024, and RD stated, "I really defer those type things to the foodservice director." RD stated the only involvement she had within the foodservice operation was completing quarterly sanitation audits, attending their meetings, and conducting an in-service on occasion. RD stated she was a clinical RD. The functions of the role of the RD at the hospital did not align with the FANS org. chart, or the RD JD that indicated "The position monitors Nutrition Services provided to patients to ensure that standards of care are met in accordance with all associated regulatory agencies." Regulations require there be an RD to provide guidance to ensure systems, and written P&Ps are in place for FANS staff to assure the foodservice operates in a safe and sanitary manner. RDs have a role in monitoring FANS for purposes of identifying unsafe and unsanitary practices in order to rectify immediately for the health and safety of patients, in addition to ensuring staff are competent on food preparation of modified diets. (Refer to federal regulation A-0618, state regulation CA Health & Safety Code 1265.4 (a) and CCR Title 22 70275(a).)

During a review of FSSA, dated "6/4", the RD identified inconsistent and incorrect dating of food for storage practices by dietary staff. The hospital failed to ensure the identified issue was rectified as inconsistent dating was observed during this survey and the hospital did not have a written P&P that addressed dating and labeling of food. (Refer to A-0620, A-0621).

During a review of RD JD [undated], the JD indicated, "To ensure the accuracy of food production as related to modified diets, the Dietitian acts in a supervisory capacity, as needed and performs other project assignments. . ., Conducts in-service on Nutrition/modified diets to Nutrition Services staff and other disciplines. . . "

During the survey from 8/12/24 to 8/14/24, the survey team identified the hospital's SB6 diet was not prepared nor implemented in accordance with physician orders/diet manual (most current version dated 2024) and the IDT (interdisciplinary team) was not trained/knowledgeable on what texture/size of bite sized pieces of food constituted SB6. (Refer to A-0631). The hospital was not organized to ensure the requirements of the RD JD were met.

Based on observation, interview, and record review, the hospital failed to ensure one of one sampled Registered Dietitian (RD) was competent in her assigned duty when:

1. One of one sampled RD did not complete an accurate "Food Safety and Sanitation Audit." This failure resulted in unidentified unsanitary practices within the foodservice operation and a lack of written policies and procedures to reflect the range of functions carried out by dietary staff. This had the potential to affect the hospital census of 59 highly susceptible patients.

2. One of one sampled RD did not ensure Nutrition Services staff and other disciplines were knowledgeable on the hospital's modified therapeutic Soft and Bite Sized (SB6) diet routinely ordered at the hospital.
This failure resulted in the hospital not serving the SB6 diet as prescribed to two of six sampled patient's (Patient 1, Patient 2), and there were four additional patients with a physician ordered SB6 diet (Patient 3, Patient 4, Patient 5, Patient 6) which had the potential to affect the patient's nutritional needs and place the patient's at an increased risk of choking.

Findings:

1. During a concurrent observation and interview on 8/12/24 at 10:16 a.m., with Dishwasher (DW), Controller (C) and Chief Nursing Officer (CNO), after dishes were ran through the dish machine (dishwasher), DW inserted a chem (chemistry) test strip into the tank water to check the concentration of the chlorine sanitizer. DW, C, and CNO observed the dipped chem strip. The chem strip was completely white. DW stated the chlorine sanitizer was less than 100 parts per million (PPM) and continued to use the dish machine.

During a concurrent interview and record review on 8/12/24 at 10:20 a.m. with DW and Cook 1, the manufacturer's guidelines (MGs) located on the bottle of sanitizer (Ecolab Keystone Sanitizer) that was currently hooked up to the dishmachine was reviewed. The MGs indicated, "Active ingredient: Sodium hypochlorite [chlorine]. . .For sanitizing tableware in low temperature warewashing machines, inject Keystone Sanitizer into the final rinse water at 100-200 ppm available chlorine."

During a concurrent interview and record review on 8/12/24 at 10:22 a.m. with DW, DW pointed to a log titled "Quaternary Ammonium Log", dated August 2024, posted on the wall in the dishmachine room. DW stated he documented the concentration of sanitizer (chlorine) from the dishmachine on the log (labeled as a quaternary ammonium sanitizer log). The log had 5 columns per day to document "Test Strip" results. The log for 8/12/24 had an entry of "200 and 175" documented on the "Test Strip" column. The log contained instructions that indicated, "Test the concentration of the ammonium in the quaternary sanitizer using the proper strips. At least once per day, record concentration reading of the quaternary chemical you are using. Ammonium reading should be at least 150-200 ppm, or manufacturers recommendation. Alert Dietary Supervisor if ammonium levels are below minimum."

During an interview on 8/12/24 at 11:01 a.m., with Quality Risk Manager (QRM), QRM stated the hospital did not have a policy and procedure (P&P) on the dishmachine.

During a concurrent interview and record review on 8/13/24 at 10:30 a.m. with Registered Dietitian (RD), RD reviewed a Food Safety and Sanitation Audit form (FSSA), dated 8/8/24, completed by the RD. The FSSA indicated 100% compliance within the foodservice operation as indicated by all categories marked "Yes" for in compliance next to, "Procedures are in place to prevent cross-contamination, knives and other utensils are appropriately maintained and sanitized before each use, food service utensils are sanitized prior to use. . ., Dishwashing machine is filled and used according to manufacturer recommendations, Dishwashing machine chemicals used are monitored for proper dispensing on a routine basis. . ." RD stated her primary role over the foodservice operation was to complete the FSSA on a quarterly basis. RD was asked if she was aware that the foodservice operation did not have P & Ps for the dishmachine to ensure the required temperatures were met per manufacturer guidelines. RD stated, "There is no requirement for temperature for the dishmachine, only for sanitation." RD was asked if she were aware the wrong log for monitoring sanitation was currently in use for the dish machine for August 2024, and RD stated, "I really defer those type things to the foodservice director." RD stated the only involvement she had within the foodservice operation was completing quarterly sanitation audits, attending their meetings, and conducting an in-service on occasion. RD stated she was a clinical RD. RD stated she needed to improve her skill set related to sanitation and food safety requirements for a foodservice operation since she had a role in monitoring nutrition services (FANS).

During a concurrent interview and record review on 8/13/24 at 3:31 p.m. with Food & Nutrition Service Director (FNSD), the "Quaternary Ammonium Log", dated August 2024, posted on the wall in the dishmachine room used by DW was reviewed. FNSD stated the dietary staff used the wrong log and it was not for a dishmachine.

During a review of the FDAFC, dated 2022, the FDAFC indicated, "To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved." (FDA Food Code Annex 3, 4-501.15 Warewashing Machines)

During a review of the FDAFC Annex (FDAFCA), dated 2022, the FDAFCA indicated, "When chemical sanitizers are used, specific minimum temperatures must be met because the effectiveness of chemical sanitizers is directly affected by the temperature of the solution. (4-204.115 Warewashing Machines, Temperature Measuring Devices)

During a review of the FDAFC Annex (FDAFCA), dated 2022, the FDAFCA indicated, "The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed." (4-501.110 Mechanical Warewashing Equipment, Wash)

During a review of RD's job description (JD), the JD indicated, "The position monitors Nutrition Services provided to patients to ensure that standards of care are met in accordance with all associated regulatory agencies." Regulations require there be an RD to provide guidance to ensure systems, and written P&Ps are in place for FANS staff to assure the foodservice operates in a safe and sanitary manner. RDs have a role in monitoring FANS for purposes of identifying unsafe and unsanitary practices in order to rectify immediately for the health and safety of patients, in addition to ensuring staff are competent on food preparation of modified diets. (Refer to federal regulation A-0618, state regulation CA Health & Safety Code 1265.4 (a) and CCR Title 22 70275(a).)

During a review of the FDAFC, dated 2022, the FDAFC indicated, "To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved." (FDA Food Code Annex 3, 4-501.15 Warewashing Machines)

During a review of the FDAFC Annex (FDAFCA), dated 2022, the FDAFCA indicated, "When chemical sanitizers are used, specific minimum temperatures must be met because the effectiveness of chemical sanitizers is directly affected by the temperature of the solution. (4-204.115 Warewashing Machines, Temperature Measuring Devices)

During a review of the FDAFC Annex (FDAFCA), dated 2022, the FDAFCA indicated, "The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed." (4-501.110 Mechanical Warewashing Equipment, Wash)

2. During a concurrent observation and interview on 8/12/24 at 11:42 a.m. with Diet Technician (DT) 1, in the presence of CNO, in the kitchen, Patient 1's lunch meal tray ticket indicated, "sherry beef tips (sirln [sirloin]) 3 oz SB (4 oz)...banana chopped. . ." The beef tips (appeared chopped) served onto Patient 1's meal tray, and the chopped banana located in a mug appeared to be larger than 1/2" [half an inch]. DT 1 was asked what size the food should be when served for a SB6 diet, and DT 1 stated, "SB6 is not a specific size because it's not a minced and moist diet." DT 1 was the last person to check the accuracy of Patient 1's meal tray before placing on the meal delivery cart for distribution.

During a concurrent observation and interview on 8/12/24 at 11:44 a.m. with Cook 2 in the kitchen, Cook 2 was asked if he was trained on what size of food should be served for a SB6 diet, Cook 2 stated, "No, just chopped."

During a concurrent observation and interview on 8/12/24 at 12:20 p.m. with ST (Speech Therapist) in the cafeteria/dining room, in the presence of Chief Nursing Officer (CNO), Patient 1 and Patient 2 were observed with an SB6 diet, as indicated per their meal tray card, in which the meat appeared greater than 1/2 " [inch] in size. ST stated she completed the trial diet with SB6 and Easy to Chew food for Patient 2 and had time for an interview. ST stated she did not know what size of food should be served for a SB6 diet. ST stated SB6 diets were already in place at the hospital when she began her employment in July, so that might be why she had not received training on the SB6 diet. ST stated she thought the SB6 diet food size would be available on the list of posted therapeutic diets, but it was not. ST stated she would look into the hospital's SB6 diet and discuss more later.

During an interview on 8/12/24 at 12:25 p.m. with CNO, CNO was asked if she knew what the food size should be with a SB6 diet order, and CNO stated, "Can I look and get back to you?" CNO stated she could not recall if or when IDDSI (International Dysphagia Diet Standardization Initiative) training was provided and that IDDSI was implemented a while back. CNO was asked to let the hospital Quality Risk Manager (QRM) know that a copy of the IDDSI training and date implemented was requested.

During an interview on 8/12/24 at 3:14 p.m. with Speech Therapist (ST), ST stated she found out the hospital's "SB6 diet should be 1.5 centimeter [cm, 1.5 cm = .59 inch] by 1.5 cm in size." ST stated Patient 1 had already finished eating but he had untouched beef left on his meal tray and she was able to observe the size of chopped beef [beef tips]" and they were too large." ST stated the SB6 diet served to Patient 2 for lunch today was not 1.5 cm x 1.5 cm in size for the food. (Refer to A-0631)

During a review of the hospital's approved diet manual, dated 2024, for "Level 6 Soft And Bite-Sized (SB6)" diet, [undated] the SB 6 diet indicated "Definition: The Level 6 Soft and Bite-Sized diet is prescribed for people who have difficulty chewing hard, tough, stringy or crunchy food and are unable to safely bite off pieces of food. Some chewing ability is required to break further into pieces and to move food around for a safe swallow. This diet requires a texture modification so that foods are soft, tender, moist and have no separate thin liquids. Foods should have a particle size no larger than 1.5 centimeters x 1.5 centimeters. Foods should further meet the complete descriptive and testing specifications of the International Dysphagia Diet Standardization Initiative (IDDSI, 2019a; IDDSI, 2019b)...Foods Not Recommended. . .Protein foods in sizes larger than 1.5 cm x 1.5 cm pieces."

During an interview on 8/12/24 at 3:58 p.m. with RD, RD stated IDDSI diets had been implemented at the hospital since at least 2021. RD stated she could not recall about hospital training on IDDSI. IDDSI training records were requested.

During an interview on 8/13/24 at 2:58 p.m. with RD, RD stated she attended quality council meetings. RD stated she currently had two qualitative items that are being tracked related to her role as the clinical nutrition Dietitian. RD stated those are tracking timeliness of RD nutrition assessments and follow ups and completing nutrition assessments and patient education for those patients taking Warfarin (a medication used to treat and prevent blood clots) that were started in 2021. RD was asked if she currently had any other performance improvement (PI) projects she was working on, and RD stated, "Not right now." RD was asked if she had adequate time to address PI projects, and RD stated, "If I identified one, I would make the time."

During a review of "NCM [Nutrition Care Manual] News Bites Spring 2021 (NCM), dated Spring 2021, the NCM indicated, "The Academy of Nutrition and Dietetics is pleased to announce that beginning October 2021, IDDSI will be the only texture-modified diet recognized."

During a review of the hospital's job description (JD) for position titled "Dietitian", [undated], the JD indicated, "Position Purpose: The Dietitian plans therapeutic diets and confers with patients, doctors, nursing staff and patient family members concerning these diets. The position monitors Nutrition Services provided to patients to ensure that standards of care are met in accordance with all associated regulatory agencies and the administrative policies of the hospital. The dietitian instructs patients in diets for home use prior to discharge and as outpatients. . .To ensure the accuracy of food production as related to modified diets, the Dietitian acts in a supervisory capacity, as needed and performs other project assignments, Responsibilities and Tasks:. . .Ensures updated diet manuals are current/available in Nutrition Services Department, nursing units. Conducts in-service on Nutrition/modified diets to Nutrition Services staff and other disciplines."

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

1. Ensure Diet Technician (DT) 2 was knowledgeable on the hospital's policy and procedure (P&P) titled, "Allergies" and on the Registered Dietitian's (RD) expectation to be informed by DT 2 when one of one sampled patient's (Patient 7) informed DT 2 he may have a milk allergy or lactose intolerance during DT 2 assisting Patient 7 with his menu choices in which pudding was selected.

2. Ensure one of one sampled patient's (Patient 9) lunch tray was served per the planned select menu for a regular diet.

3. Ensure an RD consult order for dialysis (purification of the blood) was completed for one of two sampled patient's (Patient 8) within 72 hours per the hospital's policy and procedure.

4. Ensure planned menu portion size was followed during observation of lunch trayline for green beans.

As a result of failing to alert the Physician, nursing and RD, to any potential food allergies or lactose intolerance impeded timely assessment and development of a plan of care to ensure patients nutritional needs are met in a safe manner.

As a result of failing to serve the menu as planned a patient's nutritional needs may not be met which could result in unplanned weight loss.

Findings:

1. During an observation on 8/12/24 at 11:43 a.m. of lunch trayline for patients on the cafeteria/dining room side of the kitchen, Patient 7's meal tray card (MTC) located on his lunch meal tray indicated, allergy to "butter and milk" with "No milk, no caffeine, no butter" also listed. Patient 7's MTC also had "No known Allergies" listed near the allergy to milk and butter located at the top of the meal tray card. Patient 7's meal tray card had a circle around pudding. Diet Technician (DT) 1 was observed placing pudding on his meal tray and placed his lunch meal tray in the meal delivery cart for distribution. There was not a Food & Nutrition Services Director nor an RD present for interview.

During a concurrent observation and interview on 8/12/24 at 2:59 a.m. with DC in the dining room, DC reviewed Patient 7's meal tray card located in the E[electronic]-Menu software via a tablet. DC stated Patient 7's E-Menu listed milk and butter as a food allergy. DC stated if a food was listed under allergy, then it was an actual food allergy and not just a food dislike. DC showed the area in the E-menu where food dislikes would be listed which was blank. DC stated she assisted Patient 7 in completing his lunch selections from a select menu, and DC stated pudding was circled meaning it was his choice and dietary staff should provide pudding. DC was asked if pudding was milk based, and DC stated, yes. DC stated she communicated with the RD (DC specified the name of RD) about Patient 7's request for pudding, and RD stated he could have pudding. DC stated Patient 7 told her he was not sure if he had a milk allergy or if he was lactose intolerant and that she had informed RD (DC specified the name of RD) of that as well. DC was asked if the E-menu software interfaces with Patient 7's electronic medical record, and DC stated, no.

During a review of the facility's "Patient Dining Details Report (PDDR)", dated 8/12/24, the PDDR indicated, Patient 7 had a food allergy to butter, milk and also there was an "A" for allergy listed next to "No Known Allergies", and a list of food dislikes consisting of "No milk, no caffeine, no butter."

During a concurrent interview and record review on 8/12/24 at 3:45 p.m. with RD, in the presence of Chief Nursing Officer (CNO), RD was asked if she was made aware of Patient 7 stating he may have a milk allergy and requesting pudding. RD stated, no, that was not brought to her attention. RD was asked if she had been made aware of Patient 7 stating he did not know if he had a milk allergy or was lactose intolerant, and RD stated, no. RD reviewed Patient 7's electronic medical record (EMR) and stated there was no documentation in the EMR that Patient 7 had a food allergy or lactose intolerance. The CNO reviewed Patient 7's EMR to review where nursing would document a food allergy if a patient reported one, and CNO stated there was no documentation of a milk allergy or lactose intolerance. RD was informed that Patient 7's E-Menu (that generates Patient 7's meal tray card used by kitchen staff when plating Patient 7's meals) indicated Patient 7 had a food allergy to milk and butter, yet he was provided pudding during lunch today. RD was asked if E-Menu software via the tablet interfaces with a patient's EMR, and RD stated, yes. RD stated she would speak with DC to further investigate the disconnect between food allergy information contained in the E-Menu software used by the Food & Nutrition Department versus Patient 7's EMR used by the physician responsible for the care of the patient. RD stated she would have expected DC to communicate with her immediately when Patient 7 reported a food allergy or lactose intolerance concern for timely nutrition assessment and development of a nutrition plan of care.

During an interview on 8/13/24 at 10:03 a.m. with RD, RD stated she clarified with Patient 7 this morning and "he is lactose intolerant." RD stated she was further investigating how food allergies were listed in the E-Menu for Patient 7.

During a review of the facility's policy and procedure (P&P) titled, "Allergies, dated 9/29/23, the P&P indicated, "Purpose: Ensure proper documentation and identification of allergies. Definitions: An allergic reaction is defined as the hypersensitive response of the immune system to an allergen. Responsibility: It is the responsibility of the Chief Nursing Officer and other clinical leaders to implement and sustain compliance with this policy. Policy:. . .The person learning of the allergy is responsible for reporting it to the nurse assigned to the patient. The allergy and the nature of the allergic response shall be documented in the medical record. . .Notify pharmacy and interdisciplinary team. . .Notify dietary of food allergies on admission and/or during length of stay. . .Notify the physician of all suspected allergic reactions and document in medical record."

During a review of the facility's P&P titled, "Nutritional Assessment, Re-assessment and Care Planning", dated 9/29/23, the P&P indicated, "Purpose: To provide appropriate nutritional care based upon an organized system of evaluating patient needs, deficiencies and subsequent nutritional care goals. Responsibility: It is the responsibility of the Registered Dietitian to complete Nutritional Assessment in a timely manner and document in the patient's medical record,"

2. During an observation on 8/12/24 at 12:04 p.m. in a hallway, Certified Nursing Assistant (CNA) 2 walked lunch tray to Patients 9's room. CNA 2 assisted Patient 9 with lunch tray set up and walked out of room.

During a concurrent observation and interview on 8/12/24 at 12:12 p.m. with Patient 9, in Patients 9's room, Patients 9's lunch tray contained: chicken breast, dinner roll, and a white lump material food item. Patient 9 compared her lunch tray items to her meal ticket (order). Patient 9 stated she was missing her baked potato, green beans, and vanilla pudding. Patient 9 stated this was not what she ordered.

During a concurrent observation and interview on 8/12/24 at 12:13 p.m. with CNA 2 in Patient 9's room, Patient 9's lunch meal tray with Patient 9's individualized meal ticket was observed. CNA 2 stated at times the kitchen would substitute food items on meal trays. CNA 2 stated this meal ticket did not have any substitutions on it.

During an interview on 8/12/24 at 12:15 p.m. with Registered Nurse (RN) 1, RN 1 stated he only checked the meal carts when he was passing trays. RN 1 stated he did not check the lunch trays today.

During a review of Patient 9's "Meal Ticket (MT)," dated 8/12/24, the MT indicated, "No restrictions, Greek roasted chicken, green bean casserole, baked potato, dinner roll, vanilla ice cream pudding."

During an interview on 8/14/24 at 9:50 a.m. with Nutrition Services Director (FNSD), FNSD stated she had confirmed with dietary staff that Patient 9's lunch meal tray was served with missing food items that were chosen by Patient 9 on her select (list of choices) menu.

During a review of the facility's policy and procedure(P&P) titled, "Patient Tray Identification/Delivery System," dated 9/29/23, the P&P, indicated, "Trays are clearly identified by means of patient meal [sic] tickets; these meal tickets are double checked with the patient's identification band to assure that the patient receives the correct tray and the appropriate diet as ordered. Trays are clearly identified by means of patient selective menu slips; these menus slips are double checked . . . to assure that the patient receives the correct tray and the appropriate diet as ordered."

3. During a concurrent interview and record review on 8/13/24 at 10:45 a.m. with the Registered Dietitian (RD), in the presence of the Chief Nursing Officer (CNO), Patient 8's electronic medical record (EMR) was reviewed. Patient 8's "Facesheet [admission]" indicated Patient 8 was admitted to the hospital on 8/6/24. Patient 8's "Order Sheet [OS]", dated 8/6/24, indicated, "Diet. . .Regular [texture], liquid consistency. . .Consistent Carbohydrate [for diabetes diet]." Patient 8's "OS", dated 8/7/24, indicated "Hemodialysis (removes waste and extra fluids from the blood) ". RD stated a dialysis order would trigger an RD consult order, in which RDs have 72 hours to complete. RD was asked how RDs get notified when there was an RD consult order. RD stated if an RD consult was ordered it would automatically display on a "multipatient task list". RD stated it was the "multipatient task list" that she utilized to see if there were any RD consult orders that needed to be addressed. RD reviewed Patient 8's EMR and was unable to find a completed nutrition assessment for Patient 8 since admission. RD reviewed the "multipatient task list" and stated there was no RD consult order placed for Patient 8. Concurrently, the CNO reviewed Patient 8's EMR and was unable to locate an order for an RD consult.

During a concurrent interview and record review on 8/13/24 at 11:00 a.m. with the Registered Dietitian (RD), in the presence of the Chief Nursing Officer (CNO), Patient 8's "OS", dated 8/9/24, indicated, "Diet. . .texture :. . . Regular. . .Restrictions: Renal [kidney]. . .1500mL [milliliter]; Order comments: pt [patient] is a ESRD [end stage renal disease], on HD [hemodialysis] MWF [Monday, Wednesday, Friday]." RD was asked if a therapeutic renal diet and/or fluid restriction of 1500mL per day would trigger an RD to complete an individualized nutritional needs assessment in order to evaluate tolerance and whether the therapeutic diet was meeting the patient's nutritional needs. RD stated, no, therapeutic diets do not trigger an RD to conduct an individualized nutrition assessment in and of themselves. RD again, confirmed Patient 8 had not had a nutrition assessment completed since admission.

During a concurrent interview and record review on 8/13/24 at 11:16 a.m. with the Dialysis Program Manager (DPM), in the presence of the RD, CNO and Quality Risk Manager (QRM), the DPM stated any patient who would need dialysis would also have an RD Consult order. DPM stated she would receive notification in advance that a patient had been authorized to be admitted to the hospital and would know in advance whether the patient would be needing dialysis. DPM stated she placed an RD Consult Order for Patient 8, triggered by being a known dialysis patient, as a "Proposed Order", on 8/6/24. DPM stated "Proposed Order" meant the patient was not physically at the hospital yet and had not been admitted to the hospital yet.

During a review of Resident 8's "OS", dated 8/6/24, the "OS" indicated, "Consult to Dietitian, ESRD on HD Order comments: Date & Time called - Called to-. . ." There were no documented details as to "Date & Time called", it was blank.

During an interview on 8/13/24 at 11:23 a.m. with RD, in presence of DPM, QRM and CNO, RD stated there was a communication system failure because when the order was entered as a "Proposed Order", the order had not automatically populated the "multipatient task list" which she used to become aware that a RD Consult order was placed. RD stated, "I didn't know. It was missed."

During a concurrent interview and record review on 8/14/24 at 12:15 p.m. with the QRM, QRM stated the hospital did not have a specific policy and procedure to detail the RD Consult order should be placed when hemodialysis was first ordered but did verify that was the hospital practice within the hospital's "Chronic Dialysis Services Program Plan (CDSPP)." The CDSPP indicated, "The plan provides the framework, guidelines, and structure to support entity and quality control, quality assessment, and performance improvement activities related to the provision of care and service as a Chronic Dialysis Program. . ., The scope of services includes. . .To educate patients and their families about. . .diet. . .To ensure that appropriate discharge plans are formulated and implemented for each patient. . .Responsibilities. . .The requirements of this plan apply to all departments, services, committees and other organizational elements of [name of hospital] Chronic Dialysis Program. . .The Core Chronic Dialysis Program Members includes: . . .Dietician. . ."

During a review of the facility ' s policy and procedure (P&P) titled, "Nutritional Assessment, Re-assessment, and Care Planning," dated 9/23/23, the P&P indicated, "Purpose: To provide appropriate nutritional care based upon an organized system of evaluating patient needs, deficiencies and subsequent nutritional care goals. Responsibility: It is the responsibility of the Registered Dietitian to complete Nutritional Assessment within 72 hours of the order for dietitian consultation. . .The Registered Dietitian then interprets and documents findings such as: confirmation of diet order and statement of appropriateness of diet order if change is indicated. . .estimated current kcal/protein/fluid requirements. . .Based on these findings, the Registered Dietitian establishes the nutrition care plan for the patient identifies goals, recommends specialized nutrition care interventions, and determines the frequency of follow up. . ."

4. During a concurrent observation and interview on 8/12/24 at 11:34 a.m. with Cook 2 in the cafeteria/kitchen during observation of trayline for patients, Cook 2 was observed using a stainless steel slotted serving spoon to serve green beans to those patients who chose green beans on their select menu. Per the planned menu a 1/2 cup of green beans was to be served as indicated on individual meal tray cards if a patient selected green beans. Cook 2 was asked if the large, slotted serving spoon indicated a measured amount, or portion size. Cook 2 did not respond, and he left the trayline area. Diet Technician (DT) 1, who was also working at trayline, stated the slotted spoon was too large of a portion of green beans and he went to get a different serving utensil. Cook 2 promptly returned with a # [number]16 scoop. DT 1 informed Cook 2 that he needed a gray handled #8 scoop which would be 1/2 cup for the green beans. DT 1 and Cook 2 left the trayline area and promptly returned both stating the kitchen did not have any more gray handled #8 scoops. Cook 2 stated he would just use a #16 scoop (equivalent to two ounces) twice. There was not a Food & Nutrition Services Director (FNSD), nor a Registered Dietitian present during trayline observation to interview.

During an interview on 8/13/24 at 9:38 a.m., the (FNSD), FNSD stated that the foodservice operation had adequate quantity of gray handled #8 scoops (1/2 cup) available for use. FNSD stated staff had informed her that an incorrect portion of green beans were served yesterday with a slotted serving spoon.

During a review of the facility's policy and procedure (P&P) titled, "Service of Meals," dated 9/29/23, the P&P indicated, "Purpose: To ensure the highest level of quality food service. Responsibility: The Nutrition Manager/Director and Management Team ensure these procedures are taught, followed and enforced. Policy: All foods shall be handled and served. . .adhering to the safe sanitary standards and nutrition principles and procedures defined to ensure quality, accuracy. . .of meal service. . .All food is served by qualified individuals, trained at a level their position requires, who adhere to the policies and standards of the facility...Appropriate portioning utensils and equipment are available to personnel for proper preparation or serving."

During a review of the facility's "Portion Control Chart," located in the kitchen, the Portion Control Chart indicated, "Control accurate portions. . .Find the correct disher/scoop utensil for your serving size. . .Disher/Scoop Size #16 was capacity of 2 ounces, Scoop Size #8 was capacity 4 ounces."

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT) (Speech Therapist, Food and Nutrition Services Department/all positions, and Nursing) were knowledgeable on the therapeutic Soft and Bite Sized (SB6) diet routinely ordered at the hospital when the hospital did not correctly prepare and serve the physician ordered SB6 diet to two of six sampled patient's (Patient 1, Patient 2).
This failure had the potential to place all patients with a physician ordered SB6 diet (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6) at an increased risk of choking, decreased nutrient intake which may lead to unplanned weight loss.

Findings:

During a concurrent observation and interview on 8/12/24 at 11:42 a.m. with Diet Technician (DT) 1 in the kitchen, Patient 1's lunch meal tray ticket indicated, "sherry beef tips (sirln [sirloin]) 3 oz SB (4 oz).. .banana chopped. . ." The chopped beef (beef tips) served onto Patient 1's meal tray, and the chopped banana located in a mug appeared to be larger than 1/2" [half an inch]. DT 1 was asked what size the food should be when served for a SB6 diet, and DT 1 stated, "SB6 is not a specific size because it's not a minced and moist diet." DT 1 was the last person to check the accuracy of Patient 1's meal tray before placing on the meal delivery cart for distribution.

During a concurrent observation and interview on 8/12/24 at 11:44 a.m. with Cook 2 in the kitchen, Cook 2 was asked if he was trained on what size of food should be served for a SB6 diet, Cook 2 stated, "No, just chopped." There was not a Registered Dietitian (RD) or a Food & Nutrition Services Director (FNSD), or any supervisor or manager present in the kitchen knowledgeable on therapeutic diets to double check the meal tray for accuracy. The Speech Therapist (ST) was requested but then the Chief Nursing Officer (CNO) pointed to the ST who was occupied assisting Patient 2 in the cafeteria/dining room with his meal. The Controller (C) was present who stated he was in charge of the dietary department although he relied on Cook 1 to answer his questions related to food safety, while the FNSD was out of the State.

During a concurrent observation and interview on 8/12/24 at 12:10 p.m. with Patient 1 in the cafeteria/dining room, Patient 1 was observed eating lunch with assistance/supervision from Certified Nursing Assistant (CNA) 1. CNA 1 was observed assisting with a bite full of chopped beef with a beef tip that appeared greater than 1/2".

During a concurrent observation and interview on 8/12/24 at 12:15 p.m. with Speech Therapist (ST) and Patient 2 in the cafeteria/dining room, ST was sitting at the dining table across from Patient 2. Patient 2's lunch meal tray card indicated SB6 diet. ST was asked if the SB6 diet served was appropriate in size for the meat. ST stated she was conducting a trial diet of SB 6 and "Easy to Chew" diet texture modifications.

During a concurrent observation and interview on 8/12/24 at 12:20 p.m. with ST in the cafeteria/dining room, in the presence of Chief Nursing Officer (CNO), ST stated she completed the trial diet for Patient 2 and had time for an interview. ST stated she did not know what size of food should be served for a SB6 diet. ST was asked if she had received training on the IDDSI (International Dysphagia Diet Standardization Initiative) diets, and ST stated IDDSI diets were already in place at the hospital when she began her employment in July, so that might be why she had not. ST stated she thought the SB6 diet food size would be available on the list of posted therapeutic diets, but it was not. ST stated she would look into the hospital's SB6 diet and discuss more later.

During an interview on 8/12/24 at 12:25 p.m. with (Chief Nursing Officer) CNO, CNO was asked if she knew what the food size should be with a SB6 diet order, and CNO stated, "Can I look and get back to you?" CNO stated she could not recall if or when IDDSI training was provided and that IDDSI was implemented a while back. CNO was asked to let the hospital's Quality Risk Manager (QRM) know that a copy of the IDDSI training and date implemented was requested.

During an interview on 8/12/24 at 3:14 p.m. with ST, ST stated she found out the hospital's "SB6 diet should be 1.5 centimeter (cm, 1.5 cm = .59 inch) by 1.5 cm in size." ST stated Patient 1 had already finished eating but he had untouched beef left on his meal tray and she was able to observe the size of chopped beef (beef tips) "and they were too large." ST stated the SB6 diet served to Patient 2 for lunch today was not 1.5 cm x 1.5 cm in size for the food.

During a review of Patient 1's "Facesheet (Admission)", Patient 1 was admitted to the hospital on 7/30/24 for "Medical Service: CVA (Cerebrovascular Accident; a loss of blood flow to part of the brain) Stroke Program; Subspecialty: PUL (branch of medicine that deals with the causes, diagnosis, prevention and treatment of diseases affecting the lungs) Pulmonary Program."

During a review of Patient 1's "Order Sheet (OS)", dated 7/31/24, the "OS" indicated, "Texture Level 6 - Soft & Bite Sized. . ."

During a review of Patient 1's "Nutrition Assessment (NA)", dated 7/31/24, the "NA" indicated, "RD assessment triggered by system consult for dysphagia (difficulty swallowing)."

During a review of Patient 2's "Facesheet (Admission)", Patient 2 was admitted to the hospital on 7/23/24 for "Medical Service: CVA Stroke Program."

During a review of Patient 2's "Order Sheet (OS)", dated 8/8/24, the "OS" indicated, "Texture: Level 6 - Soft & Bite-Sized. . ."

During a review of Patient 2's "DOC [documentation] Speech Therapy (DST)", dated 8/12/24, the "DST" indicated, "Patient declined diet upgrade to regular consistency diet; Will continue with Soft & Bite-Sized diet."

During an interview on 8/12/24 at 3:58 p.m. with Registered Dietitian (RD), RD stated IDDSI diets had been implemented at the hospital since at least 2021. RD stated she could not recall about hospital training on IDDSI. IDDSI training records were requested.

During an interview on 8/13/24 at 2:58 p.m. with RD, RD stated she attended quality council (QC) meetings. RD stated she currently had two qualitative items that are being tracked via "QC" related to her role as the clinical nutrition Dietitian. RD stated those are tracking timeliness of RD nutrition assessments and follow ups and completing nutrition assessments and patient education for those patients taking Warfarin (a medication used to treat and prevent blood clots) that were started in 2021. RD was asked if she currently had any other performance improvement (PI) projects she was working on, and RD stated, "Not right now." RD was asked if she had adequate time to address PI projects, and RD stated, "If I identified one, I would make the time."

During an interview on 8/14/24 at 9:40 a.m. with QRM, RD, FNSD and CNO, it was discussed that SB6 diet was not followed and IDT and dietary staff not knowledgeable on SB6 diet had been identified by the survey team and was of concern. In addition, it was discussed that not only was the meat size not followed but other aspects of SB6 were not followed as well per the diet manual and standards of practice. It was communicated it was the hospital's responsibility to identify gaps in nutritional care with not only SB6 but to further investigate all IDDSI diets, their operations related to IDDSI and address their training needs.

During a review of Patient 3's "Facesheet (Admission)", Patient 3 was admitted to the hospital on 8/10/24 for "Admit Reason: L5 fracture (fracture of bony segments composing the spinal column of the lower part of the back)."

During a review of Patient 3's "Order Sheet (OS)", dated 8/10/24, the "OS" indicated, "Texture: Level 7 - Easy to Chew. . ."

During a review of the hospital's "Patient Dining Details Report (PDDR)", printed on 8/12/24 at 9:59 a.m., the "PDDR" indicated, Patient 3's "Diet Order: . . .SB6."

During a review of Patient 4's "Facesheet (Admission)", Patient 4 was admitted to the hospital on 8/10/24 for "Sepsis (a body 's extreme reaction and response to an infection, causing organ failure)."

During a review of Patient 4's "Order Sheet (OS)", dated 8/10/24, the "OS" indicated, "Texture: Level 6 -Soft & Bite-Sized. . ."

During a review of Patient 4's "DOC - Speech Therapy (DST)", dated 8/12/24, the "DST" indicated, "Swallow Evaluation. . .Diet Type: 8/10/24, Texture: Level 6 -Soft & Bite-Sized. . .Diet- Ordered 8/12/24, Texture: Level 7 - Regular. . .Swallowing progress towards goals: Diet upgraded to Regular consistency. . .Assessment:. . .Diet upgraded from Soft & bite-sized to regular consistency on this date. Nursing staff notified."

During a review of Patient 5's "Facesheet (Admission)", Patient 5 was admitted to the hospital on 8/10/24 for "Neurological Cond [condition]."

During a review of Patient 5's "Order Sheet (OS)", dated 8/10/24, the "OS" indicated, "Texture: Level 7-Regular. . ."

During a review of Patient 5's "DOC [documentation] Speech Therapy (DST)", dated 8/12/24, the "DST" indicated, "Swallow Evaluation. . .Swallowing Pre-Assessment; Diet Type 8/10/24; Texture: Level 7 - Regular. . ., Diet - Ordered 8/12/24 Texture: Level 6 -Soft & Bite-Sized. . .Diet Consistency Recommendation: Level 6 -Soft & Bite-Sized. . .Assessment:. . .Pt [patient] declined solids as he reports feeling weak and too fatigued. SLP [speech language pathologist] discussed prior recommended diet of SB6, which pt agreed is easier for him to consume. . ."

During a review of Patient 6's "Facesheet (Admission)", Patient 6 was admitted to the hospital on 8/07/24 for "Neurological Conditions."

During a review of Patient 6's "Order Sheet (OS)", dated 8/8/24, the "OS" indicated, "Texture: Level 6 -Soft & Bite-Sized. . ."

During a review of Patient 6's "DOC [documentation] Speech Therapy (DST)", dated 8/08/24, the "DST" indicated, "Swallow Evaluation. . .Swallow Assess/Recommendations. . .Diet Consistency Recommendation: Level 6 -Soft and Bite-Sized. . .Planned Treatments: Dysphagia therapy. . ."

During a review of the facility's policy and procedure (P&P) titled, "Diet Orders and Confirmation", dated 9/29/23, the P&P indicated, "Purpose: To provide a multi-disciplinary method to ensure diet orders are recorded by an authorized individual in the medical record and confirmed before a diet is served to the patient. Responsibility:. . .The Nutrition Department is responsible for providing meals which reflect the current diet order. It is the responsibility of the Registered Dietitian to monitor compliance to this standard and to communicate discrepancies to appropriate department managers when the standard is not met. Policy:. . .Diet orders comply with accepted terminology as stated in the Academy of Nutrition and Dietetics Nutrition Care Manual. . ."

During a review of the facility's P&P titled, "Diet Manual", dated 9/29/23, the P&P indicated, "Purpose: To provide medically accepted diet manual for hospital use as standard for nutritional care. Responsibility: Registered Dietitian, Nutrition Services Manager/Director, Chief Nursing Officer, Policy: The standard Diet Manual, for which therapeutic diet menus are based, is the Academy of Nutrition and Dietetics Nutrition Care Manual. The Diet Manual is approved by the Dietitian and the Medical Director and authorized by governing body."

During a review of the hospital's approved diet manual, (most recent version dated 2024) for "Level 6 Soft And Bite-Sized (SB6)" diet, undated, the SB 6 diet indicated "Definition: The Level 6 Soft and Bite-Sized diet is prescribed for people who have difficulty chewing hard, tough, stringy or crunchy food and are unable to safely bite off pieces of food. Some chewing ability is required to break further into pieces and to move food around for a safe swallow. This diet requires a texture modification so that foods are soft, tender, moist and have no separate thin liquids. Foods should have a particle size no larger than 1.5 centimeters x [by] 1.5 centimeters. Foods should further meet the complete descriptive and testing specifications of the International Dysphagia Diet Standardization Initiative (IDDSI, 2019a; IDDSI, 2019b)...Foods Not Recommended. . .Protein foods in sizes larger than 1.5 cm x 1.5 cm pieces."

During a review of on-line source titled "IDDSI.Org", dated 2024, IDDSI indicated, "Yes, all foods (sandwiches included) need to meet the particle size requirements for Level 6 - Soft & Bite-sized. . . In order to avoid asphyxiation (when you don't get enough oxygen in your body; example: food blocking your airway), particles should be small enough to pass through rather than block the trachea (the air passage from the throat to the lungs). The average tracheal size for adult males is 22 mm [millimeters, unit of measurement] and for adult females is 17 mm (Brodsky et al., 1996). Particle sizes of 15 mm (i.e. 1.5 centimeters [cm]) size are therefore more likely to pass through the trachea, than block it." (https://iddsi.org/FAQ/Foods)

During a review of the facility's policy and procedure (P&P) titled, "Service of Meals", dated 9/29/23, the P&P indicated, "Purpose: To ensure the highest level of quality food service. Responsibility: The Nutrition Manager/Director and Management Team ensure these procedures are taught, followed and enforced. Policy: All foods shall be handled and served. . .adhering to the safe sanitary standards and nutrition principles and procedures defined to ensure quality, accuracy. . .of meal service. . .Patient meals trays are prepared in the Nutrition Services department and are delivered to the Nursing units, to be distributed to patient room or group dining areas."

During a review of the hospital's job description (JD) for position titled "Dietitian", undated, the JD indicated, "Position Purpose: The Dietitian plans therapeutic diets and confers with patients, doctors, nursing staff and patient family members concerning these diets. The position monitors Nutrition Services provided to patients to ensure that standards of care are met in accordance with all associated regulatory agencies and the administrative policies of the hospital. The dietitian instructs patients in diets for home use prior to discharge and as outpatients. . .To ensure the accuracy of food production as related to modified diets, the Dietitian acts in a supervisory capacity, as needed and performs other project assignments, Responsibilities and Tasks:. . .Ensures updated diet manuals are current/available in Nutrition Services Department, nursing units. Conducts in-service on Nutrition/modified diets to Nutrition Services staff and other disciplines."

(The hospital had not provided any evidence of hospital wide training on IDDSI diets prior to exit.)

Based on observation, interview and record review, the facility failed to ensure one of two housekeeping carts was secure and locked. This failure had the potential to result in patients, visitors and staff exposure to chemicals.

Findings:

During an observation on 8/12/24 at 10:35 a.m. on east hallway, there was a housekeeping cart between the public restrooms with no staff present, unlocked, with cleaning chemicals inside.

During an interview on 8/12/24 at 10:50 a.m. with House Keeping (HK)1, HK1 stated housekeeping carts should be locked at all times.

During an interview on 8/12/24 at 11:07 a.m. with HK 2, HK2 stated his cart should be locked but the lock was broken. HK2 stated he did not report the broken lock to his supervisor. HK2 stated he left his house keeping cart, with cleaning chemicals, in the hallway, between the public restrooms, unattended.

During an interview on 8/13/24 at 9:30 a.m. with Facility Maintenance Director (FMD), FMD stated housekeeping carts needed to be locked. FMD stated," that's unacceptable."

During a review of the facility's policy and procedure (P&P) titled, "Hazardous Materials and Waste Management Plan," dated 6/20/19, the P&P indicated," Performance standards exist in the form of policies and . . . routine procedures for incident reporting, and inspection, preventive maintenance and testing of applicable equipment. There are also mechanisms in place, which provide specific precautions, procedures, and protective equipment used during hazardous materials and waste spills or exposures."