HospitalInspections.org

Based on staff interview and facility document review, the hospital failed to ensure that 1 of 5 employee personnel records had a current CPR certification as required by their duty statement and as indicated in the facility policies.

Findings:

On 6/24/10 at 10:30 a.m., review of five personnel records indicated that 1 of 5 staff, assigned to work in the acute hospital, did not have a current CPR certification.

During an interview on 6/24/10 at 11:00 a.m., Staff C acknowledged that Staff D last attended CPR review on 11/5/07. Staff C further acknowledged that Mandatory training was a requirement as indicated in the policy and procedures and Review of the Physician Duty statement indicated that participation in education both in or out of the facility was a requirement.

Based on clinical record review and staff interview, the hospital failed to ensure that 1 of 15 patient's records reviewed contained evidence that the family/representative was contacted upon admission to the hospital and consent for treatment was obtained (Patient 7).

Findings:

On 6/22/10 Patient 7's clinical record was reviewed, the consent for treatment form was not signed and the record did not contain evidence that the patient's family/representative was contacted to obtain consent for treatment.

During an interview with the hospital nursing manager (Staff A), it was confirmed that the patient's record did not contain documentation that consent for treatment had been obtained or that the patient's family/representative had been contacted upon admission to the hospital.

Based on clinical record review and staff interview, the hospital failed to ensure that 1 of 15 patient's records reviewed contained evidence that the family/representative was contacted upon admission to the hospital. (Patient 7).

Findings:

On 6/22/10 Patient 7's record was reviewed, the consent for treatment form was not signed and the record did not have evidence that the patient's family/representative was contacted to obtain consent for treatment.

During an interview with the hospital nursing manager (Staff A), it was confirmed that the patient's record did not contain documentation that consent for treatment had been obtained or that the patient's family/representative had been contacted upon admission to the hospital.

Based on medical record review and staff interview, the hospital failed to ensure that the information within the record was useful in monitoring nutritional status for two of five closed records reviewed for nutrition information (patient 14 and Patient 15). By not having useful timely information within the medical record there was the potential for inaccurate assessments.

Finding:

1. Patient 14 was admitted to the hospital on 3/19/10. Patient 14 who was five feet eleven inches had a history of colostomy with infection, constipation, hypertension, depressive psychosis, PICA (eating non-food items) and incurred a recent weight gain of 12 lbs in the past three months --having a weight of 169.7 lbs. Closed record review conducted on 6/29/10 between 1:15 p.m. and 1:30 p.m., revealed that the initial nutrition assessment (screen) for Patient 14 was one day late per Dietitian 1 who also reviewed the record.

On 3/23/10 Patient 14 was assessed by a registered dietitian and determined to be at moderate nutrition risk and needing additional dietary fiber. This screen and recommendation was four days after admission which was a one day delay. The policy, "Meeting Nutritional Needs of Clients" stipulates that the screen must be completed by a dietitian within 72 hours of admission so as to better ascertain nutritional needs.

2. Patient 15 was admitted to the hospital on 5/13/10. According to the nutrition assessment (screen) of 5/14/10 Patient 15 who was an adult male was five feet two inches, weighed 100 lbs and had incurred a 14.5 lb weight loss in 9 months. The registered dietitian (Dietitian 4) who conducted the screen noted that the weight trend was undesirable and circled both high risk and moderate risk which was a departure from the procedure described by Dietitian 1 on 6/22/10 at 3 p.m.

Further, there was erroneous weight data on 5/18/10 within the medical record which was incorporated in the nutrition assessment of 5/20/10. The latter was of concern as the recorded weight was 86.2 lbs which was not verified by nursing staff although prompted by Dietitian 3 on 5/19/10. The latter was of significance, given Patient 15's nutritional risk, history of weight loss, food refusal, dysphagia and depressive disorder as well as on-going notes from Dietitian 3 who was recommending nutrition support in lieu of an oral diet.

Based on document review and staff interview, the hospital failed to indicate how the facility ensures that the medical staff and pathologist determines the type of examination required to be performed on tissue specimens.

Findings:

On 6/21/10 review of the General Laboratory Handbook section on tissue specimens failed to indicate how the facility ensures that the medical staff and a pathologist determine the type of examination required to be performed on tissue specimens.

During an interview with laboratory staff on 6/21/10 at 12:30 p.m., Staff B stated that the section of the laboratory handbook was updated on 9/26/08 and that this information was thought to have been included in the policy. Staff B further stated that the requesting physician fills out a form which accompanies the biopsy. A copy of the form was not available for review.

Based on observation, staff interview and document review the hospital failed to ensure that it was organized with respect to nutrition care and foodservice operations. By not having such organization there was the potential for: inaccurate, incomplete nutrition assessments; confusion regarding nutrition risk categorization; infrequent updates regarding standards of practice, including advancements in nutrition support; insufficient surveillance and remediation of specific concerns, inclusive of equipment operations, food quality and patient rights for food choices; untimely evaluations of foodservice staff responsible for safe, sanitary food production and distribution; confusion in referencing approved policies, including those pertaining to emergencies/disasters; and lack of guidance from hospital staff responsible for employee health.

Findings:

1. On 6/24/10 between 10: a.m. and noon and then between 1:30 p.m. and 3:12 p.m. while in an administrative conference room review of the dietetic service organization and support documents, inclusive of departmental policies and procedures with Dietitian 2 revealed:

a. There was no standard in-house, approved guideline or reference for registered dietitians to evaluate food/drug interactions and related considerations. At 10:30 a.m. Dietitian 2 stated that the evaluation of interactions, e.g. food/drug and special considerations for enteral feeding had been discretionary on the part of the hospital's dietitians.

b. Review of departmental policies revealed that there were inconsistent descriptions for nutritional risk (e.g. high and moderate), inclusive of timeframes for assessments. At 10:40 a.m. Dietitian 2 stated that this had been due to categorization of levels of care on the premises of the facility and that there had not been recent evaluation of the categories, given severity of diagnoses, age and modes of feeding.

c.There had been the failure to have registered dietitians participate in the hospital therapeutics committee within the past year. At 10:55 a.m. Dietitian 2 stated that this had not been done because of the small size of the hospital and that aside from charting, there was no documentation of such interchange.

d. There had been the lack of on-going education (e.g. for total parenteral nutrition) for registered dietitians assigned to the hospital. At 11:02 a.m. Dietitian 2 stated that "daily conversations" had occurred, but that there was no organized system to ensure not only adherence to current standards of practice, but advancements in nutrition support.

e. Review of the department quality assurance data for the past year revealed that there were no separate quality assurance projects unique to the hospital's nutrition care and foodservice operations as data for varied levels of care had been combined. At 11:21 a.m. Dietitian 2 stated that these had been "oversights" and that there was uncertainty as to what could be considered.

Dietitian 2 added that there had not been any recent evaluation of food preparation and quality following advanced preparation, inclusive of blast-chilling and retention of foods under refrigeration until re-thermalization. The latter was of interest per verbal report of Dietitian 2 (who reiterated and detailed what Dietitian 1 had stated on 6/22/10) given that foods prepared on Thursday can be served on Sunday (breakfast, lunch and dinner) and Monday, (breakfast) and that on Friday, food is prepared for Monday (lunch and dinner) and Tuesday (breakfast and lunch).

f. Review of personnel records revealed that four of five randomly selected dietetic service staff did not have timely annual performance evaluations.

Respective dates for Dietetic Service Staff 3, 4, 5 and 6 were 7/8/08, 9/11/08. 9/12/08 and 4/23/08. At 2:25 p.m. Personnel Supervisor 1 stated that these evaluations were "overdue" and that she did not know why the dietetic service department management had continued to be "late" in completing the evaluations.

g. Reference to emergency/disaster procedures pertaining to manual dishwashing in the policy and procedure manual approved in 5/10 revealed a shortcoming. Review revealed that it had been inadvertently omitted and that reference within the policy had utilized the wrong number (as had been determined in the former manual).

At 2:30 p.m. Dietitian 2 attributed this error to "reformatting" and that the new manual and as well as any cross-referencing "needs to be checked" to ensure accuracy. Dietitian 2 stated that this would be "very important" not only for regular service, but for reference by both dietetic service staff and other hospital staff during emergency/disaster conditions. Additionally, Dietitian 2 stated that she was not sure "why" those who had signed the manual had not verified accuracy in policy number when established policies and procedures referred to other documents by number.

h. Review of employee health records revealed that one of five randomly selected dietetic service staff (Dietetic Service Staff 6) had not completed the 2/10/10 TB questionnaire. At 3:12 p.m. Dietitian 2 stated that she had not been aware of this and the need to address this with employee (occupational) health staff for guidance.

Based on clinical record review and staff interview, the hospital failed to ensure that the nutritional needs of a patient had conformed to recognized dietary practices. (Patient 12). By not utilizing verified, correct weight in a nutrition assessment there was uncertainty as to the adequacy of the recommended dietary regimens.

Finding:

Patient 12 was an adult male admitted 2/25/10 and discharged on 3/5/10. Patient 12 had the following diagnoses and conditions: pneumonia. epilepsy, hypothyroidism, profound mental retardation, cardiomegaly (enlargement of the heart) and had a history of ataxia, constipation, osteoporosis and edema.

On 2/26/10 a registered dietitian determined Patient 12's nutritional needs, noting that Patient 12 who was five feet five inches had gained weight and was above ideal body weight range (IBWR) although this determination based on standards of practice would be based on an IBW of 136 lbs +/- 10 %.The latter is significant as a crossed-out weight on the assessment form was 158 lbs and there was an undated entry of 142 lbs. Using the crossed- out weight, Patient 12 would have been above IBWR, but if using the weight of 142 lbs, he was within IBWR.

On 3/2/10 Dietitian 3 wrote an assessment note in which she stated that Patient 12's actual weight was"142 lbs, not 158 lbs"without identifying the source of this information. Dietitian 3 added that there had been a recent (2/28/10) weight of 147 lbs., yet Dietitian 3 wrote that she was basing her recommendations on the weight of 158 lbs. yielding 1670 kcals, 67 gm protein and 2,340 cc's of fluid with a recommendation that if tube feeding was started Jevity 1.5 (if selected) at the goal volume (1120 ml/24 hr) with additional water (flushes or via IV fluid) it would provide 1680 kcals, 71 gms protein and 2,350 ml fluid/day.

Although Patient 12 had been NPO for seven days per the nutrition assessment done by Dietitian 3 on 3/4/10 Patient 12 had edema and a weight of 145.5 lbs on 3/3/10 which Dietitian 3 noted was an increase of 3.5 lbs since admission. The nutrition assessment did not include a comprehensive review of Patient 12's intake of kcals, protein, fluid and nutrients as there was a lack of comparison between actual versus recommended intakes.

On 6/29/10 at 1 p.m. while in an administrative conference room review of the nutrition assessments conducted by Dietitian 3 with input via interview revealed that she could not determine why she had considered both admission reference weights as reliable irrespective of the fact that the recommended intake had not been accomplished.

Based on observation, staff interview and document review the facility failed to ensure that equipment in dietetic services as well as the warehouse had been maintained to support safe and efficient processes for food service operations for both regular and emergency/disaster conditions. By not having sufficient surveillance to have ensured sufficient, operable equipment there was the impingement upon operable equipment.

Findings:

1. On 6/28/10 between 12:35 p.m. and 3:10 p.m. inoperable, malfunctioning and missing devices related to refrigeration and freezing were found in the warehouse and main kitchen.

a. At 12:35 p.m. in the warehouse, there was an inoperable, empty walk-in refrigerator and a walk-in refrigerator which had a damp interior such that moisture had accumulated not only on the ceiling, but on the exterior of two 50 lb bags of oat bran. At 12:40 p.m. Dietetic Service Staff 1 stated that while familiar with the inoperable refrigerator, he was surprised by the condition of the one containing dry goods.

b. Between 12:50 p.m. and 3:10 p.m. in the main kitchen during inspection of the refrigeration and freezing equipment there were three inoperable, empty walk-in units and an inoperable, empty under counter unit. The impact was such that remaining walk-in refrigeration was compactly stocked during the shut-down, maintenance and cleaning. Further, at 2 p.m. inspection and report by Dietetic Service Staff 1 revealed that there had been concerns recently regarding reach-in refrigeration that was "not trusted at night" -- such that contents were removed at the end of the day shift and allowed to be shut down and re-started daily.

2. Additionally, between 2:21 p.m. and 4:05 p.m. inspection revealed the following:

a. A walk-in freezer which had a six inch icicle hanging from a pipe, just above two partially opened boxes-one containing whipped topping and the other individual shakes.

b. A walk-in refrigerator which had an inoperable gauge, ice on the condenser and beaded water on the fan.

c. A walk-in freezer with a paper thin sheet of ice on the interior of the door as well as a chunk of ice the size of a medium-sized apple on a pipe.

d. A walk-in refrigerator designated for produce which had no gauge and had an ambient temperature of 33 degrees F (only one degree above the freezing point of water).

e. A walk-in freezer which had foods hard to the touch, but which had a gauge registering 19 degrees F, an internal thermometer registering 26 degrees F (only six degrees below the freezing point of water and within one degree of the melting point of ice cream as well as a patch of frozen ice droplets which was at least two feet by two feet on the ceiling.

Also, there was a reach-in refrigerator which had a gauge registering 24 degrees F and an internal thermometer registering 32 degrees F while barbecued chicken was at 29.8 degrees F. The latter was of significance as there was potential for the chicken to fluctuate between frozen and thawed states which could affect textural quality.

3. On 6/29/10 at 9:30 a.m., Engineer 1 presented his 6/28/10 "Main Kitchen Inspection Report," based upon surveillance and remediation conducted the evening of 6/28/10 following identification of concerns by the survey team, including the amount of equipment malfunction and impingement upon storage.

Engineer 1 identified the replacement of a condensing unit in a reach-in refrigerator; the replacement of a thermostat in a reach-in refrigerator; the need to "pump down" the system in a "cooler" and "change the dryer" and identification of the need to get a new thermostatic expansion valve for an evaporator in a "cooler" to prevent icing.

4. On 6/29/10 at 10 a.m., Dietitian 1 presented the updated inventory of inoperable equipment which included not only remaining refrigerator problems, but out-of-order items, e.g. "food grinders-2 each, meat slicer-1 each, food chopper (large commercial size)-1 each. Food disintegrator (grinds/blends food)-1 each, food dicer/chopper (Urschell) 1 each, and steam kettles-2 each." On an attached note it stated that the first three items did not have work orders, but "will be added 6/29/10."

Based on observation, staff interview and document review the hospital failed to ensure that the dietetic service department was safe and sanitary. By not having ensured that food had been stored, prepared, distributed and served under sanitary conditions, there was the potential for cross-contamination and foodborne illness.

Findings:

1. On 6/28/10 between 9:45 a.m. and 12:55 p.m. inspection of the main kitchen dry storage room, ancillary storage and warehouse revealed unsafe, unsanitary conditions and practices.

a. At 9:45 a.m. in the main kitchen dry storage room there was a #10 can (which contains 20-25 half cup servings) of pitted prunes with a sharp dent on the side and another #10 can of pitted prunes with a flat dent on the side. At 9:45 a.m., Dietetic Service Staff 1 stated that the damaged canned goods had come from another State facility and that the delivery " had been awhile ago, but not all the cans had been looked at. " Upon identification, Dietetic Service Staff 1 stated that the damaged cans would be removed from storage and potential service of the prunes.

b. At 9:48 a.m. in the main kitchen dry storage room, there was a semi-opaque 68 oz (2 lbs, 4 oz) container of pineapple sauce in which the top third had turned medium brown and there was no evidence of a pack date. At 9:48 a.m. Dietetic Service Staff 1 stated that the sauce "doesn't look good" and that he would discard it.

c. At 9:50 a.m. in the main kitchen dry storage room, atop a pallet there was a 50 lb sack of sugar with fine gray matter of uncertain origin and above it, within two feet there was a grimy pallet coated with comparable matter underneath.

d. At 9:52 a.m. in the main kitchen dry storage room, there was a partially opened box of canned Jevity (an enteral formula) which was within one foot of a spray bottle containing a commercial sanitizing solution with a caution, "Do Not Drink." At 9:53 a.m. Dietitian 1 stated that the practice "looks unsafe" and that the solution should have been stored with other chemicals, not food.

e. At 9:55 a.m. in ancillary dry storage, there was the storage of one bin of rice and another bin containing oats within 15 inches of two brooms.

At 9:55 a.m. Dietitian 1 asked Dietetic Service Staff 1, "Why are these things together here?" Also, in the same location there was a partially opened cardboard box filled with loosely packed pasta which had at least one tablespoon of white powder of uncertain origin on the top exterior. When mentioned, Dietetic Service Staff 1 then placed his fingers in the powder and tasted it, stating that it was "pudding powder."

Although potentially unsafe to taste unknown items, there was the potential for cross-contamination as Dietetic Service Staff 1 failed to wash his hands and continued to touch food contact surfaces during the inspection and without direction by Dietitian 1.

f. At 9:58 a.m. in the main kitchen bakery, there was a plastic bin filled with grimy plastic lids, two of which had old tape with handwritten dates still affixed. At 9:58 a.m. Dietetic Service Staff 1 stated that the lids had been "cleaned" and that removal of "old labels" was "a problem."

g. At 10 a.m. in the ancillary storage room across from the main kitchen dry storage room there were six bins and six stacks of assorted uncovered clean cloth items: table covers, napkins and aprons. At the end of the ancillary storage there was an unprotected, opened doorway. At 10 a.m. Materials Staff 1 stated that the conditions were "typical" and that the cloth items had come from another State facility.

h. At 10:02 a.m. in the ancillary storage across from the main kitchen dry storage room, there was a shirt, a sweater and two freezer jackets (worn when stocking and procuring) hung adjacent to each other. At 10:02 a.m. Dietetic Service Staff stated that the items should not have been co-mingled as "staff have a place to store their personal items (e.g. a shirt or a sweater)."

Additionally, there were other unsanitary conditions in the room, e.g. retention of three soiled napkins atop the lid of a container designated for soiled cloth items and an undated, half-filled container of thickening agent.

i. At 10:14 a.m. in another ancillary storage room, a freezer jacket was hung with a personal jacket belonging to a dietetic service staff member. A freezer jacket which had grimy cuffs, had been hung with another freezer jacket. At 10:01 a.m. Dietitian 1 stated that the conditions were "dirty."

At 10:24 a.m. in the main kitchen dry storage room, there was a freezer jacket left atop a desk chair and at 10:45 a.m. in a locker there was a freezer jacket stored with a clean apron.

At 11 a.m. in another area, there were three soiled uniform tops and two soiled aprons hung against shelving where there were uncovered stacks of clean cloth towels. At 10:45 a.m. Dietitian 1 stated that the potential for cross-contamination was "awful "

j. At 10:24 a.m., upon return to the main kitchen dry storage room, observation of the rolling rack revealed that there was a #10 can of vanilla pudding with a rim dent, a #10 can of chocolate pudding which had a rim dent and three #10 cans of pumpkin pie filling which had moderately rusted edges and two of these cans also had a rim dent on the top lid, sticky bottom lids and white spots of uncertain origin.

At 10:24 a.m. Dietetic Service Staff 1 stated that the canned goods had come from another State facility, "at least two or three months ago," and that the canned goods had not been inspected upon receipt.

Further, Dietetic Service Staff 1 stated that the contents had not been used in food production. Dietetic Service Staff 1 added that that the damaged canned goods would be discarded and the other canned goods "looked at". However, Dietetic Service Staff 1, having handled the rusted, sticky cans continued to tour the kitchen, touching food contact surfaces without washing his hands and was not directed by Dietitian 1 to do so.

2. At 10:45 a.m. in the main kitchen dish room, Dietetic Service Staff 2 stated that the prior worker had left a basin in a pot wash area filled with "another chemical solution since we don' t have any bleach." Testing of the solution revealed that it registered 100 ppms of sodium hypochlorite, but review of the manufacturer's label revealed that it did not specify use for food contact surfaces as the other product had.

Although Dietetic Service Staff 2 stated that the items rinsed in this basin would be run-through the dish machine to be washed, rinsed and sanitized, the introduction of the product into the area was of concern.

Further, as there was an uncertainty as to water treatment during an emergency/disaster,
Dietetic Service Staff 2 stated that he thought that "at least the first bleach" would be safe to disinfect water for consumption, yet reference to the manufacturer ' s directions did not specify this usage.

3. On 6/28/10 at 10:55 a.m. in the main kitchen open area near the dish machine where sanitized wares were air-drying, there was a capped, half-filled quart of water on the same shelf and within one foot of metal items. At 10:55 a.m. Dietetic Service Staff 1 stated that staff were not to have such items in the area as the implication was they would drink there and potentially cross-contaminate surfaces.

4. On 6/28/10 between 12:10 and 12:20 p.m., during inspection of the warehouse, the door was open and there was no protection from environmental contaminants.

At 12:10 p.m. upon noticing two flying insects, a maintenance staff stated that the conditions were "typical" and even though there was no thermometer, "I know it is hot and that's why we have flies." Maintenance staff further stated that the cans were "cleaned by dietary," but did not know how jugs of wine vinegar, containers of Splenda, plastic bags containing marshmallows and dry cereal, boxes of juices and containers of salad dressings were to be protected from environmental contaminants.

5. On 6/28/10 at 12:20 p.m. in the warehouse, there was a walk-in refrigerator used for stocking dry goods. It had a gauge registering 34 degrees F and an internal thermometer at 35 degrees F.

Upon entrance, there was water dripping from the ceiling panels and fine black matter of uncertain origin in the ceiling junctures. At 12:25 p.m. upon inspection and finding that there were two 50 lb bags of oat bran with at least two ounces of water on the exterior of each, Dietetic Service Staff 1 opened the bags which were neither lined nor coated with a substance rendering them impervious.

Upon exposure, one of the two bags had cool, slightly damp contents. At 12:25 p.m. Dietetic Service Staff 1 and Dietitian 1 conferred and concluded that the bag containing the damp oat bran would have to be discarded and the function of the walk-in refrigerator "checked" given the risk of the growth of microorganisms and toxin development under unsafe conditions.

6. On 6/28/10 between 2:20 p.m. and 3:10 p.m., there were unsanitary conditions in the refrigerators and freezers in the now-vacated main kitchen.

a. At 2:20 p.m. in a walk-in refrigerator there were four packages of thawing, unsliced turkey with an accumulation of at least one ounce of water on the exterior of the packaging. Although there was no apparent leakage, Dietetic Service Staff 1 decided to retain the turkey, not knowing the source of the water.

b. At 2:21 p.m. in a stocked walk-in refrigerator, there was a dirty fan, and another stocked walk-in refrigerator had a soiled gasket.

At 2:50 p.m. there was a stocked reach-in refrigerator with a grimy gasket. Dietitian 1 stated that she would have to look at the cleaning schedule to see when the units were to "be cleaned next."

c. At 2:35 p.m. in a reach-in refrigerator which had a gauge registering 31 degrees F and an internal thermometer at 36 degrees F, there was a spill of at least two ounces of milk atop a covered pan of limp cooked broccoli dated 6/23/10 for date of preparation and 6/28/10 for use-by.

he milk had come from a near-solid yet thawing quart of milk which had a cracked exterior and which had a use by date of 6/23/10. At 2:35 p.m. Dietetic Service Staff 1 stated that he did not know why and for how long the milk had been in this condition and stated that the broccoli should have been kept for " no more than three days" and could not locate a reference for departmental standards.

There were two pint containers of slightly soft, indented blueberries which had been dated for 6/23/10 and use-by, 6/28/10. Dietetic Service Staff 1 stated that the blueberries "are only good for three days."

7. On 6/28/10 between 3:28 p.m. and 3:36 p.m. while in the main kitchen production area, inspection of the cutting boards revealed that ten were scratched and stained. Of the ten, two had one nickel-size white spot of uncertain origin and one had black smudges of uncertain origin. At 3:36 p.m. Dietetic Service Staff 1 stated, "We can get new boards."