Encompass Health Rehabilitaton Hospital of Bakers

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 27157 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.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 27157 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.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 27157 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.””

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 27157 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.””

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 27157 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.)”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 45654 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.””

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 39650 Based on observation, interview and document review, the hospital failed to ensure the Condition of Participation, CFR 482.28 Food and Dietetic Services was met when: 1. Based on interview and document review, the hospital failed to follow their job description for one of one Nutrition Service Manager (NSM) when NSM did not have the required education. 2. The hospital failed to ensure the Nutrition Service Manager (NSM) was effective in the daily management of the dietary services during an emergency water advisory to not use the city water when the emergency supplied water for the dish washing had the potential to be contaminated. (Cross Reference A-0620) 3. The hospital failed to ensure the Nutrition Service Manager (NSM) was effective in the daily management of the dietary services when Nutrition Service Aide (NSA) 1 did not receive unit orientation, competency validation and neither NSA 1 nor Cook completed a safe food handling course. (Cross Reference A-0620, A-0622) The cumulative effect of these systemic problems resulted in the inability of the hospital’s food and nutrition services to ensure there was a qualified NSM to direct daily operations and staff in such a manner to ensure the nutritional needs of patients were met in accordance with acceptable standards of practice and safety of the emergency water used for the the needs of the patients was met as required by the mandated Condition of Participation for Food and Dietetic Services. This had the potential to affect the hospital census of 69 highly susceptible patients. According to the FDA (Food and Drug Administration) Food Code 2022, “A “Highly susceptible population” means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; ... or older adults; and (2) Obtaining food at a facility that provides services such as...health care...hospital.” 47734”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 39650 Based on observation, interview and document review, the hospital failed to ensure the Condition of Participation, CFR 482.42 for Infection Prevention Control Antibiotic Stewardship was met when: 1. The hospital failed to have an Infection Preventionist (IP), who was qualified by education and training to monitor facility infection control practices during a “DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]” issued by the city on 6/4/24. (Cross Reference A-0748) 2. The hospital failed to implement infection control practices in food and nutrition services. (Cross Reference A-0750) The cumulative effect of these systemic problems resulted in the inability of the hospital’s IP to effectively provide infection control surveillance of the food and nutrition services in such a manner to ensure safety of the emergency water used for the the needs of the patients, visitors, and staff were met in accordance with acceptable standards of practice as required by the mandated Condition of Participation for Infection Control Surveillance. This had the potential to affect the hospital census of 69, visitors, and staff.”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 47734 Based on interview and document review, the facility failed to ensure one of one Nutrition Service Manager (NSM) who had been granted the authority and delegated responsibility by the hospital for the operation of the daily management of dietary services met the state’s education qualification requirements according to California Title 22 (70275(b)) and Health & Safety Code (H & SC 1265.4). This failure had the potential to result in a lack of oversight of dietary services. Findings: During an interview on 6/7/24 at 10:38 a.m. with Nutrition Service Manager (NSM), NSM stated he managed the day-to-day operations in the kitchen. NSM stated he had a food handler certificate (food safety) and nothing else. During an interview on 6/7/24 at 11:48 a.m. with Director of Quality/Risk Management (DQRM), DQRM stated Dietary (Food & Nutrition Services) Director and Dietary Manager position titles were considered the same positions and the Dietary Manager for the facility was the NSM. During a review of California Code of Regulations (CCR), Title 22, Division 5, Chapter 1, Section 70271 defines Dietetic service as providing safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies. During a review of CCR, Title 22, Division 5, Chapter 1, Section 70275 (b) If a registered dietitian is not employed full-time, a full-time person who meets the training requirements to be a dietetic services supervisor specified in section 1265.4(b) of the Health and Safety Code shall be employed to be responsible for the operation of the food service. During a concurrent interview and record review on 6/7/24 at 2:45 p.m. with NSM and Chief Nursing Officer (CNO), in the presence of QRM, Nurse Manager (NM), Director of Human Resources (DHR), Regional Director of Quality Risk Management (RDQRM), Chief Executive Officer (CEO), Clinical Dietitian (CD), California Code, Health and Safety Code 1265.4 (HSC) was reviewed. H & SC 1265.4 indicated, “(a) A licensed health facility, as defined in subdivision (a), (b), (c), (d), (f), or (k) of Section 1250, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. The dietetic services supervisor shall have completed at least one of the following educational requirements:”...and proceeded to list seven different educational requirements pathways that would meet the state’s criteria for NSM to be the designated authorized responsible person for the day-to-day management of the foodservice operation. NSM stated, he did not meet any of the listed educational requirements numbered one through six in the H & SC 1265.4, but he did have years of experience in foodservice as he was a cook in the military for number seven. H & SC 1265.4 # [number]7) indicated, “Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6).” During a concurrent interview and record review on 6/7/24 at 2:45 p.m. with NSM, NSM reviewed H & SC 1265.4 (2), (3), and (6). H & SC 1265.4 indicated “(2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association, and (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision”, and NSM stated he did not meet any of the educational requirements of (2), (3) or (6) as listed in #(7). NSM stated the facility provided the survey team the only educational certificate NSM had, which was titled “In recognition for completing Food Handler Training California Version.” NSM stated, “I did not see that listed in the Health & Safety Code 1265.4 as meeting qualifications.” NSM verified he did not meet any of the seven available educational requirements that was required by state law to be qualified to be responsible for the operation of the food service. During a concurrent interview and record review on 6/7/24 at 2:45 p.m. NSM stated the hospital’s full-time Registered Dietitian (RD) recently went out on family medical leave act. NSM stated the majority of the RD’s duties were clinical nutrition, acting as liaison with medical and nursing staff, overseeing menus and therapeutic diets, meeting with patients and family for therapeutic diet counseling, providing periodic in-services to himself and dietary staff, and completed audits within the foodservice operation. NSM stated he was responsible for the day-to-day foodservice operations. NSM description of the full time RD role would satisfy the component of H & S Code 1265.4 that required “the dietetic services supervisor [the person delegated authority to be responsible for the day-to-day foodservice operation] shall receive frequently scheduled consultation from a qualified dietitian” and would meet CCR “70275 (a). A registered dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis and of sufficient duration and frequency to provide continuing liaison with medical and nursing staffs, advice to the administrator, patient counseling, guidance to the supervisor and staff of the dietetic service, approval of all menus and participation in development or revision of dietetic policies and procedures and in planning and conducting in-service education programs.” However, the interview verified the full time RD was not responsible for the operation of the food service, and therefor the hospital needed to have a full-time dietary services supervisor (role of NSM) to have met one of the educational pathways as listed in H & S Code 1265.4, as indicated in Title 22 “70275(b) If a registered dietitian is not employed full-time, a full-time person who meets the training requirements to be a dietetic services supervisor specified in section 1265.4(b) of the Health and Safety Code shall be employed to be responsible for the operation of the food service.” NSM and CNO stated they did not have any further questions or any further information they wanted to submit to the survey team for review. During a review of facility’s job description (JD) for Nutrition Services Manager, the JD indicated, “Position Purpose: The Nutrition Services Manager plans, directs, and coordinates the activities of the Nutrition Services Department to provide nutritional services to patients ... The position establishes policies and procedures to provide administrative direction for cafeteria management, food preparation, distribution, service, budgeting, purchasing, sanitation standards, safety practices, staffing and staff development. In addition, the Manager may assist Dietitian with nutrition assessments if qualified. The Nutrition Services Manager creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient-centered treatment. . .License or Certification: CDM [Certified Dietary Manager] or Dietetic Technician registration with Academy of Nutrition and dietetics if required by State ...Current member of Academy of Nutrition and Dietetics if required by State or other regulatory agency.” During a review of facility’s job description (JD) for Dietitian, 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 standard 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. The Dietitian monitors past and present nutritional status and makes recommendations to the health care team based on available data. 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.””

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 47734 Based on interview and document review, the hospital failed to follow their job description for one of one Nutrition Service Manager (NSM) as evidenced by: 1. NSM did not have the required education. 2. NSM permitted potentially contaminated water to be used to wash kitchen wares (cookware, utensils and appliances for use in a kitchen). 3. NSM did not ensure a Sanitizer log was maintained for one of one 3 - compartment sink. 4. NSM did not orient or ensure competencies for One of one dietary staff (Nutrition Service Aide - NSA) 1. These failures resulted in a lack of oversight of Dietary Services and had the potential to result in food borne illness to patients, staff, and visitors. Findings: 1. During an interview on 6/7/24 at 10:38 a.m. with Nutrition Service Manager (NSM), NSM stated he managed the day-to-day operations in the kitchen. NSM stated he had a food handler certificate and nothing else. During an interview on 6/7/24 at 11:48 a.m. with Director of Quality/Risk Management (DQRM), DQRM stated Dietary (Food & Nutrition Services) Director and Dietary Manager position titles were considered the same position and the Dietary Manager for the facility was the NSM. During a review of NSM’s Job Description (JD) Approval 2019, dated review period 01/01/2019 - 12/31/2019, the JD Approval indicated NSM signed the JD Approval on 5/3/2019. The JD Approval indicated under Job Description: “Maintains sanitation and proper temperature as well as correct food handling techniques in department to ensure compliance with all regulatory agencies ...Ensures that in-service education meetings are held and courses are completed as required by ...Meets position requirements and performs essential functions. Completes mandatory training and courses by completion date ...Maintains current licensure and/or certifications, if applicable.” During a review of facility’s job JD for Nutrition Services Manager, the JD indicated, “Position Purpose: The Nutrition Services Manager plans, directs, and coordinates the activities of the Nutrition Services Department to provide nutritional services to patients. . .The position establishes policies and procedures to provide administrative direction for cafeteria management, food preparation, distribution, service, budgeting, purchasing, sanitation standards, safety practices, staffing and staff development ...The Nutrition Services Manager creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient-centered treatment. . .License or Certification: CDM [Certified Dietary Manager] or Dietetic Technician registration with Academy of Nutrition and dietetics if required by State ...Current member of Academy of Nutrition and Dietetics if required by State or other regulatory agency ...” 2. During a review of “City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]” dated 6/4/24. The “Advisory” indicated, “City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer’s property backflowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food.” During an observation on 6/6/24 at 10:39 a.m. outside, by the entrance to the kitchen, a large white tank was approximately half full of liquid with an opening on top. The intake inlet opening was partially open to the environment. A red colored hose was curled up on top of the tank. During an interview on 6/6/24 at 4:40 p.m. with DFO, DFO stated on 6/5/24 he observed the 500 gallon tank’s inlet opening, which supplied water for the 3-compartment dish wash sinks with gray tape partially covering the water inlet opening. The opening exposed the water to potential contamination. DFO stated the opening in the water inlet was why the kitchen was shut down on 6/5/24 by the city. During a concurrent observation and interview on 6/7/24 with Director of Facility Operations (DFO) and Infection Preventionist (IP), outside by the entrance to the kitchen, the white water tank did not indicate what it contained or if it was potable. IP stated there were no markings on the tank which indicated what it contained or if it was potable. IP stated the DFO obtained the tank for use in the kitchen. IP stated she visually inspected the tank when it arrived. DFO stated the tape used to partially cover the opening was not ideal and they did not have a way to monitor or secure the water tank to ensure contamination did not occur. The facility was unable to provide documentation the red hose used to transfer water from the tank to other containers to the kitchen was food-grade. During a review of the Food and Drug Administration Food Code 2022 (FDAFC), the FDAFC indicated many pathogens transmitted through food are also spread through water. During a review of the FDAFC dated 2022, the FDAFC indicated the person in charge of the day to day foodservice operations is expected “to have knowledge to include identifying the source of water used and measures taken to ensure that it remains protected from contamination”, as it relates to foodborne disease prevention. (FDA Food Code 2022; 2-102 Knowledge) During a review of the FDAA dated 2022, the FDAA indicated, “Some tanks are designed with an access opening to facilitate the cleaning and servicing of the water tank. The access must be constructed to prevent the opening from becoming a source of contamination of the water.” (FDA Food Code 2022 Annex, 5-302.12) 3. During an interview on 6/6/24 at 12:18 p.m. with Cook 1, Cook 1 stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium test strip into the sanitizer and water solution in the third sink (of the 3-compartment sink) for 25-30 seconds which was an incorrect length of time. Cook 1 stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds. During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment dish wash sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes. During a review of “QT-10 HYDRION” container instructions, the instructions indicated, “for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET.” During a review of the FDAFC, the FDAFC indicated a chemical sanitizer will not sanitize a dirty dish. During a review of the FDAFC, dated 2022, the FDAFC indicated concentration of the sanitizing solution shall be accurately determined by using a test kit in accordance with the manufacturer’s label. 4. During an interview on 6/6/24 at 4:41 p.m. with Nutrition Service Manager (NSM), NSM reviewed NSA 1’s personnel file. NSM stated he was unable to provide documentation NSA 1 completed orientation to the dietary/kitchen department, had his competencies evaluated or had a ServSafe California Food Handler Certificate of Achievement (completed a food safety course).”

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 39650 Based on observation, interview, and record review the facility failed to ensure competent staff when: 1. One of one Nutrition Services Aide (NSA) 1 did not receive dietary department specific orientation or validated competencies. This failure resulted in NSA 1’s incorrect process to verify sanitizer concentration in the pots and pans sink (sink three) which put patients at risk for food borne illnesses. 2. Two of three nutrition service staff (NSA 1 and Cook 2) did not obtain their ServSafe California Food Handler Certificate of Achievement (a food safety course). This failure put patients, staff, and visitors at risk for food borne illnesses. Findings: 1. During an interview on 6/6/24 at 12:18 p.m. with Cook 1, Cook 1 stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium (sanitizer) test strip into the sanitizer and water solution in the third sink for 25-30 seconds. Cook 1 stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds. Cook 1 stated if sanitizer levels are not correct bacteria can remain on dishes. During a concurrent interview and record review on 6/6/24 at 3:04 p.m. with Director of Human Resources (DHR), NSA 1’s employee personnel record (EPR) undated, was reviewed. The EPR indicated, NSA 1 was hired as a Nutritional Service Aide on 3/14/23. DHR stated there was no record of NSA 1’s nutrition services department orientation or unit specific competencies available. DHR stated NSA 1 should have received unit specific orientation and competency verification. During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes. During a review of “QT-10 HYDRION” container instructions. The instructions indicated, “for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET.” During a review of Food and Drug Administration Food Code 2022 (FDAFC), the FDAFC indicated concentration of the sanitizing solution shall be accurately determined by using a test kit in accordance with the manufacturer’s label. 2. During a concurrent interview and record review on 6/6/24 at 3:04 p.m. with DHR, NSA 1 and Cook 2’s employee EPR undated, were reviewed. DHR stated there was no record of NSA 1’s or Cook 2’s ServSafe California Food Handler Certificate of Achievement. During a review of the facility’s policy and procedure (P&P) titled, “New Employee Orientation,” dated 12/22/2023, the P&P indicated, “All new staff members will participate in a formal orientation program to learn the fundamental workings of the facility. The formal orientation program will consist of two phases: 1) General Orientation and, 2) Department Orientation. . .2. Department Orientation is the responsibility of the Department Director/Manager. . .Once completed a copy of the orientation checklist will be forwarded to the Human Resources Department to be placed in the individual employee file.” During a review of “JOB DESCRIPTION [JB]. . .Nutritional Service Aide,”undated,” the “JB” indicated, “The Nutrition Services Aide assists in preparing. . .diets for patients as well as preparing meals for employees, visitors and special functions. The Nutrition Services Aide assists in maintaining inventory, serviceware and sanitary conditions within the department. . .Cleans and sanitizes all assigned areas. . .Completes mandatory training and courses required by completion date. . .POSITION REQUIREMENTS License or Certification: Food handlers permit. . .Machines, Equipment Used. . .dish washer. . .may be required to perform other duties as assigned by supervisor.””

“SPRINKLER SYSTEM CFR(s): (8) When a sprinkler system is shut down for more than 10 hours, the hospital must: (i) Evacuate the building or portion of the building affected by the system outage until the system is back in service, or (ii) Establish a fire watch until the system is back in service. This Standard is not met as evidenced by: 39650 Based on interview and record review, the facility failed to ensure the fire suppression sprinkler system was safe and a fire watch was implemented when a do not drink and do not use advisory due to city water system contamination was in effect. This failure put the patients, staff, and visitors at risk for exposure to unsafe water in the event of an activation of the fire suppression sprinklers. Findings: During a review of “City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]” dated 6/4/24. The “Advisory” indicated, “City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer’s property backflowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food.” During an interview on 6/6/24 at 9:40 a.m. with the Director of Facility Operations (DFO), DFO stated the facility did not request verification the fire suppression sprinkler system was safe to use during the do not use the city water system advisory the facility received on 6/4/24. DFO stated the fire suppression sprinkler system had a supply of water but once exhausted the city water would be used. DFO stated the water in the sprinkler system would only last about one hour, and then city water would be flowing into the sprinkler system. DFO stated the facility did not implement a fire watch when the city water system do not use advisory was received on 6/4/24.”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 47444 Based on observation and interview, the facility failed to ensure one of one Infection Preventionist (IP) was qualified by education and training to monitor facility infection control practices during a “DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]” issued by the city on 6/4/24. This failure had the potential to expose staff, patients and visitors to hazards from contaminated water. Findings: a. During a review of “City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]” dated 6/4/24. The “Advisory” indicated, “City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer’s property back flowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food.” During an observation on 6/6/24 at 10:39 a.m. outside, by the entrance to the kitchen, a large white tank was approximately half full of liquid with an opening on top. The intake opening was partially uncovered, and open to the environment. A red hose was coiled on the top of the tank. During a concurrent observation and interview on 6/6/24 at 3 p.m. with Infection Preventionist, pictures of the water tank were reviewed. IP stated the kitchen staff used the water in the tank yesterday (6/5/24) to fill the 3-compartment sink in the kitchen to wash pots and pans. IP stated the partially covered opening on the water tank was a concern for infection control. During a concurrent observation and interview on 6/7/24 at 10:50 a.m. with Director of Facility Operations (DFO) and IP, outside by the entrance to the kitchen, the white water tank did not indicate what it contained or if it was potable. IP stated the Director of Facilities (DFO) obtained the tank for use in the kitchen. IP stated she visually inspected the tank when it arrived and was aware of the tape partially covering the top. IP stated she was not involved in the water tank use. DFO stated the tape used to partially cover the opening was not ideal and they did not have a way to monitor or secure the water tank to ensure contamination did not occur. The facility was unable to provide documentation of the red hose attached to the water tank was food grade as requested. b. During an interview on 6/6/24 at 12:18 p.m. with Cook, Cook stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium (sanitizer) test strip into the sanitizer and water solution in the third sink for 25-30 seconds. Cook stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds. Cook stated if sanitizer levels are not correct bacteria can remain on dishes. During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes. During a review of “QT-10 HYDRION” container instructions. The instructions indicated, “for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET.” c. During an interview with IP on 6/6/24, at 2:28 PM, IP stated she was a certified Critical Care Registered Nurse. IP stated in 2004 she took the position of Case Manager (ensure patient gets the care and equipment needed while in the facility and after discharge from the facility) and then transitioned into the infection preventionist/education role. IP stated she did not have formal training in IP but had some training from corporate and Regional Support. IP stated she attended quarterly meetings at the local Association for Professionals in Infection Control (APIC). IP stated her responsibilities included patients in isolation, provide references for staff, review cultures, tracking infections, monitoring staff hand hygiene practices During a review of IP’s Completed Training List covering 7/22/2022 through 5/27/24, IP’s Completed Training List indicated the following training completed on: 8/29/2022 Quality Indicator Training - Nursing PT 1 & 2 (Live) 9/30/2022 2022 Annual Re-training - Clinical 10/25/2022 Education Plan Training for Hospital Leadership 12/8/2023 2023 Annual Re-training for Clinical Employees 4/3/2024 Job Description for Infection Preventionist/Hospital Educator No training for Infection Prevention was indicated. During a review of the Job Description for Infection Preventionist/Hospital Educator, undated, the Job Description indicated “The Infection Preventionist/Hospital Educator implements and manages the Infection Control Program... The Infection Preventionist acts on behalf of hospital leadership to prevent the spread of infections throughout the hospital. The Infection Preventionist has authority to implement and monitor compliance with all policies, procedures, protocols and other requirements relating to Infection Control and Prevention. The Medical Executive Committee authorizes the IP to take any actions necessary (within the limits of standard practice) to prevent the outbreak and spread of infection. In doing so the aid to the extent possible, the Infection Preventionist shall consult with...all federal, state and local health districts that may have jurisdiction...Responsibilities and Tasks...Conducts ongoing infection and infection risk surveillance and investigation activities...Performs environmental surveillance of all patient care areas and appropriate departments during safety/risk rounds in order to monitor compliance with infection control policies and procedures...Position Requirements...Minimum Qualifications...Experience in hospital infection control practice preferred. Training in infection control and epidemiology. Certification in Infection Prevention and Control (CIC, standardized measure of the basic knowledge, skills and abilities expected of professionals working in the field of infection prevention and control) preferred...” During a review of the Certification Board of Infection Control and Epidemiology (CBIC), IP was not listed as having a CIC certificate.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47444 Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One of one portable 500 gallon water tank, which supplied water for the 3 - compartment dish wash system (due to an advisory to not use the city water) had an open water intake inlet at the top of the water tank. 2. Facility did not log the chemical concentration of Quaternary Ammonium (sanitizer) test strips used in one of one three (3)-compartment sink (sink used for sanitizing clean cooking utensils, pots and pans) for April 2024, May 2024, June 1st, June 2nd, and June 3rd, 2024. 3. One of one dietary staff (Nutrition Service Aide - NSA) 1 did not test the chemical concentration in the pots and pans sink per Quaternary Ammonium test strip directions. These failures had the potential to place patients at risk for food borne illnesses. Findings: 1. During a review of “City of [name] Water System. . . DO-NOT-DRINK & DO-NO-USE ADVISORY [advisory]” dated 6/4/24. The “Advisory” indicated, “City of [name] Water System customers. . . are advised to not drink nor use their tap water until further notice. . .Failure to follow this advisory could result in illness. . .oil from a private customer’s property backflowed into the water distribution system. . .DO NO USE YOUR TAP WATER-USE ONLY BOTTLED WATER. Bottled water should be used for all drinking. . .brushing teeth, washing hands, washing dishes, making ice, and preparing food.” During an observation on 6/6/24 at 10:39 a.m. outside, by the entrance to the kitchen, a large white tank was approximately half full of liquid with an opening on top. The intake inlet opening was two thirds covered with gray tape and one third uncovered and open to the environment. The tank did not indicate what the liquid was or the intended use. There was a red colored hose attached to the tank curled up on top. During a concurrent observation and interview on 6/6/24 at 3 p.m. with Infection Preventionist (IP), pictures of the water tank were reviewed. IP stated the water in the tank was being used yesterday (6/5/24) to fill the 3-compartment sink in the kitchen to wash pots and pans. IP stated the partially covered opening on the water tank was a concern for infection control. During an interview on 6/6/24 at 4:40 p.m. with DFO, DFO stated on 6/5/24 he observed the 500 gallon water tank’s inlet opening, which supplied water for the 3-compartment dish wash sinks with gray tape partially covering the water inlet opening. The opening exposed the water to potential contamination. DFO stated the opening in the water inlet was why the kitchen was shut down on 6/5/24 by the city. During a concurrent observation and interview on 6/7/24 with Director of Facility Operations (DFO) and IP, outside by the entrance to the kitchen, the white water tank did not indicate what it contained or if it was potable. IP stated there were no markings on the tank which indicated what it contained or if it was potable. IP stated the DFO obtained the tank for use in the kitchen. IP stated she visually inspected the tank when it arrived and was aware of the tape covering the top but was not involved in its use. DFO stated the tape used to partially cover the opening was not ideal and they did not have a way to monitor or secure the water tank to ensure contamination did not occur. The facility was unable to provide documentation the red hose used to transfer water from the tank to other containers to the kitchen was food-grade. 39650 During a review of the Food and Drug Administration Food Code 2022 (FDAFC), the FDAFC indicated many pathogens transmitted through food are also spread through water. In addition, a chemical sanitizer will not sanitize a dirty dish. During a review of the FDA Food Code Annex 2022 (FDAA), the FDAA indicated, “Effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution. It is important that surfaces be clean before being sanitized to allow the sanitizer to achieve its maximum benefit.” (FDA Food Code 2022 Annex; 4-701.10) During a review of the FDAFC dated 2022, the FDAFC indicated the person in charge of the day to day foodservice operations is expected “to have knowledge to include identifying the source of water used and measures taken to ensure that it remains protected from contamination”, as it relates to foodborne disease prevention. (FDA Food Code 2022; 2-102 Knowledge) During a review of the FDAA dated 2022, the FDAA indicated, “Some tanks are designed with an access opening to facilitate the cleaning and servicing of the water tank. The access must be constructed to prevent the opening from becoming a source of contamination of the water.” (FDA Food Code 2022 Annex, 5-302.12) 2. During a concurrent interview and record review on 6/6/24 at 12:18 p.m. with Cook, the QUATERNARY AMMONIUM [sanitizer] LOG [quat log]” for the 3-compartment sink (wash, rinse, sanitize), dated June 2024 was reviewed. The “quat log” indicated “ INSTRUCTIONS: Test the concentration of the ammonium in the quaternary sanitizer using the proper strips. . .Ammonium reading should be at least 150-200 ppm (parts per million - unit of measure). . .or manufactures recommendation. Keep log on file in the Dietary Department for one year.” Documented on June 4 and June 5 the test strip read 400 (ppm). No other tests results were documented. Cook was unable to provide quat logs for the 3-compartment sink for the months of April 2024 or May 2024. Cook stated the quat levels should be tested in the 3rd compartment of the 3-compartment sink each time they were filled. Cook stated the 3-compartment dish wash sink water and sanitizing solution was changed three times a day (breakfast, lunch, and dinner) prior to advisory to not use the city water issued on 6/4/24. During a review of the FDAFC, dated 2022, the FDAFC indicated the person in charge of the day to day foodservice operations should ensure that employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of sanitizing solution chemical concentration. (FDA Food Code 2022, 2-103.11 Person in Charge) 3. During an interview on 6/6/24 at 12:18 p.m. with Cook 1, Cook 1 stated on 6/5/24, he and Surveyor 1 observed NSA 1 place the quaternary ammonium test strip into the sanitizer and water solution in the third sink (of the 3-compartment sink) for 25-30 seconds which was an incorrect length of time. Cook 1 stated NSA 1 should have left the quaternary ammonium test strip in the sanitizer and water solution for 10 seconds not 25-30 seconds. During a review of “QT-10 HYDRION” container instructions, the instructions indicated, “for testing n-alkl dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride (sanitizer agents) IMMERSE FOR 10 SECONDS COMPARE WHEN WET.” During an interview on 6/6/24 at 3:56 p.m. with NSA 1, NSA 1 stated on 6/5/24 he took a piece of a quaternary ammonium test strip and placed it in the third compartment of the 3-compartment dish wash sink which contained the sanitizer and water solution as Surveyor 1 observed. NSA 1 stated he held the quaternary ammonium test strip in the water and sanitizer solution for approximately 25-30 seconds until it turned blue. NSA 1 stated when the quaternary ammonium test strip turned blue the sanitizer solution was okay to use for the dishes. During a review of the FDAFC, dated 2022, the FDAFC indicated concentration of the sanitizing solution shall be accurately determined by using a test kit in accordance with the manufacturer’s label. During an interview on 6/6/24 at 4:41 p.m. with Nutrition Service Manager (NSM), NSM stated he was unable to provide documentation NSA 1 completed orientation to the dietary/kitchen department, had his competencies evaluated or had a ServSafe California Food Handler Certificate of Achievement (completed a food safety course). During a review of the facility’s policy and procedure (P&P) titled, “Infection Control Plan,” dated 3/29/24, the P&P indicated, “Vision To promote disease prevention and the reduction of Hospital-Acquired Infections through the implementation of Infection Prevention and Control principles and practices. Mission Ensure safety, health and welfare for all customers, visitors and staff in an economically sound, effective manner. . . Integration of Infection Control and Prevention: Departmental Specific Involvement . . . 3. Dietary: A. Maintaining a controlled environment for safe aseptic preparation and serving of food for patients and staff by using Standard Precautions and policies.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36543 Based on interview, and record review, the hospital failed to ensure for one of one sampled patient (Patient 5) with hypoglycemia the Condition of Participation (COP) for the Nursing Services was met when: 1. RN did not report the “Electrocardiogram [EKG- a heart functioning test] for one of 30 patients (Patient 5) to Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine). Refer A395 2. RN did not follow facility hypoglycemia (low blood sugar) protocol to: a) Immediately provide a source of glucose (sugar) during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s). b) Monitor blood sugar levels every 15 to 30 minutes during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s). c) Report a critical low blood glucose result for one of 30 patients (Patient 5) to DO. Refer A395 The cumulative effect of these systemic practices resulted in the failure of the hospital to ensure the provision of health care services to meet the needs on the patients.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 36543 The Governing Body failed to ensure the Medical Staff fulfilled their responsibility to ensure the quality of care provided to patients when the hypoglycemia protocol was not in alignment with Centers for Disease Control and Prevention (National Health Agency) and American Diabetes guidelines for one of 30 sampled patients (Patient 5) with a blood glucose (sugar) level of 50 (normal blood glucose level 70 - 100 milligrams/deciliter [mg/dl]). This failure resulted in an unplanned transfer of Patient 5 by to a higher level of care and ultimate death. Findings: During a record review on Patient 5’s Finger Stick record (FS measures blood sugar), dated 10/19/2023, was reviewed. The FS indicated the following blood glucose levels: 3:49 p.m., Patient 5’s glucose level was 50 (low) mg/dl. 4:11 p.m. Patient 5’s glucose level was 54 (low) mg/dl. 4:52 p.m. Patient 5’s glucose level was 47 (critical low) mg/dl. 5:06 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 5:43 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 6:16 p.m. Patient 5’s glucose level was 51 (low) mg/dl. 7:13 p.m. Patient 5’s glucose level was 60 (low) mg/dl. 7:28 p.m. Patient 5’s glucose level was 57 (low) mg/dl. During a review of the facility provided Hypoglycemia Protocol, (undated), the Protocol indicated, “For patients that can take food orally or have a feeding tube, perform the following steps: 1. If blood glucose is less than 70, administer 1 tube of glucose gel, 4 oz. juice (apple if renal patient), or 8 oz. milk. 2. Re-check in 15-30 minutes. 3. If the blood glucose is still less than 70, repeat Step #1 ....5. Re-check in 15-30 minutes. 6. If blood glucose is still less than 70, call MD for further orders ...” The P&P did not indicate a procedure for blood glucose less than 55 mg/dl. During a review of the American Diabetes Association’s peer-reviewed journal titled “Diabetes Care” volume 46, supplement 1, dated 1/23, the journal indicated “16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023 ...The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted ...Among hospitalized patients, hyperglycemia, hypoglycemia, and glucose variability are associated with adverse outcomes, including increased morbidity and mortality (1). Careful management of people with diabetes during hospitalization has direct and immediate benefits ...Considerations on Admission High-quality hospital care for diabetes requires standards for care delivery, which are best implemented using structured order sets and quality improvement strategies for process improvement ...Where feasible, there should be structured order sets that provide computerized guidance for glycemic management ...Hypoglycemia in hospitalized patients is categorized by blood glucose concentration and clinical correlates [connections]. Level 1 hypoglycemia is defined as a glucose concentration of 54-[to]70 mg/dL (3.0-3.9 mmol/L). Level 2 hypoglycemia is defined as a blood glucose concentration <[less than]54 mg/dL (3.0 mmol/L), which is typically the threshold for neuroglycopenic symptoms [brain deprivation of oxygen resulting in confusion, sensation of warmth, weakness or fatigue, severe cognitive failure, seizure, coma]. Level 3 hypoglycemia is defined as a clinical event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery. Levels 2 and 3 require immediate correction of low blood glucose. Prompt treatment of level 1 hypoglycemia can prevent progression to more significant level 2 and level 3 hypoglycemia ...” During a review of the American Diabetes Association document titled “Treatment & Care Hypoglycemia (Low Blood Glucose),” undated, the document indicated “Low blood glucose is when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. This is usually when your blood glucose is less than 70 mg/dL...The 15-15 rule-have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes. If it’s still below 70 mg/dL, have another serving. Repeat these steps until your blood glucose is at least 70 mg/dL. Once your blood glucose is back to normal, eat a meal or snack to make sure it doesn’t lower again. This may be: Glucose tablets (see instructions) Gel tube (see instructions) 4 ounces (1/2 cup) of juice or regular soda (not diet) 1 tablespoon of sugar, honey, or corn syrup... When low blood glucose isn’t treated and you need someone to help you recover, it is considered a severe event...” During a review of the Centers for Disease Control and Preventions (National Health Agency) document titled “How To Treat Low Blood Sugar (Hypoglycemia)” dated 12/30/ 2022, the document indicated “For low blood sugar between 55-69 mg/dL, raise it by following the 15-15 rule: have 15 grams of carbs and check your blood sugar after 15 minutes. If it’s still below your target range, have another serving. Repeat these steps until it’s in your target range. Once it’s in range, eat a nutritious meal or snack to ensure it doesn’t get too low again ...Treating Severely Low Blood Sugar Blood sugar below 55 mg/dL is considered severely low. You won’t be able to treat it using the 15-15 rule...Injectable glucagon is the best way to treat severely low blood sugar.” During a review of the Medical Staff By-laws dated 3/8/2023, the Medical Staff Bylaws indicated “Article 2: Mission of the Medical Staff; Responsibilities of the Medical Staff; and Responsibilities of Members...2.3 Policies and Procedures. The Medical Staff shall recommend to the Governing Body any and all policies and procedures necessary to promote the quality, safety, and appropriateness of patient care at the Hospital, including, but not limited to...review of clinical practice guidelines ...””

“CRITERIA FOR MEDICAL STAFF PRIVILEGING CFR(s): 482.22(c)(6) [The bylaws must:] Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. For distant-site physicians and practitioners requesting privileges to furnish telemedicine services under an agreement with the hospital, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in §482.12(a)(8) and (a)(9), and §482.22(a)(3) and (a)(4). This Standard is not met as evidenced by: 36543 Based on interview and record review, the facility failed to ensure one of six physical rehabilitation physicians (Doctor of Osteopathy, DO, doctor emphasizing a whole-person approach to medicine) was privileged to interpret or analyze an Electrocardiogram (EKG test to record activity from the heart every time it beats) on one of 30 sampled patients (Patient 5). This failure had the potential for an inaccurate EKG interpretation. Findings: During a concurrent interview and record review on 4/16/24 at 10:44 am, with Medical Staff Coordinator, (MSC) Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine) DO’s Core Privileges were reviewed. MSC stated, DO’s core privileges did not include interpretation of EKGs. MSC stated, DO’s file did not indicate the Medical Staff granted DO privileges to interpret EKGs. During a review of Patient 5’s “Discharge Summary” dated 10/20/23, by DO, the Discharge summary indicated “[Patient 5] Admit Date 10/18/2023 ...During medication reconciliation [process of comparing patient’s medication orders to all medications patient has been taking] it was noted that patient [Patient 5] was on several QT [heart rhythm disorder] prolonging medications. In light of this an EKG was ordered for the following morning to determine corrected QT interval ...I spoke with the nurse in the morning asking for the EKG however a paper copy was not available. The only scanned in copy available was a tracing without any header or QT information. QTc [heart rate corrected interval] was calculated to be grossly normal by review.” During a review of Patient 5’s EKG dated 10/19/23, at 7:17 a.m. the EKG indicated, “** ** ACUTE MI ** ** Abnormal ECG.” During a review of an article titled “ACC/AHA [American College of Cardiology/American Heart Association] Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography” in Circulation (a peer reviewed journal) Volume 104, Number 25, dated 12/17/2001, the Article indicated Electrocardiograms are interpreted by physicians in many specialties, including cardiology, internal medicine, family practice, and emergency medicine. Interpretative skills vary among specialists. The Institute for Clinical Evaluation (ICE) is a foundation of the American Board of Internal Medicine (ABIM) that offers certifying examinations in clinical skills. A physician in any specialty whose interpretations of ECGs contribute to clinical decision-making should have a sufficient knowledge base to make accurate diagnoses. An adequate knowledge base should include the ability to define, recognize, and understand the basic pathophysiology of certain electrocardiographic abnormalities. A competent ECG reader should also be able to recognize potential clinical diagnoses on the basis of ECGs. Although these clinical syndromes do not always produce a diagnostic ECG pattern, ECG interpreters should recognize the characteristic patterns. “Granting clinical staff privileges to physicians to interpret AECGs is one of the mechanisms used by hospitals to ensure quality of care.” During a review of the Medical Staff By-laws dated 3/8/2023, the Medical Staff Bylaws indicated “Article 4 Clinical Privileges 4.1 Exercise of Clinical Privileges. Each Practitioner providing healthcare services at the Hospital shall exercise only those Clinical Privileges specifically granted by the Governing Body. Clinical Privileges granted by the Governing Body must be within the scope of the Practitioner’s license to practice in the State. Regardless of the Clinical Privileges granted, each Practitioner must obtain consultation when necessary for the safety of his or her patients ...” 47095 During a concurrent interview and record review on 4/16/24 at 3:46 p.m. with Chief Executive Officer (CEO), the document titled, DO’s “Delineation of Privileges,” dated 6/1/23- 9/29/23, was reviewed. The DO’s “Delineation of Privileges” indicated, “Approved CORE PRIVILEGES Admit, evaluate, diagnose, consult and provide nonsurgical therapeutic treatment and rehabilitation to adolescent and adult patients. . . Core Privileges Include: Comprehensive assessment and recommendation of a diagnostic plan and/or prescription for treatment that may include the use of physical agents. . . and/or other medical interventions; comprehensive evaluation, prescription, and supervision of medical rehabilitation treatment and establishment of goals. This includes ordering physical, occupational and speech/language therapies.” CEO stated the facility staff are “absolutely” expected to follow professional standards of practice and adhere to the facility’s P&P’s. Attempted to contact DO for interview on 4/17/24 at 9:28 a.m., on 4/17/24, at 2:43 p.m., and on 4/18/24 at 11:44 a.m. DO did not return call for interview. During a review of the facility P&P titled, “Electrocardiograms,” dated 6/15/23, indicated, “PURPOSE To insure[sic] no cardiac compromise that could inhibit participation in the rehab programs. POLICY. . . EKGs must be formally interpreted by a physician privileged to read EKGs as part of his/her hospital privileging.” During a review of the Medical Staff By-laws, dated 3/8/2023, the Medical Staff Bylaws indicated, “Article 2: Mission of the Medical Staff; Responsibilities of the Medical Staff; and Responsibilities of Members...2.2.9 Credentialing. Credentials shall be processed in a manner that matches verified qualifications, performance, and competence with Clinical Privileges for all Applicants, and that ensures these individuals are licensed and meet other applicable standards required by State law. 2.2.10 Recommendations to the Governing Body. The Medical Staff, acting through the Medical Executive Committee, shall make recommendations directly to the Governing Body with respect to Medical Staff appointments, reappointments, Medical Staff categories, Clinical Privileges...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47095 Based on interview and record review the facility failed to ensure a Registered Nurse (RN) evaluated the care of one of 30 sampled patients (Patient 5) with a change of condition when: 1. RN did not report the “Electrocardiogram [EKG- a heart functioning test] for one of 30 patients (Patient 5) to Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine). 2. RN did not follow facility hypoglycemia (low blood sugar) protocol to: a) Immediately provide a source of glucose (sugar) during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s). b) Monitor blood sugar levels every 15 to 30 minutes during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s). c) Report a critical low blood glucose result for one of 30 patients (Patient 5) to DO. These failures resulted in a delay in care, the hospital transferring Patient 5 to a higher level of care and may have contributed to Patient 5’s ultimate death. Findings: 1. During an interview on 4/11/24 at 9:36 a.m. with RN 3, RN 3 stated the facility EKG patient care process was for respiratory therapists (RT) to perform the EKG, provide the patient’s EKG result to the RN, and the RN notified the physician. RN 3 stated for abnormal EKG’s, nurses notify the doctor and document in the patient’s medical record (MR) the doctor was notified. RN 3 stated complete documentation includes the date, time, patient condition and doctor notification. During a concurrent interview and record review on 4/11/24 at 2:09 p.m. with Chief Nursing Officer (CNO), Patient 5’s EKG dated 10/19/23, at 7:17 a.m. was reviewed. The EKG indicated, “** ** ACUTE MI ** ** Abnormal ECG.” CNO stated, it was her expectation for the RN to telephone the physician if there was an abnormal EKG result. CNO stated there was no documentation in Patient 5’s medical record indicating the RN notified the DO of Patient 5’s abnormal EKG result at this time. During a concurrent interview and record review on 4/11/24 at 3:08 p.m. with RT 1, Patient 5’s EKG dated 10/19/23 time 7:17 a.m. was reviewed. The EKG indicated, “** ** ACUTE MI ** ** Abnormal ECG.” RT 1 stated the facility EKG patient care process was for RT to perform the EKG and provide the RN with the EKG result. RT 1 stated she was unable to find documentation the nurse notified DO of Patient 5’s EKG. Attempted to contact DO for an interview on 4/17/24 at 9:28 a.m., on 4/17/24 at 2:43 p.m., and on 4/18/24 at 11:44 a.m. with no return call from DO for interview. During a review of the Agency for Healthcare Research and Quality Case Study titled “Electrocardiogram Results” dated 11/1/12, the Case study indicated “Take-Home Points ...All ECGs [EKGs] should be shown to the nurse responsible for the patient. Any disturbing statement in the computer reading of the ECG should be referred to the attending physician for any action required ...” During a review of the facility Policy and Procedure (P&P) titled, “Electrocardiograms,” dated 6/15/23, the P&P indicated, “Give original to MD for review ...original print will be given to the Unit Secretary to be scanned ...and be filed ...” 2a) During an interview on 4/11/24 at 9:38 a.m. with RN 3, RN 3 stated, nurses must call the doctor when a patient’s blood sugar was 50 milligrams per deciliter (mg/dl, normal blood sugar levels 70 mg/dl to 120 mg/dl). RN 3 stated, it was expected to notify the doctor when the patient condition changes, because the changes could be fast and unpredictable. During a concurrent interview and record review on 4/11/24 at 2:40 p.m. with CNO, Patient 5’s Doctor’s PN, dated 10/19/23, at 8:06 p.m. was reviewed. The PN indicated, “I [DO] was called at 6:16pm[sic] for a reported BG [blood glucose] of 47.” CNO stated DO’s documentation indicated RN notification for Patient 5’s critical low blood sugar of 47 performed at 4:52 p.m. was at 6:16 p.m. 1 hour and 20 minutes after RN 1 obtained the result. During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5’s “Flowsheet Lab View,” dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated the following Point of Care (at bedside) glucose results on 10/19/2023, at: 3:49 p.m., Patient 5’s glucose level was 50 (low) mg/dl. 4:11 p.m. Patient 5’s glucose level was 54 (low) mg/dl. 4:52 p.m. Patient 5’s glucose level was 47 (critical low) mg/dl. 5:06 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 5:43 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 6:16 p.m. Patient 5’s glucose level was 51 (low) mg/dl. 7:13 p.m. Patient 5’s glucose level was 60 (low) mg/dl. 7:28 p.m. Patient 5’s glucose level was 57 (low) mg/dl. RM stated the nurse called DO at 5:19 p.m. (17:19, approximately one and a half hours after Patient 5’s low value of 50) and received an order for glucose (sugar) gel. During a review of the facility P&P) titled “Critical Test Results,” dated 9/29/2023, the P&P indicated To ensure effective communication to the responsible caregiver of diagnostic procedures and test results that can be critical to patient outcomes and to enable provision of timely, appropriate treatment to the patient ...1. Upon receipt of a critical value, the nurse will contact the physician immediately and report the critical test results to the physician. Time of receipt of critical value will be documented in the medical record ... Report of the critical value must occur within one hour of receipt ...3. The nurse (or RT) will then document physician notification of the critical value and record the time the critical value was reported to the physician ...Glucose LOW: Less Than 50 mg/dl ...” 2b) During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5’s “Flowsheet Lab View,” dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated on 10/19/2023, at 3:49 p.m., Patient 5’s glucose level was 50 (low) milligrams per deciliter (mg/dl). RM stated there was no documentation nursing provided any oral intake to Resident 5 at 3:49 pm. The Flowsheet indicated on 10/19/2023, at 4:11 p.m., Patient 5’s glucose level was 54 (low) mg/dl. RM stated there was no documentation nursing provided any oral intake to Resident 5 at 4:11 pm. The Flowsheet indicated on 10/19/2023, at 4:52 p.m., Patient 5’s glucose level was 47 (critical low) mg/dl. RM stated there was no documentation nursing provided any interventions. The Flowsheet indicated on 10/19/2023, at 5:06 p.m., Patient 5’s glucose level was 49 (critical low) mg/dl. RM stated the bedside nurse called rapid response team (RRT, provides early, rapid interventions in order to prevent adverse events) overhead at 5:07 p.m. and DO was called at 5:19 p.m. The Flowsheet indicated on 10/19/2023, at 5:43 p.m., Patient 5’s glucose level was 49 (critical low) mg/dl. RM stated there was no documentation nursing provided any interventions. During a concurrent interview and record review on 4/16/24 at 2:17 p.m. with RN 1, Patient 5’s “Flowsheet Lab View”, dated 10/18/23 to 10/19/23 was reviewed. RN 1 stated on 10/19/23, at 3:49 p.m. Patient 5’s blood glucose was low. RN 1 stated on 10/19/23 at 5:19 p.m. she made the first call to DO regarding Patient 5’s low and critical low blood sugar levels. RN 1 stated she should have contacted DO earlier. RN 1 stated she should have followed the hypoglycemia protocol. During a review of the facility document titled “Hypoglycemia Protocol” undated, the Protocol indicated “1. If blood glucose is less than70[sic], administer 1 tube of glucose gel, 4 oz. [ounce] juice (apple if renal patient), 8 oz. skim milk 2. Re-check in 15-30 minutes. 3. If the blood glucose is still less than 70, repeat Step #1 ...6. If blood glucose is still less than 70[sic], call MD [doctor] for further orders.” 2c) During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5’s “Flowsheet Lab View,” dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated on 10/19/2023, at 4:11 p.m. Patient 5’s glucose level was L (low) 54 mg/dl. The Flowsheet indicated on 10/19/2023, at 4:52 p.m., Patient 5’s glucose level was C (critical) 47 (critical low) mg/dl. RM stated the C indicated a critical value. RM stated there were 41 minutes between the two glucose level checks. RM stated the facility was not short staffed on 10/19/2023. The Flowsheet indicated on 10/19/2023, at 6:16 p.m., Patient 5’s glucose level was 51 (low) mg/dl. The Flowsheet indicated on 10/19/2023, at 7:13 p.m., Patient 5’s glucose level was 60 (low) mg/dl. RM stated there were 58 minutes between the two glucose level checks. During a concurrent interview and record review on 4/16/24 at 2:17 p.m., with RN 1, Patient 5’s “Flowsheet Lab View”, dated 10/18/23 to 10/19/23 was reviewed. The flowsheet indicated on 10/19/23 at 3:49 p.m., Patient 5’s glucose level was 50 mg/dl. RN 1 stated no nursing interventions were documented addressing Patient 5’s low glucose level of 50 mg/dl. RN 1 stated that no documentation indicated “not done.” The flowsheet indicated on 10/19/23, at 4:11 p.m., Patient 5’s glucose level was 54 (low) mg/dl. RN 1 stated there was no oral intake provided to Patient 5 at 4:11 p.m. The flowsheet indicated on 10/19/23, at 4:52 p.m., Patient 5’s glucose level was 47 (critical low) mg/dl. RN 1 stated there were no interventions done. The flowsheet indicated on 10/19/23, at 5:06 p.m., Patient 5’s glucose level was 49 (critical low) mg/dl. RN 1 stated DO was contacted with a rapid response at 5:07 p.m. one hour and 18 minutes from Patient 5’s intial low glucose level of 50 mg/dl at 3:49 p.m. RN 1 stated, “The rapid [response] should have been called sooner.” The flowsheet indicated on 10/19/23, at 5:43 p.m., Patient 5’s glucose level was 49 (critical low) mg/dl. RN 1 stated Patient 5’s continued low blood glucose lab results were a priority and the “nurse [was] responsible to review and call with critical [values and] contact the doctor.” RN 1 stated she should have followed the hypoglycemia protocol and called DO for Patient 5’s continued low blood sugar results. During a concurrent interview and record review on 4/16/23 at 3:34 p.m., with RN 1, Patient 5’s “MAR Summary”, dated 10/19/23 was reviewed. The MAR summary indicated, “glucagon [a medication that increases blood sugar levels] 1 mg[milligram] @1830[6:30 p.m.]. RN 1 stated Patient 5’s blood sugar was consistently low and was emergently sent out to the hospital. RN 1 stated there was no documentation indicating Patient 5’s low blood sugar level had been treated from 6:30 p.m. to the arrival of EMS and Patient 1’s transfer to the emergency department (ED) from the facility at 7:45 p.m. During an interview on 4/16/24 at 4 p.m., with RM, RM stated the facility does not have a diabetic management policy and the facility policies go through corperate. During a review of the facility document titled “Hypoglycemia Protocol” undated, the Protocol indicated “1. If blood glucose is less than70[sic], administer 1 tube of glucose gel, 4 oz. [ounce] juice (apple if renal patient), 8 oz. skim milk 2. Re-check in 15-30 minutes ...5. Re-check in 15-30 minutes.” During a review of the Centers for Disease Control and Preventions (National Health Agency) document titled “How To Treat Low Blood Sugar (Hypoglycemia)” dated 12/30/ 2022, the document indicated “For low blood sugar between 55-69 mg/dL, raise it by following the 15-15 rule: have 15 grams of carbs and check your blood sugar after 15 minutes. If it’s still below your target range, have another serving. Repeat these steps until it’s in your target range. Once it’s in range, eat a nutritious meal or snack to ensure it doesn’t get too low again ...Treating Severely Low Blood Sugar Blood sugar below 55 mg/dL is considered severely low. You won’t be able to treat it using the 15-15 rule...Injectable glucagon is the best way to treat severely low blood sugar.” During an interview on 4/16/24 at 3:51 p.m. with Chief Executive Officer (CEO), CEO stated the facility staff are “absolutely” expected to follow professional standards of practice and adhere to the facility’s P&P’s. During a review of Resident 1’s “ED [Emergency department] Physician Note (EDN),” dated 10/19/2023, from Hospital 1, the “EDN” indicated, Chief complaint: unresponsive. History of present illness: This 64-year-old female (Patient 1), with a history of high blood pressure, diabetes mellitus, high cholesterol. (Patient 1 was unresponsive and found to be pulseless with a blood sugar of 56 mg/dl. EMS administered dextrose [sugar] en route, bringing Patient 1’s blood sugar up to 96 mg/dl. Upon arrival at the ED, Patient 1’s blood sugar had come down to 54 mg/dl, D50 (dextrose) administered. Patient 1 did not have a heartbeat (asystole), EMS performed CPR (cardiopulmonary resuscitation-an emergency lifesaving procedure) during transport...ED Course, Data, and Interventions: Patient arrived at the ED with CPR being carried out by EMS. No agonal breathing (gasping for air) or cardiopulmonary/neurological (brain) activities were observed upon arrival. Patient 1 was emergently intubated (tube inserted into airway/windpipe to deliver oxygen] with CPR still in progress. Patient 1 was subsequently shocked [the use of electrical current to help the heart return to a normal rhythm] out of V-Tach (Ventricular tachycardia- a heart rhythm problem caused by irregular electrical signals) IV (intravenous- in the vein) Amiodarone (a medication to prevent and treat a fast or irregular heartbeat) was administered, with return of a wrist pulse, and subsequent return to asystole. Three Successive ultrasound [a test that uses sound waves to make pictures of organs, tissues, and other structures inside the body] showed no cardiac activity. Patient 1 was pronounced expired [deceased] at 8:37 p.m. During a review of Resident 1’s “CERTIFICATE OF DEATH (COD),” dated 4/17/24, the COD indicated “CAUSE OF DEATH (A) CARDIOPULMONARY ARREST (heart stops beating) (B) KIDNEY FAILURE (kidneys are bean shaped organs found on the right and left side of the body that are responsible for filtering and removing waste, and controlling the body’s fluid balance) (C) DIABETES MELLITUS TYPE 2, (7) DATE OF DEATH 10/19/2023, (8) HOUR 2027 [8:27 p.m.]. During a review of the facility P&P titled, “Plan for the Provision of Patient Care”, dated 3/8/23, indicated, “Nursing Department ...Nursing care is provided through a team-nursing approach in which the Registered Nurse (RN) bears primary responsibility and accountability for nursing practice based on specialized knowledge, judgment, and skills ...The needs of each patient are assessed every shift and as needed, to determine the level of patient acuity.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 47095 Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 5) had an accurate and complete medical record. This failure had the potential to negatively affect the care of Patient 5. Findings: 1. During a concurrent interview and record review on 4/11/24 at 2:09 p.m. with Chief Nursing Officer (CNO), Patient 5’s EKG, dated 10/19/23 at 7:17 a.m. was reviewed. Patient 5’s electrocardiogram (EKG or ECG, test to record activity from the heart every time it beats) indicated “** ** ACUTE MI ** ** Abnormal ECG.” Patient 5’s nursing documentation was reviewed. CNO stated there was no documentation nursing notified Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine) of Patient 5’s abnormal EKG result. During a concurrent interview and record review on 4/11/24 at 3:08 p.m. with Respiratory Therapist (RT) 1, Patient 5’s EKG, handwritten dated 10/19/23 and at 7:17 a.m. was reviewed. Patient 5’s EKG indicated, “** ** ACUTE MI ** ** Abnormal ECG.” RT 1 stated the facility EKG patient care process was for the RT to perform the EKG, place the patient identification label, then the RT initials, dates the printed EKG result (does not input the date or time into the machine) and provide the patient’s RN the EKG result. RT 1 stated she “cannot find” documentation that Patient 5’s EKG was provided to the Registered Nurse (RN) 1 and or the DO. 2. During a concurrent interview and record review on 4/11/24 at 3:08 p.m. with RT 1, Patient 5’s EKG, handwritten dated 10/19/23 and at 7:17 a.m. was reviewed. RT 1 stated, the date indicated at the bottom of Patient 5’s EKG was inaccurately dated January 1, 2001. During a concurrent interview and record review on 4/15/24 at 12:38 p.m. with RT Supervisor (RTS), the facility 300 wing EKG machine’s “test sheet” was reviewed. The “test sheet” printed date indicated “01. Jan.2001 00:00:09.” RTS stated, “That’s why all the RT [Respiratory Therapists] write it down [current date and time] and initial it.” RTS stated the facility process is to strike out the incorrect date “01. Jan.2001 00:00:09” because it’s not accurate. During an observation and interview on 4/15/2024, at 12:40 pm with RT Supervisor, on the East Wing, the facilities second EKG machine (MAC 1200) had a Service Due Sticker dated 2/2025. RT Supervisor performed a test print. RT Supervisor stated the EKG test printed a run date of January 1, 2001, that was why the RT wrote the date of the EKG test on the strip. RT Supervisor stated, the RT staff did not enter any patient data into the machine, but instead would affix a patient label to the EKG strip. RT Supervisor stated, the printed time would not match the time written by the RT on the EKG strip. During an observation, interview and record review, on 4/16/24, at 11:30 a.m., with RT Supervisor, in the 300 wing, RT Supervisor stated her former supervisor trained her on the EKG machine. RT Supervisor stated the default date on the EKG machine was not correct. The Manufacturer’s Instructions for Use were reviewed. RT Supervisor stated the Instructions were provided to set the date and time. RT Supervisor stated she trained the RTs to black out the incorrect printed date on the EKG strip. RT Supervisor stated the patient’s medical record should be correct and incorrect information should be blacked out. During a review of Patient 5’s “Discharge Summary” dated 10/20/23, by DO, the Discharge summary indicated “[Patient 5] Admit Date 10/18/2023 ...During medication reconciliation [process of comparing patient’s medication orders to all medications patient has been taking] it was noted that patient [Patient 5] was on several QT [heart rhythm disorder] prolonging medications. In light of this an EKG was ordered for the following morning to determine corrected QT interval ...I [DO] spoke with the nurse in the morning asking for the EKG however a paper copy was not available. The only scanned in copy available was a tracing without any header or QT information. QTc [heart rate corrected interval] was calculated to be grossly normal by review.” During a review of the facility’s P&P titled, “Electrocardiograms”, dated 6/15/23, indicated, “PURPOSE To insure[sic] no cardiac compromise that could inhibit participation in the rehab programs. POLICY The respiratory therapist, nurse, or other technician with training and competency (as allowed by state) may perform EKGs. EKGs must be formally interpreted by a physician privileged to read EKGs as part of his/her hospital privileging. . . 7. Give original to MD for review. If requested the EKG to be read, the original print out will be given to the Unit Secretary to fax to the contracted cardiologist. . . If MD suggests that that[sic] the original prin[sic] out does not need to be read the original print out will be given to the Unit Secrestary [sic] to be scanned. . . and be filed in the patient’s soft chart.” 3. During a concurrent interview and record review on 4/11/24 at 2:40 p.m. with CNO, DO’s Progress Notes for Patient 5, dated 10/19/23, at 8:06 p.m. was reviewed. The PN indicated, “I [DO] was called at 6:16pm[sic] for a reported BG [blood glucose] of 47.” CNO stated there was no documentation nursing notified DO of Patient 5’s critical low blood glucose level result of 47 on 10/19/23, at 4:52 p.m., prior to 6:16 p.m. During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5’s “Flowsheet Lab View,” dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated the following Point of Care (at bedside) glucose results on 10/19/2023, at: 3:49 p.m., Patient 5’s glucose level was 50 (low) mg/dl. 4:11 p.m. Patient 5’s glucose level was 54 (low) mg/dl. 4:52 p.m. Patient 5’s glucose level was 47 (critical low) mg/dl. 5:06 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 5:43 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 6:16 p.m. Patient 5’s glucose level was 51 (low) mg/dl. 7:13 p.m. Patient 5’s glucose level was 60 (low) mg/dl. 7:28 p.m. Patient 5’s glucose level was 57 (low) mg/dl. RM stated the nurse called DO at 5:19 p.m. (approximately one and a half hours after Patient 5’s low value of 50). During a concurrent interview and record review on 4/16/24 at 2:17 p.m. with RN 1, Patient 5’s Medication Administration Record (MAR) Summary, dated 10/19/23 was reviewed. The “MAR Summary” indicated “glucagon [medication to increase blood sugar] 1 mg [milligram] @1830 [6:30 p.m.].” RN 1 stated there was no documentation indicating Patient 5’s low blood sugar had been treated from 6:30 p.m. to the arrival of EMS and Patient 1’s transfer to the emergency department (ED) from the facility at 7:45 p.m. RN 2 stated, no documentation means “that’s not done.” During a review of Patient 5’s “DC [discharge] Info/Summary,” dated 10/20/23 at 12:23 p.m. the DC Info/Summary indicated “Hospital Course: Please refer to rapid response note. Patient was admitted to our [Hospital] service on 10/18/2023 ...Later that evening I was called during a rapid response for a blood sugar of 47. EMS was called and patient transported to [Hospital 2] ...” During a review of the facility document titled “Hypoglycemia Protocol” undated, the Protocol indicated “1. If blood glucose is less than70[sic], administer 1 tube of glucose gel, 4 oz. [ounce] juice (apple if renal patient), 8 oz. skim milk 2. Re-check in 15-30 minutes. 3. If the blood glucose is still less than 70, repeat Step #1 ...6. If blood glucose is still less than 70[sic], call MD [doctor] for further orders ...” During a review of the facility P&P titled “Critical Test Results,” dated 9/29/2023, the P&P indicated To ensure effective communication to the responsible caregiver of diagnostic procedures and test results that can be critical to patient outcomes and to enable provision of timely, appropriate treatment to the patient ...1. Upon receipt of a critical value, the nurse will contact the physician immediately and report the critical test results to the physician. Time of receipt of critical value will be documented in the medical record ... Report of the critical value must occur within one hour of receipt ...3. The nurse (or RT) will then document physician notification of the critical value and record the time the critical value was reported to the physician ...Glucose LOW: Less Than 50 mg/dl ...” 4. During a review of Patient 5’s “Flowsheet Lab View,” dated 10/18/23 to 10/19/23 the Flowsheet indicated the following Point of Care (at bedside) glucose results on 10/19/2023, at: 3:49 p.m., Patient 5’s glucose level was 50 (low) mg/dl. 4:11 p.m. Patient 5’s glucose level was 54 (low) mg/dl. 4:52 p.m. Patient 5’s glucose level was 47 (critical low) mg/dl. 5:06 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 5:43 p.m. Patient 5’s glucose level was 49 (critical low) mg/dl. 6:16 p.m. Patient 5’s glucose level was 51 (low) mg/dl. 7:13 p.m. Patient 5’s glucose level was 60 (low) mg/dl. 7:28 p.m. Patient 5’s glucose level was 57 (low) mg/dl During a concurrent interview and record review on 4/16/24, at 3:39 p.m. with RN 1, Patient 5’s “Acute Care Transfer” note dated 10/19/23, at 9:22 p.m. was reviewed. The “Acute Care Transfer” note indicated “19:25 [7:25 p.m.] HR 116, 73 % 02, BP [Blood Pressure] 12/63[sic]. . . 19:39[7:39 p.m.] Blood sugar was 91. RN 1 stated the blood sugar checks completed at the facility should be in Patient 5’s lab results section and automatically uploads into the patient’s MR. RN 1 stated, “We dock the glucometer and automatic upload even when turn off it uploads.” RN 1 stated, she was not sure of where the additional blood sugar at 7:39 p.m. came from. RN 1 stated the documentation “should be there” (in Patient 5’s lab results section). 5. During a concurrent interview and record review on 4/11/24 at 2:50 p.m. with CNO, Patient 5’s “Progress Note (PN),” dated 10/19/23 at 7:16 p.m. was reviewed. The “PN” indicated, “ PT [Patient 5] FOUND SWEATY, COLD CLAMMY, AND UNRESPONSIVE WITH SLIGHT AGONAL BREATHING. . . 911 CALLED. . . BEGAN PROVIDING RESCUE BREATHS. . . PT MOAN TO. . . STERNAL RUB. . . EMS [emergency medical services] ARRIVED. . . EMS LEFT WITH PATIENT [5].” CNO stated Patient 5’s discharge was unplanned. CNO stated Patient 5’s condition was unresponsive, low blood sugars with rescue breathing. CNO stated Patient 5 required an emergent transfer on 10/19/23 at 7:45 p.m. During a review of Patient 5’s “DC [discharge] Info/Summary,” dated 10/20/23 at 12:23 p.m. the DC Info/Summary indicated “Hospital Course: Please refer to rapid response note. Patient was admitted to our [Hospital] service on 10/18/2023 ...Physical Exam on Discharge: General: Bag breathing, Heart: Regular Rate, Lungs: Non-labored ...Neuro: non-responsive ...Disposition: Discharge to Living Setting ...Patient was prepared for discharge with the appropriate follow-ups, medications and continued rehabilitation as ordered ...Condition at Discharge: Stable and improved ...Discharge instructions reviewed with patient and/or caregiver ...[electronic signature] DO Electronically Authenticated on 10/20/2023 12:23 PM.” Attempted to contact DO for an interview on 4/17/24 at 9:28 a.m. and 2:43 p.m., on 4/18/24 at 11:44 a.m. with no return call from DO for interview. During an interview on 4/16/24 at 3:51 p.m. with Chief Executive Officer (CEO), CEO stated the facility staff are “absolutely” expected to follow professional standards of practice and adhere to the facility’s P&P’s. During a review of the facility’s P&P titled, “Plan for the Provision of Patient Care”, dated 3/8/23, indicated, “Nursing Department. . . Nursing care is provided through a team-nursing approach in which the Registered Nurse (RN) bears primary responsibility and accountability for nursing practice based on specialized knowledge, judgment, and skills. . . The needs of each patient are assessed every shift and as needed, to determine the level of patient acuity.””