Results from a Multi-facility
Nutrition Services Healthcare System
Tacoma, Washington
May 2002

Survey Team:
Administrator: Phillip Todd
Nurse Surveyor: Ruth Mrozek, RN
Physician Surveyor: Lee Toon, MD

Three facilities within this system were toured and scored as follows:
Facility A/B combined = 415 beds/ 105 beds with a combined score of: 92
Children’s Hospital = 70 beds with a score of 96
Home Health = score of 99 

Kitchen Tour

Surveyor, Phillip Todd, asked that we start in the coolers and then go to hot production, tray line and then the dish room.

1. In the coolers he looked for dates on everything. 

2. He asked about HACCP and wanted to know about their procedures. He liked that this was part of the department competency. He liked the refrigerator temperature charts.

3. He touched the tops of cooler doors and found dust. He looked at cleanliness carefully and said that it looked good overall.

4. He asked for specific days for food temperature, dish machine titration levels and test trays (July '01, December '01, April 02, January '02). These were reviewed on at the EOC document review session.

5. He looked at dates of dry stock, formula, etc.

6. He looked at the operation in the dish room. Asked who is responsible for getting chipped china out of service. He asked how employees are trained to perform this. 

7. He asked about cleaning the hoods, how frequent? He wanted documentation when cleaning was performed. Engineering Department provided the cleaning service and documentation.

8. He asked about how often the ice bins are cleaned. He checked to see that ice scoops were not inside the machine. They need to be stored face down and in a clean container.

9. He went to the dry storeroom and checked dates on all items. He also where the sterno is stored. (It needs to be in a flameproof container or storage area of some sort).

Facility overall score:
Acute care multi-facility healthcare system

Document Review:
The following documents were requested by the inspector:

• Taste test documentation for 4 specific months that the inspector identified.

• Chemical titration levels for dish machine for same 4 identified months.

• Dish machine temperature documentation for same 4 identified months.

• Tray line food temperatures for 4 specific days he identified.

Clinical Nutrition Findings

Tacoma General/Allenmore (sister facility)

Nurse Surveyor, Ruth Mzorek

• Cautioned all disciplines - that we do not “chart by exception.” We do “chart by variance.”

• Disciplines (nutrition, social work, etc.) should draw (and document) a conclusion after their assessment and then incorporate their plan into the care plan. Looking for multi-disciplinary approach.

• Clinical pathway should incorporate non-nursing disciplines as well as nursing.

• Interested in how patient is involved in their plan of care, how patient responds to treatment, how we connect to the patient’s spirituality (not just religious denomination, but values, quality of life, etc.)

• Focused on putting the pieces together about how the patient is doing (what does the data mean?) and connecting to the care plan.

• She asked about over-the-counter medications and herbals. This was documented on the Pharmacy medication review sheet at this facility.

• Pain assessment-the surveyor wanted to know if the RD took pain issues into account when assessing food intake of that patient. If so, how was it documented?

• The inspector reviewed clinical competencies

• The inspector offered an idea for process improvement. She suggested that we combine job description, competencies and performance appraisal onto one form. 

• The inspector noted use of FMLA is high at MultiCare and that span of control is high.

• She was not happy with NICU nutrition screening policy of 72 hours (average length of stay 16 days in ICN, 30+ days NICU). Dietitians screen all patients. But the policy was changed to 48 hours. 

• The inspector felt RD’s weren’t doing enough on Drug-Nutrient Interactions (this facility only teaches about MAOI’s; pharmacists do Warfarin); no findings since they met their stated policy but wanted to see drugs covered, expanded.

• The surveyor suggested that we make the patient menu all “healthy” and not have to write special diets. (Interesting concept!!)

Clinical Nutrition, cont. 

Administrative Surveyor, Mr. Phillip Todd
Over Counter-Herbal Medications: The surveyor questioned how caregivers are prompted to ask about the over counter and herbal supplements patients are taking and wanted to know where it was documented in the chart. This was a focus throughout the visit.

Physician Surveyor, Dr. Lee Toon

• Documentation of pain assessment; documentation of over-the-counter medications and herbals.

• From HR interview, looked at age-specific competencies and thought they were a bit too general.

• A Type 1 was given for untimely performance appraisals.

Mary Bridge Children’s Hospital and Health Center (sister facility)

Physician surveyor, Dr. Lee Toon

• Surveyor focused on nutrition screening/assessment in PICU. and was pleased with RD screening and following all patients.

• A very detailed medical records review yielded very few issues (seventeen year-old not on a growth chart [in house for 26 hours], account number discrepancy, no pain assessment on patient while in ER (but one was completed upstairs when patient was admitted). This resulted in a supplemental finding.

• Type 1 given for untimely performance appraisals

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