HospitalInspections.org

Based on medical record review, document review and interview, in 1 (one) of 12 medical records reviewed, nursing staff did not ensure that a patient with distended abdomen and abnormal vital signs received ongoing assessment and monitoring (Patient #1).

Findings include:

Review of medical record for Patient #1 identified a 56 year old male who was admitted on 11/19/16 from a group home, with a diagnosis of acute sepsis and pneumonia. The patient's past medical history included hyperbilirubineamia and profound mental retardation.

On 12/15/16 at 8:00 AM, nurse noted the patient has abdominal pain and rigidity. At 8:16 AM, vital signs were noted as follows: Temperature 97.5 F, Pulse 116 (normal is 60-100), Respiration 20, Blood Pressure 133/69 and Oxygen saturation was 93% (normal is (96-100%).

At 12/15/16 at 9:55 AM, nurse documented that a sitter informed her that the patient was "breathing funny". Resuscitative measures failed and the patient was pronounced dead at 10:22 AM.

Review of facility policy titled: Nursing Standard of Care/Standard of Practice, revised 12/15, states vital signs are completed according to Nursing Policy, unite routine, physician order, or as patient condition warrants.

There was no documentation in the medical record that the patient received ongoing assessment and monitoring after the 8:00 AM assessment that revealed abdominal distention, pain and rigidity, and the 8:16 AM vital signs that showed a fast heart rate and low oxygen saturation.

During interview with Staff B, Chief Nursing Officer on 3/16/17 at 2:00 PM she acknowledged findings.

Based on medical record review and interview, in 1(one) of 12 medical records reviewed, nursing staff did not develop care plan to ensure that the food intake of a patient identified as a high nutritional risk was monitored (Patient #1).

Findings include:

Review of medical record for Patient #1 identified a 56- year-old patient who was admitted on 11/19/16.

On 11/22/16 at 12:05 PM, the initial nutrition assessment noted the patient was on Phenylketonuria (PKU) diet. The dietitian notes that the patient's oral intake should be monitored.

On 11/30/16 at 2:43 PM the dietitian noted that the patient was upgraded to a level III which is a high degree of nutritional risk requiring continual monitoring of intake.

There was no documentation in the medical record that nurses consistently monitored the patient's intake.

Review of Nursing Measurement Report revealed that 35 of the 78 meals consumed by the patient was not monitored and documented.

During interview with staff G, Nurse Manager on 3/16/17 at 11:00 AM, Staff G confirmed that meals were not consistently monitored.

Based on medical record review and interview, in 1 (one) of 12 medical records reviewed, the dietary department did not ensure that a patient's nutritional need was met (Patient #1).

Findings include:

Review of medical record for Patient #1 noted a 56-year-old male who was admitted from a group home on 11/19/16. The patient's past medical history included profound mental retardation, organic brain damage, autism, mitral valve prolapse, phenylketonuria, rectal prolapse, diabetes insipidus and hypothyroidism.

On 11/19/16 at 11:44 AM, a diet order by a nurse practitioner notes "phenelalanine (PKU) -free diet from home."

On 11/22/16 at 12:05 PM, the initial nutrition assessment by a registered dietitian classified the patient as a level II- moderate nutrition risk. The dietitian documented that the patient was on "clears (only apple and orange juice), group home providing food secondary to PKU." In a follow-up assessment of the patient on 11/30/16 at 2:43 PM, the dietitian upgraded the patient to a level III- High degree of nutritional risk.

There was no documentation in the medical record that the dietitian consulted with the medical staff regarding the diet orders which lacked supplementation of the PKU diet.

There was no documentation that the dietitian assessed the meals supplied by the group home to determine that it was therapeutic and met the patient's nutritional needs.

During interview with Staff I, Chief Clinical Dietitian on 3/16/17 at 9:30 AM, Staff I acknowledged the findings.