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Tag No.: A0395
Based on medical record review and staff interview, it was determined the hospital failed to ensure a comprehensive nutritional admission assessment was conducted by the RN for 2 out of 11 patients (Patient #3 and #8) whose records were reviewed. This failure had the potential to result in delayed patient healing and improvement. Findings include:
The National Institutes of Health website, accessed 10/05/15, stated "There are many factors that can affect wound healing which interfere with one or more phases in this process, thus causing improper or impaired tissue repair. Wounds that exhibit impaired healing, including delayed acute wounds and chronic wounds, generally have failed to progress through the normal stages of healing. Such wounds frequently enter a state of pathologic inflammation due to a postponed, incomplete, or uncoordinated healing process. Multiple factors can lead to impaired wound healing. Most obvious is that malnutrition or specific nutrient deficiencies can have a profound impact on wound healing after trauma and surgery. Patients with chronic or non-healing wounds and experiencing nutrition deficiency often require special nutrients. Energy, carbohydrate, protein, fat, vitamin, and mineral metabolism all can affect the healing process."
1. Patient #3 was a 75 year old female admitted to the hospital on 9/20/14, with a diagnosis of bacterial sepsis. Additional medical problems included recurrent left leg cellulitis, UTI, history of DVTs (blood clots in the leg), DM Type II, HTN, high cholesterol, and depression. Her record for her hospital admission from 9/20/14 to 9/27/14, was reviewed.
Patient #3's record included an Admission Assessment, completed by an RN on 9/20/14 at 12:30 PM. The Admission Assessment included a section for a nutritional screening. The RN documented Patient #3 had a "decreased appetite and ... an open or unhealing wound."
The Nursing Care Plan for Patient #3 did not include a plan, interventions, or goals related to her nutritional screening findings. Additionally, her meal intake was documented twice from 9/20/14 to 9/23/14. The first entry was documented on 9/23/14 at 9:00 AM, 3 days after her admission. The entry stated Patient #3 ate 0% of her meal. The second entry was documented on 9/23/14 at 6:00 PM, and stated Patient #3 had "bites of her meal."
Patient #3's record included an order for a nutritional consult dated 9/20/14 at 4:13 PM. The order stated "Nutrition referral placed due to responses on nutrition screening: Decreased appetite. (Calculated Weight change is 0 kg.) Presence of open or unhealing wounds."
The nutritional consult was not documented in Patient #3's record until 9/24/14, her fourth day of admission.
The nutritional assessment was completed on 9/24/14 at 9:25 AM, by a Registered Dietician. The Registered Dietician documented Patient #3 stated she had no appetite and was requesting cream of wheat or oatmeal. Additionally, the Registered Dietician documented Patient #3's intake was poor and she had consumed less than 25% of her last 3 meals.
During an interview on 9/30/15 at 4:40 PM, the Manager of Quality Performance and Improvement reviewed the record. She stated if the RN filling out the Admission Assessment answered yes to any of the questions for the nutritional screening, an order for a nutrition assessment was automatically generated in the EMR. The Manager of Quality Performance and Improvement confirmed Patient #3's nutritional consultation by the Registered Dietician was not completed until her fourth day of admission. She further confirmed nutrition was not part of the Nursing Care Plan and Patient #3's food intake was not frequently assessed.
The RN failed to provide interventions and reassess Patient #3's nutritional needs.
2. Patient #8 was a 50 year old female admitted to the hospital on 10/12/14, with complaints of abdominal pain, nausea and vomiting. Additional medical problems included DM, HTN, chronic kidney disease and depression. Her record for her hospital admission from 10/12/14 to 10/16/14, was reviewed.
Patient #8's record included an Admission Assessment, completed by an RN on 10/12/14 at 9:08 PM. The Admission Assessment included a section for a nutritional screening. The RN documented Patient #8 did not have an open or unhealing wound. However, Patient #8's ED record stated she had a hysterectomy and tummy tuck 10 days prior to her ED visit. Additionally, it stated she had a long incision across her lower abdomen that was "reddened and draining purulent material."
Patient #8 was initially ordered an NPO diet (no food or drink by mouth) on 10/12/14 at 8:24 PM, related to her nausea and vomiting. On 10/13/14 at 7:25 PM, a carbohydrate consistent diet, with no calorie level specified, was ordered for Patient #8. The American Academy of Family Physicians website, accessed 10/05/15, stated "Suboptimal glycemic control in hospitalized patients with type 2 diabetes mellitus can have adverse consequences, including increased neurologic ischemia, delayed wound healing and an increased infection rate." Additionally, it stated for patients who are not eating, insulin and some other non-oral source of calories are necessary.
During an interview on 9/30/15 at 4:45 PM, the Manager of Quality Performance and Improvement reviewed the record. She confirmed the nutritional screening question related to wounds was answered inaccurately by the RN. The Manager of Quality Performance and Improvement stated a nutritional consultation was likely not ordered because the question was answered inaccurately, and Patient #8 was initially NPO.
Patient #8's nutritional screening assessment was inaccurate and failed to generate the need for a consultation by a Registered Dietician.
The hospital did not provide adequate RN supervision to ensure comprehensive patient care.
Tag No.: A0800
Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure post-hospitalization discharge needs were identified early in the admission process. This failure placed patients at risk of adverse health events after discharge, due to lack of needed services. Findings include:
A policy, "Discharge Planning," revised October 2013, stated "Registered Nurses complete the nursing admission assessment tool which includes discharge planning assessment questions. Referrals to Clinical Resource Management (CRM)/Case Management (CM) are made based on nursing assessment findings. Such referrals should be made based on, but not limited to initial assessment indicators, perceived need for ongoing community based assistance, request of the family for assistance beyond the scope of the frontline nurse, Licensed Independent Practitioner's (LIP) order, or circumstances involving such issues as current living situations, functional and mobility deficits and needs."
The Admission Assessment tool was completed for each patient by the floor RN. The tool included a section, "Functional/Discharge Screening." The questions under this section were related to identifying any perceived or anticipated problems the patient was experiencing prior to or upon admission to the hospital.
During an interview on 9/30/15 at 1:55 PM, an RN Case Manager was questioned about the discharge screening process. She stated the initial screening was completed by the floor RN at the time of her initial assessment. The RN Case Manager stated the Admission Assessment included a section for discharge planning. She stated when any of the questions under this section were answered with a yes, a referral was automatically generated for discharge planning in the EMR.
During an interview on 9/30/15 at 11:00 AM, an RN from the Medical/Surgical unit was questioned about the discharge screening process and evaluation of the patients' needs for discharge planning. She stated the evaluation was completed by the Case Manager. The RN stated if discharge questions or needs arise she contacted the Case Manager, or a Social Worker if the need was on an evening or weekend. She confirmed the floor nurses were responsible for completing the Admission Assessment. The RN stated she was not aware questions, related to the discharge screening, automatically generated a referral in the EMR to the Case Management Department.
During an interview on 9/30/15 at 11:15 AM, an RN from the ICU was questioned about the discharge screening process and evaluation of the patients' needs for discharge planning. The RN stated discharge planning began at admission with Case Managers visiting the patient to talk with them about their needs. She confirmed floor nurses completed the Admission Assessment. The RN stated she was not aware questions, related to the discharge screening, automatically generated a referral in the EMR to the Case Management Department.
During an interview on 9/28/15 at 2:30 PM, the Manager of Case Management stated Case Managers were RNs and were assigned to a specific physician each day. The Manager said Case Managers participated in patient rounds each morning, Monday through Friday, with their assigned physician, and an interdisciplinary team, to discuss patients and assess their needs. She stated the interdisciplinary team could include a Registered Dietician, Therapy Services representative, and a charge RN. The Manager of Case Management stated discharge planning evaluations were completed either by referral from a physician, by a family member request, or through daily rounding with the team. She stated the goal of the department was to see all patients through interdisciplinary rounding. The Manager of Case Management stated this "did not always happen."
During an interview on 9/29/15 at 3:45 PM, a second RN Case Manager was questioned about the discharge screening process. She stated she performed discharge planning on "as many patients as we can." The RN Case Manager stated patients' discharge needs were determined through rounding with the interdisciplinary team. She stated a discharge screening was not completed on every patient for discharge planning needs.
The Case Management team and floor RNs who completed the Admission Assessments, were not aware of the discharge planning process. Two RNs, 1 Case Manager, and the Manager of the Case Management Department, were not aware that by answering yes to any of the questions in the "Functional/Discharge Screening" section of the Admission Assessment, an order for referral to discharge planning was automatically generated in the EMR. As a result, patients' in need of discharge planning, may not have been identified.
The hospital failed to ensure patients' discharge planning needs were identified early in the admission process.
Tag No.: A0821
Based on medical record review and staff interview, it was determined the facility failed to ensure discharge plans were reassessed after changes in patient status for 1 out of 10 patients (Patient #8) who received discharge planning and whose record was reviewed. This had the potential to result in patients' post-hospitalization needs not being addressed and inappropriate placement after discharge. Findings include:
Patient #8 was a 50 year old female admitted to the hospital on 10/12/14, with complaints of abdominal pain, nausea and vomiting. Additional medical problems included DM, HTN, chronic kidney disease and depression. Her record for her hospital admission from 10/12/14 to 10/16/14, was reviewed.
Patient #8's ED record stated she had a hysterectomy and tummy tuck 10 days prior to her ED visit. Additionally, it stated she had a long incision across her lower abdomen that was reddened and draining purulent material.
During an interview on 9/28/15 at 2:30 PM, the Manager of Case Management stated discharge planning was completed by the hospital's Case Managers, and documented in Case Management Progress Notes.
Patient #8's record included a Case Management Progress Note, dated 10/13/14. The note stated an initial assessment was completed. It stated Patient #8 lived in a SNF, and planned to return there following her discharge from the hospital. The note stated the SNF was updated regarding Patient #8's status. Additionally, it stated Patient #8 would be followed for further discharge needs. Patient #8's record did not include additional Case Management Progress Notes.
Patient #8's record included a Wound Progress Note completed on 10/14/14, and signed by the wound care RN. The note stated a Wound VAC was placed on Patient #8's abdominal wound. (Wound VACs use foam dressings and a vacuum device to apply negative pressure to a wound for wound healing. The foam dressings are typically changed 3 times a week.)
Patient #8's record included a discharge summary dated 10/17/14, signed by her physician. The summary stated she was discharged from the hospital, and returned to the SNF on 10/16/14. Her discharge summary stated she was to continue using the Wound VAC following discharge. Additionally, her discharge summary stated she was to continue intravenous antibiotic therapy through a PICC line for 2 weeks following discharge.
Patient #8's record did not include documentation of an update to her discharge plan. Additionally, it did not include documentation of contact with the SNF to coordinate care related to her wound VAC and IV therapy.
During an interview on 9/30/15 at 2:45 PM, the Manager of Case Management reviewed Patient #8's record and confirmed there was no documentation of contact with the SNF to inform them of her wound care and IV therapy needs.
The hospital failed to provide updated discharge planning to ensure Patient #8's post-hospitalization needs were met.