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Based on record review and staff interview, it was determined that the registered nurse failed to ensure appropriate care was provided to 3 (#18, #19, #25) of 39 sampled patients. This practice does not ensure patient care goals are achieved.


Findings include:

1. Patient #18 was admitted to the facility on 1/10/12. Review of the nursing assessment revealed he was determined to be at risk for skin breakdown. Review of the nursing documentation revealed that the patient was positioned on his back on 1/10/12 at 6:25 p.m. There was no documentation that the patient was repositioned until 10:02 a.m. on 1/11/12. The nurse manager for the telemetry unit was interviewed on 1/17/12 at approximately 1:30 p.m. and confirmed there was no evidence of repositioning and that the patient should have been repositioned every two hours to prevent skin breakdown.


2. Patient #19 was admitted to the facility on 1/16/12. The physician ordered Sequential Compression Devices to be placed on both lower extremities on 1/16/11. Review of nursing documentation revealed no documentation that the devices had been placed on 1/16/12. The nurse manager confirmed the findings during interview on 1/18/12 at approximately 2:00 p.m.


3. Review of the medical record of patient #25 revealed the physician wrote an order for a tap water enema to be given on 1/17/12 at 11:25 a.m. Review of nursing documentation revealed no evidence the enema was administered as ordered. The nurse manager confirmed the finding during interview on 1/18/11 at approximately 11:30 a.m.

Based on record review and staff interview, it was determined that the nursing staff failed to keep the plan of care current regarding meeting nutritional needs for 2 (#20, #21) of 39 sampled patients. This practice does not ensure patient care goals are achieved.



Findings include:

1. Review of the care plan for patient #20 revealed that he was admitted to the facility on 1/13/12 with the diagnosis of diabetic ketoacidosis. Review of the care plan revealed the nursing staff had identified nutrition as a problem to be addressed. The expected outcomes included nutritional intake of greater than 50 %. Review of the nursing documentation of meal consumption revealed the staff had failed to document the percentage of meals consumed. The Director of Nursing Informatics confirmed the staff failed to implement the plan of care related to nutritional needs during an interview on 1/19/11 at approximately 10:30 a.m.

2. Patient #21, was admitted as an observational patient on 1/14/12 and inpatient admission on 1/17/12. The clinical problem list identified the patient was to receive a regular diet with aspiration precautions. The care plan dated 1/14/12, stated the " Nutritional goal is to have a 50% meal intake. " A review of the Intake and Output for meal consumption recorded intakes as : 1/16/12 Lunch 25%, Dinner 40%; 1/17/12 Breakfast 40%, Lunch 45%, and Dinner____ no entry.
On 1/18/12, at 10:30 am, interview was conducted with the nurse assigned to the patient care. She stated the patient is fed by the Patient care Tech. The patient knows what he likes and will not eat certain foods. The surveyor asked if the care plan had been re-evaluated or the patient reassessed for lack of meeting the stated care plan goals (to consume 50% of meals). Further the nursing notes reviewed for 1/14/12 to current did not address the patient was not consuming meals or adjusting a plan to meet the patient needs.

Based on record review and staff interview, it was determined that the staff failed to ensure medications were administered as ordered by the physician for 2 (#18, #25) of 39 sampled patients. This practice does not ensure therapeutic goals are achieved.


Findings include:


1. Review of the medical record for patient #18 revealed he was admitted to the facility on 1/10/11 with the diagnosis of end stage renal disease. The physician order hemodialysis to be done on 1/11/12. The orders included Epogen 5000 units. Review of the nurse's documentation revealed the Epogen was not documented as being given. The nurse manager for the telemetry unit confirmed the medication had not been administered as ordered during an interview on 1/17/11 at approximately 2:30 p.m.

2. Review of the medical record for patient #25 revealed that he was admitted to the facility on 1/14/12 with diagnosis of shortness of breath. Review of the progress notes on 1/16/12 revealed that the patient had an episode of aspiration. The physician wrote and order for solumedrol 60 milligrams to be administered intravenously every 6 hours at approximately 10:30 p.m. Review of the medication administration record revealed the first dose was administered at 11:13 p.m. The next was administered at 6:01 a.m. on 1/17/12. The third dose was due at noon, but was not administered until 3:49 p.m., nearly 4 hours late. Review of the medical record revealed the patient had been taken to the endoscopy suite for a procedure at between 11:30 a.m. and noon. The nurse manager of the telemetry unit was interviewed on 1/17/12 at approximately 1:30 p.m. She indicated that the medication should have been given and there was no reason to hold the medication.

Based on record review and interview the facility did not ensure that menus were nutritionally balanced and met the needs for three of 39 sampled patients, (#'s 25, 36 and 37).

Findings include:

1. Record review for patient #25 revealed he was prescribed a regular diet and had lactose intolerance listed in the record under food allergies. Record review and interview with nursing found the food allergy lactose listed on a prior admission of 11/05/11 and this was listed in the current electronic record when the patient was admitted on 01/15/12. The doctor prescribed a regular diet this admit and stated in the patient's History & Physical dated 01/15/12 at admit that patient was lactose intolerant. Review of the Wednesday, 01/18/12, menu for this patient reveals it does not meet the needs of the patient because it has removed the dairy component and has not substituted for this food group at each meal with a soy milk or lactaid milk. The facility's electronic record system has picked up the diet as a regular diet and in interfacing with dietary and nutrition has printed the menu as regular without substituting for the milk and dairy food group. Interview with the Food and Nutrition Director related that the kitchen does have lactaid milk and soy milk to substitute but this is not listed on this patient's menu. The patient's menu does not meet the needs of the patient as it omits a food group and doesn't allow for a selection of foods that meet the nutritional needs of the patient.

2. Record review 01/19/12 9:00 a.m. for patient #36, admitted on 01/16/12, lists a diet order of mechanical soft lactose free. Record review and interview with nursing found that under food allergens were listed for this patient lactose, eggs and seeds. The lactose free had become part of the diet prescribed but did not include the eggs and seeds.

3. Record review 01/19/12 9:00 a.m. for patient #37, admitted on 01/17/12, lists a diet order of regular which does not include allergies to all seafood, citrus and some preservatives. Dietary Patient ADT Listing printed 01/18/12 at 3:08 p.m. includes under the allergens all seafood and the diet prescribed as regular. The facility's electronic record system review and interview with nursing found that under food allergens were listed not only all seafood but also citrus and some preservatives. The citrus and some preservatives had not become part of the diet and menu for the patient.

Based on kitchen and food service observation and interviews on 01/17/12 and 01/18/12 the facility did not ensure maintenance of a sanitary physical environment for food sanitation during mechanical dish machine washing and food delivery of lunch trays to patients by a hospital volunteer.

Findings include:

1. Kitchen observation on 01/18/12 from 10:00 a.m. to 10:30 a.m. found that the facility used a heat sanitizing mechanical dish machine and a pot/pan heat sanitizing mechanical dish machine in the kitchen. Both dish machines were observed operating at the manufacturer's specifications. Observation of the dietary employees handling the dishes revealed a lack of hand hygiene between handling the dirty and clean dish ware. The dietary employees handling dirty dish ware and dirty pots and pans were observed to handle the clean dishes and pots and pans without washing of hands or using hand sanitizer between these tasks. The dietary employee at the dish machine was observed four times during this observation to handle dirty dishes while wearing plastic gloves, he then removed the plastic gloves each time and grabbed a new pair of plastic gloves and put them on without washing hands or using hand sanitizer before handling of the clean dishes. Observation of the dietary employee at the pot and pan dish machine room found he was by himself handling dirty and clean pots and pans. Observation during this time found that this dietary employee did not wash his hands nor use hand sanitizer between dirty and clean handling of pots and pans. Neither dish machine room was observed to have a hand washing sink. Interview during this time with the Food and Nutrition Director verified that appropriate hand hygiene was not being done between the tasks of handling dirty and clean dish ware and pots and pans.

2. On 01/17/12 from 12:35 p.m. to 12:40 p.m. observation was made of a hospital volunteer in the telemetry unit delivering lunch trays to patients. The volunteer had a two-tier plastic cart with two lunch trays and a covered Styrofoam plate on the top tier. The volunteer was observed to wheel the cart into room 303P. The lunch tray underneath the other lunch tray was to be delivered to the patient in this room. The volunteer was observed to take the top lunch tray and set it on a chair in the patients room. He delivered the other lunch tray and set it on the over bed table of the patient. The volunteer then picked up and placed the lunch tray in the chair back on the cart and wheeled the cart out of the patient's room. The volunteer wheeled the cart to the door of room 325W and delivered the remaining lunch tray setting it on the over bed table of the patient.

On 01/18/12 at 10:45 a.m. interview with the Food and Nutrition Director and the Food Service Manager regarding training of volunteers for food delivery and infections control related that the kitchen/food service does not have any volunteers. The above observation was shared with this staff and they did remember that they utilized a volunteer yesterday, 01/17/12, to deliver some patient lunch trays. They did not know if volunteers were trained to deliver food trays to patients.

Based on record review and staff interview, it was determined the facility failed to ensure was implemented screening was performed to ensure appropriate post hospital placement for 2 (#34,#35) of 39 sampled patients.



Findings include:

42 CFR 483.100 requires that the facility transferring a patient to a Skilled Nursing Facility (SNF) ensures that a Pre-Admission Screening and Resident Review (PASRR) be completed prior to the patient's being transferred to the SNF to ensure appropriate placement. During interview with the social worker on 1/18/12 at approximately 2:00 p.m., that she does not perform the PASRR screen. She stated it is done by the receiving SNF. She also confirmed there is no policy regarding the facility's responsibility to ensure the PASRR screen is performed before the patient is transferred,

3. Review of the medical records of patients #34 and 35 revealed each was transferred to a SNF for continuing care. Neither of the records had evidence the PASRR was completed prior to the transfer. The Director of Nursing Informatics confirmed the screen had not been performed during an interview on 1/19/12 at approximately 2:00 p.m.