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Based on contract review, policy and procedure review, medical record review and personnel interview, the facility failed to assure contracted dietary services assessed patient according to facility protocol for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. At approximately 12:55 PM on 1/23/14, review of the Dietitian Services Contract, signed January 26, 2012, for contracted dietary services, indicated "the Registered Dietitian that is designated will fulfill the State and Federal requirements."

2. Policy No.: III.E.5.3, titled "Consulting Dietitian", revised/reapproved 1/2014, was reviewed on 1/23/14 at approximately 12:14 PM, and indicated on pg. 1 under:
A. Specific Responsibilities section, "1. Screen, assess, plan treatment, evaluate care, educate and follow-up on patients according to state/federal/accreditation rules and regulations. Ensure continuous improvement in performance outcomes...3. Collect nutrition risk data on patients to determine priorities for care...4. Conduct comprehensive nutrition assessments in a timely manner according to facility policy/rules/accreditation requirements."

3. Policy No.: II - A.11, titled "Nutritional Screening", revised/reapproved 12/11, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated under Procedure section, point 3., "When the need to consult the contracted Registered Dietitian arises, she will be contacted by phone and/or written communication is placed in the Dietary mailbox. The contracted dietitian will perform an assessment within 72 hours or as the patient's need warrants."

4. Review of closed patient medical records on 1/21/14 at approximately 3:01 PM and 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N1 was a 75-year-old admitted to the facility on 1/3/14 for bipolar schizophrenia. Documentation in the medical record included:
a. per Nursing Admission Assessment dated 1/3/14, weigh was 80.7 kg or 178 pounds and nutritional services was contacted at 1835 for a dietary order. A 2gm Na+ diet was ordered. According to nursing documentation on Patient Care Flow Sheets weight was 151 pounds the next day on 1/4/13 and 144 pounds on transfer on 1/8/14. There is no documentation that nursing contacted the consulting dietitian for an assessment.

5. Personnel P13 was interviewed on 1/22/14 at approximately 4:18 PM and confirmed:
A. patient N1 had a diet order for a 2gm Na+ (sodium) diet, which means it is 2000mg low sodium diet. It may be used for renal insufficiency or in this patient's case "elevated sodium" or serum sodium level. There is documentation that this type of diet was ordered and communicated to dietary services via Dietary Orders communication sheet 1/3/14. On the Neuropsych side of the facility we see patient when we are consulted and we do an assessment within 72 hours and make recommendations if appropriate.
B. when this patient was on F5 I did a nutrition assessment on 12/29/13 and the patient's weight was 178 pounds. I met with the patient and the family that day at mealtime. Patient was very threatening and difficult to assist to feed. Patient had difficulty getting food to mouth due to physical limitations, cognitive deficits, and aggressive behaviors.
C. was not notified by nursing to reassess patient even after a Nurse Practitioner documented on 1/5/14 that patient had "poor appetite" and was "drinking poorly". Nursing does a nutrition screening on admission, NPs or MDs order consultations with the Dietitian to assess the patient ' s nutritional status, then nursing communicates that to Dietary Services on the Dietary Orders communication sheet, they contact the Dietitian and we assess the patient. This protocol was not followed for this patient to the best of my knowledge.

Based on policy and procedure review, medical record review, and personnel interview, the medical staff failed to identify in the medical record any follow-up of critical lab values provided to patients for 3 of 4 (N1, N3, and N4) closed patient medical records reviewed.

Findings:

1. Rules and Regulations of the Medical Staff, revised/reapproved 12/13, was reviewed on 1/23/14 at approximately 12:55 PM, and indicated on pg. 7, under section I. Medical Records, "1. The attending physician shall be held responsible for the preparation of a complete and legible medical record for each individual evaluated or treated as an inpatient, patient which accurately reflects the patient's condition and care.

2. Policy No.: II.C.4, titled "Critical Test Results", revised/reapproved 1/2014, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1 under:
A. Policy section, "to provide a mechanism for expedient reporting of critical values to designated care providers in order to ensure timely and appropriate patient treatment interventions."
B. Definitions section, under Critical Values, "Critical Values are laboratory results with the following attributes...they have the potential for serious adverse consequences if not dealt with promptly; they require an appropriate action..."
C. Procedures section, points D and E, "The Attending Physician will document in a progress note that the critical value(s) were reviewed and actions taken within twenty-four (24) hours...The following laboratory values are defined as critical in this facility...Sodium < or = 120 mEq/L to > or = 160 mEq/L."

3. Review of closed patient medical records on 1/21/14 at approximately 3:01 PM and 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N1 was a 75-year-old admitted to the facility on 1/3/14 for bipolar schizophrenia. Documentation in the medical record included:
a. per Laboratory Report a critical sodium level of 164 mEq/L was reported to nursing staff at 1838 on 1/8/14, results were called to the Nurse Practitioner (NP) at 2000 and "no new orders" given.
b. last Physician Progress Note was documented on 1/8/14 at 1000 and stated "Medical problems: dehydrated...possible cascading stroke, new dysphagia, get repeat CT (computed tomography) scan" and by an NP on 1/8/14 at 1025 "per nursing - having trouble swallowing, alert but lethargic, respiratory effort diminished throughout, needs new head CT...new dysphagia, ? acute CVA (cerebrovascular accident), hypernatremia, dehydration, start IV (intravenous)..." These Progress Notes are approximately 10 hours and 50 minutes prior to patient's transfer.
c. lacked documentation in progress note of follow up of critical sodium value by Physician or NP prior to transfer at 2050 on 1/8/14.

B. N3 was a 76-year-old admitted to the facility on 12/18/13 for vascular dementia, altered mental status. Documentation in the medical record included:
a. a. per Laboratory Report a critical sodium level of 161 mEq/L was reported to nursing staff at 0230 on 12/24/13, results were called to the NP at 0305 and "no new orders" given.
b. last Physician Progress Note was documented on 12/23/13 at 1230 and stated "patient sleeping" (the rest is illegible) and by an NP on 12/24/13 at 1130 "sedated, River Crest ?, yes per Dr. Posar, order written...multi lobar pneumonia, elevated WBC's (white blood cell), chronic respiratory failure, oxygen dependent COPD (chronic obstructive pulmonary disorder), type II diabetes with renal manifestations, chronic kidney disease stage II..."
c. lacked documentation in progress note of follow up of critical sodium value by Physician or NP prior to transfer on 12/24/13 at 2300.

C. N4 was a 79-year-old admitted to the facility on 12/11/13 for acute psychosis, altered mental status with dementia. Documentation in the medical record included:
a. per Laboratory Report a critical glucose level of:
i. 51 mg/dL was reported to nursing staff at 1829 on 12/13/13, results were called to the NP at 1030 on 12/16/13 and no new orders given.
ii. 486 mg/dL was reported to nursing staff at 0324 on 12/17/13, results were called to the NP on 12/17/13, no time documented, and no new orders given.
b. last Physician Progress Note was documented on 12/17/13 at 1800 and stated "chronic kidney disease...12/16/13, need to resolve issues with fluids versus transfer to another facility (doubtful), very violent last night, 1mg Ativan given to sleep, pleasant through am...12/17/13, discharged to [F3] after I spoke with [physician]."
c. lacked documentation in progress note of follow up of critical glucose values by Physician or NP prior to transfer on 12/17/13 at 1505.

4. Personnel P10 was interviewed on 1/22/14 at approximately 11:00 AM and confirmed facility policy and procedure was not followed related to documenting follow up in progress notes and monitoring/evaluating critical lab values by physicians or other health care providers.

Based on document review, policy and procedure review, patient medical record review and personnel interview, it was determined that the hospital failed to ensure nursing staff supervised and evaluated the nursing care for each patient related to reporting critical lab values, following physician orders related to an order for IV (intravenous) administration, completion of transfer records according to policy and procedure for 3 of 4 (N1, N3 and N4) closed patient medical records reviewed (Refer to A 395), following physician orders related to intake and output for 4 of 4 (N1-N4) closed patient medical records reviewed and 1 of 4 (N6) open patient medical records reviewed (Refer to A 395) and notified the Dietitian of need for reassessment for 1 of 4 (N1) closed patient medical records reviewed (Refer to A 395). As a result, it was determined that the Conditions of Nursing services was not in compliance.

At the time of the survey, the facility census ranged from 19-17 inpatients. Critical lab values reporting had not yet been fully addressed, placing these patients at serious risk for lack of timely follow-up to critical lab results.

An Immediate Jeopardy (IJ) and serious threat to patients' safety and wellbeing was created from the cumulative effects of these systematic problems that resulted in the hospital's inability to ensure nursing services were furnished and supervised by a registered nurse.

Based on document review, policy and procedure review, medical record review and personnel interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to reporting of critical lab values, following physician orders related to an order for IV (intravenous) administration, completion of transfer records according to policy and procedure for 3 of 5 (N1, N3, and N4) closed patient medical records reviewed; and following physician orders related to intake and output for 4 of 5 (N1-N4) closed patient medical records reviewed and 1 of 1 (N6) open patient medical records reviewed; and notification of Dietitian of need for reassessment for 1 of 4 (N1) closed patient medical records reviewed.

Findings:

1. Review of closed patient medical records on 1/21/14 at approximately 3:01 PM and 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N1 was a 75-year-old admitted to the facility on 1/3/14 for bipolar schizophrenia. Documentation in the medical record included:
a. per Laboratory Report a critical sodium level of 164 mEq/L was reported to nursing staff at 1838 on 1/8/14, results were called to the Nurse Practitioner (NP) at 2000 and "no new orders" given. This is approximately 1 hour and 22 minutes after nursing staff received the result.
b. lacked documentation of this result on the Critical Values Report form.
c. per Physician Orders dated:
i. 1/3/14 at 1000, 2gm Na+ (sodium) diet.
ii. 1/5/14 at 1239, "Strict I & O (intake and output)."
iii. 1/8/14 at 1040, "Head CT without contrast, IV D5 1/2 NS (Normal Saline) - give 500ml bolus now and then 100ml/hour." 500ml bolus was not given until 1600.
d. per Nursing Admission Assessment dated 1/3/14, weight was 80.7 kg or 178 pounds and nutritional services was contacted at 1835 for a dietary order. A 2gm Na+ diet was ordered. According to nursing documentation on Patient Care Flow Sheets weight was 151 pounds the next day on 1/4/13 and 144 pounds on transfer on 1/8/14. There is no documentation that nursing contacted the consulting dietitian for an assessment.
e. unable to determine exact time IV was inserted because there is no time documented on 1/8/14 in the MAR (Medication Administration Record), only the nurse's initials that it was done.
f. lack of I & O totals on Patient Care Flow Sheets from 1/3/14 through 1/8/14.
g. per Nurses Notes on 1/8/14 at:
h. 1600 "has IV bolus given per NP order, 500cc left wrist, CT, CXR (chest x-ray), ST (speech therapy) canceled." Order for bolus was for now (at 1040). First documentation of IV bolus as given is 1600.
ii. 1705, "IV now at 100cc/hour."
iii. 2000, "in bed sleeping, lungs wet with audible gurgles, nonverbal, to be transferred to [other acute care facility]. Critical results called to NP of sodium 164, no new orders."
iv. 2050, "picked up by [ambulance] to be transported to [F2]. Discontinued IV, kept reseal in per hospital request. Called [F2] and informed nurse of critical sodium level of 164."
v. 2110, "faxed critical lab results to [F2]."
vi. 2200, "EMS (emergency medical services) that was transporting this patient called and informed this nurse that on way to [F2] patient went into respiratory distress and they took patient to [F3] ER (Emergency Room), to work on him/her. Stated wasn't looking good and requested this nurse to call [F3] where family was waiting and inform them..."
i. Patient Transfer Form lacked documentation of transferring physician, receiving physician, who report was called to and when, what records were sent with the patient, date and time of current vital signs, and what the patient is at risk for.
j. Discharge Disposition Form lacked nurse's signature and date/time discharged.
k. Patient Transfer Assessment lacked nurse's signature and date/time.
l. Patient Transfer Orders were signed by a NP, but dated 1/10/14 at 1225 which was 2 days after the transfer occurred.

B. N2 was a 72-year-old admitted to the facility on 12/30/13 for agitation. Documentation in the medical record included:
a. per Physician's Orders dated 1/5/14 at 1239, "Strict I & O (intake and output)."
b. lack of I & O totals on Patient Care Flow Sheets from 12/30/13 through 1/13/14.

C. N3 was a 76-year-old admitted to the facility on 12/18/13 for vascular dementia, altered mental status. Documentation in the medical record included:
a. per Laboratory Report a critical sodium level of 161 mEq/L was reported to nursing staff at 0230 on 12/24/13, results were called to the NP at 0305 and "no new orders" given. This is approximately 35 minutes after nursing staff received the result.
b. per Nurses Notes on 12/24/13 at:
i. 1103, "WBC's greater than 22, NP notified, new orders to start IV D51/2 NS at 75ml/hr...IV 24 gauge started in right hand...shallow respirations noted, NC (nasal cannula) at 2 liters in mouth due to patient breathing more through mouth..."
ii. 1740, "up in geri chair with IV infusing, no adverse reactions noted, appetite poor, restless at times but redirectable. No distress noted."
c. lacked documentation of nurse's notes from 1740 on 12/24/13 until transfer same date at 2300 (according to Patient Transfer Assessment). Unsure of exact transfer time due to lack of documentation of transfer time.
d. lack of I & O totals on Patient Care Flow Sheets from 12/18/13 through 12/24/13. Has chronic kidney disease, stage III.
e. Patient Transfer Form lacked documentation of transferring physician, and who report was called to and when. Current vital signs dated 12/24/13 at 1800, which is approximately 5 hours prior to transfer.
f. lacked Discharge Disposition Form.
g. Patient Transfer Orders (Medications pages) were signed by a NP, but dated 12/26/13 at 1000 which was 2 days after the transfer occurred.

D. N4 was a 79-year-old admitted to the facility on 12/11/13 for acute psychosis, altered mental status with dementia. Documentation in the medical record included:
a. per Laboratory Report a critical glucose level of:
i. 51 mg/dL was reported to nursing staff at 1829 on 12/13/13, results were called to the NP at 1030 on 12/16/13 and no new orders given. This is approximately 3 days after nursing staff received the result.
ii. 486 mg/dL was reported to nursing staff at 0324 on 12/17/13, results were called to the NP on 12/17/13, no time documented, and no new orders given. Unsure of exactly time between lab report and physician notification after nursing staff received the result.
b. per Nurses Notes on 12/17/13 at:
i. 1505, "discharged to [F4] per family request, transferred via [ambulance]."
ii. 1520, "report called to RN at [F4], face sheet and allergies faxed over, personal belongings list reconciled."
c. lack of I & O totals on Patient Care Flow Sheets from 12/11/13 through 12/17/13. Has chronic kidney disease.
d. Patient Transfer Form lacked documentation of receiving physician and who report was called to and when. Current vital signs dated 12/17/13 at 0700, which is approximately 8 hours prior to transfer.
e. Discharge Disposition Form lacked time of discharge.

E. N6 was a 76-year-old admitted to the facility on 1/16/14 for dementia with behaviors. Documentation in the medical record included:
a. per Physician's Orders dated 1/20/14 at 1230, "Strict I & O."
b. lack of I & O totals on Patient Care Flow Sheets from 1/16/14 through 1/23/14. Has chronic kidney disease.

2. Personnel P10 was interviewed on 1/22/14 at approximately 11:00 AM and confirmed the protocol for critical lab results is for nursing staff to notify physician or on-call provider of the results within 30 minutes. This was changed recently in a policy revision from within 15 minutes. Facility policy and procedure was not followed related to reporting of critical lab values by nursing staff and monitoring/evaluating critical lab values by physicians or other health care providers. Also, orders were not followed for patient N1 related to IV start and bolus administration or strict I & O as described above and transfer documentation was not completed according to facility policy and procedure. In addition, patient N1 weight was documented on the Patient Transfer Form as 144 pounds, which is a 34 pound weight loss from admission to transfer in 5 days. At the time this patient was here, staff was using 2 different scales to weigh patients, one was a standing scale and one was a bed scale. This may explain the weight differences.

3. Personnel P13 was interviewed on 1/22/14 at approximately 4:18 PM and confirmed:
A. patient N1 had a diet order for a 2gm Na+ (sodium) diet, which means it is 2000mg low sodium diet. It may be used for renal insufficiency or in this patient's case "elevated sodium" or serum sodium level. There is documentation that this type of diet was ordered and communicated to dietary services via Dietary Orders communication sheet 1/3/14. On the Neuropsych side of the facility we see patient when we are consulted and we do an assessment within 72 hours and make recommendations if appropriate.
B. when this patient was on the Neuromedical side I did a nutrition assessment on 12/29/13 and the patient's weight was 178 pounds. I met with the patient and the family that day at mealtime. Patient was very threatening and difficult to assist to feed. Patient had difficulty getting food to mouth due to physical limitations, cognitive deficits, and aggressive behaviors.
C. was not notified by nursing to reassess patient even after a Nurse Practitioner documented on 1/5/14 that patient had "poor appetite" and was "drinking poorly". Nursing does a nutrition screening on admission, NPs or MDs order consultations with the Dietitian to assess the patient ' s nutritional status, then nursing communicates that to Dietary Services on the Dietary Orders communication sheet, they contact the Dietitian and we assess the patient. This protocol was not followed for this patient to the best of my knowledge.

4. Rules and Regulations of the Medical Staff, revised/reapproved 12/13, was reviewed on 1/23/14 at approximately 12:55 PM, and indicated on pg:
A. 6, under section G. Transfer of Patients, "Prior to transferring a patient to another facility or to a community agency, the attending physician shall ensure: 1. Available medical treatment necessary to minimize the risks to the patient is provided before and during transfer. 2. The receiving facility...has agreed to accept the transfer. 3. Copies of all medical records available at the time of transfer are sent to the receiving facility. 4. With respect to unstable patients, the attending physician shall also ensure that the patient is only transferred after either the patient requests transfer in writing after being informed of the risks and benefits of the transfer or a certification of transfer is completed verifying the medical necessity of the transfer and that the medical benefits of treatment at the facility outweigh the risks of transfer..."
B. 7, under section I. Medical Records, "1. The attending physician shall be held responsible for the preparation of a complete and legible medical record for each individual evaluated or treated as an inpatient, patient which accurately reflects the patient's condition and care.

5. Policy No.: II.C.4, titled "Critical Test Results", revised/reapproved 1/2014, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1 under:
A. Policy section, "to provide a mechanism for expedient reporting of critical values to designated care providers in order to ensure timely and appropriate patient treatment interventions."
B. Definitions section, under Critical Values, "Critical Values are laboratory results with the following attributes...they have the potential for serious adverse consequences if not dealt with promptly; they require an appropriate action..."
C. Procedures section, points B, D, and E, "The Nurse will complete the Critical Values Report form and document on the log sheet designated for tracking of 'Critical Value' data...Notification: Name of Physician and Time Notified...Action ordered and Taken; Check 'Yes' to confirm completion of documentation on the critical values report form; initial log, with identification of initials/signature at bottom of page...The following laboratory values are defined as critical in this facility...Sodium < or = 120 mEq/L to > or = 160 mEq/L." This policy applies to patient N1 because of the date of their critical lab value and the revised date of this policy.

6. Policy No.: II.C.4, titled "Critical Test Results", revised/reapproved 7/2012, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1 under:
A. Policy section, "A. The responsible physician will be notified within 15 minutes of receipt of critical laboratory and diagnostic radiologic test results...F. The following laboratory values are defined as critical in this facility...Glucose < or = 50mg/dL to > or = 600mg/dL...Sodium < or = 120 mEq/L to > or = 160 mEq/L." This policy applies to patients N3 and N4 because of the dates of their critical lab values and the revised date of this policy.

7. Policy No.: C.65, titled "Standardized Medication Administration", revised/reapproved 12/13, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated on pg. 1, under Procedure section, point 2.0 and 2.3, "Definitions: When used within medication orders...'Now' means 'within one (1) hour'." Policy No.: II - A.11, titled "Nutritional Screening", revised/reapproved 12/11, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated under Procedure section, point 3., "When the need to consult the contracted Registered Dietitian arises, she will be contacted by phone and/or written communication is placed in the Dietary mailbox. The contracted dietitian will perform an assessment within 72 hours or as the patient's need warrants."

Based on policy and procedure review, medical record review and personnel interview, the nursing executive failed to ensure the documentation of follow-up of medications given on the MAR (Medication Administration Record) for 1 of 1 (N6) open patient medical records reviewed.

Findings:

1. Policy No.: II - F.20, titled "Medication Administration Record Documentation", revised/reapproved 12/11, was reviewed on 1/22/14 at approximately 9:10 AM, and indicated under Policy section, "to ensure complete and accurate records of medication administration, Nursing Services and Pharmacy Services will maintain a daily medication administration record (MAR) for inpatients."

2. Review of open patient medical records on 1/22/14 at approximately 10:00 AM, indicated Patient:

A. N6 was a 76-year-old admitted to the facility on 1/16/14 for dementia with behaviors. Documentation in the medical record included:
a. per Restraint & Seclusion Packet dated 1/16/14, on pg:
i. 1, Geodon 10mg IM (intramuscularly) and Ativan 1mg IM were given at 2220 and "medication follow-up and patient education must be noted on MAR (Medication Administration Record)"; there was no follow-up documented on the MAR.
ii. 1/20/14, on pg. 1, IM injection to right thigh (no medication name documented) and "medication follow-up and patient education must be noted on MAR (Medication Administration Record)"; there was no follow-up documented on the MAR.
b. still admitted to facility at time of survey.

3. Personnel P10 was interviewed on 1/21/14 at approximately 3:59 PM and on 1/22/14 at approximately 11:00 AM and confirmed, on the Restraint & Seclusion Packet for patient N6 dated 1/16/14 on pg. 1, medication follow-up was not documented on the MAR as required and stated needs to be completed on this form.