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Based on observation, staff interview, clinical record and administrative document review the hospital failed to protect patient rights when least restrictive interventions were not used prior to restraining 1 of 28 Patients with wrist restraints (Patient 7). This failure resulted in a loss of Patient Rights for Patient 7.

Findings:

On 10/23/12 at 8 a.m., during a concurrent observation and interview, Charge Nurse (CN) confirmed Patient 7 was restrained with bilateral wrist restraints (devices attached to both wrists and tied to a secure fixture). CN stated the restraints were placed due to Patient 7 attempting to remove her peripheral IV (a device used to infuse medications into the bloodstream).

On 10/23/12 at 8:15 a.m., during a concurrent interview and clinical record review, CN confirmed there was no documentation indicating less restrictive interventions were used prior to use of bilateral wrist restraints. Less restrictive interventions include a one to one monitor (someone sitting with and monitoring anothers behavior) or mittens (devices used to restrict hand dexterity)

On 10/23/12 at 8:20 a.m., during an interview, CN and Nurse Manager (NM) 2 stated a one to one monitor and mittens would have been less restrictive but were not used. NM 2 stated we should have used mittens.

The facility policy and procedure titled "RESTRAINT" dated 8/12 indicated, "...II. SCOPE AND APPLICABILITY: Restraints may only be used to improve the patient's-well being when less restrictive interventions have been determined to be ineffective in protecting the patient-or others from harm."...

Based on staff interview and clinical record review the hospital failed to ensure 2 of 28 patients (Patients' 14 and 28) clinical record entries' were complete. These failures resulted in incomplete medical records and incomplete information being provided to the patients.

Findings:

1. On 10/23/12 at 9:35 a.m., a concurrent interview and clinical record review was conducted for Patient 14. RN 1, Clinical Educator for the mother baby unit stated, "Patient 14 was admitted by residents (a hospital staff physician obtaining further clinical training) and they followed her care. The form for Patient 14's surgical cesarean section (abdominal incision delivery) titled "Identification of Persons Performing Significant Surgical Tasks (Part A) and dated 10/22/12 at 3:01 a.m., contained under Surgical Assistant: (Name/Credential). The Name/Credential area of the form was completed with "Residents" and failed to record the physician's name and title. A second form titled "Delivery Room Record" and dated 10/22/12 at 4:30 a.m. failed to list the physician's name and title and instead listed "PEDS: Residents". RN 1 verified that both forms reviewed should have identified the specific name and title of the resident(s) but did not.

2. On 10/23/12 at 9:35 a.m., a concurrent interview and record review with RN 2 regarding Pediatric Patient 28. RN 2 stated Patient 28 was admitted by residents. The admission form titled "General Orders" and dated 10/24/12 at 6:53 p.m. indicated under "Admitting Physician" the words "Dr. Residents". RN 2 acknowledged the form failed to identify the name and title of the resident(s) following the care of the patient.

On 10/24/12 at 10:55 a.m., a concurrent interview and clinical record review for Patient' s 14 and 28 was conducted with Health Information Management Director (HIMD), Health Information Management Manager (HIMM), and Health Information Management Supervisor/Systems (HIMS/S). The staff were requested to review the forms. They agreed if they saw a clinical record which lacked specific staff names/titles where requested, they would question it and it would not be acceptable. They also agreed clinical records must be complete, authenticated, and consistent with hospital policies and procedures and medical staff rules and regulations.

On 10/24/12 at 2:30 p.m.,the Vice President of Medical Affairs stated that when issues regarding clinical record entries come up they are usually brought forward to the medical staff for review. He acknowledged the issue regarding clinical record entries lacking specific Resident names and their titles and this issue was not brought forward to the medical staff so corrective action could be taken.

Based on observation, staff interviews, and review of hospital documents, the hospital failed to ensure: 1) the menus were analyzed for the nutritional components to meet the current national standards including the Recommended Dietary Allowances (RDA ) and the (Dietary Reference Intake (DRI) of the Food and Nutrition Board of the National Research Council; and 2) the renal diet (a diet for patients with kidney impairment) was analyzed and meeting the appropriate amount of protein each day on the nonselect diet. Failure to have a nutrient analysis of the menu has the potential for the patients in the hospital to receive inadequate nutrition.

Findings:

On 10/22/12 at 2:10 p.m. the Director of Nutrition and Environmental Services (DN&ES) was requested for the nutrient analysis of the menus. The DN&ES stated the Clinical Nutrition Supervisor (CNS) prepared all the menus and they only used what was provided on the food label since it was time consuming. Review of the nutrient analysis indicated they only looked at calories, protein, fat, carbohydrate, cholesterol, calcium, sodium, and iron.

On 10/25/12 at 9:15 a.m. an interview was conducted with the DN&ES and CNS regarding the nutrient analysis. The CNS stated she had not looked into further parameters other than what was provided on the nutrient analysis. The CNS stated she has not pulled all the other vitamins or minerals or fiber into the computer program. The CNS acknowledged she has not ensured all the nutritional components were being met or analyzed. The CNS stated the renal diet should provide 60 grams of Protein, 2 grams of sodium and 2 grams of potassium. The CNS stated she was not aware the renal diet had that much variation in the protein for each day and it should not be that way. The CNS stated she was not sure what daily value was in the computer system or if that level was appropriate for their patient population.

Further review of the renal diet indicated the grams of protein were as follows: 65.1, 46.6, 82.1, 79.7, 76.7, 50, and 50. The daily value was the parameter to meet which indicated they were striving for 50 grams per day on the nutrient analysis instead of 60 grams per day for protein. The daily value for sodium indicated it was 2400 milligrams instead of 2000 milligrams (2 grams). There was no potassium value on the nutrient analysis therefore it is unclear how much potassium was being provided.

All RDA's/DRI's are age and gender specific. Since the hospital menus were not evaluated for all of the vitamins/elements there was no way to ensure the menus served met the RDA's or RDI's.

Based on dietary staff interview, and dietary document review, the hospital failed to ensure the diet manual was consistently utilized to develop the hospitals' diets. Lack of a current and comprehensive diet manual that reflected hospital developed diets could result in inaccurate guidance to dietary and hospital staff when following physician ordered diets. This failure could result in not meeting the nutritional needs of patients and could further compromise their medical status.

Findings:

On 10/23/12 at 2:50 p.m., the hospital diet manual was reviewed. During a concurrent interview and hospital diet manual review, the Director of Nutrition and Environmental Services (DN&ES) and the Clinical Registered Dietitian (RD) stated the hospital subscribed to the American Dietetic Association (ADA) Nutrition Care Manual (NCM).

On 10/23/12 at 2:50 p.m., the RD was interviewed and asked to show the surveyor how to look up the renal and diabetic diets in the electronic diet manual. RD was unable to pull up or show what this diet would provide at the hospital. The RD stated most of the information was information the RD's could use to educate the patients. At this time, the surveyor asked if this showed how to order diets at the hospital, if there was someplace that defined what the diets provided, or if there were any sample menus. The DN&ES stated they had another binder that contained some other components but this was not online. Review of the binder indicated "diet information to customize the ADA and NCM". There were sample menus for the following diets: regular, renal, pediatric regular 1-3 years of age, pediatric diet 4-6 years of age, sodium controlled, mechanical soft, clear liquid, full liquid, calorie controlled, 1500 calorie controlled, 1800 calorie controlled, and 2000 calorie controlled. The renal diet indicated it was 3-4 grams of sodium, low potassium, low phosphorus, and low protein.

Review of the nutrition analysis of the renal diet indicated the grams of protein were as follows: 65.1, 46.6, 82.1, 79.7, 76.7, 50, and 50. The daily value was the parameter to meet which indicated they were striving for 50 grams per day on the nutrient analysis instead of 60 grams per day for protein. The daily value for sodium indicated it was 2400 milligrams. There was no potassium value on the nutrient analysis therefore it is unclear how much potassium was being provided.

On 10/25/12 at 9:15 a.m. an interview was conducted with the DN&ES and CNS (Clinical Nutrition Supervisor) regarding the nutrient analysis. The CNS stated the renal diet should provide 60 grams of Protein, 2 grams of sodium and 2 grams of potassium. The CNS stated she was not aware the renal diet had that much variation in the protein for each day and it should not be that way. The CNS stated she was not sure what daily value was in the computer system. The DN&ES acknowledged the diet manual should reflect what was in the nutrition analysis.

Review of the hospital policy titled Menu Planning dated 05/10, indicated menus were developed by the RD consistent with diets referenced in the approved Diet Manual. Review of the hospital policy titled "Diet Manual", dated 05/10, indicated a current diet manual shall be used as the basis for diet orders and for planning of modified diets.

The NCM is an Internet based nutrition information manual which the ADA described as "a professional resource". The NCM did not provide specific kinds of diets that were provided by the hospital, and therefore could not be used as guidance for ordering patient's diets.

Based on observation, dietary staff interview and document review of emergency preparedness, the hospital failed to ensure the required food and water supplies planned for use in a disaster were adequate to meet the hospital developed plan. Failure to ensure adequate food and water supplies were located within the hospital could result in the supplies not being available in the event of a disaster.

Findings:

During food storage observations, concurrent dietary management staff interview, and dietary document review on 10/22/12 at 2:40 p.m., the hospitals' disaster meal planning was reviewed. DN&ES stated that the hospital was planning to provide food for a total of 811 people including patients and staff. It was noted that the hospital developed a menu for a total of 3 days. DN&ES stated she knew they did not have enough food and water onsite at this time. DN&ES stated they just got approval from the Vice President that they can use another storage space on the dock to store the food items since they did not have enough space in the kitchen.

The surveyor conducted a spot check of the items on 10/22/12 at 2:40 p.m. The hospital did not have adequate supplies of the canned entrees including beef stew, ravioli, chili, pureed meat and had a limited supply of peanut butter, nutrition supplements, as well as canned fruits and vegetables. In a concurrent interview, DN&ES stated most of the emergency water was stored at the other campus but they knew it needed to be onsite at the main hospital. The DN&ES stated they were short the 217 cases that were supposed to be at the hospital and the 653 cases at the other site would need to be brought over to the main hospital.

The standard of practice would be to ensure that the hospital maintained all disaster supplies in the general acute care licensed hospital building onsite.