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Based on interview and record review, the hospital failed to perform quarterly narcotic audits as required by its policy and procedure. This had the potential to result in the inability to account for all controlled substances.

Findings:

The facility's policy titled, "Medication Inventory", revised 11/11, read as follows: "Quarterly, the Pharmacist in charge will conduct a tracer of one highly utilized narcotic. The report will be kept on file by the Pharmacy Coordinator."
During a review of facility documents, the quarterly narcotic audit form could not be located.
During an interview on 3/27/12 at 11:45 am, Administrative Staff A confirmed that the quarterly audit had not been completed. She provided the Biennial Narcotic Inventory, dated 10/11 and confirmed the quarterly narcotic audit should have been done in the month of 1/12.
During an interview on 3/27/12 at 1:25 pm, Pharmacist GG confirmed he had forgotten to complete the quarterly narcotic audit.







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Based on staff interviews and document review the hospital failed to ensure one of six patients that were reviewed for nutrition care had a nutritional assessment (Patient 41). Failure to effectively identify patients at nutritional risk may result in compromising the clinical status of patients.

Findings:

A clinical record review was initiated on Patient 41 on 3/26/12. Patient 41 was admitted to the hospital on 3/13/12 for diagnoses that included spinal stenosis in the cervical region. Review of the Nursing Admission Database notes dated 3/13/12 indicated Patient 41 had a 40 pound weight loss since 9/11. Patient 41 was 5'9" and 134 pounds. Patient 41 had lost 22% of his usual weight in a six month period. According to the Omnibus Reconciliation Act (OBRA) of 1987, a significant unintentional weight loss is a 10% loss in 6 months. There was no documentation of a nutrition assessment of this weight loss in the clinical record.

On 3/27/12 at 8:15 a.m. an interview was conducted with the Registered Dietitian (RD). When asked, the RD stated she would consider a 40 pound weight loss to be significant and that she would need to be notified so she would assess the patient. The RD stated the policy is that she is to be notified when there is a 10% weight loss over a six month period.

On 3/27/12 at 2 p.m. an interview was conducted with the RD. The RD stated the nutrition screening form probably needed to be revised to include weight loss parameters that were on the nutrition assessment policy and this would better capture all the patients that fell in these guidelines.

On 3/27/12 at 2:50 p.m. an interview was conducted with Administrative Nurse E. Administrative Nurse E stated according to their nutrition screen criteria, that would not have triggered nursing to notify the RD. Administrative Nurse E acknowledged the nutrition screening form does not match with the nutrition assessment policy and it needed to.

Review of the hospital policy titled Nutritional Indications Assessment revised 2/12, indicated through the admission nutrition screen and ongoing patient assessment process by licensed nurses they would identify patients with risk factors for nutrition related complications thereby triggering RD nutrition assessment. The indications for RD nutrition assessment included an unintentional weight loss of 5% or more within the last month, or an unintentional weight loss of more than 10% or more in the last six months.