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Based on interview and record review, the hospital failed to ensure the dietary recommendations for one of 33 sampled patients (20) were communicated to the nursing staff and the physician. This failure had the potential to result in inadequate care and treatment.

Findings:

During a concurrent interview and review of Patient 20's clinical record with the Regulatory Coordinator (RC), on 6/20/16, at 12:18 PM, the "Physician Orders- Dietitian Recommendations" form indicated the Registered Dietitian (RD) had seen the patient on 5/31/16. The RD indicated the patient had a pressure ulcer (injury to the skin and underlying tissues) and recommended to start administering Multivitamin tablets daily and Vitamin C tablets twice daily. The RC reviewed the patient's records and was unable to find documentation the dietitian had notified the nursing staff or the physician of the dietary recommendations.

During an interview with the Clinical Dietitian (CD) in the presence of the Food and Nutrition Manager, on 6/20/16, at 1:50 PM, the CD stated the "Physician Orders- Dietitian Recommendations" form was supposed to be flagged in the chart so the physician would know there was a recommendation from the dietitian. She also stated the dietitian was supposed to communicate the recommendations to the patient's nurse who would follow-up with the physician.

The hospital policy and procedure titled "Nutrition Consult and Care Policy", dated 10/2014, indicated medical record documentation standards were to be established and maintained "In order to effectively communicate, in writing, nutrition care recommendations to medical and multidisciplinary staff" and effective communication was to be established and maintained with "medical, nursing, administrative and nutrition staff."

Based on observation, interview, and record review, the hospital failed to ensure physician orders for the use of restraints were complete for three of 33 sampled patients (26, 18, and 9) which had the potential to result in the least restrictive measures not used to protect patients' safety.

Findings:

1. During an observation on 6/20/16 at 10 AM, in the Critical Care Unit, Patient 26 was in bed with bilateral soft wrist restraints in place.

During a concurrent interview and review of the clinical record for Patient 26 with Registered Nurse (RN) 1, the physician order for the use of restraints was signed and dated by the physician on 6/19/16 at 2 PM. The "Restraint Justification" section and the "Type of Restraint" sections were blank on the orders. RN 1 verified that the restraint orders were incomplete.



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2. During a concurrent interview and review of the clinical record for Patient 18 with the Regulatory Manager (RM), on 6/20/16, at 11:43 AM, the physician orders for the use of restraints was signed and dated by the physician on 5/16/16 at 9:50 AM. The "Restraint Justification" section and the "Type of Restraint" sections were blank on the orders. The RM verified that the restraint orders were incomplete.



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3. During a concurrent interview and review of Patient 9's clinical record with the Quality Coordinator (QC), on 6/21/16, at 8:23 AM, Patient 9's "Restraint Order", dated 6/13/16, 6/17/16, and 6/20/16 did not indicate the reason for the use of physical restraints. The QC acknowledged the findings.

During an interview with Nurse Manager 1, on 6/21/16, at 9:05 AM, she reviewed the restraint orders for Patient 9 and stated the clinical indication for applying the physical restraints were supposed to be checked.

The hospital policy and procedure titled "Restraint Policy", dated 8/2015, indicated "The LIP (Licensed Independent Practitioner) primarily responsible for the patient's ongoing care must order the use of a restraint." It also indicated the conditions or symptoms that warranted the use of the restraints must be documented in the medical record.

Based on interview and record review, the hospital failed to implement their policy and procedure to monitor the condition of two of 33 sampled patients (26 and 18) when restraints were used which had the potential to result in injury due to the use of restraints.

Findings:

1. During a concurrent record review and interview with Registered Nurse (RN) 1, on 6/20/16, at 10 AM, she reviewed the clinical record for Patient 26 and was unable to find monitoring completed on 6/17/16 from 8 AM through 7 PM. RN 1 verified documentation in the clinical record that Patient 26 was in restraints during that time.



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2. During a concurrent review of the clinical record for Patient 18 and interview with the Regulatory Manager (RM), on 6/20/16, at 11:58 AM, he reviewed the clinical record for Patient 18 and was unable to find monitoring completed on 6/16/16 from 8 AM through 7 PM, and 7 PM through 8 AM for 6/18/16. The RM verified the physician orders in the clinical record indicating Patient 18 was in restraints during that time.

The hospital policy and procedure titled "Restraint Policy", dated 8/2015, indicated "Monitoring and Care...Non-Behavioral Restraint Standard: Patients will be observed frequently. Monitoring and care must be documented in the patient's record at least every two hours or more often based on the patient's assessment."

Based on interview and record review, the hospital failed to analyze data collected for restraint management which had the potential to result in missed opportunities for improvement. (Cross reference A 175)

Findings:

During an interview with Registered Nurse (RN) 6, on 6/20/16 at 10:10 AM, she stated there is a quality improvement project related to restraint management. RN 6 stated data is collected every night by assigned staff and this data is included in the quality improvement report. A copy of the "Restraint Audit Tool, non-violent, non-destructive (Med/Surg)" form was provided. The form included multiple quality measures that included documentation of "Nursing Assessment Completed every 2 hours".

During an interview and concurrent record review with the Clinical Data Analyst (CDA), on 6/20/16 at 11:35 AM, she stated she receives the audit tools completed by staff on the nursing units. She stated she does not compile all data that is collected. She compiles data related to restraints by day of the week, age, type, reason, rate by each nursing unit and percentage of orders not signed, dated and timed. The CDA reviewed the "Restraint Scorecard" dated 5/26/16 and stated it did not indicate data analysis regarding compliance to the policy regarding patient monitoring.

During an interview with Director of Quality Management, on 6/20/16 at 12 PM, she stated the staff performing the restraint use audits and complete the entire audit form. She stated not all data collected on the form is reported to the Quality Committee. She stated if the audit revealed an issue, then staff were to address the issue in real time.

Based on interview and record review, the hospital failed to ensure the nursing care plan was complete for two of 33 sampled patients (24 and 18) which had the potential to result in lack of continuity of care and failure to meet patient care needs.

Findings:

1. During a concurrent interview with Registered Nurse (RN) 3 and review of the clinical record for Patient 24, the current care plan was reviewed. Under the category for "Elimination" there was no entry or plan of care related to the use of a urinary catheter (a tube inserted into the bladder to drain urine). RN 3 verified Patient 24 currently had a catheter and the plan was to discharge her with the catheter in place. RN 3 stated the care plan should have been updated to reflect the use of the urinary catheter.



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2. During a concurrent review of the clinical record for Patient 18 and interview with the Regulatory Manager (RM), on 6/20/16, at 11:50 AM, the care plan was reviewed. Under the category "Restraints" there was no entry or plan of care dated 5/16/16 related to the use of a restraint (a physical or mechanical devise, attached or adjacent to the body that the individual cannot easily remove which restricts freedom of movement). The RM verified Patient 18's medical record did not have a care plan for the use of restraints. The RM stated the care plan should have been updated to reflect the use of the restraint.

The hospital policy and procedure titled "Interdisciplinary Care Plan", dated 5/2015, indicated "The plan of care will be reviewed regularly... The plan of care will be revised as appropriate to the patient's condition and the ongoing assessment process."

Based on interview and record review, the hospital failed to ensure physician orders were written according to the policy and signed by the physician in a timely manner for one of 33 sampled patients (17). This failure had the potential for inaccurate patient care.

Findings:

During a concurrent interview and review of Patient 17's clinical record with the Regulatory Coordinator (RC), on 6/20/16, at 12:11 PM, the records indicated the orders received via telephone and handwritten by Registered Nurse (RN) 7 in a "Physician Orders" form did not indicate a date and time. The RC stated according to the electronic clinical record, RN 7 indicated in his notes he received the orders on 5/19/16 (approximately a month ago). The RC also acknowledged the telephone order received was not signed by the physician in a timely manner.

The hospital policy and procedure titled "Verbal, Telephone, and Written Physician Orders", dated 2/2014, indicated the individual receiving the telephone order will indicate the date and time the order was received. It also indicated the telephone order shall be countersigned by the practitioner within 48 hours.



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Based on interview and record review, the hospital failed to ensure the physician order for discharge was documented in the clinical record for one of 33 sampled patients (22) which had the potential to result in a lack of direction for discharge to an appropriate level of care to ensure continuity of care to meet the patient's needs.

Findings:

During a review of the clinical record for Patient 22, the admission assessment, dated 6/16/16, indicated Patient 22 was bedbound. The Physical Therapy/Inpatient Evaluation, dated 6/17/16, indicated Patient 22 was unable to sit fully upright at the edge of the bed, had persistent trunk leaning, needed maximal assistance for sitting balance and was unable to stand. The Physical Therapy discharge recommendation was for Patient 22 to be discharged to a skilled nursing facility for rehabilitation. The physician orders, dated, 6/17/16, indicated Patient 22 was to be discharged to a skilled nursing facility. The clinical record indicated Patient 22 was discharged to an assisted living facility (a type of facility that provides a lower level of services than those received in a skilled nursing facility and the patient needs to be somewhat independent to provide self care) with home health and physical therapy services.

During an interview with the Director of Coordinated Care (DCC), on 6/20/16 at 1:10 PM, she reviewed the clinical record and found documentation that the planned discharge to an assisted living with home health and physical therapy was discussed with the physician. The DCC stated the physician order for discharge should have been updated to reflect the change in the discharge disposition.

Based on interview and record review, the hospital failed to implement it's policy and procedure for discharge planning for one of 33 sampled patients (33) which had the potential to result in a lack of plan to meet patient care needs at time of discharge.

Findings:

During a concurrent interview with Registered Nurse (RN) 4 and RN 5 on 6/21/16 at 9:30 AM, they reviewed the clinical record for Patient 33 and stated Patient 33 was readmitted back to the hospital on 5/9/16. RN 4 and RN 5 reviewed the clinical record and were unable to find an initial assessment or screen for discharge planning needs. They stated that discharge planning is discussed in the weekly interdisciplinary (IDT) rounds. They were unable to find documentation of the IDT rounds or any documentation regarding discharge planning in the clinical record.

During an interview with Care Coordinator (CC) 1, on 6/21/16 at 9:30 AM, she stated discharge planning is discussed during the weekly IDT rounds. She provided a binder of Interdisciplinary NICU (neonatal intensive care unit) ROUNDS forms. She stated these forms were not a part of the clinical record. The IDT NICU Round form for Patient 33, dated 5/24/16 indicated a referral to social services. The Discharge Plan was blank. The IDT NICU Rounds form for Patient 33, dated 5/31/16, indicated referrals to social services, regional center and high-risk infant referral. CC 1 could not find any documentation in the clinical record that these referrals were made. CC 1 stated Social Services attends the IDT NICU meetings. CC 1 stated family members are not invited to the IDT NICU meetings.

During an interview with Social Services (SS) 1, on 6/21/16 at 9:45 AM, she reviewed the clinical record and could not find documentation of action for the above referrals. She stated she was unable to attend IDT NICU rounds due to time constraints. SS 1 stated she was not aware of the referrals.

The hospital policy and procedure titled "Care Coordination Discharge Planning" dated 3/15/16, indicated "The discharge planning process is a collaborative approach that will include the patient, family/caregiver/other patient-identified support persons, attending physician and other members of the health care team. This approach recognizes the shared responsibilities of health care professionals and facilities as well as patients and their support persons throughout the continuum of care." The policy and procedure further indicates "Within 24 hours of admission, the admitting RN will screen all inpatients to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning..." "The RN Care Coordinator and/or Social Worker will perform an evaluation of the post-discharge needs of inpatients..." "An RN Care Coordinator and/or Social Worker will develop a discharge plan if the discharge planning evaluation indicates clinical or psychosocial risk factors that require post acute resources or referrals."



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Based on interview and record review, the hospital failed to include discharge planning evaluations in the clinical record for one of 33 sampled patients (33) which had the potential to result in inadequate information to healthcare team members to determine discharge care needs to ensure the continuum of care.

Findings:

During a concurrent interview with Registered Nurse (RN) 4 and RN 5 on 6/21/16 at 9:30 AM, they reviewed the clinical record for Patient 33 and stated Patient 33 was readmitted back to the hospital on 5/9/16. RN 4 and RN 5 reviewed the clinical record and were unable to find an initial assessment or screen for discharge planning needs. They stated that discharge planning is discussed in the weekly interdisciplinary (IDT) rounds. They were unable to find documentation of the IDT rounds or any documentation regarding discharge planning in the clinical record.

During an interview with Care Coordinator (CC) 1, on 6/21/16 at 9:30 AM, she stated discharge planning is discussed during the weekly interdisciplinary rounds. She provided a binder of Interdisciplinary NICU (neonatal intensive care unit) ROUNDS forms. She stated these forms were not a part of the clinical record and were kept in a binder in her office. She stated team members did not have access to these forms.