HospitalInspections.org

Based on observation interview and record review the facility failed to ensure that the nursing staff develop and keep current a plan of care for 1 (SP#16) of 43 sampled patients.

Findings include:

Observation was made of sampled patient # 16 on 5/18/2011 at 12:15pm, who was observed in his room with an intravenous (I.V.) noted in his arm. Review of the medical record on 5/17/2011 revealed that sample patient # 16 came to the emergency room on 4/25/2011 with a complaint of vomiting and diarrhea with a history of weight loss. He was admitted as an inpatient with a primary diagnosis of weight loss. His admitting orders included strict I/O (intake and output), regular diet, and social work for testing. Further review of the his medical record revealed that sample patient #16 had a history or a 30 lbs. (pounds) weight loss prior to entering the hospital. Sample patient #16 also had a regular diet ordered, and was NPO (nothing by mouth) for procedures and surgery. There is very little documented evidence that his dietary intake was being monitored by the nursing staff. Record review also revealed that a nutritional assessment was done by a dietitian on 5/11/2011 (16 days from the patient's admission) where it was noted that sample patient #16 had loss an additional 3kgs (6.6lbs) since admission. The patient had an order for boost a nutritional supplement to be taken twice a day , with an intervention to monitor weight weekly, and intake of at least 75% of meals and to change boost to boost plus. The next note dated 5/16/2011( 5 days later) has that sample patient #16 was not drinking the boost plus but the regular boost instead. His records also revealed that there was no monitoring of the dietary intake and weight during that time. There is also a doctor's note dated 5/16/2011 that has documented of a stage II sacral pressure ulcer which was not noted on admission, that call for a plan to optimize nutrition.
During an interview with the dietitian and the director of nursing on 5/17/2011 at 11:02am, the dietitian stated that she saw the patient on admission but she did not write any notes. She also stated that we do interdisciplinary rounds each day with the nurses, however, if they do not have any concerns we don't do any written assessments. Interview with the director of nursing on 5/17/2011 at 11:15am , she also stated that there are no nursing triggers for an assessment by a dietitian for patient who are admitted with a
diagnosis of weight loss, there has to be an order written from the doctor and then the nurse has to initiate the process. Interview with the Unit Coordinator registered nurse on 5/19/2011 at 10:25am, she stated that she did not know this patient, and that she was getting ready to attend the interdisciplinary rounds to discuss the sample patient (SP#16).

Review of the facility's policy regarding how the facility monitors strict intake and output, the policy subject: Hygiene basic needs-bathing, surgical scrub linens, sitz bath, linens (soiled) and diaper changes, was provided. The policy states Output measurement of urine and stool will be documented according to measurement needs such as strict I&O versus frequency notations, and to remove the diaper and weigh on diaper scale of [if] strict I&O indicated. The policy does not include any process of measuring dietary intake.

Further record review of sample patient #16 medical record on 5/18/2011 revealed that the nursing notes has documented that discharge planning for sample patient #16 as daily. There are no notes as describing what the daily assessment of sample patient # 16 entailed. There is also a note in sample patient #16 medical record stating that the patient was seen by the social worker and expressed concerns regarding graduating from high school on time. There is another note written a day earlier on 5/2/2011 by the social worker that has documented that a letter was faxed to sample patient ' s #16 school. There is however, no documented evidence that discharge planning was initiated for sample patient #16 to include follow up on the patient's schooling. Interview on 5/19/2011 at 10:45am with the social worker who works with the patients on 3 North, she stated that we did not start discharge planning for sample patient #16 because he does not have a diagnosis and a discharge date yet, and we cannot place him in home bound school program because of that fact. She also stated that we do not begin discharge planning on any patient until we get a diagnosis so we can know how to plan. During an interview with the social worker who was assigned the patient while he was on the 3 North-East unit, she confirmed that there was no discharge planning initiated for sample patient #16.
Review of the facility's policy for discharge planning reveals that the Registered Nurse will complete an assessment and screening on admission of the discharge needs of all patients, and will daily reassess the needs throughout the hospital stay and that after needs are identified during rounds, the discharge team will collaborate in making arrangements.