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Based on clinical record review and staff interview, the hospital failed to provide an accurate medical record for one out of seven reviewed clinical records (Patient 301) as the recapped order for Neutra-Phos failed to show a two day duration (held internally in the system) as originally ordered two days prior to the recap, that the physician could see when he issued a telephone order for the recapped order. As written, the order would have been good for 30 days unless the pharmacist called the physician to clarify the duration of the order with the physician (which was possible as the electronic version of the order did contain a two day duration with the order which the verifying pharmacist could see via the pharmacy computer system).

Findings:

On 4/25/11 a review of Policy and Procedure PCM VI.A.8 entitled AUTOMATIC STOP ORDERS (Approved 11/17/10; Revised: 3/11) indicated that it stipulated a number of classes of medications with automatic stop dates less than 30 days. These were controlled substances (drugs subject to abuse and hence under tight control as stipulated by law), antibiotics, anticoagulants (blood thinners), and ketorolac (used to treat pain). Those medications not so included among these designated medications would automatically stop after 30 days if not continued by the physician. Neutra-Phos was one of the latter medications as it was not included in those medications specifically designated by the hospital policy to have a shorter automatic stop date. Neutra-Phos is used to replace phosphorous lost secondary to excessive phosphorous elimination by the kidney or due to poor adsorption in the diet. It comes in 1.25 gm packets that contain the medication in powder form which can be dissolved in water so a patient can drink the resulting solution.

On 4/26/11 a review of Patient 301's clinical record indicated that on 4/14/11 a physician ordered that Patient 301 receive Neutra-Phos two packets three times daily for two days. The patient then changed level of care on 4/16/11 (went to a different area of the hospital) and a "Transfer/Discharge Medication Review & Order Sheet" (TDMROS: included each drug order the patient had been on and which provided boxes for each order which a physician could check to indicate if the drug was to be continued or discontinued). In this case the TDMROS was taken as a telephone order from a physician by a nurse. The Neutra-Phos order was recapitulated and the continue box was checked by the nurse for the physician. There was no duration (such as "for two days") that appeared on the written recapped medication order so at that point, the order would be considered to be good for 30 days. The order subsequently dropped off the record the next day.

During an interview of Administrative Pharmacist M at 10:06 a.m. on that date, he stated that a stop date was built into the order but it did not print out on the TDMROS. He stated that it was a "systems issue" and that the trouble with this particular form is it did not indicate the duration of the order. He stated that a pharmacist would have been able to see the two day stop period entered into the electronic profile for this order as was done when the order was originally entered. He checked the electronic clinical record for Patient 301 and could find no evidence that the pharmacist had called the physician to see if that physician had wanted to continue the order as a two day order as originally ordered on 4/14/11 or to go for 30 days as indicated by the physician on the telephone order.

Based on medical record review and interview, the hospital failed to ensure the nutritional needs of 1 patient (Patient 252) in a sample of 3 patients, reviewed for nutritional care, as evidenced by the lack of review by physicians' for nutritional recommendations. Lack of an effective system to ensure comprehensive planning for patient nutritional needs may further compromise the clinical and nutritional status of patients.

Findings:

Patient 252 was admitted with diagnosis including small bowel obstruction. Admission diet order was NPO (nothing by mouth). A follow up diet order dated 4/6/11 noted the initiation of total parenteral nutrition (TPN-feeding through a vein). Admission height was 5 feet 8 inches and weight was 112 pounds. It was also noted that the patients' body mass index (BMI) was 16.64 which is a measure of fat in relationship to a patients' height and weight. BMI's of 19 or below may be indicative of compromised nutritional status (World Health Organization, 2011). Lab work dated 4/5/11 noted an albumin (a measure of protein stores) of 1.8 gm/dl (normal 3.5-5.0 mg/dl). A comprehensive nutrition assessment dated 4/8/11 noted that the patient had a depleted vitamin D level of 22 ug/dl (normal 30-95 gm/dl). The assessment also recommended Vitamin D supplementation of 3,000 units/day. A follow up nutrition assessment dated 4/12/2 again recommended supplementation. Similarly there were nutritional recommendations dated 4/17 and 4/22/11 regarding the possibility of implementing enteral feeding (feeding through a nasal tube into the stomach) in an effort to maintain gut function. There was no documentation that the physician(s) responsible for the care of the reviewed and/or acknowledged the registered dietician's (RD's) recommendations.


In a concurrent interview with DMS JJ she was asked to describe how RD's followed up on nutritional recommendations to physicians. She stated that within the electronic medical record the RD's had the ability to put in recommended interventions. She also stated that the RD's would rely on the physician to review the recommendations. The surveyor asked that if it did not appear that recommendations were reviewed would the RD's contact the physician. She stated that likely they would not. Hospital policy titled "Clinical Dietitian Recommendations" dated 11/09 revealed that the procedure for nutritional recommendations would be for the RD to write the nutritional intervention on the physicians' order page and stamp the page with the options of implementation or decline of the intervention. There was no indication the RD documented the recommended interventions per hospital policy, rather the RD charted the recommendations on a form titled "Multidisciplinary Recommendation Form for MD." It was also noted that this form was not intended to part of the permanent medical record.

Based on food storage observations and dietary staff interview, the hospital failed to ensure that all necessary patient equipment was maintained as evidenced by the integrity of the wainscoting in the walk-in refrigerator. Failure to ensure the quality of the interior or necessary patient equipment may result in bacterial growth behind the surfaces exposing foods to potential cross contamination.

Findings:

During the initial tour on 4/25/11 beginning at 11 am, it was noted that the plastic wainscoting, measuring 5-6 inches wide and 6 feet tall, along the entrance of the walk-in refrigerator was buckling away from the door jam, exposing a brown-rust like material. It was also noted that the joints of the wainscoting were exposed resulting in a surface that was not smooth and cleanable. In an interview on 5/26/11 at 10 am, with DMS I he stated acknowledged that the surface was no longer in tact. He also stated he was aware of it; however to date had not implemented any corrective action. It would be the standard of practice to ensure that all non-food contact surfaces were free of unnecessary crevices, ledges and projections and were constructed to facility cleaning (Food Code, 2009).