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Based on review of a list of hospital staff, personnel files and interviews with hospital staff, the hospital failed to maintain verification of current licensure and training for personnel working in the hospital.

Findings:

1. Staff #B told surveyors the facility used contract dietitians to provide nutritional services. There was no information provided to surveyors to document the hospital verified licensure, proof of training, education, and qualifications to perform patient care. There was no documentation the facility oriented and trained the contract dietitians.

2. In an interview on 9/21/11 surveyors were told by Staff B that Staff E was the clinical dietitian. Patient #3's medical record documented Staff F had completed a nutritional assessment and requested dietary supplements. Staff B told surveyors Staff F was the dietitian that was working in the place of Staff E while she was taking time off. There was no information provided to surveyors the dietitian was contracted. There was no verification of licensure, documentation of training, orientation, or competency.

Based on record review and interviews with hospital staff, the governing body does not ensure that all services performed under contract are provided in a safe and effective manner. Services provided to the hospital by contract are not monitored and evaluated by the hospital's quality assessment and performance improvement (QAPI) program to ensure that they are provided in a safe and effective manner.

1. On the morning of 9/21/11 surveyors reviewed contract personnel files. Two of two dietitians providing care to patients did not have documentation of licensure/certification, orientation, and training.

2. On 9/21/2011 surveyors reviewed the dietitians contract. The contract stipulates the dietitian will perform consultation in menu planning, food production and service, and therapeutic diet orders. The dietitian is to perform nutritional assessments and patient education, inservice food service personnel, and submit a written report summarizing consulting activities and evaluation of food services department. The facility did not have documentation the dietitian was providing any service other than consults. Later on 9/21/11 surveyors reviewed the "annual contract service evaluation". The measurement performance indicators listed as used in the evaluation of performance were;(1) Monitor consults to see if completed within three days of the order, and (2) Complete consult log to keep track of consult requests. The evaluation was performed by the Plant Operations Director. Not all of the services provided under contract are reviewed and evaluated by the Governing Body to ensure services are provided in a safe and effective manner.

Based on the review of abuse and neglect policies and procedures, a written letter from a hospital staff member, patient complaints/grievances and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

The hospital provided policies for review. The policy states staff will be trained to identify possible victims of abuse (physical assault, rape, sexual molestation, domestic abuse, elder neglect or abuse and child neglect or abuse). The proper procedure for reporting suspected abuse will be included in orientation. The policy further stipulates "any staff member who witnesses or suspects staff to patient abuse is responsible to immediately report to their supervisor". The policy did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

This deficiency was previously cited during a 5/10/2011 survey.

Based on review of hospital documents and meeting minutes and interviews with hospital staff, the hospital failed to track and analyze quality indicators hospital-wide to improve patient care. The Quality program failed to include dietary indicators addressing clinical outcomes.

Findings:

1. Dietary indicators addressed in the hospital's Quality Management program did not address nutritional outcomes. Indicators addressed are "nutritional consults completed within three days, and patient nutritional consult log completion". The facility does not have indicators developed to determine if the nutritional services are meeting the needs of the patients.

2. The contractor evaluation is completed by the Director of Plant Operations. The Director of Plant Operations does not have education, training, and experience to evaluate clinical dietetics.

3. This finding was reviewed and verified with hospital administration on the afternoon of 09/21/2011.

Based on review of medical records,and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) supervised the nursing care for each patient. The supervisory nurse failed to ensure physicians' orders and hospital policies were followed. This occurred in 3 of 3 patient charts (Patients 1, 3, 5)

Findings:

1. According to the hospital policy Nursing Assessment/Reassessments, a continuous evaluation of patient needs and nursing interventions to meet those needs with appropriate documentation in the Nurse's Notes is the expectation for all nursing staff. Further in the policy, it stipulates. physical limitations/restrictions will be identified by patient and/or nurse and reported to the attending physician for patient specific orders. The policy also stipulates all staff members are expected to report and document any signs of change in the patient's condition to the RN: changes in vital signs, changes in level of consciousness, changes in behavior, changes in physical abilities, suspected side effects of medications. The RN is responsible to document and report the observed changes to the attending physician or physician on-call.

Another policy "Hydration Protocol" reviewed 5/10 in the protocol section stipulates "If lab work is complete and potassium is less than 4.0 then electrolyte replenishment begins by giving electrolyte replenishment provided by the Pharmacy-If potassium is less than 3.5, the physician is to be notified to obtain further orders." Further in the protocol, it states "when the patient is on any type of rehydration therapy, all input and output must be recorded."

2. Patient #3 (the patient mentioned in the complaint) The patient, an 86 year old female, was admitted on 06/6/11 for assessment and evaluation of aggressive behavior and medication stabilization. According to the Intake/Assessment Call sheet the patient 's medical/physical/dental conditions listed were Dementia, HTN (hypertension), post CVA (cerebrovascular accident), asthma, hyperlipidemia, GERD (gastroesophageal reflux disease). This form was not signed.

History and Physical dictated 6/7/2011 indicates the patient had experienced escalating delusions and agitation. In the medical history illnesses were listed as hypertension, hyperlipidemia, a history of cerebrovascular accident with left-sided weakness, asthma, gastroesophageal reflux, and osteoporosis. Review of systems stipulates "in general, the patient does have the medical illnesses listed as above and also has a history of dementia, agitation, and hyponatremia. There is also a possible history of bladder problems." Later in the physical exam portion documentation stipulates "gait is of nonambulatory status and patient uses wheel chair. She does have some ability to stand, but requires assistance."

Nursing assessment documents on admission the patient was 5'2" and weight 154. "lungs: CTA (clear to auscultation)", requires assist with ADLs (activities of daily living), skin assessment documents no bruises, reddened buttocks, no opened areas. The nursing assessment further stipulates the patient is unsteady, can transfer wheelchair. Other history noted on the nursing assessment, asthma, hip fx (fracture) 1/10, elevated cholesterol, HTN (hypertension) benign osteoarthritis wheelchair use, GERD gastroesophageal reflux disease, edema, history of hyponatremia, gen. (generalized) pain.

Physician orders on admission included a comprehensive metabolic panel (CMP), complete blood count (CBC), and urinalysis with culture and sensitivity. CMP abnormal results were sodium 135 (low), creatinine 0.6 (low), total protein 9.4, albumin 3.3 (low), total bilirubin 1.3. Lab results for the urinalysis indicate trace protein, white blood cells, and red blood cells, the sample specimen was unacceptable for culture. There was no documentation in the chart the physician was notified and orders changed. No further specimens were collected for this order.

On 6/10 the patient had a dietary consult. The dietitian indicated the patient needed to be offered nutritional supplements if dietary intake was less than 70%. The order was noted. There was no order placed on the Kardex. This was verified with Staff A on 9/21/11. The facility failed to follow policy and procedure. The facility failed to follow physician orders.

Intake and output documentation on Patient 3's chart did not provide specific volume measures only hash marks for the number of times the patient voided or defecated. Intake when listed was % of meals. There was no documentation on the chart of amounts of fluids the patient received. On 6/10/11 dietary intake was documented at all three meals as less than 20%, 45%, 10%. There was no documentation a nutritional supplement was offered. Intake and output documentation from 6/10 until transfer indicated the patient's intake did not reach 70% of meals throughout the stay. 50 of 51 opportunities to provide nutritional supplements the hospital failed to provide supplements as ordered. The facility failed to follow physician orders.

On 6/14 lab CMP indicated serum sodium was 145, potassium 3.2 (low), total protein 8.3, albumin 2.9 (low) alkaline phosphatase 38 (low). Urinalysis indicated trace protein, small blood, large leukocytes, bacteria-many, RBC 6-10. The lab sheet included documentation the physician had been notified and no orders received.


There was no documentation of vital signs, intake and output on 6/17, 6/19, 6/24. There was no documentation of intake on 6/16, 6/20, 6/21. There was no documentation of output 6/16,6/20, 6/21, 6/25. From 6/16/2011 documentation of intake was was either missing or listed as zero or refused. There was no documentation the physician was notified the patient was not eating on any of these days. Physical assessments were not documented from 6/7 through 6/26 except for Staff A wrote on 6/15 "patient has productive cough with dark yellow expectorant. Daily documentation by registered nursing addressed behavioral status. The facility failed to follow policy.

The physician progress note on 6/11/11 indicated "lab studies, clinically unremarkable, medical status, "no significant change". The physician progress note on 6/14 indicated + (positive) culture, + UTI (urinary tract infection) with E. Coli, Bactrim DS BID, Lexapro 20, Acytilcysteine 375 bed. Progress notes on 6/15, 6/17, 6/18, 6/21, 6/22, 6/23 did not address medical problems.

On 6/27/2011 the patient was transferred to a nearby hospital. On admission to the nearby hospital the history and physical stipulates "the patient assessment on arrival: Hypernatremia, hypokalemia, dehydration, acute tubular necrosis, acute renal failure, delirium, dementia, status post stroke, behavioral disturbance, hypertension, asthma, probable moderate to severe protein calorie malnutrition. Will await prealbumin on that. Urinary tract infection. Possible aspiration pneumonia. Chest Xray looks like she may have an infiltrate in her right and left lower lobes, difficult to tell because she is so dehydrated." On 6/28/11 the patient was discharged to a hospital closer to her home. The discharge diagnosis listed: Hypernatremia, dehydration, hypokalemia, sepsis, aspiration pneumonia, urinary tract infection, acute tubular necrosis, delirium, acute renal failure, status post stroke, behavioral disturbance, hypertension, asthma, severe protein calorie malnutrition, heme positive stool.

3. Patient #1 65 Female admitted to the facility on 5/5/2011. An admissions assessment was performed on 5/5/2011 where an initial physiological and psychological assessment was performed. Patient was admitted due to significant behavioral changes, alzheimer dementia, multi-infarct with delusions, and depressive disorder non-origin specific. Patient #1 also had physiological diagnoses such chronic kidney disease, cerebral atherosclerosis, Esophageal reflux, pure hypercholesterolemia, chronic renal failure, hyperpotassemia, lumbosacral spondylosis, CVA (cerebrovascular accident), TIA (transient ischemic attack), and dietary surveillance. On the following days; 5/6/2011, 5/7/2011, 5/8/2011, 5/9/2011, 5/10/2011, 5/11/2011, 5/12/2011, 5/13/2011, 5/14/2011, 5/15,2011, 5/16/2011, 5/17/2011, and 5/18/2011 the facility's licensed staff failed to perform a daily assessment on the patient's full body sytem's. On the days listed above, the patient did not have a complete full body assessment performed by a registered nurse.

4. Patient #5 26 year old male admitted to the facility for behavioral issues on 4/20/2011. An initial nursing assessment was completed on the patient. None of the documentation during the patient's stay indicates the patient had physical assessments after the initial assessment was completed. The patient was discharged 5/1/2011.

Based on record review and interviews with hospital staff the hospital does not ensure there is a organized dietary service with oversight by a registered dietitian. The hospital did not have evidence that a dietitian was providing oversight or services with regularly scheduled visits.

Findings:

1. No dietitian reports were provided during the survey to show the dietitian was actively supervising dietary services at the hospital. In an interview at on 9/21/11 at 1510 Staff C told surveyors the consultant did not provide a monthly report. Staff C told surveyors the consultant presented to the facility when there was a nutritional consult needed. Staff C stated the dietitian did not provide inservice, evaluation of the dietary services, or oversight of nutritional services.

2. A contract was provided showing that the hospital had a contract with a dietitian to provide services as the manager for the dietary department of the hospital for a ten to twelve hours per month. The contract stipulates the dietitian will consult in menu planning food production and service, and therapeutic diet orders. The contract further stipulates the dietitian will provide a monthly personnel inservice education, perform monthly written reports summarizing consulting dietitian's activities and evaluation of the food service. There were no monthly reports, inservice education, or documents supporting the dietitian was overseeing the food service

3. The hospital did not have documentation the consulting dietitian was licensed. There was no documentation in the files indicating the dietitian had been oriented and trained to provide services at the hospital. Review of Patient #3's chart indicated a dietitian not listed on the contract provided to surveyors consulted on Patient #3. The facility did not have any information on the non-contracted dietitian.

4. A list of personnel was provided to surveyors 9/21/11. Staff C was listed as the dietary manager. Personnel records did not have dietary training, competency, or evaluation for Staff C. Staff C was not a certified dietary manager or dietary technician. There was no education record in the file.

5. Meeting minutes reviewed for 2011 did not document that a dietitian was attending or providing reports in any of the hospital's meetings such as medical staff, committee of the whole or governing board.

6. Dietary policies and procedures were provided to surveyors 9/21/11. The policies and procedures had not been reviewed and revised since 2007.

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Based on review of hospital documents and interviews, the hospital failed to ensure a qualified dietitian supervises the nutritional aspects of patient care.

Findings:

1. The hospital did not have documentation that the persons doing nutritional screenings on patients were qualified (licensed/registered dietitians). There was no evidence consultants were licensed and qualified as dietitians.

2. The licensed/registered dietitian does not supervise the serving of modified diets to hospital patients. On 9/21/11 at 1510, in an interview with Staff C surveyors were told the dietitians do not monitor/oversee the food service. Staff C told surveyors that Staff G was the Director over dietary department. Staff G's title on the personnel list was "Director of Plant Operations". There was no documentation indicating Staff G had education, training, and experience to oversee clinical nutrition services.

3. This information was provided in an exit conference 9/21/11. No further documentation was provided.

Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary and nursing personnel.

Findings:
1. On 09/21/11 surveyors asked Staff C, the dietary manager, who was responsible for nutritional supplements. Staff C told surveyors nursing was responsible for reviewing the orders and providing supplements to the patient as ordered. Staff C told surveyors dietary staff stocked the floors with supplements but did not include supplements on trays unless the nurses called and asked. Staff A, the nursing supervisor told surveyors supplements were usually supplied on trays if there was an order for supplements. Staff A also told surveyors nursing staff would place the supplement on the medication administration order as part of noting the order. Patient #3's medical record indicated the dietitian had completed a nutritional assessment and nutritional supplements were ordered. There was no documentation nutritional supplements were provided to the patient. There was no documentation on the medication administration record of the supplement order. 50 of 51 opportunities the facility failed to provide patient #3 nutritional supplements. The facility failed to train and oversee dietary and nursing staff on clinical nutritional services.

2. On 09/21/11 Staff C told surveyors she was dietary manager. Surveyors asked if anyone had received training by the dietitian on food preparation, storage and handling specific to the dietary department at the hospital. Staff C told surveyors there had not been any specific dietary training. Staff C told surveyors she was not a certified dietary manager. There were no records of dietary orientation, training, or evaluation of services in Staff C's personnel record.

3. This information was provided in the exit conference 9/21/11. No further documentation was provided.

Based on a review of policies and procedures, medical records, and staff interviews, the hospital failed to ensure the menus were meeting the needs of the patients.

Findings:

1. According to the Nutritional Assessment -Department of Nursing policy a brief assessment of each patient's nutritional status will be done as part of the admission nursing assessment. No further assessment is required if nutritional problems are not identified. The policy does not define specific "nutritional problems/conditions" that would trigger a consultation by the dietitian. In an interview on 9/21/11 Staff B told surveyors screening protocol was contained on the nursing assessment. The policy does not address the screening protocol or specifics to triggering a dietary consult.

Another policy "Hydration Protocol reviewed 5/10" the protocol section stipulates "If lab work is complete and potassium is less than 4.0 then electrolyte replenishment begins by giving electrolyte replenishment provided by the Pharmacy-If potassium is less than 3.5, the physician is to be notified to obtain further orders. Further in the protocol "when the patient is on any type of rehydration therapy, all input and output must be recorded."

The dietary policy "patient charting" stipulates "meal checks and daily rounds will be made by the Food Service Director. Potential problems and observations pertinent to dietetic treatment will be charted whenever necessary regardless of diet order".

2. On 09/21/11 surveyors asked Staff C, the dietary manager, who was responsible for nutritional supplements. Staff C told surveyors nursing was responsible for reviewing the orders and providing supplements to the patient as ordered. Staff C told surveyors dietary staff stocked the floors with supplements but did not include supplements on trays unless the nurses called and asked. Staff A, the nursing supervisor told surveyors supplements were usually supplied on trays if there was an order for supplements. Staff A also told surveyors nursing staff would place the supplement on the medication administration order as part of noting the order.

Patient #3's medical record indicated the dietitian had completed a nutritional assessment and nutritional supplements were ordered. There was no documentation nutritional supplements were provided to the patient. There was no documentation on the medication administration record of the supplement order. There was no documentation the Food Service Director charted potential problems and observations pertinent to dietetic treatment. There was no documentation the Food Service Director made daily rounds or meal checks. 50 of 51 opportunities the facility failed to provide patient #3 nutritional supplements. The facility failed to train and oversee dietary and nursing staff on clinical nutritional services.

Based on review of medical records,and interviews with hospital staff, the hospital failed to ensure the dietary policies were followed and nutritional status was monitored.

Findings:

1. According to the Nutritional Assessment -Department of Nursing policy a brief assessment of each patient's nutritional status will be done as part of the admission nursing assessment. No further assessment is required if nutritional problems are not identified. The policy does not define specific "nutritional problems/conditions" that would trigger a consultation by the dietitian. In an interview on 9/21/11 Staff B told surveyors screening protocol was contained on the nursing assessment. The policy does not address the screening protocol or specifics to triggering a dietary consult.

2. Another policy "Hydration Protocol reviewed 5/10" the protocol section stipulates "If lab work is complete and potassium is less than 4.0 then electrolyte replenishment begins by giving electrolyte replenishment provided by the Pharmacy-If potassium is less than 3.5, the physician is to be notified to obtain further orders. Further in the protocol "when the patient is on any type of rehydration therapy, all input and output must be recorded." On 6/14 lab results indicate the patient's potassium was 3.2. There was no documentation the patient was placed on hydration protocol.

3. The dietary policy "patient charting" stipulates "meal checks and daily rounds will be made by the Food Service Director. Potential problems and observations pertinent to dietetic treatment will be charted whenever necessary regardless of diet order". On 6/10 the patient had a dietary consult. The dietitian indicated the patient needed to be offered nutritional supplements if dietary intake was less than 70%. The order was noted. There was no order placed on the Kardex. Intake and output documentation on Patient 3's chart did not provide specific volume measures only hash marks for the number of times the patient voided or defecated. Intake when listed was % of meals. There was no documentation on the chart of amounts of fluids the patient received. On 6/10/11 dietary intake was documented at all three meals as less than 20%, 45%, 10%. There was no documentation a nutritional supplement was offered. Intake and output documentation from 6/10 until transfer indicated the patient's intake did not reach 70% of meals throughout the stay. 50 of 51 opportunities to provide nutritional supplements the hospital failed to provide supplements as ordered. There was no documentation the Food Service Director reviewed the chart or checked the patient record to determine if the order was carried out and the patient was receiving adequate nutrition, hydration, and supplementation.

4. According to the hospital policy Nursing Assessment/Reassessments, a continuous evaluation of patient needs and nursing interventions to meet those needs with appropriate documentation in the Nurse's Notes is the expectation for all nursing staff. Further in the policy, it stipulates. physical limitations/restrictions will be identified by patient and/or nurse and reported to the attending physician for patient specific orders. The policy also stipulates all staff members are expected to report and document any signs of change in the patient's condition to the RN: changes in vital signs, changes in level of consciousness, changes in behavior, changes in physical abilities, suspected side effects of medications. The RN is responsible to document and report the observed changes to the attending physician or physician on-call.

Patient #3's nursing documentation reflects the patient intake was not documented or documented as 5% from 6/16/11 until discharge. The intake is documented in percentage of meal. The documentation does not quantify oral intake. Several days of intake and output documentation are missing. There is no documentation the nursing staff or dietary staff notified the physician about lack of intake.

5. On 6/27/2011 the patient was transferred to a nearby hospital. On admission to the nearby hospital the history and physical stipulates "the patient assessment on arrival: Hypernatremia, hypokalemia, dehydration, acute tubular necrosis, acute renal failure, delirium, dementia, status post stroke, behavioral disturbance, hypertension, asthma, probable moderate to severe protein calorie malnutrition. Will await prealbumin on that. Urinary tract infection. Possible aspiration pneumonia. Chest Xray looks like she may have an infiltrate in her right and left lower lobes, difficult to tell because she is so dehydrated."
On 6/28/11 the patient was discharged to a hospital closer to her home and placed on hospice. The discharge diagnosis listed: Hypernatremia, dehydration, hypokalemia, sepsis, aspiration pneumonia, urinary tract infection, acute tubular necrosis, delirium, acute renal failure, status post stroke, behavioral disturbance, hypertension, asthma, severe protein calorie malnutrition, heme positive stool. On 6/29/2011 the patient expired. Discharge diagnosis at the time of death stipulates 1. Sepsis secondary to urinary tract infection, 2. urinary tract infection, present on admission; 3. Severe dehydration; 4. Severe protein calorie malnutrition; 5. Failure to thrive.