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Based on review of the Plan of Correction (PoC) for previously cited deficiencies, document review, medical record review, and interview, it was determined the Governing Body (GB) failed to provide oversight and monitoring for the nursing and dietetic care and services provided and ensure the Quality Assessment and Performance Improvement Program (QAPI) analyzed data, identified continued deficient practices and implement appropriate interventions for improvement.

The findings included:

1. The GB failed to ensure the Chief Executive Officer (CEO) assumed responsibility, and assisted in the identification of areas of continued noncompliance
Refer to A057.

2. The GB failed to ensure the QAPI program implemented the PoC for maintaining an active hospital - wide performance improvement program that analyzed and tracked quality indicators related to Hospital Acquired Pressure Ulcers (HAPU), identified deficient and problem areas and revised interventions as indicated.
Refer to A 309.

3. The GB failed to ensure nursing services provided appropriate interventions in the treatment and prevention of HAPU.
Refer to A 392.

4. The GB failed to ensure the Dietary Services provided appropriate assessments and interventions to meet compromised patients' nutritional needs.
Refer to A 621.




29706

Based on review of the Plan of Correction (PoC) for previously cited deficiencies, document review, medical record review, and interview, it was determined the hospital failed to fully implement its PoC and ensure the Chief Executive Officer (CEO) assumed responsibility and provided direct oversight and monitored for compliance with the PoC, and assisted in identifying continued deficient practice areas requiring interventions and improvement. This resulted in the lack of evidence to ensure deficient practices had been identified, corrected, and a system had been established to maintain compliance with the Conditions of Participation (CoP).

The findings included:

1. Review of the PoC dated 6/18/13 documented, "...To ensure the deficient practice does not reoccur, the CEO &/or Assistant Administrator will begin checking all monitoring tools in the areas with deficient practices daily for three weeks then weekly until substantial compliance has been obtained ...Any issues identified will be evaluated, investigated and an action plan put into place and reported to the CEO ..."

2. Review of the "Quality Improvement Trending Report" dated June 2013 documented the "Target Incidence Rate" goal for health care acquired pressure ulcers (HAPU) to be 2 percent (%). The report documented the "Actual Incidence Rate" of June 2013 to be high at 2.4 %. There was no documentation the QAPI committee had revised interventions for the prevention of HAPU.

Review of 4 of 5 (Patients #1, 2, 3, and 4) sampled medical records revealed the patients had developed HAPUs and had not received appropriate dietetic assessments and interventions. Patient #5 was admitted with pressure ulcers and there was no documentation a nutritional assessment and interventions for the patient's nutritional status. There was no documentation the QAPI committee had identified dietetic services as a deficient practice area and implemented interventions for improvement.

There was no documentation the CEO had identified, evaluated and investigated the deficient practice areas.

Refer to A392 and A621.



29706

Based on review of the facility's Plan of Correction (PoC) for previously cited deficiencies, document review, observation and interview, it was determined the facility failed to implement its PoC for maintaining an effective on-going, hospital-wide, data driven Quality Assessment performance Improvement (QAPI) program that monitored implementation of the PoC, correctly identified deficient and problem areas, made adjustments as indicated and utilized the Indicators to focus on improved health outcomes.

The findings included:

1. The Governing Body (GB) failed to ensure the QAPI program implemented the Poc for maintaining an active hospital-wide performance improvement program that analyzed and tracked quality indicators related to Hospital Acquired Pressure Ulcers, and identified continued deficient practice areas in order to revise interventions to improve in those areas.
Refer to A 309.




29706

Based on review of the facility's Plan of Correction (PoC) for previously cited deficiencies, document review, medical record review, and interview, it was determined the hospital failed to ensure the QAPI program implemented the PoC for maintaining an active hospital - wide performance improvement program that analyzed and tracked quality indicators related to Hospital Acquired Pressure Ulcers (HAPU), identified deficient and problem areas and made revisions to interventions to improve in the deficient areas.

The findings included:

1. Review of the hospital's "Quality Improvement Trending Report" revealed the "Target Incidence Rate" goal for health care acquired pressure ulcers (HAPU) was 2 percent (%). The report documented the "Actual Incidence Rate" for the month of June 2013 was high at 2.4 %. There was no documentation the QAPI committee had developed and revised interventions for the prevention of HAPUs.

Review of the 4 of 5 (Patients #1, 2, 3, 4 and 5) sampled records revealed the patients had development HAPUs and had not received appropriate nutritional interventions and services. There was no documentation the HAPUs had been analyzed, and action plans developed for the prevention of further HAPUs. Review of Patient #5's medical record revealed the patient had been admitted with pressure ulcers and had not received a nutritional assessments and interventions. There was no documentation the QAPI had identified a deficient practice with dietetic services providing appropriate assessments and interventions.
Refer to A392 and A621.

Based on facility policy, record review, observation and interview, it was determined the hospital failed to have an organized nursing service that accurately assessed patient's needs and provided appropriate interventions to patients who had pressure ulcers and who were nutritionally compromised.

The findings included:

1. Nursing services failed to appropriately assess patient's needs to ensure appropriate care and interventions were provided for patients with pressure ulcers and who were nutritionally compromised.
Refer to A392.

Based policy review, record review, observation and interview, it was determined nursing services failed to provide appropriate interventions in order to prevent hospital-acquired pressure ulcers, weigh patients per protocol, and ensure consultation with the Registered Dietician (RD) for patients who were nutritionally compromised for 4 of 5 (Patients #1, 2, 3 and 4) sampled patients.

The findings included:

1. The "NUTRITION SCREENING, ASSESSMENT, REASEESSMENT" policy documented, "...Policy: Upon admission, nursing staff screens the patient for nutrition risk. Both nursing staff and dietetic staff perform ongoing screening throughout the hospital stay...Screening Procedure: 1. Nursing A. Patients 18 years of age or greater...The admitting nurse completes the Admission Data base Assessment on admission...and consults the clinical Dietitian for any patient presenting with one or more of the following criteria...Less than 18 on Braden Score...Skin breakdown-any stage [pressure wound/ulcer/blister/area]...Nausea, vomiting, diarrhea, or frequent indigestion...Loss of appetite, malnourishment or dehydration 2. The Registered Dietitian [RD] reviews data and screens any patient with the following...Albumin < [less than] 2.6 or Prealbumin <18...> [greater than] 80 years of age...LOS [Length of Stay] > 7 days for adult patients...NPO [nothing by mouth] > 5 days ..."


2. Observations on 7/23/13 at 2:35 PM revealed Patient #1 in a bed with Bucks traction to the left leg. Observation of the patient's right heel revealed a pressure ulcer that was approximately 0.8 cm x 0.6 cm. A second reddened area was observed to the side of the heel that was red and approximately 0.5 cm x 0.5 cm. The left heel had a pressure ulcer that was approximately 1.2 cm x 1.0 cm and also a reddened area to the side of the left heel that was approximately 0.5 cm x 0.5 cm. The surrounding area of the left heel was slightly reddened.

Medical record review for Patient #1 revealed the patient was 97 years old and was admitted to the hospital on 7/11/13 with a fractured left hip and Myocardial Infarction.

Review of the nursing "Weekly Wound Report" for 7/12/13 to 7/19/13 revealed the patient had developed a hospital-acquired pressure ulcer measuring 0.8 centimeters (cm) by (x) 0.6 cm "SDTI [suspected deep tissue injury]" pressure ulcer to the right heel on 7/14/13, and a 2 cm x 1.8 cm SDTI pressure ulcer to the left heel on 7/16/13.

Review of the laboratory (lab) results revealed the patient's Albumin levels continued to drop after admission and were 2.9 on 7/12/13, 2.6 on 7/13/13, 2.3 on 7/17/13, 2.2 on 7/21/13 and 2.3 on 7/22/13. The 7/23/13 lab results revealed the patient's pre-albumin level was low at 8.3 (normal 17.6-36).

Review of the medical record revealed no documentation of weights for the patient, and no documentation nursing services had communicated with the RD regarding the patient's pressure wounds and low albumin levels. There was no documentation nursing services had developed interventions to prevent further hospital acquired pressure ulcers.

During an interview on 7/23/13 at 11:10 AM the Director of Nursing Service (DNS) when questioned about weighing patients, the DNS stated that all patients in swing beds should be weighed weekly on Sundays, and Patient #1 had not been weighed because he was in traction. There was no physician's order to hold the patient's weights. At 11:10 AM the DNS stated the nurse notified the physician and an order was obtained to remove the Bucks traction long enough to weigh the patient weekly.

On 7/23/13 at 11:15 AM the RD was interviewed regarding the lack of documentation of an nutritional assessment performed by a RD since admission. The RD stated, "...Because of the demands of my job, I just review and look over some charts. He [Patient #1] seems to be eating about 50 percent [%], 50 % is fair. This is based on nursing documentation. I was never notified there was a pressure ulcer. I can't be over everything."

3. Medical record review for Patient #2 revealed the patient was 88 years old, and was admitted to the hospital on 7/4/13 with diagnoses of Septicemia and Aspiration Pneumonia.

Review of the patient's lab results revealed the patient's albumin levels were as follows:
7/3/13 in the hospital's emergency department it was 3.0 (normal is 3.4 to 5.0).
7/5/13 was 2.5.
7/6/13 was 2.3.
7/7/13 was 2.4
7/8/13 was 2.4.
7/9/13 was 2.5.

There was no documentation nursing notified the RD of the patient's declining albumin levels, or requested nutritional interventions.

4. Observations on 7/23/13 at 2:20 PM revealed Patient #3 was laying in bed. Observations of the nursing assessment of the patient revealed the patient had a left buttock pressure ulcer measuring 3 cm x 2 cm.

Medical record review for Patient #3 revealed the patient was 71 years old and was admitted to the hospital on 7/17/13 with the diagnosis of Fractured Right hip and status post surgical hip replacement procedure on 7/17/13.

A nursing Wound Care note dated 7/19/13 documented the patient had developed a hospital acquired pressure ulcer to the left buttock measuring 3 cm x 2 cm. There was no documentation nursing services developed interventions to prevent further development of hospital-acquired pressure ulcers.

There was no documentation nursing service had communicated with the RD regarding the patient's development of a hospital acquired pressure ulcer.

5. Medical record review for Patient #4 revealed the patient was 74 years old and admitted to the hospital on 7/18/13 with the diagnoses of Fractured Left Hip, Alzheimer's, Dementia and Incontinence.

Review of the 7/18/13 Nursing Assessment revealed nursing had assessed the patient with a Braden score of 14, and checked that no referral was needed to the RD.

Review of the 7/21/13 Nursing Wound Care note revealed the patient had developed a hospital acquired pressure ulcer to the right hip measuring 1.1 cm x 2.2 cm. There was no documentation nursing services developed interventions in order to prevent further hospital-acquired pressure ulcers.

Review of the patient's lab results revealed upon admission the patient's albumin level was 3.9 and on 7/23/13 the patient's albumin had dropped to 2.5.

There was no documentation the RD had been notified of the Braden score of 14, the development of the pressure ulcer or low albumin level.

During an interview on 7/24/13 at 11:45 AM, RN #1 assisting the DNS, stated there were no dietary/nutrition notes for this patient.

Based on record review and interview, it was determined the hospital's dietetic services failed to provide appropriate assessments and interventions for patients with a compromised nutritional status for 5 of 5 (Patients #1, 2, 3, 4 and 5) sampled patients.

The findings included:

The hospital's dietetic services failed to ensure the Registered Dietitian performed nutritional assessments in order to determine the level of nutritional risk and needs of patients, and provided recommendations and interventions for compromised patients with nutritional risks.
Refer to A 621.

Based on facility policy, record review, observation and interview, it was determined the Registered Dietician (RD) failed to provide appropriate assessments and interventions to meet the nutritional needs for 5 of 5 (Patients #1, 2, 3, 4 and 5) sampled patients.

The findings included:

1. Review of the hospital's "Medical Nutrition Therapy [MNT]" policy revealed, "Policy: In order to provide an efficient and effective process for initiating nutrition therapy recommendations by the Registered Dietitian (RD), this Medical Nutrition Therapy protocol will be followed...Procedure... 2. The Registered Dietitian...a. May utilize the protocol whenever the RD is involved in the multidisciplinary care of a patient. b. may write orders per approved protocol...Protocol: 1. Diet Modifications...Change diet texture and/or liquid consistency...Modify diets based on patient medical condition...Determine and order appropriate calorie and protein levels...Liberalize the diet within the prescribed diet order...Request a Speech therapy Consult/swallow evaluation ...2. Fortification of Diets/Oral Nutritional Supplements...Initiate, change, or discontinue nutrition supplements within the diet order based on the RD's nutrition assessment...May be ordered at the time of assessment/reassessment when the average intake is sub-optimal, if visceral proteins are depleted, or wounds present/poor skin integrity present...Add liquid protein intake...3. Vitamins and Minerals...Order a multivitamin (MVI) when diet intake is inadequate to achieve 100% [percent] of the RDA [Recommended Daily Allowance], presence of pressure ulcers or non-healing wounds...Order 500 mg [milligrams] Vitamin C BID [twice a day] if the patient has Stage II or greater pressure ulcer or non-healing wounds...Order 200 mg Zinc Sulfate daily if deficiency is suspected/documented if patient has Stage III or IV wounds....5. Laboratory Data...Order a prealbumin to determine nutritional status or status of visceral protein stores..."

Review of the hospital's "NUTRITION SCREENING, ASSESSMENT, REASEESSMENT" policy revealed, "...Policy: Upon admission, nursing staff screens the patient for nutrition risk. Both nursing staff and dietetic staff perform ongoing screening throughout the hospital stay...Screening Procedure: 1. Nursing A. Patients 18 years of age or greater...The admitting nurse completes the Admission Data base Assessment on admission...and consults the clinical Dietitian for any patient presenting with one or more of the following criteria...Less than 18 on Braden Score...Skin breakdown-any stage...Nausea, vomiting, diarrhea, or frequent indigestion...Loss of appetite, malnourishment or dehydration 2. The Registered Dietitian reviews data and screens any patient with the following...Albumin < [less than] 2.6 or Prealbumin <18...> [greater than] 80 years of age...LOS [Length of Stay] > 7 days for adult patients...NPO [nothing by mouth] > 5 days ...3. The Registered Dietitian determines the level of nutrition risk...within 48 hours of referral or screening. A nutrition assessment is completed on patients determined to be at moderate or high risk...6. Reassessments are performed and documented as follows...Level I (HIGH potential for risk)-every 1-3 days...Level II (MODERATE potential for risk)-every 3-5 days until stable...Level III (LOW/MILD/LO potential for risk)-every 7 days...7...Recommendation(s) and physician orders are reflected by documentation in the patient's medical record...8. Plan of Care...A plan of care is determined from the findings of the Nutritional Assessment...The patient is reassessed per protocol to determine any needed changes in the plan of care..."

2. Medical record review for Patient #1 revealed the 97 year old patient was admitted to the hospital on 7/11/13 with diagnoses of a fractured left hip and had a Myocardial Infarction.

Review of a physician's order dated 7/11/13 revealed the patient was ordered a Cardiac diet and to have 5 pounds (lbs) Bucks traction applied to the fractured left hip.

Review of the Nursing Weekly Wound Report dated 7/12/13 to 7/19/13 revealed the patient had developed a hospital-acquired pressure ulcer to the right heel on 7/14/13 measuring 0.8 centimeters (cm) by (x) 0.6 cm. The nurse documented the pressure ulcer as "SDTI [suspected deep tissue injury]."

The Weekly Wound Report dated 7/16/13 documented the patient had developed a 2nd hospital-acquired pressure ulcer to the left heel measuring 2 cm x 1.8.

Review of the 7/22/13 nursing wound care assessment documented the patient's right heel was purple, non-blanchable and measured 0.8 cm x 0.6 cm. The left heel was documented to be non-blanchable and measured 1.2 cm x 1.0 cm.

Review of the 7/11/13 admission laboratory (lab) results revealed the patient's Albumin level was low at 3.2 (normal 3.4 - 5.0). On 7/12/13 the albumin level was 2.9, on 7/13/13 was 2.6, on 7/17/13 was 2.3, on 7/21/13 was 2.2, and on 7/22/13 was 2.3. The patient's 7/23/13 pre-albumin level was low at 8.3 (normal 17.6-36).

There was no documentation nursing the RD had performed a nutritional assessment or provided interventions for the patient's compromised nutritional status.

During an interview on 7/23/13 at 11:15 AM the RD was interviewed regarding the lack of interventions and documentation for the patient's compromised nutritional status. The RD stated, "...Because of the demands of my job, I just review and look over some charts. He [Patient #1] seems to be eating about 50 percent [%], 50 % is fair. This is based on nursing documentation. I was never notified there was a pressure ulcer. I can't be over everything."

After the surveyor interview with the RD, the RD performed a nutritional assessment of the patient's nutritional status and documented, "...change to Regular soft to assist with po [by mouth] intake 2nd to pt having dentures. Pt [patient] with fair po intake currently with a BMI [Body Mass Index] of 25. RD has reviewed labs and meds. Pt with alb [albumin] 2.2...will send Ensure Plus po TID [three times a day] one bottle on all meal trays and Ensure pudding BID on on lunch and supper trays. RD will also discuss ordering Megace with MD [physician] to stimulate appetite...has ordered PAB [pre-albumin]...RD will monitor po intake, labs, and overall nutritional status and follow up in 1 - 3 days..." The RD based the BMI of 25 on the patient's 7/11/13 admission weight of 170 pounds as the patient had not been weighed since admission.

3. Medical record review for Patient #2 revealed the 88 year old was admitted to the hospital on 7/4/13 with diagnoses of Septicemia and Aspiration Pneumonia.

Review of a 7/4/13 physician's order revealed the patient was NPO and for the patient to have a Nutritional consult.

Review of the 7/4/13 Nutritional screen conducted by the Certified Dietary Manager (CDM) documented, "...Provide diet as needed, re-screen weekly as requested. Monitor oral intake and changes in status. Monitor for potential nutritional problem."

Review of a RD note dated 7/5/13 revealed the RD documented the patient was an 88 year old female admitted from the Emergency Room (ER) with Respiratory Distress. The RD documented the Pt was a, "DNR and comfort measures. Pt is currently NPO...will order ST [speech therapy] consult for bedside swallow study and diet recommendations. RD will monitor diet status, wt [weight], and overall nutritional status."

Review of the patient's lab results revealed the following albumin levels:
7/3/13 in the ER was 3.0 (normal is 3.4 to 5.0).
7/5/13 was 2.5.
7/6/13 was 2.3.
7/7/13 was 2.4
7/8/13 was 2.4.
7/9/13 was 2.5.

On 7/13/13 the patient was transferred to palliative care.

There was no documentation the RD continued to monitor the patient's diet status, weight and nutritional status.

4. Medical record review for Patient #3 revealed the 71 year old was admitted to the hospital on 7/17/13 with the diagnosis of Fractured Right hip and status post surgical hip replacement procedure on 7/17/13.

Review of the 7/17/13 Admission Nursing Assessment revealed the patient's Braden score was low at 17.

Review of the 7/17/13 CDM screen revealed the patient was to be NPO and, "...Provide diet as needed, re-screen weekly as requested. Monitor oral intake and change in status. Monitor for potential nutrition problems."

Review of the 7/19/13 Nursing Wound Care note revealed the patient had developed a pressure wound to the left buttock measuring 3 cm x 2 cm.

There was no documentation the RD had performed a nutritional assessment and provided interventions for the patient's compromised nutritional status.

5. Medical record review for Patient #4 revealed the 74 year old was admitted to the hospital on 7/18/13 with the diagnoses of Fractured Left Hip, Alzheimer's, Dementia and Incontinence.

Review of the 7/18/13 Nursing Assessment revealed the patient was admitted from a nursing home and the patient's admission Braden score was low at 14.

Review of the 7/21/13 nursing wound care note revealed the patient had developed a hospital acquired pressure ulcer to the right hip measuring 1.1 cm x 2.2 cm.

Review of the lab results documented the patient had an albumin of 3.9 (normal) on admission. The patient's albumin level on 7/23/13 was 2.5.

There was no documentation the RD had performed a nutritional assessment for the patient's compromised nutritional status or provided nutritional interventions.

During an interview on 7/24/13 at 12:00 PM the RD stated, "Sure there has been a screen..." After reviewing the patient's medical record the RD stated, "...no documentation of a screen or dietary assessment...I try to look at the labs on everyone in the computer...The Dietary Manager screens all patients that come in...If anything triggers on the nursing assessment, it automatically prints out a consult in my department..."

During an interview on 7/24/13 at 11:45 AM Registered Nurse (RN) #1, who was assisting the DNS, stated there were no dietary/nutrition notes for Patient #4 in the computer.

6. Medical record review for Patient #5 revealed the 73 year old was admitted to the hospital from a nursing home on 7/18/13 with diagnoses of Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease and Iron Deficiency Anemia.

Review of the 7/18/13 admission physician's telephone orders revealed the patient was ordered to be NPO until seen by the physician.

Review of the 7/18/13 nursing wound care note revealed the patient had 3 pressure ulcers to the buttock/sacral/coccyx areas on admission. The ulcers were numbered #2, #3 and #4. Pressure ulcer #2 was documented to be red, non-blanchable and measured 5 cm x 5 cm. Pressure ulcer #3 was documented to be red, non-blanchable and measured 1.5 cm x 2.0 cm. Pressure ulcer #4 was documented to be non-blanchable and 1.0 cm.

Review of the 7/18/13 CDM note revealed the CDM wrote a diet had not been ordered for the patient and to "...Provide diet as needed, re-screen weekly as requested: Monitor oral intake and changes in status; Monitor for potential nutritional problems." There was no documentation the RD had performed a nutritional assessment of the patient's compromised nutritional status or provided nutritional interventions.

On 7/26/13 at 11:30 AM a telephone interview was conducted with the DNS. The DNS was requested to provide information regarding when the patient was started on a diet and a copy of any assessment the RD had conducted. The DNS stated the patient was started on a diet as tolerated on 7/19/13. The DNS stated there was not an RD nutritional assessment in the medical record.