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Based on observation, interview and record review, the facility failed to provide a medically prescribed diet and lunch on 6/3/24 that was appropriate for Patient 12's medical condition of colitis (a chronic digestive disease characterized by inflammation of the inner lining of the colon), when the Patient 12 received beans, corn and raw vegetables which were contraindicated for Patient 12's medical diagnosis. This had the potential to exacerbate Patients 12's GI (gastrointestinal tract - The organs that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces) symptoms.

Findings:

During an observation and concurrent interview with Patient 12 on 6/3/24, at 12:06 pm, Patient 12 was lying in her bed; she appeared in discomfort. She stated she ate a few bites of her turkey sandwich but it was her first time eating in a week, and she wanted something more plain. She stated she asked for mashed potatoes and gravy and toast three hours ago and she just now received it. She stated she came into the hospital last Sunday, and she was diagnosed with colitis. Patient 12's lunch was on her bedside table; it consisted of a turkey sandwich on wheat bread, lettuce, tomato, baby carrots, and black bean and corn salad. Patient 12 stated she could not eat raw vegetables and beans with her current condition.

During an interview with the Registered Dietitian (RD-M), on 6/6/24, at 10:31 am, RD-M stated Patient 12 was NPO (nothing by mouth) for seven days. He stated the Doctor advanced Patient 12's diet from diabetic clear liquid (diet that is made up of only liquids and foods that are clear liquids at room temperature. Clear liquids are easy to digest and include water, broth, gelatin, plain tea and coffee, popsicles and juices) to a regular diet. He stated he should have recommended to start her with a full liquid diet (no solid foods and only consumes liquids, such as soups, juices, and smoothies) and then advanced her to a low fiber diet (is for people who need to rest their digestive system and includes cooked vegetables, fruits, white breads, and meats and avoids beans, whole grains, and raw vegetables).

During a review of the facility, "Diet Manual," dated March 2021, indicated, "A low fiber diet may be used with a reduction in stool frequency and volume is desirable. Diet is generally for short-term use following colitis, partial bowel obstruction, diverticulitis or recent intestinal surgery." In addition, "Foods to avoid: products made from whole grain such as whole grain bread, raw vegetables, corn and potatoes with skins. Dried peas, beans, or legumes."

During a review of Patient 12's medical record, a document titled, "Medical Nutrition Therapy Assessment," dated 6/3/24, indicated, "patient medical history: diverticulosis, patient was admitted for colitis."

During a review of Patient 12's medical record, a document titled, "Progress Note," dated 6/424, indicated, "80 y/o (year old) female with hx (history) of DM2 (diabetes mellitus 2 - Type 2 Diabetes is characterized by high levels of sugar in the blood), HTN (high blood pressure- is when the pressure in your blood vessels is too high -140/90 mmHg or higher), gastritis (when your stomach lining gets red and swollen/inflamed), diverticulosis (the formation of abnormal pouches in the bowel wall) ... Pt was admitted for colitis....Assessment: ongoing nausea and abdominal pain, poor intake ..."

Based on observation, interview and record review, the facility failed to screen and assess the nutrition status of patients during their long-term (greater then 24 hours) stay in the Emergency Room, when:

1. Patient 11 had a long-term Emergency Room stay that lasted 27 days and was admitted for failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function (body's natural defense system that fights infections is impaired), and low cholesterol) and during that time lost one kilogram (unit of measure for weight) of body weight. Unintentional weight loss in elderly patients is associated with an increased risk of morbidity and mortality (having an illness or health condition and death rate).

2. In addition, during a look-back period of three months, Patient 1, 2, 3, 4, 5 and 6, also had long-term Emergency Department stays (greater than 24 hours) and were not screened for nutrition risk.

This system failure resulted in seven of 30 medically compromised sampled patients to not be screened for nutrition risk, which could negatively affect their nutrition status and further compromise their health status.

Findings:

1. During a review of Patient 11's medical record, a document titled, "H&P (History and Physical)," dated 2/3/24, indicated Patient 11 was a 77 year-old male admitted to the Emergency Room with a chief complaint of, "Failure to Thrive." Patient 11 had a history of, "Diabetes Mellitus 2 (also know as Type 2 Diabetes is characterized by high levels of sugar in the blood), Hypertension (high blood pressure- is when the pressure in your blood vessels is too high, 140/90 mmHg or higher), HLD (Hyperlipidemia - is the clinical term for an imbalance of LDL ("bad") cholesterol), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients), and stroke (occurs when something blocks blood supply to part of the brain)." A document indicated, "patient does not qualify for Hospice (Medical care for people with an anticipated life expectancy of six months or less, and the focus shifts to symptom management and quality of life) despite declining to eat and drink but about every 48 hours he eats a meal."

During a review of Patient 11's medical record, a document titled, "HBS (History, Behavior and Symptom) Progress Note," dated 2/21/24, indicted, "he (Patient 11) is not eating meals but drinking intermittently".

During a review of Patient 11's medical record, a document titled, "Weight & Height," undated, indicated, "February 3, 2024 Patient 11 weighed 67 kilograms (kg), on February 19, 2024 patient weighed 66.2 kg."

During a review of Patient 11's medical record, a document titled, "Progress Note," on the date of discharge 3/2/24, indicated, "Admission date February 3, 2024, Today's date March 2, 2024, hospital stay: 27 days.....Hospital summary: 77-year-old male with history of vascular dementia with left hemiplegia (a symptom that causes complete or severe paralysis on one side of the body) requiring higher level of care, boarding in the emergency department for 25 days due to lack of indication for hospital admission and lack of safe disposition.....Physical Exam: General appearance- sleeping but arousable, chronically ill and frail appearing."

During an interview with the Director of Food and Nutrition Services (DFNS) on 6/4/24, at 9:55 am, the DFNS stated that usually in the Emergency Department they only do nutrition assessments when ordered by the Physician.

During an interview with Registered Nurse-H (RN-H), at 11:53 am, on 6/4/24, RN-H stated Patient 11 refused to eat, but they could sometimes get him to drink fluids. RN-H stated Patient 11 did not want to eat at normal times. RN-H stated it was rare to have patients in the Emergency Room (ER) for extended periods of time. He stated, since they usually did not have patients in the ER for that long, that may be why Patient 11 was never triggered for a Registered Dietitian (RD) consult. He stated they did not do nutrition screening in the ER.

During an interview with the Registered Nurse -I (RN-I), at 12:07 pm, on 6/4/24, RN-I stated they did not ever request for Registered Dietitian (RD) consults in the Emergency Room (ER). He stated the typical stay in the ER was three to five hours.

During an interview with the Registered Dietitian (RD-J) at 2:25 pm, on 6/5/24, RD-J indicated that for the Emergency Room (ER) Physicians would usually consult an RD to make tube feeding orders (medical device used to provide nutrition to people who cannot obtain nutrition by mouth) or for nutrition education for the patient. RD-J stated nutrition screening was triggered on admission to the hospital and would not be done in the ER. RD-J stated Patient 11 would have most likely been a moderate or high nutrition risk if he was admitted to the hospital. She stated there was no way to know if Patient 11's nutrition status was being monitored if an RD was not called for consult.

During an interview with Hospitalist Physician-L (HP-L) (a physician who works exclusively in a hospital and provides medical care to inpatients) on 6/6/24 at 3:33 pm, HP-L indicated Patient 11 was boarding in the Emergency Room (ER) because he did not meet the criteria for admission to the hospital, and they could not find placement for him. HP-L stated nurses in the Emergency Room could request a nutrition consult. He stated that during the time Patient 11 was in the ER, the ER was primarily staffed by ER nurses. HP-L stated medical surgery (med surg) nurses (med-surg nurses provide direct care to hospitalized patients) were more astute to identifying patient needs for a dietary consult. He stated the med-surge nurses were more used to long-term hospital stays and documenting patient meal intake.

2. During an observation and concurrent interview with Patient 6, on 6/3/24, at 3:15 pm, Patient 6 was pacing back and forth in his room in the Emergency Room (ER). Patient 6 stated his lunch was fine, and he did not want to answer any more questions.

During an interview with the Emergency Department Nurse (EDN-K) on 6/3/24, at 3:18 pm, EDN-K stated Patient 6 had been in the Emergency Room (ER) for 291 hours, since 5/22/24. EDN-K stated he was a psych (psychiatric) patient and was awaiting placement in another facility.

During a review of Patient 6's medical record and concurrent interview with the Registered Dietitian (RD-J) and the Director of Food and Nutrition Services (DFNS) on 6/4/24, at 9:55 am, RD-J indicated Patient 6 was not screened for nutrition risk. DFNS stated, usually in the ER they only do a nutrition assessment by consult from the Physician.

During an interview with the Registered Dietitian (RD-J), on 6/5/24, at 2:25 pm, RD-J stated there was no way to know Patients 6's nutrition risk without a nutrition screen.

During a review of the medical record document titled, "ED (Emergency Department) Progress," dated 6/2/24, indicated Patient 6 was an, "ED boarder....Awaiting affirmation of placement with [hospital name]."

During a review of an ED log for a look-back period from 31/24 to 5/31/24, five other patients (Patients 1, 2, 3, 4 and 5) were also identified to have long-term Emergency Room admissions:
Patient 1 stayed for nine days (from 3/9/24 to 3/17/24);
Patient 2 stayed for seven days (from 3/13/24 to 3/19/24);
Patient 3 stayed for nine days (from 3/17/24 to 3/25/24);
Patient 4 stayed for nine days (from 3/20/24 to 3/29/24); and,
Patient 5 stayed for six days (from 5/15/24 to 5/21/24).

During a concurrent interview and review of Patient 1, 2, 3, 4 and 5's ED records, with EDN-N, on 6/5/24 at 4:09 p.m., EDN-N confirmed all five patients were in the ED longer than five days and did not get nutritional risk screening during their ED stay, nor were nutrition consults ordered for them.

During the same interview on 6/6/24 at 3:33 p.m., HP-L stated nutrition consults could be ordered for any ED patient, should they require it. HP-L stated Patient 11 could have benefited from a nutrition consult.

During a review of the facility policy titled, "Provision for Clinical Nutritional Care- Medical Nutrition Therapy and Nutrition Care Practices," dated August 2023, indicated, "Patients admitted to [Hospital Name] will receive a level of nutritional care consistent with organization, the joint commission (an independent organization that evaluates and accredits healthcare facilities), HIPPA (acronym for the Health Insurance Portability and Accountability Act regulates the use and disclosure of protected health information), and state regulations.....The initial nutritional screening is completed by nursing personnel in the first 24 hours of admission using the MST (malnutrition screening tool) tool in [Facility Organization Initials]. (See attachment #1). A secondary nutritional screening is preformed by the DTR/RD (Dietetic Technician Registered/Registered Dietitian) within 24 hours using the nursing MST (malnutrition screening tool) score and the department clinical nutrition screening protocol. (See Attachment #2) Exceptions to this process are patients admitted to L&D (Labor and Delivery) and Maternity. These patients are evaluated upon request from nursing, MD (Medical Doctor) or if length of stay is >5 (greater than 5) days they will be screened using standard hospital screening criteria."

During a review of the facility policy document titled, "Attachment #2", dated August 2023, indicated, "1-day assessment (high) - burns, compartment syndrome (a buildup of pressure around your muscles), Enteral/Parental (Enteral nutrition is delivered through a tube to your stomach or the small intestine/Parenteral feeding refers to liquid nutrition processed by the veins) Nutrition Support, Failure to Thrive."


41175

Based on observation, interview, and record review, the facility:
1) Failed to ensure medical staff established and implemented policies and procedures governing the care for 1 of 30 sampled Boarder Status patients (Patient 11; Boarder status patients are that can spend several days and nights in the hospital but are not formally admitted as inpatients) and 7 unsampled Patients (Patients 1, 2, 3, 4, 5, 6 and 11).

This failure:

1) Caused 1 outpatient ED Boarder (Patient 11), who was diagnosed with failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function (body's natural defense mechanism does not effectively protect against infection), and low cholesterol) to lose weight; he was in the ED for approximately 27 days without receiving a nutritional assessment; Unintentional weight loss in elderly patients is associated with an increased risk of morbidity (having a specific illness or condition) and mortality (number of deaths due to a specific illness or condition );

2) Contributed to 7 outpatient CDA patients (Patients 1, 2, 3, 4, 5, 6 and 11) being in the ED for over five days; they were not screened for nutritional risk, which could negatively affect their nutrition status and further compromise their health status.

Findings

During an observation and tour of the ED on 6/4/24 at 3:15 p.m., Manager D stated the ED had CDA patients, and staff generally placed them in the D-pod (a designated area in the ED where more stable patients were roomed) to assist with nursing assignments.

During an interview on 6/5/24 at 10:30 a.m., Quality Staff R (QS-R) was asked to provide a Scope of Service (policy identifying a department's goal of service, type of patients served, standards of practice, staffing, etc.) for CDA patients in the ED. QS-R stated CDA patients were part of the ED, and the ED BUCS (Basic Unit of Care Standards; policy and procedure for various hospital departments) would cover these patients.

During an interview on 6/5/24 at 11 a.m., Quality Staff Q (QS-Q) and QS-R stated the Standards of Care (treatments/practices that are appropriate for specific disease that are both accepted by medical authorities and widely used by healthcare professionals; also called best practice) for CDA patients were covered, in the Medical/Surgical/Telemedicine policy standards (medical patients, surgical patients, and patients who are having their hearts monitored - telemetry). QS-Q stated the facility had no other policies specific to CDA-status patients.

Review of the BUCs titled, "Basic Unit Gare Standards (BUGS), Med/Surg Units" (approved 7/2022), revealed CDA and Boarder-status patients were not identified/included in the policy.

Review of the BUCs titled, "Basic Unit of Gare Standards for the Emergency Department" (revised 5/2024), revealed CDA and Boarder-status patients were not identified/included in the policy.

During a review of Patient 11 's medical record, a document titled, "Progress Note," on the date of discharge, 3/2/24, indicated, "Admission date February 3, 2024, Today's date March 2, 2024, hospital stay: 27 days .... Hospital summary: 77-year-old male with history of vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes) with left hemiplegia (total or nearly complete paralysis on one side of the body), boarding in the emergency department for 25 days due to lack of indication for hospital admission and lack of safe disposition .... Physical Exam: General appearance- sleeping but arousable, chronically ill and frail appearing"

During a review of Patient 11's medical record, a document titled, "HBS (Hospital Based Service; a physician) Progress Note," dated 2/21/24, indicted, "he (Patient 11) is not eating meals but drinking intermittently."

During a review of Patient 11's medical record, a document titled, "Weight & Height," undated, indicated, "February 3, 2024, Patient 11 weighed 67 kilograms (kg), on February 19, 2024, patient weighed 66.2 kg."

During an interview with the Registered Dietitian (RD-J) at 2:25 p.m., on 6/5/24, RD-J indicated the ED Physicians usually consulted an RD for nutrition education for the patient. RD-J stated nutrition screening was triggered on admission to the hospital and would not be done in the ED. RD-J stated Patient 11 would have most likely been a moderate or high nutrition risk if he was admitted to the hospital. She stated there was no way to know if Patient 11's nutrition status was being monitored if an RD was not called for consult.

During a review of an ED log for a look-back period from 3/1/24 to 5/31/24, five patients (Patients 1, 2, 3, 4 and 5) were identified to have long-term Emergency Room admissions (ED Boarders): Patient 1 stayed for approximately eight days (from 3/9/24 to 3/17/24), Patient 2 stayed for approximately six days (from 3/13/24 to 3/19/24), Patient 3 stayed for approximately eight days (from 3/17/24 to 3/25/24), Patient 4 stayed for-approximately nine days (from 3/20/24 to 3/29/24), and Patient 5 stayed for approximately six days (from 5/15/24 to 5/21/24).

During a concurrent interview and review of Patient 1, 2, 3, 4 and 5's ED records with Emergency Department Nurse N (EDN-N) on 6/5/24 at 4:09 p.m., EDN-N confirmed all five patients were in the ED longer than five days and did not get nutritional risk screening during their ED stay, nor were nutritional consults ordered for them.

During an interview on 6/6/24 at 10 a.m., Manager D and Administration Officer (AO) were asked about the Scope of Service for CDA patients and Boarders in the ED. Manager D confirmed the CDA scope of service was not included in the 2024, Plan for Provision of Patient Care (approved by the Medical Executive Committee on 12/28/23). When queried why CDA patients were not in policies covering ED patients, Manager D stated she would need to follow-up. When queried why long-term patients (like Boarders) were not included in ED policies or procedures, Manager D stated she needed to follow-up. When asked what the standard of care expectation was for long-term (Boarders) patients in the ED, Manager D stated it was, "MD (Physician) order driven." She stated the standard of care was similar to care received by inpatients (people admitted to the hospital).

During an interview on 6/6/24 at 10:13 a.m., Quality Leader X (QL-X) stated having long-term boarders (in the ED) was not a new practice, and it was utilized, "all over" (in other sister-facilities).

During an interview on 6/6/24 at 11:02 a.m., QL-X, Manager D, AO, and Director B discussed CDA patients at the facility. Director B stated CDA was a classification for patients, and they were managed as observation patients, and there were no policies and procedures nor BUCs guiding their care. She stated their care was based on unit care standards and provider (Physician) orders. Director B stated observation-status patients received the same nursing care as admitted patients. When asked why the CDA patient status was not included in any policies and procedures, Director B stated she could not speak to that.

During an interview with Hospitalist Physician-L (HP-L) on 6/6/24 at 3:33 p.m., HP-L indicated Patient 11 was boarding in the Emergency Room (ER) because he did not meet the criteria for admission to the hospital, and they could not find placement for him. He stated a hospital boarder was a patient in the ED or CDA area who had a hospital stay longer than 24 hours. HP-L stated nurses in the Emergency Room could request a nutrition consult. HP-L stated ED Boarders were treated (medically) the same as patients admitted to inpatient status, and CDA patients were treated by Hospitalist's (Physicians treating inpatients, not ED Physicians) after they were in the ED for twenty-four hours.

During a virtual interview and concurrent record review on 6/7/24; 11 :10 a.m., Director Z, COO, Director B, Director W, QL-X, Quality Staff Y, Quality Staff Q, and Director C discussed the care and services of ED patients who stayed in the ED over 24-hours. A list of CDA patients (from April and May 2024) was referenced, and the COO confirmed multiple patients were in observation (outpatient) status for over twenty-four hours, and one 94-year-old patient (Patient 13) was in observation status for eighty-six hours (from 5/16/24 through 5/20/24). One virtual attendee stated a patient (Patient 11) was held in the ED (as a Boarder/ outpatient status) for twenty-seven days because he did not meet hospital admission criteria, and the facility was arranging his discharge to a Board and Care home.