HospitalInspections.org

Based on a review of facility documentation and staff interviews (EMP) it was determined that the facility failed to institute interventions to improve outcomes for routine monitoring and documentation of weights outlined on the facility's "Enteral Nutrition Standing Order Form."

1) Review of facility documentation "Routine Monitoring of Patients Receiving Enteral Support (Weekly Weights)" dated June 2013-May 2014 revealed that the facility identified a benchmark for compliance of 90%. In June of 2013 when the monitoring began staff compliance was at 71% for the 42 medical records that were reviewed. Further review revealed that staff compliance peaked in September, October, and November of 2013 at 79% and eventually declined to 50% compliance in May of 2014 with a slight increase noted of 57% compliance in May of 2014.

2) During the data collection period of June 2013 through May of 2014 a total of 458 medical records were reviewed of which 141 medical records were found to be deficient. This resulted in a compliance rate of 69% for the review period.

3) A request for all meeting minutes regarding discussion of the quality project was made on July 3, 2014 at approximately 2:00 PM. and the following meeting minutes were provided. At the time the meeting minutes were provided EMP1 revealed "...this is all the discussion we had in the meetings..."

4) A review of the facility's Nutritional Care Committee dated March 21, 2013 revealed "...Indicator IV is monitoring the percent on enteral feeds for greater than a week with a weekly weight documented in SCM [Attachment F.] We experienced an increase to 88% and 83% in December and January...During the December, 2012 meeting [EMP X], RN suggested the development of a standard nursing guideline to promote consistency in obtaining weekly weight throughout the facility. [EMPX] contacted [EMPY] to ask for the Quality Council's help with the development of a guideline and [EMPY] agreed to help..."

5) Review of Nutritional Care Committee meeting minutes dated June 6, 2013 on August 1, 2014 at approximately 10:00 AM revealed "...Indicator IV is monitoring the percent of patients on enteral feeds for greater that a week with a weekly weight documented in SCM [Attachment F.] We experienced a decrease to 76% in February, an increase to 95% in March and a decrease to 69% in April...[EMPX] contacted [EMPY] to ask for help in developing a guideline to weigh patients on enteral feedings on a specific day of the week...Registered dieticians to continue to review unacceptable outcomes with nursing directors and clinical supervisors and request they obtain weekly weights..."

6) Review of Patient Care Council meeting minutes dated June 13, 2014 on August 1, 2014, at approximately 10:10 AM revealed "...Patients on enteral feedings now need to be weighed every Wednesday..."

7) Review of Nutritional Care Committee meeting minutes dated September 19, 2013, on August 1, 2014, at approximately 10:15 AM revealed "...Indicator IV is monitoring the percent patients on enteral feeds for greater that a week with a weekly weights documented in SCM [Attachment F.] We experienced in increase to 72% in May and decreases to 71% in June and 60% in July...It was suggested "weight Wednesday" be added to the Quality Calendar as reminder to unit staff......Registered dieticians to continue to review unacceptable outcomes with nursing directors and clinical supervisors and request they obtain weekly weights..."

During interview on August 1, 2014, at approximately 11:45 AM EMP1 confirmed the above findings and revealed when asked why there no further interventions implemented relative to the poor outcomes after "weight Wednesday" was suggested in the September 13, 2013, Nutritional Care Committee meeting revealed "...yes there are still issues that need to be addressed...I guess the managers did not communicate to their staff..."












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