HospitalInspections.org

Based on policy review, record review, and interview, nursing services failed to provide appropriate interventions and assessments related to pain for 2 of 4 (Patient #1 and #3) patients; failed to ensure patients were turned and re-positioned, and failed to document oral input to ensure the patient's needs were met for 1 of 4 (Patient #2) patients; failed to ensure patients were assessed properly for nutritional needs for 1 of 4 (Patient #4) patients; and failed to take temperatures daily on 1 of 4 (Patient #4) sampled patients.

The findings included:

1. Review of the facility policy "Pain Assessment and Management" revised on 9/2021 revealed, "...This organization recognizes the patient's right to appropriate pain assessment and treatment. The health care providers commitment to quality patient care includes recognition that pain is a subjective and complex issue with multiple quantifiable attributes, which if left untreated may have adverse physical and/or psychological effects...Pain assessment scales-Numeric Rating Scale (NRS) is 0-10, 0 indicates no pain, 4-6 indicates moderate pain, 10 indicates worse pain experience...The goal of pain management is no pain or pain that is tolerable for the patient and does not require any intervention...Guidelines: all patients are to be assessed for the presence of pain by any health care provider...A pain assessment is completed every shift and documented in patient's medical record using approved pain assessment scales to establish baseline for the location of the pain identified. Once this baseline is established, subsequent assessments only require assessment and documentation of rating and location...Intervention Follow up: Pain rating follow up will be completed after the administration of a pain medication or the use of a pain management technique at a time specific to the intervention utilizing the appropriate pain assessment scale or observation...Follow up will be documented in the patient's medical record...".

Review of the facility's "Assessment & [and] Reassessment - Patient Guidelines" policy with a revision date of 11/2019 revealed, "...This policy applies to Saint Francis Hospital - Memphis, its employees, medical staff, contractors and patients regardless of service location or category of patient...To establish guidelines to ensure that each patient's physical psychological and social status is assessed to determine the patient's care needs and to ensure patient's changing needs are reassessed in response to treatment and care provided...The assessment process is structured with two components: assessment and reassessment...The following applies to all patient:...ED [Emergency Department]...An admission assessment will be completed by the RN [Registered Nurse] within twelve (12) hours. The history must be completed within the first twenty-four (24) hours admission...Included in the admission assessment are Braden skin assessment, Morse Fall Risk Assessment, Pain and Venous Thromboembolism (VTE) prevention assessment...The patient is screened on admission for any nutritional, functional, social service which included abuse and suicide and discharge planning issues...The RN, after review of the history and assessment data, will identify problems utilizing the nursing process based on individual patient's needs. identified problems will be listed on the patient's interdisciplinary plan of care...Reassessment is completed by a nurse every 12 hour shift in inpatient areas...Braden skin assessment, Morse Falls Risk and pain assessments are performed on every 12 hour shift) and as patient condition warrants. VTE reassessment is performed daily...Reassessment included but is not limited to review of the following parameters...Nutritional status...Nutrition...In addition to the collaborative interdisciplinary variable the following discipline specific variable apply...Assessment...The nutritional screen completed by the nursing department during the patient admission assessment includes the following pertinent data collection...New onset chewing or swallowing problems...tube feeding or TPN [Total Parenteral Nutrition]...NPO [nothing by mouth] or clear liquids 4 days or longer...Evaluation of nutrition risk will be completed upon receipt of nursing referral within 48 hours. Potential and high risk patients will be assessed by the registered dietitian. Nutrition assessment will include consideration of...Conditions that may affect nutritional status, including conditions that affect ingestion, digestion, absorption or use of nutrients...Diet prescription or number of days NPO or only clear liquids..."

2. Medical record review revealed Patient #1 arrived at Hospital #1's Emergency Department (ED) on 9/28/2021 at 2:02 PM with complaint of left thigh cyst. Patient #1 was triaged on 9/28/2021 at 2:45 PM. There was no documentation Patient #1 was assessed for pain upon admission.

Review of the ED note dated 9/28/2021 at 2:04 PM revealed the Nurse Practitioner documented under Physical Exam that the patient had a skin abscess to left groin approximately two (2) centimeters (cm) by three (3) cm with fluctuant center.

Review of the Procedure note dated 9/282021 at 5:20 PM revealed the Nurse Practitioner documented, "...Incision and Drainage (I&D) of Abscess of left groin. Timeout was performed. Patient, side, site, and procedure was verified. Verbal Consent was obtained prior to the procedure. Indications, risks, and benefits were explained at length. The affected location was anesthetized with 1% (percent) lidocaine local anesthesia and the abscess was incised using an 11-blade scalpel...6 milliters (mls) serosanguinous material was expressed. Loculations were broken up using blunt dissection and the cavity irrigated. The patient [Patient #1] tolerated the procedure well and there were no apparent complications. A sterile dressing was applied...Discussed results, medications, and plan of care with patient. Patient verbalized understanding of plan of care and agreed to return to the ED if symptoms worsening, do not improve, or new symptoms arise..." At 5:47 PM, the Nurse Practitioner documented, "...stable. Instructed patient on proper care post I & D [Incision and Drainage] and need for removal of iodoform gauze tomorrow. Patient verb [verbalized] understanding..."

There was no documentation in the medical record that Patient #1 was assessed for pain at the time of admission, before the procedure, after the procedure or at the time of discharge. There was not a pain scale documented in the record.

Review of the Medication Administration Record (MAR) for Patient #1 revealed RN #1 documented Acetaminophen 650 milligram (mg) oral tablet was administered on 9/28/2021 at 4:38 PM. (acetaminophen is a non-narcotic pain reliever used to treat mild to moderate pain)).

On 9/28/2021 at 4:39 PM RN #1 documented Lidocaine 1 percent (%) injectable solution was administered Intradermal to the Left thigh. (Lidocaine 1 percent (%) injectable solution is a local anesthetic (numbing medication) that is used to numb an area of your body to help reduce pain or discomfort caused by invasive medical procedures).

On 9/28/2021 at 5:45 PM RN #1 documented Acetaminophen-Hydrocodone 325 mg/5 mg one (1) tablet was administered. (Acetaminophen-Hydrocodone 325 mg/5 mg is a narcotic used to treat moderate to severe pain).

Review of physician orders dated 9/28/2021 at 5:39 PM revealed discharge medications orders for Acetaminophen 325 mg two (2) tablets every six (6) hours as needed for pain for ten (10) days and Clindamycin 300 mg capsule 1 capsule three (3) times a day for ten (10) days.

Patient #1 was discharged home in stable condition on 9/28/2021 at 5:54 PM with orders to follow up with Primary Care Physician within 1-2 days to re-evaluate abscess, take medications as prescribed and return to the ED if symptoms change or worsen.

In a telephone interview on 1/31/22022 at 3:09 PM Patient #1 stated, "...I had an abscess on my left groin that was really hurting me. I'm a diabetic and get them a lot. The last one I had they put me in the hospital and put me to sleep to drain it, that was back in April. This time I stayed in the emergency room and the Nurse Practitioner told me she would numb it. They didn't give me anything for pain before they did it. I told them it was real tender. She [Nurse Practitioner] numbed it but I could still feel it and it hurt more after she numbed it. I was screaming in pain and she [Nurse Practitioner] just went ahead and did it. When they were through, they left me laying in the bed and put a dressing on it. No one came in to check on me, except when they came in to tell me I could go home and ask me where to send the medicine I would be getting at home. No one helped me get dressed or walked me out of the ER. I could hardly get off the bed. I was hurting".
When asked if she told the nurse or the Nurse Practitioner that she was in pain Patient #1 stated, "...yes, I told the nurse, but she said I did good, and it wasn't that bad. I got tired of waiting on someone to help me, so I just left..."

In an interview in the conference room on 1/31/2022 at 3:55 PM Nurse Practitioner #1 who performed the I &D procedure on Patient #1 stated she did not remember this patient. The Nurse Practitioner reviewed the medical record and stated she still not did not remember the patient. When asked about the procedure that was done for Patient #1 the Nurse Practitioner stated, "...We do not put patients to sleep for that procedure. We give Ibuprofen, Tylenol and numb with Lidocaine. We do not do conscious or deep sedation for that procedure, but she would have been medicated for pain..."

In an interview in the conference room on 1/31/2022 at 3:59 PM RN #4 stated she did not remember Patient #1. RN #1 reviewed her documentation in the medical record and stated she still did not remember the patient. RN #1 stated she would have assessed for pain upon admission and after medication was giving. RN #1 verified she did not see where Patient #1's pain or a pain scale was documented in the medical record. RN #1 stated, "...we would not have continued the procedure for someone who cannot tolerate it and was in pain. We would have offered more pain medication or a different pain medication..." RN #1 stated that Patient #1 was more than likely in the rapid treatment area in the emergency department. RN #1 stated this is a very common procedure that is done quite often.

3. Medical record review for Patient #2 revealed Patient #2's caregiver called Emergency Medical Services (EMS) due to the patient falling on his right shoulder and was in pain. Pt #2 was transported to Hospital #1's Emergency Department (ED). Patient #2 arrived at the ED via ambulance on 9/5/2021 at 3:20 PM.

Review of the ED History and Physical/ Admission Note dated 9/5 /2021 at 9:00 PM revealed, "... patient presents to the ED with complaints of abdominal pain versus chest pain. Patient is nonverbal from previous CVA [Cerebrovascular accident, stroke] ...pt is nonverbal but communicates with hand gestures...Right sided hemiparesis"

On 9/6/2021 at 8:00 AM RN #3 documented Patient #2 had very limited mobility, was chair bound, was non weight bearing with trace movement to right lower extremity and potential problem for friction and shear.

On 9/6/2021 at 7:00 PM RN #2 documented under the section titled Morse Fall Risk that Patient #2's gait was impaired. RN #2 documented call light in reach, fluids offered and toileted.

There was no other documentation in the medical record of Patient #2's call light being in reach, fluids offered or that Patient #2 was toileted.

On 9/6/2021 at 8:57 PM RN #2 documented Patient #2 had slightly limited mobility, was chair bound with limited range of motion to right upper and lower extremity and potential problem for friction and shear.

There was no documentation of Pt #2 being turned or repositioned. There was no documentation that oral care or a bath was provided to Pt #2.

Review of the discharge summary for Patient #2 dated 9/7/2021 at 5:07 PM revealed the physician documented, "...During his stay, patient never received a room and family is insistent on him going home. Patient appeared to be at baseline and stable. He was discharged on antibiotics with close follow up..."

Patient #2 was discharged home on 9/7/2021 at 5:06 PM in stable condition. RN #1 documented Pt #2 left with caregiver/girlfriend in wheelchair.

In an interview on 1/31/2022 at 11:45 AM, the Director of the Emergency Department stated the nurses are responsible for turning and repositioning patients stating, "...they [nurses] should be documenting in the chart when they turn or reposition a patient..."

In an interview on 2/1/2022 at 9:10 AM, RN #1 stated she did not remember providing care to Patient #2. After reviewing the medical record for Patient #2 (provided to her by the Risk Manager before this interview), RN #1 stated she could not remember Patient #2, stating, she read in the medical record where she had discharged him in a wheelchair with his caregiver.

In a telephone interview on 2/1/2022 at 1:10 PM, RN #3 verified she was working in the ED holding area on 9/6/2021. RN #3 stated she provided care to 3 males in ED holding that day. RN #3 does not remember the names of the patients. RN #3 stated none of the males were incontinent and they could move on their own without assistance.

4. Medical record review revealed Patient #3 was admitted on 1/7/2022 at 12:39 PM, with diagnosis of Mental Status Changes, Multiple Decubitus, and Severe Anemia.

Medical History includes Hypertension, Diabetes Mellitus Type 2, History of Cerebrovascular Accident (CVA), Chronic bedbound debility, Multiple Decubitus, Dysphasia requiring Percutaneous Gastrostomy Tube (PEG, feeding tube) feedings.

Review of Physician medication orders revealed on 1/6/2022 at 8:40 PM-Acetaminophen-Hydrocodone 325 milligrams(mg)-5 mg oral tablet every four (4) hours as needed (PRN) for moderate pain.

On 1/14/2022 at 1:33 PM Morphine one (1) milliliter (ml) injection every three (3) hours as needed for moderate pain.

Review of Wound Care orders revealed Patient #3 had Stage 4 wounds to Left Hip and Sacrum, Stage 3 to Left Heel and non-staged wounds to Right Heel and Left Ankle.

Wound care orders revealed;
On 1/7/2022- "Pulse lavage with Dankins moist gauze packing after pulse lavage daily. Clean Right Heel and Left Heel with Vashe and apply foam dressing daily".

On 1/14/2022- "Pulse lavage to Left Hip and Sacral area change to every other day".

On 2/4/2022- "Sacrum. Daily and PRN if soiled. Cleanse wound with Vashe -skin prep the periwound -Zinc paste to wound edge-Dakins moistened gauze to wound bed-cover with an ABD pad and Medipore tape".

"Cleanse with Vashe -skin prep Zinc to periwound - Medihoney Alginate to wound bed- cover with a Foam on the ankle and ABD with Kerlix to the heel. Pulse lavage is a therapeutic irrigation of the wound with a solution".

Review of wound care treatment notes revealed on 1/7/2022 at 3:33 PM, RN #6 documented wound care was provided and wound dimensions were documented as follows:

"Stage 3 to Right Heel has a resolving pressure injury". The wound is 1 [centimeter] (cm) x (by) 1.3 cm x 0.1 cm,

"Stage 3 to Left Heel - 2.4 cm x 1.5 cm x 0.1 cm."

"Stage 4 to Left Ischial - 12 cm x 5.5 cm x 5 cm-undermining 6 cm."

"Stage 4 to Sacrum -12 cm x 8 cm x 4.5 cm -undermining 8 cm, not suitable for NPWT (negative pressure wound therapy) at this time due to extensive amount of slough in ischial wound and extent of sacral wound. Pain also is an issue".

There was no documentation of a pain assessment before or after wound care. There was no documentation Patient #3 received any pain medication on 1/7/2022.

On 1/8/2022 at 10:30 AM RN #11 documented wound care was provided to Left Hip and Sacrum.
There was no documentation of a pain assessment before or after wound care. There was no documentation Patient #3 received any pain medication on 1/8/2022.

On 1/9/2022 at 12:57 PM, Physical Therapist (PT) #2 documented wound care was provided to Left Hip and Sacrum and "Patient non-verbal; moaning, sister present".
"Wound dimensions as follows: Sacrum: 7 cm x 7.5 cm x 2.5 cm, Left Hip: 6.5 cm x 1 cm x 2.5 cm."
There was no documentation on 1/9/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication.

On 1/10/2022 at 3:14 PM, PT #3 documented wound care was provided to Left Hip and Sacral area and "Patient Stuporous, impaired due to cognition".
Review of the MAR revealed Acetaminophen-Hydrocodone 325 mg-5 mg oral tablet was administered at 1:28 PM. There was no documentation pain was assessed before or after wound care.

On 1/11/2022 at 11:24 AM PT #3 documented wound care was provided to Left Hip and Sacral area. Patient indicated pain, moaning restlessness and "Pt premedicated before lavage".
Review of the MAR revealed Acetaminophen-Hydrocodone 325 mg-5 mg oral tablet was administered at 10:20 AM. There was no documentation pain was assessed after wound care.

On 1/12/2022 at 12:38 PM, PT #1 documented wound care was provided to Left Hip and Sacral area and "Pt disoriented x 4 [person, place, time and situation], confused".
Review of the MAR revealed Acetaminophen-Hydrocodone 325 mg-5 mg oral tablet was administered at on 1/12/2022 at 12:16 PM (22 minutes before wound care). There was no documentation of a pain assessment after wound care.

On 1/14/2022 at 3:51 PM, PT #1 documented lavage discontinued. There was no documentation if wound care had been provided.

On 1/15/2022 at 5:16 PM, RN #7 documented wound care provided to Sacral area, Left Hip and Left Heel. There was no description of the wounds or of the wound care that was provided.
There was no documentation on 1/15/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication.

On 1/17/2022 at 7:31 PM, RN #5 documented wound care was provided. Wound dimensions were as follows:
"Stage 4 to Left Hip- 3 cm x 6 cm x 3.0 cm".
"Stage 4 to Sacrum - 7.5 cm x 11 cm x 6 cm, bone is exposed on the left side of the wound. It is attached and fans out over the buttock. The wound bed is rather large cavity and is open down to the rectal bridge. There is a smaller ulcer distal to the wound on the Left buttock: 1.6 cm x 2.5 cm".
"Left Heel 1.5 cm x 2.5 cm x 0.1 cm appears to be resolving when cared completed".
There was no documentation on 1/17/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication.

On 1/28/2022 at 4:00 AM, RN #8 documented wound care was provided to Left Hip, Sacrum, Right Heel. There was no description of the wounds or of the type of wound care provided.
There was no documentation on 1/28/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication.

On 1/29/2022 at 3:30 AM, RN #8 documented wound care was provided to Left Hip, Sacrum, Right Heel, Right Hip and Left Heel.
Review of the MAR revealed Acetaminophen-Hydrocodone 325 mg-5 mg oral tablet was administered at 3:13 AM (17 minutes before wound care). There was no documentation of a pain assessment after wound care.

On 2/2/2022 at 4:46 AM, RN #9 documented wound care was provided to Left hip and Sacrum
There was no documentation on 2/2/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication on 2/2/2022.

On 2/3/2022 at 8:34 AM, RN #10 documented wound care was provided to Left Hip, Sacrum, Right Heel, Right Hip, Left Heel
There was no documentation on 2/3/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication on 2/3/2022.

On 2/4/2022 at 5:48 PM, RN #5 documented she had performed extensive wound care on Patient #3. There was no description of the wounds or of the type of wound care provided.
There was no documentation on 2/4/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication on 2/4/2022.

On 2/7/2022 PM, RN #5 documented Wound dimensions as follows:
"Stage 3 to Left Heel - 6.5 cm x 13 cm x 3.2 cm with undermining of 0.7 cm."
"Stage 4 to Left Hip- 3 cm x 6 cm x 3.0 cm. with undermining of 3.6 cm."
"Stage 4 to Sacral - 12.7 cm x 8.5 cm x 5.2 cm, with undermining of 6.5 cm. The wound itself is very deep and the patient finds it is very painful to touch."
"Unstageable to Right Hip - 9 cm x 8 cm wound with a center of 3.5 cm x 4 cm of darkened eschar".
"Stage 3 to Right Ankle - 1 cm x 1.2 cm x 0.2 cm".
There was no documentation on 2/7/2022 that pain was assessed before wound care was initiated or after wound care was completed. There was no documentation Patient #3 received any pain medication.

Observation in Patient #3's room on 2/7/2022 at 3:00 PM revealed Patient #3 is in isolation and all staff and surveyor donned proper PPE before entering room. Pt #3 was laying on her left side on a specialty mattress (P500 low air loss) as ordered by the physician. Bilateral heel boots were on. Patient #3 was not medicated with pain medication before wound care was initiated. Wound care was completed by RN #5. Two additional RNs assisted with turning and positioning patient for wound care. Wound care to the Left Hip, Sacral area and Right Thigh was completed per physician orders and no infection control issues were noted by this surveyor. Patient #3 was grimacing when being turned to right side.

In an interview on 2/7/20221 at 2:30 PM, RN #5 stated wounds are measured one (1) time a week. RN #5 stated Physical Therapy does wound care for Patient. #3 daily. RN #5 sated she has spoken to Patient #3's daughter several times related to the status of Patient #3's wounds. RN #5 stated the wounds are getting better now that she is receiving pulse lavage during wound care. RN #5 stated Patient. #3 can indicate pain by shaking her head.

In an interview on 2/7/2022 at 3:40 PM, Physician #1, the attending physician for Patient #3, when asked why pain medication was not given to Patient #3 prior to wound care, Physician #1 stated, " ...She [Patient #3] has a PRN for pain medication. The nurses assess her for pain. We do not want a scheduled pain medication order. We do not want the patient to become sedated ..."

5. Medical record review revealed Patient # 4 was admitted on 1/7/2022 with diagnoses of Acute Encephalopathy, Pneumonia, Respiratory insufficiency and Congestive Heart Failure Exacerbation.

Review of the physician's orders on 1/7/2022 revealed an diet order for ""NPO [nothing by mouth].

Review of the lab values on 1/7/2022 revealed Albumin 3.1 [3.5 -5.0] indicating nutruiton risk.

Review of the physician's orders on 1/8/2022 revealed an order for a Cardiac diet.

Review of Nursing Assessments from 1/8/2022 - 1/27/2022 revealed no nutrition assessments.

There was no documentation about the Cardiac diet that was order on 1/8/2022 if Patient #4 received it or if any
problems occurred.

Review of Nursing Assessments from 1/8/2022 - 1/27/2022 revealed no nutrition assessments.

Review of the physician's orders on 1/10/2022 at 9:07 AM revealed an order for Bedside Swallowing evaluation and Treatment.

Review of the physician's orders on 1/10/2022 at 12:38 PM revealed an order for a Cardiac diet.

Review of a Rehabilitation Services note on 1/10/2022 revealed, "...Previous Swallow Studies Completed: No known studies... 1/10/2022 at 3:25 PM, revealed, "...Patient endorsed eating regular foods at baseline but patient was not a reliable historian at time of eval...1/10/2022 15:25 [3:25 PM]...Volitional Swallow...delayed, incomplete laryngeal elevation...1/10/2022 15:25 [3:25 PM]...Bedside Swallow Pharyngeal Symptoms...Coughing and choking, Delayed swallow, Reduced laryngeal elevation...10/22/2022 15:25 [3:25 PM]...Diagnostic Findings...Patient presented with thin liquid via teaspoon, and straw, nectar thick liquid via straw, puree and solid consistency. Patient demonstrated immediate coughing and drop in SpO2 [oxygen saturation] following thin liquid trials. Patient tolerated nectar thick liquids and tastes of puree consistency without clinical signs or aspiration. Patient did not allow solid consistencies beyond her teeth. Recommend downgrading to a clear liquid diet with Nectar Thick Liquids. ST [speech therapy to follow up to upgrade diet as tolerated...10/22/2022 15:25 [3:25 PM]...Skilled Speech Services Justification...Ensure safe and effective nutrition, Prevent aspiration pneumonia...10/10/2022 15:25 [3:25 PM] Patient will tolerate LRD [Least Restrictive Diet] without clinical signs of aspiration 90% OTT [over the top] while using safe feeding strategies..."

Review of the physician's orders on 1/10/2022 at 6:28 PM revealed an order for a clear liquid diet with nectar thick liquids.

Review of the physician progress notes on 1/10/2022 revealed, "...Assessment / Plan...Bedside Swallowing Evaluation & [and] Treatment Cardiac Diet...Speech Therapy Follow-up.."

Review of the physician's orders on 1/11/2022 revealed an order for "TPN" [Total Parenteral Nutrition]/"PPN" [Peripheral Parenteral Nutrition] consult.

Review of the ED triage form final report nurse screening on 1/7/2022 at 00:05 [12:05 AM] revealed, "...Nutritional Risk Factors: No nutrition problems noted..."

This review revealed no nursing documentation for an complete nutritional admission assessment, an incorrect daily assessment for 1/7/2022, and no daily nutrition assessments from 1/8/2022 thur 1/27/2022. There was no correct nutritional risk assessment completed within 48 hours.

Review of Nutrition Documents on 1/12/2020 revealed, "...Assessment Weight 110 kg [kilograms]...Assessment Weight Used...dosing...Nutrition Diagnosis #1...Inadequate oral intake...Inability to consume solid food/liquid, Other...mental status/resp [respiratory] status...need for modified diet...Nutrition Goals Comment..f/u [follow-up] within 2-5 days...Monitor pt-controlled diet compliance and reinforce, Parenteral nutrition (TPN [Total Parenteral Nutrition]/PN [Parenteral Nutrition]...Monitor Patient Nutrition Plan: Calorie and protein intake, Lab results, Weight, I & O [Input and Output]...Days until Dietician Follow-up...2-5 days..."

In the nutritional assessment by the Registered Dietician on 1/12/2020 revealed they used the dosing weight (recorded weight by the physician or nurse) that was obtained on 1/7/2022 instead of an actual weight. Patient had been on a NPO [nothing by mouth] and Clear Liquid with nectar thick liquids since 1/7/2022.

Review of the physician's orders on 1/13/2022 revealed an order for a Pureed Diet with a restriction for thin liquids.

Review of the physician's order on 1/14/2022 revealed an order for a mechanical soft diet.

In an e-mail sent to the Director of Risk Management on 2/11/2022 at 9:35 AM all Speech Therapy notes were requested.

Review of the physician's order on 1/17/2022 revealed an order for a dietary consult follow up.

Review of Nutrition Documents on 1/20/2020 revealed, "...Reassessment...Nutrition history...Clinimix 4.25/5% @ [at] 75ml [milliliters]/hr [hour]...Diet Information...Mechanical Soft Diet...1/14/2022...Enhanced covid isolation/RD [Registered Dietician] assessed remotely. per RN [Registered Nurse] Husband feeds pt. Stated pt. will usually eat about 50% of meals...Assessment Weight 110 kg [kilograms] Assessment weight: Used...Estimated weight...Monitor Patient Nutrition Plan: Diet/supplement tolerance, Oral Intake, Lab results, Weight, I & O [Intake and Output]..."

The Patient Nutrition Plan was calorie and protein intake, weight and Input and Output. There was no documentation for calorie or protein intake, no weight or oral input. Review of the oral input from 1/7 though 1/11/2020 revealed no documentation for oral input.

In an telephone interview on 2/9/2022 beginning at 12:15 PM, with Registered Dietician (RD) #1, the RD was asked when do you do the initial nutrition assessment and the RD stated, "...when you receive an malnutrition screen, significant weight loss screen, patient is in a NPO [nothing by mouth] status..."
The RD was asked after a patient is NPO how long is it before a nutrition screen should be completed and the RD stated, "...5 days..."
The RD was asked what weight was used on your initial assessment and the RD stated, "...the dosing weight..."
The RD was asked what is dosing weight and the RD stated, "...the weight recorded by the doctor or nurse".
The RD was asked if she uses the 110 kg [kilograms] weight was the weight recorded on admission and the RD stated, "...Yes..."
The RD was asked if the 110 kg weight was what you are calling the dosing weight and the RD stated, "Yes..."
The RD was asked if the 110 kg weight was used for the patient's initial nutritional assessment on 1/12/2022 after the patient had been NPO from 1/7/2022 to 1/10/20222 and then changed to a clear liquid diet with nectar thick liquids on 1/10/2022 and the RD stated, "...Yes..."
The RD was asked why was Patient #4 not re-weighed for her her actual weight and he RD stated, "...We usually just use the dosing weight not the actual weight unless they have had a significant weight lost".
The RD was asked how would you know if there had been a significant weight lost if you have not actually weighted the patient and the RD stated, "...well we ask the patient, ask the family, look at previous hospitalizations, if they come from nursing home we will look at that documentation".
The RD was asked how do you weight a patient and the RD stated, "...well we can weight them on the their beds if the bed scales are working..."
The RD stated, "...The consult on 1/12/2022 was because of the patient going on TPN [Total Parenteral Nutrition]..."
The RD was asked how long after the initial consult was completed should the reassessment have been done and the RD stated, "...5 days."
The RD was asked if the reassessment was done within 5 days and the RD stated, "...No, it wasn't..."

This surveyor request in an e-mail request on 2/11/2022 for Speech Therapist notes from 1/10/2022 - 1/21/2022, Physical Progress notes from 1/10/2022 - 1/21/2022, Medication Administration Record for the discontinuation of Input and Output documentation from 1/12/2022 - 1/21/2022. As of 2/14/2022 this surveyor has not received this documentation in a timely manner.

6. Medical record review revealed Patient # 4 was admitted on 1/7/2022 with diagnoses of Acute Encephalopathy, Pneumonia, Respiratory insufficiency and Congestive Heart Failure Exacerbation.

Review of Molecular Diagnostics on 1/7/2022 revealed a collected date and time of 1/7/2022 at 6:57 AM for a Covid Test and a Positive verified result time of 1/7/2022 at 12:27 PM.

There was no documentation for temperatures taken on Patient #2 for 1/8 and 1/9/2022 after a positive COVID test on 1/7/2022 and testing positive on 1/7/2022.

Patient #4 was in isolation for COVID-19.

In an interview on 1/18/2022 beginning at 10:30 AM, with the Director of Risk Management (DRM) the DRM stated, "...We follow the Center for Disease Control Guidelines..."
Refer to 0749.

Based on policy review, medical record review and interview, the hospital failed to ensure individual patient nutritional needs were meet for 1 of 4 (Patient #4) sampled patients reviewed for nutritional status.

The findings included:

1. Review of the hospital "Weights" with a revision date of 3/10 revealed, "...This policy applies...it employees, medical staff, contractors and patients regardless of service location or category of patient...To provide guidelines regarding patient weights upon admission and frequency of obtaining periodic weights...Height and weight are determined on patient admission and are later used as a baseline for comparison in nutritional status and certain medications that are weight based...Obtaining weights are measured using a consistent and reliable scale and at a consistent time. Units determine the date and time for daily and weekly weights...Scales available are the portable scale and floor scale for patients who can stand and have a good balance; and each [Named] bed has a built in scale for patients unable to stand. Patients with hyperalimentation and tube feedings will be weighed weekly according to unit schedule...Patients who are here greater that 7 days will be weighed weekly...Weights are recorded in the medical record or electronic charting..."

Review of an untitled and undated facilities policies revealed, "...An initial screening assessment and prioritization process is implemented to identify patients who may require medical nutrition therapy (ies). Patient identified at nutrition risk during the initial screening will be further evaluated with comprehensive assessment and receive nutrition interventions (s) when applicable...Initial Screening Nursing...Gathers information from patient within 24 hours of admission, based on pre-determined validated nutrition criteria and documents in the medical record. Based on results of initial screening, consults the dietitian...Registered Dietitian Nutritionist (RDN)...Acts on information/consults resulting from Nursing Admission Assessment within designated timeframes...Further assessment will be conducted following the Nutrition Care Process Model...Nutrition Monitoring and Evaluation: The RDN monitors and evaluates the patient's response to care which may include any or all of the following: nutrition reassessment, meal rounds, medical rounds and /or care plan rounds/meetings. Monitoring and evaluation may or may not results in new nutritional recommendations. The result of monitoring and evaluation are documented in the patent's medical record by the RDN..."

Review of the undated "PRIORITIZATION FOR ASSESSMENT" guidelines revealed, "By the next day or within 2 days...new order for tube feeding or parenteral nutrition...By day 5...NPO [nothing by mouth/CL [Clear Liquid]...Follow-up based on patient's care goal continue to monitor patients that remain NPO/CL and document every 2 days in the medical record and/or contact physician until the diet order changes. Other processes that will alert dietitians for follow-up may include but not limited to...Initiation of nutritional support..."

2. Medical record review revealed Patient # 4 was admitted on 1/7/2022 with diagnoses of Acute Encephalopathy, Pneumonia, Respiratory insufficiency, Covid-19 and Congestive Heart Failure Exacerbation.

Review of the physician's orders on 1/7/2022 revealed an diet order for "NPO" [nothing by mouth].

Review of the lab values on 1/7/2022 revealed Albumin 3.1 [3.5 -5.0] indicating nutruiton risk.

Review of Nursing Assessments from 1/8/2022 - 1/27/2022 revealed no nutrition assessments.

Review of the physician's orders on 1/8/2022 revealed an order for a Cardiac diet.

There was no documentation about the Cardiac diet that was order on 1/8/2022 if Patient #4 received it or if any problems occurred.

Review of the physician's orders on 1/10/2022 at 12:38 PM revealed an order for a Cardiac diet.

Review of a Rehabilitation Services note on 1/10/2022 revealed, "...Previous Swallow Studies Completed: No known studies... 1/10/2022 at 3:25 PM, revealed, "...Patient endorsed eating regular foods at baseline but patient was not a reliable historian at time of eval...1/10/2022 15:25 [3:25 PM]...Volitional Swallow...delayed, incomplete laryngeal elevation...1/10/2022 15:25 [3:25 PM]...Bedside Swallow Pharyngeal Symptoms...Coughing and choking, Delayed swallow, Reduced laryngeal elevation...10/22/2022 15:25 [3:25 PM]...Diagnostic Findings...Patient presented with thin liquid via teaspoon, and straw, nectar thick liquid via straw, puree and solid consistency. Patient demonstrated immediate coughing and drop in SpO2 [oxygen saturation] following thin liquid trials. Patient tolerated nectar thick liquids and tastes of puree consistency without clinical signs or aspiration. Patient did not allow solid consistencies beyond her teeth. Recommend downgrading to a clear liquid diet with Nectar Thick Liquids. ST [speech therapy to follow up to upgrade diet as tolerated...10/22/2022 15:25 [3:25 PM]...Skilled Speech Services Justification...Ensure safe and effective nutrition, Prevent aspiration pneumonia...10/10/2022 15:25 [3:25 PM] Patient will tolerate LRD [Least Restrictive Diet] without clinical signs of aspiration 90% OTT [over the top] while using safe feeding strategies..."

Review of the physician's orders on 1/10/2022 at 6:28 PM revealed an order for a clear liquid diet with nectar thick liquids.

Review of the physician progress notes on 1/10/2022 revealed, "...Assessment / Plan...Bedside Swallowing Evaluation & [and] Treatment Cardiac Diet...Speech Therapy Follow-up.."

Review of the physician's orders on 1/11/2022 revealed an order for "TPN" [Total Parenteral Nutrition]/"PPN" [Peripheral Parenteral Nutrition] consult.

Review of the emergency department (ED) triage form final report nurse screening on 1/7/2022 at 00:05 [12:05 AM] revealed, "...Nutritional Risk Factors: No nutrition problems noted..." This review reveal no nursing documentation for an complete nutritional admission assessment, and incorrect daily assessment for 1/7/2022, no daily nutrition assessments from 1/8/2022 thur 1/27/2022. There was no correct nutritional risk assessment completed within 48 hours.

Review of Nutrition Documents on 1/12/2020 revealed, "...Assessment Weight 110 kg [kilograms]...Assessment Weight Used...dosing...Nutrition Diagnosis #1...Inadequate oral intake...Inability to consume solid food/liquid, Other...mental status/resp [respiratory] status...need for modified diet...Nutrition Goals Comment..f/u [follow-up] within 2-5 days...Monitor pt-controlled diet compliance and reinforce, Parenteral nutrition (TPN [Total Parenteral Nutrition]/PN [Parenteral Nutrition]...Monitor Patient Nutrition Plan: Calorie and protein intake, Lab results, Weight, I & O [Input and Output]...Days until Dietician Follow-up...2-5 days..."

In the nutritional assessment by the Registered Dietician on 1/12/2020 revealed they used the dosing weight (recorded weight by the physician or nurse) that was obtained on 1/7/2022 instead of an actual weight. Patient had been on a NPO [nothing by mouth] and Clear Liquid with nectar thick liquids since 1/7/2022.

Review of the physician's orders on 1/13/2022 revealed an order for a Pureed Diet with a restriction for thin liquids.

Review of the physician's order on 1/14/2022 revealed an order for a mechanical soft diet.

Review of the physician's order on 1/17/2022 revealed an order for a dietary consult follow up.

Review of Nutrition Documents on 1/20/2020 revealed, "...Reassessment...Nutrition history...Clinimix 4.25/5% @ [at] 75ml [milliliters]/hr [hour]...Diet Information...Mechanical Soft Diet...1/14/2022...Enhanced covid isolation/RD [Registered Dietician] assessed remotely. per RN [Registered Nurse] Husband feeds pt. Stated pt. will usually eat about 50% of meals...Assessment Weight 110 kg [kilograms] Assessment weight: Used...Estimated weight...Monitor Patient Nutrition Plan: Diet/supplement tolerance, Oral Intake, Lab results, Weight, I & O [Intake and Output]..."

The Monitor Patient Nutrition Plan was calorie and protein intake, weight and input and output. There was no documentation for calorie or protein intake, no weight or oral input or consistence output. Review of the oral input from 1/7 though 1/11/2020 reveal no documentation for oral input an no consistence output.

In an telephone interview on 2/9/2022 beginning at 12:15 PM, with Registered Dietician (RD) #1, the RD was asked when do you do the initial nutrition assessment and the RD stated, "...when you receive an malnutrition screen, significant weight loss screen, patient is in a NPO [nothing by mouth] status..."
The RD was asked after a patient is NPO how long is it before a nutrition screen should be completed and the RD stated, "...5 days..."
The RD was asked what weight was used on your initial assessment and the RD stated, "...the dosing weight..."
The RD was asked what is dosing weight and the RD stated, "...the weight recorded by the doctor or nurse".
The RD was asked if she uses the 110 kg [kilograms] weight was the weight recorded on admission and the RD stated, "...Yes..."
The RD was asked if the 110 kg weight was what you are calling the dosing weight and the RD stated, "Yes..."
The RD was asked if the 110 kg weight was used for the patient's initial nutritional assessment on 1/12/2022 after the patient had been NPO from 1/7/2022 to 1/10/20222 and then changed to a clear liquid diet with nectar thick liquids on 1/10/2022 and the RD stated, "...Yes..."
The RD was asked why was Patient #4 not re-weighed for her her actual weight and he RD stated, "...We usually just use the dosing weight not the actual weight unless they have had a significant weight lost".
The RD was asked how would you know if there had been a significant weight lost if you have not actually weighted the patient and the RD stated, "...well we ask the patient, ask the family, look at previous hospitalizations, if they come from nursing home we will look at that documentation".
The RD was asked how do you weight a patient and the RD stated, "...well we can weight them on the their beds if the bed scales are working..."
The RD stated, "...The consult on 1/12/2022 was because of the patient going on TPN [Total Parenteral Nutrition]..."
The RD was asked how long after the initial consult was completed should the reassessment have been done and the RD stated, "...5 days."
The RD was asked if the reassessment was done within 5 days and the RD stated, "...No, it wasn't..."

This surveyor request in an e-mail request on 2/11/2022 for Speech Therapist notes from 1/10/2022 - 1/21/2022, Physical Progress notes from 1/10/2022 - 1/21/2022, Medication Administration Record for the discontinuation of Input and Output documentation from 1/12/2022 - 1/21/2022. As of 2/14/2022 this surveyor has not received this documentation in a timely manner.

Based on CDC guidelines, facility policy, observation and interview the hospital failed to follow the hospital's policies for the prevention and transmission of COVID-19 during 6 of 6 (1/18, 1/24, 1/25, 1/31, 2/1 and 2/7/2022) days of observations at the screening station (main entrance) of the facility. The facility failed to do a correct Infectious Exposure Screening on 1 of 4 patients (Patient #4) sampled for infectious exposure. The facility failed to do temperatures daily on 1 of 4 patients (Patients #4) sampled for temperatures.

The findings included:

1. Review of Hospital #1's undated "Guidelines for Visitation" revealed, "...To ensure the safety of our patients, physicians, and employees, we will continue to monitor the current status of COVID-19 within out community. This will provide guidance for allowing visitors in our hospital...One (1) visitor on arrival until information regarding patient is obtained; visitor then returns to vehicle unless patient is admitted...Screening will be preformed on all visitors, patients, vendors and staff entering the hospital. Each visitor will sign in on visitor sheet at the screening station at the main entrance to the hospital...Screeners will provide a visitor badge with room number and date and will be updated on daily basis. Badge must be worn at all times by visitor...will receive a badge with a date of the visit...Emergency Department: One (1) designated visitor on arrival until information regarding patients obtained; visitor then returns to vehicle unless the patient is admitted...Patients who are COVID-19 positive or a person under investigation (PUI) for COVID-19 will not be allowed visitors..."

Observations on 1/18/2022 beginning at 11:50 AM and 1/24/2022 beginning at 8:30 AM, Surveyor #1 entered facility at the main entrance and at the screening stations this surveyor did not sign a visitors sheet. Surveyor #1 was not provided a badge to be worn with a date of the visit. Six (6) foot spaces were marked off and at the screening station (information desk) there was a lady at the window talking and the guard told me to come on up to the window where the lady was standing this was this was not a 6 foot distance.

Observations on 1/24/22, 1/25/22, 1/31/22, 2/1/22 and 2/7/2022 beginning at 9:00, Surveyor #2 entered the facility at the main entrance and at the screening stations this surveyor did not sign a visitors sheet. Surveyor #1 was not provided a badge to be worn with a date of the visit.

2. Medical record review revealed Patient # 4 was admitted on 1/7/2022 with diagnoses of Acute Encephalopathy, Pneumonia, Respiratory Insufficiency, Covid-19 and Congestive Heart Failure Exacerbation.

Review of the Emergency Room Infectious Exposure Screening on 1/7/2022 at 00:05 [12:05 AM] revealed, "...Recent Travel...See Below...No travel inside or outside the country within last 30 days, No exposure to anyone traveled within last 30 days...Infectious Exposure Symptoms...None..."

Review of the ED [Emergency Department] physician final note on 1/7/2022 revealed, "...Pt's [patient's] family states that on 12/25, they were on vacation when pt was in the backseat of car unresponsive...Took her to [Named Hospital #2] in Alabama, transferred to [Named Hospital #3] in Alabama...On 12/29, pt. was transferred to St Francis. At St. Francis, tested positive for Covid-19..."

The Infectious Exposure Screening is incorrect because Patient #4 had traveled inside the country in the last 30 days and was in an out of state in 2 hospitals in Alabama.

3. Medical record review revealed Patient # 4 was admitted on 1/7/2022 with diagnoses of Acute Encephalopathy, Pneumonia, Respiratory insufficiency and Congestive Heart Failure Exacerbation.

Review of Molecular Diagnostics on 1/7/2022 revealed a collected date and time of 1/7/2022 at 6:57 AM, for a Covid Test and a Positive verified result time of 1/7/2022 at 12:27 PM.

There was no documentation for temperatures taken on Patient #4 for 1/8/22 and 1/9/2022 after a positive COVID test on 1/7/2022.

Patient #4 was in the Emergency Room waiting for a inpatient bed and was in isolation for COVID-19.

In an interview on 1/18/2022 beginning at 10:30 AM, with the Director of Risk Management (DRM) the DRM stated, "...We follow the Center for Disease Control Guidelines..."

Based on the hospital's COVID-19- Vaccination log presented to this surveyor on 2/1/2022 by the Director of Risk Management revealed the hospital failed to ensure completed documentation on the log of the specific vaccine received, the date of each dose received, if a booster was received or the date of the next scheduled dose for a multi-dose vaccine for staff documented as fully vaccinated and as receiving the first (1st) dose of the vaccine for 1035 fully vaccinated staff and 20 staff who have received the first (1st) dose.

The findings included:

Review of the Hospital's policy "CMS [Centers for Medicare/Medicaid] mandatory COVID-19 Vaccination Policy" dated 12/3/2021 revealed, "Acceptable Documentation...proof of vaccination must include the following: name of the individual, date of birth, location where vaccinated, employee ID or equivalent (when applicable), manufacturer, date(s) of vaccination, expiration date (if known), and lot number..."

Review of the hospital Vaccine Log provided to this surveyor on 2/1/2022 by the Director of Risk Management revealed there was no documentation on the log indicating the specific vaccine received, the date of each dose received, if a booster was received or the date of the next scheduled dose for a multi-dose vaccine for staff documented as fully vaccinated or as having receiving the first (1st) dose of the vaccine.