HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that registered nurses supervised and evaluated the nursing care for each patient as evidenced by failing to assess the PEG tube site for 1 of 1 patients (Patient #1) who self removed their PEG tube in a total sample of 5.
Findings:

Review of the medical record for Patient #1 revealed an admit date of 12/11/17 with diagnoses including PEG tube placement and failure to thrive.

Review of the nurses notes dated 12/23/17 at 8:30 p.m. revealed that the patient pulled off his abdominal binder and pulled his PEG tube out. The notes further revealed that a Foley catheter was placed in the stoma and the physician was notified. There was no documented assessment of the site.

Review of the nurses notes dated 12/24/17 at 10:30 a.m. revealed that the patient removed his PEG tube during the night. There was no documented assessment of the PEG site area at that time.

Further review of the record revealed no documented assessments of the PEG site until 12/27/17. Review of the physician progress note dated 12/27/17 revealed that the patient went to Endoscopy for a PEG tube replacement that day. The notes revealed that after pulling Foley catheter that was in place, the stoma and surrounding area appeared to be erythematous with keloid-like tissue. Recommendations revealed to remove the Foley catheter and allow the site to heal and treat with antibiotics.

Review of the patient's electronic medical record revealed no documented assessments of the infected PEG site until 12/29/17 at 7:45 p.m. which stated PEG site healing, scabbed. The note on 12/30/17 at 7:55 p.m. revealed the same as above.

There were no further assessments of the patient's PEG site as of 01/02/18 when the PEG tube was replaced by the physician.

On 01/05/18 at 1:50 p.m., S1RN Manager reviewed Patient #1's electronic medical record and confirmed the patient's PEG site was not being adequately assessed.

Based on record review and interview, the hospital failed to ensure that patients with documented weight loss had weights that were assessed and monitored by the Registered Dietician for 1 of 1 patient (Patient #1) diagnosed with failure to thrive in a total sample of 5.
Findings:

Review of the medical record for Patient #1 revealed a History and Physical report dated 12/11/17 stating that the patient was a direct admit to the hospital due to weight loss despite getting feedings per a percutaneous endoscopic gastrostomy (PEG) tube. The report further stated that the patient was extremely cachectic. The physician documented diagnoses including adult failure to thrive, malnourished, mental retardation and PEG tube secondary to frequent aspirations.

Review of the admit nursing assessment dated 12/11/17 revealed no documented weight of the patient. The assessment revealed the patient had a PEG tube.

Review of the progress note from S2Registered Dietician, dated 12/12/17, revealed "There is no height or weight on file to calculate body mass index." There were no further notes on that date.

Review of the progress note dated 12/15/17 from S2Registered Dietician revealed patient tolerating tube feeding. There is no height or weight on file. Review of the plan of care developed on this date revealed that S2Registered Dietician documented a goal that patient will maintain weight throughout hospitalization, with interventions including weekly weights.

Review of the progress note dated 12/19/17 from S2Registered Dietician revealed that patient's chart was reviewed. The note further revealed that the previously admitted weight was used to calculate needs.

Review of the progress note dated 12/22/17 from S2Registered Dietician revealed that the patient has been having diarrhea and diagnosed with Cryptosporidium. The documentation further revealed there was no height or weight on file.

Review of the progress note dated 12/26/17 from S2Registered Dietician revealed that the patient's chart was reviewed. Patient needs updated weight. Patient is scheduled for PEG replacement 12/27/17 and will follow up and assess for tube feeding recommendations.

Review of the progress note dated 12/28/17 from S2Registered Dietician revealed that the patient was started on Procal with lipids. Patient needs updated weight.

On 01/05/18 at 10:10 a.m., interview with S2Registered Dietician revealed that there was never a documented weight on Patient #1 during this current hospital stay. She stated that she would tell the nursing staff that she needed a current weight but it was never done. S2Registered Dietician stated that she used the patient's previous admission weight (12/07/17) because that was all she had to use (54.4 kilograms). When asked if that weight could be inaccurate due to the patient's continuous weight loss and diagnosis of failure to thrive, she stated yes. When asked if she could accurately perform her nutritional assessments without a current weight, she stated no.

On 01/05/18 at 1:50 p.m., interview with S1RN Manager revealed that the hospital did not have a policy regarding patient weights. He further stated that staff was to utilize the book titled, Lippincott Nursing Procedures 5th edition, as guidance if there was no hospital policy/procedure developed. When asked what the book stated regarding weights, he stated that it was not addressed. When asked if Patient #1's weight should have been assessed on admit and throughout his hospitalization, he stated yes.