HospitalInspections.org

Based on interview, record review, and policy review, the provider fail to ensure:
*Patients received breakfast under the registered dietitian's direction.
*Two of two sampled patients (2 and 3) impaired skin integrity had nutritional assessments completed by the registered dietitian (RD).
Findings include:

1. Observation on 7/22/24 at 9:45 a.m. of the nutrition station revealed there was a selection of foods including; juices, milk, soup packets, peanut butter, jelly, and bread.

Interview on 7/22/24 at 11:30 a.m. with certified dietary manager (CDM) C revealed:
*The nursing home was contracted to supply meals to the critical access hospital.
*The meals served were lunch and supper.
*A continental breakfast was made for the patients by the nursing staff.
*The majority of food for the continental breakfast was stored in the attached assisted living facility.
*The hospital nursing staff prepared the breakfast there and brought it to the patients.
*Snacks were provided by the hospital staff from their nutrition station.

Review of the provider's menu for Thursday 7/25/24 revealed:
*The RD had reviewed and approved the menu on 4/1/24.
*The approved menu included:
-A continental breakfast. There were no diet extensions (food and portion sizes approved for different patient needs i.e. diabetic) or amounts to be given for the breakfast.
-Lunch and supper menus had portions and diet extensions.
-Afternoon and bedtime snacks did not have portions or diet extensions indicated.
*The hospital had a small breakfast menu of items for the patients in the hospital to choose from.
*Those choices included:
-Toast, white or whole grain. Butter, jelly, and peanut butter that was diabetic friendly.
-Milk
-Juice.
-Fresh fruit (diabetic friendly).
-Boiled egg (diabetic friendly).
-Cheese (diabetic friendly).
-Oatmeal (diabetic friendly).
-Cream of Wheat.
-Cold cereal.
-Coffee and tea.
-Sugar, sweetener, salt, and pepper.
*There were no portion sizes indicated for those food items.
*There was no guidance on what diet types, other than regular diets, should have been offered from the menu.

Interview on 7/25/24 at 10:00 a.m. with registered nurse (RN) E and nursing assistant (NA) F revealed:
*Patients in the hospital were offered the above menu to choose from for their breakfast.
*The breakfast was prepared in the assisted living kitchenette by the hospital nursing staff.
*There had been no education on what amounts should have been offered to residents on a special diet or if they required modified textures.

Interview on 7/25/24 at 11:25 a.m. with CDM C confirmed:
*The continental breakfast menu should have been reviewed by the RD.
*The hospital nursing staff had not received any education on the correct portions and dietary extensions.
*He had not realized the continental breakfast should have had diet extensions.
*This was the same way it had been done for years.

Interview on 7/25/24 at 12:40 p.m. with physician's assistant G revealed:
*The providers were able to select a patient's diet from within the electronic medical record (EMR).
*There were several types of diets that could be chosen.
*He agreed it was important for certain diets to be available for patients.

Review of the 10/25/22 Agreement for Food Preparation Services revealed:
*The health care center would furnish two meals and two snacks per day for hospital inpatients.
*There was no agreement for providing a breakfast meal.


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2. Review of patient 3's EMR revealed:
*He had been admitted on 1/31/24 and discharged on 2/3/24.
*He had admission diagnoses of cellulitis and right knee ulcer (an open sore or wound that developes on the skin).
*On 1/31/24 a mini-nutritional screening tool had been completed by the admiting nurse and scored 0 (indicating no nutritional concerns).
*Patient 3 had not been assessed by dietary or the registered dietician regarding his right knee ulcer.

3. Review of patient 2's EMR revealed:
*He had been admitted on 4/22/24 and discharged on 4/25/24.
*He had admission diagnoses of right leg cellulitis and right foot ulcer.
*On 4/22/24 a mini-nutritional screening tool had been completed by the admiting nurse and he scored 0.
*Patient 2 had not been assessed by dietary or the registered dietician regarding his right foot ulcer.

Interview on 7/25/24 at 11:25 a.m. with CDM C regarding assessments of patients with wounds revealed he agreed that a note should have been entered into the patient's EMR by himself or the registered dietitian with any recommendations.

Review of the provider's revised April 2023 Nutrition Assessment and Reassessment of In-Patients policy revealed:
*Patients would have been assessed per nursing referral, physician order, or at the RD's discretion based upon diet order, diagnosis, patients receiving nutrition support, and patients with orders for supplements.
*All referrals to wound care should have been transmitted to nutrition services.
*If a patient was discharged prior to the completion of physician ordered consult, the RD would have reviewed the EMR and contact the patient, family, or primary care physician as appropriate. An addendum would have been made in the patient's EMR regarding intervention.

Based on record review, interview, and policy review the provider failed to ensure six of six sampled patients (29, 30, 31, 32, 33, and 34) had informed consent by the physician prior to their procedure. Findings include:

Review of the provider's consent-Surgery or Invasive Procedure revealed:
*"The patient's name."
*"Agree that I will have (patient words)."
*"Proposed procedure or treatment (medical terminology)."
*"The reason for this treatment/procedure is (medical condition)."
*"This will be done or supervised by."
*"By signing this consent form, I agree that I have been given the chance to read and ask questions about my condition. I understand the planned procedure(s) and/or treatment(s), options for anesthesia/sedation, other treatment options and risk of non-treatment."
*"I have discussed the procedure and the information stated above with the patient (or patient's representative) and answered their questions. The patient or their representative consented to the procedure."
*"I have verified that the signature is that of the patient or patient's representative. This form has been signed before the procedure."

1. Review of patient 29's electronic medical record (EMR) revealed:
*On 2/29/24 a colonoscopy (endoscopic visualization of the colon and small bowel) had been performed.
*There was no documention that the physician had obtained informed consent by the patient prior to the procedure.

2. Review of patient 30's EMR revealed:
*On 2/29/24 a esophagogastroduodenoscopy (endoscopic visualization of the upper gastrointestinal tract) had been performed.
*There had not been any document that the physician had obtained informed consent by patient 30 prior to the procedure.

3. Review of patient 31's EMR revealed:
*On 3/26/24 a colonoscopy had been performed.
*There was no documention that the physician had obtained informed consent by the patient prior to the procedure.

4. Review of patient 32's EMR revealed:
*On 3/26/24 a colonoscopy had been performed.
*There was no documention that the physician had obtained informed consent by the patient prior to the procedure.

5. Review of patient 33's EMR revealed:
*On 3/6/24 a colonoscopy had been performed.
*There was no documention that the physician had obtained informed consent by the patient prior to the procedure.

6. Review of patient 34's EMR revealed:
*On 6/25/24 a esophagogastroduodenoscopy and a colonoscopy had been performed.
*There was no documention that the physician had obtained informed consent by the patient prior to the procedure.

Interview on 7/24/24 at 9:00 a.m. with director of nursing (DON) B regarding the informed consent process revealed she agreed that there had been no documentation of informed consent by the physician prior to the procedures.
*She had been informed that infomred consent was not needed prior to the procedure.

Review of the provider's June 2024 Informed Consent Policy revealed:
*"A written confirmation of informed consent must be obtained prior to any medical treatment being performed. Written documentation of the informed consent may be accomplished through the use of a form or through a provider's dictated note.
*"When a form is used to confirm informed consent, it must clearly state the name of the provider who informed the patient and that the patient understood the information."
*"The consent form must be properly witnessed. The role of staff in consent process prior to the procedure is to verify the patient's understanding of the content of the consent and the treatment or procedure to which the patient is consenting."