HospitalInspections.org

Based on review of Appendix A of the State Operations Manual (SOM), hospital policies and procedures, patient records, facility documents, Department documents, and interviews, the Department determined the facility failed to require registered nursing staff to complete the one to one (1:1) patient monitoring form for patient #4 to document the patient monitoring orders were carried out as ordered and per facility policy. This deficient practice poses a risk to the health, and safety of the patients, when a provider orders 1:1 monitoring and there is no documentation of that monitoring as required and according to policy.

Findings include:

Review of the SOM section 482.23(b)(5) revealed: " ...A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available ...."

Review of a policy "Patient Observation" (PolicyStat ID: 9742509 last revised 05/2021), revealed: " ...1. The provider will order one of two observation levels ...B.2. Level II 1:1 Observation ...2. a. The patient is to be under constant visual observation ...regardless of other unit activities ...6. Staff will complete the patient observation record ...Patient Observation Monitoring Form ...."

Review of physician orders revealed that on September 09, 2021 provider #2 gave an order for 1:1 monitoring for patient #4.

Review of Department survey documentation revealed that during the unannounced on-site State Compliance survey, on September 28, 2021 to October 01, 2021, a copy of the 1:1 Patient Observation Monitoring Form for September 10, 2021 was requested for patient #12.

Staff #7 revealed in an interview conducted on September 29, 2021 at 1:30 pm that the facility was unable to provide a 1:1 Patient Observation Monitoring Form for patient #12 for September 10, 2021 and there should be one. Staff #7 further agreed that l:1 monitoring was a higher level of monitoring and required additional documentation and the facility requires a 1:1 Patient Observation Monitoring Form to be completed to document the monitoring care provided. Staff #7 stated that it was their expectation and the policy of the facility that the 1:1 form be completed and given to the RN after each shift.

At the time of the survey exit on October 05, 2021 at 10:30 am no evidence was provided documenting patient #12 received care as ordered and per facility policy.

Based on review of Appendix A of the State Operations Manual Appendix A (SOM), hospital policies and procedures, patient records, facility documents, Department documents, and interviews, it was determined that the Administrator failed to ensure that all patients received documented informed consent, including date and time, for psychotropic medications before the medications were administered. This deficient practice poses a risk to the health and safety of patients, when all of the side effects and risks of a psychotropic medication are not understood by a patient or patients representative before taking psychotropic medication.

Findings include:

Review of the SOM section 482.24(c)(4)(v) revealed: " ...Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent ...."

Review of a policy "Informed Consent" (PolicyStat ID: 10239455 last revised 08/2021) revealed: " ...Procedure ...The informed consent process includes at least the following ...Date and time consent is signed by the patient or the patients legal representative/guardian ...."

Review of physician orders revealed that on September 09, 2021 provider #2 gave orders for psychotropic medications for patient #8.

Review of the patient record on September 29, 2021 at 9:30 am together with staff #19 revealed no informed consent for psychotropic medications psychotropic medication in the patient electronic medical record (EMR).

On September 30, 2021 at 11:00 am staff #7 provided copies of the record for patient #8. Contained in the copies was an informed consent for psychotropic medications. Upon further observation, it was noted that the informed consent was not dated or timed as required by facility policy.

By the time of the survey exit on October 05, 2021 at 11:30 am, no evidence documentation was provided by the facility of informed consent, including date and time, as required by facility policy.

Based on review of Appendix A of the State Operations Manual (SOM), hospital policies and procedures, hospital documents, and staff interviews, it was determined the hospital failed to provide organized dietary services to meet the nutritional needs of the patients as evidenced by no documented alternatives for patient meals or patient nutritional screenings. This deficient practice poses a risk to the health and safety of the patients, when there is no nutritional screenings or assessments to evaluate a patient's nutritional need.

Findings include:

Review of the SOM section §482.28 revealed: " ...The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietician who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment ...."

A review of 21 clinical records conducted on September 29, 2021 through October 01, 2021 revealed no evidence of patient nutritional screenings or assessments.

A review of Department survey documentation revealed that the Food/Dietary Service policy was requested but not received.

Documents titled "Menu 2021 Week 1, Week 2," revealed no food alternatives or substitutions listed or calorie counts.

Employee #14 confirmed during an interview conducted on September 30, 2021 at 3:15 pm that there is no system for diet ordering or accommodation of non-routine occurrences like diet change orders, early/late trays or supplements are in place. Employee #14 confirmed during the same interview that there is no integration of food service into the hospital wide Quality Improvement and Infection Control Plans.

At the time of the survey exit on October 05, 2021 at 10:30 am no evidence was provided documenting the facility provides organized dietary services to meet the nutritional needs of the patients.

Based on review of Appendix A of the State Operations Manual (SOM), personnel file, documents, and interviews, it was determined that the person in charge of dietary services was not qualified or trained by education and/or experience for the position. The deficient practice poses a risk to the health and safety of the patients, when the person in charge of dietary services is not trained by education and/or experience, to understand the requirements of storing, handling or serving food provided to patients.

Findings include:

Review of the SOM section 482.28(a)(1) revealed: " ...The hospital must have a full-time employee who ...(i) Serves as director of the food and dietetic services ... (ii) Is responsible for daily management of the dietary services ...(iii) Is qualified by experience or training ...."

Staff #7 confirmed in an interview conducted on September 28, 2021 at 9:00 am that the current director of food and dietetic services is staff #1.

Staff #1 confirmed in an interview conducted on September 30, 2021 at 1:30 pm that they were not an employee but a contracted staff through a facility vendor. Staff #1 also confirmed they had no training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients. Additionally, staff #1 confirmed that they had conducted no training or evaluation of the dietary staff or food service contract for the last 12 months.

Review of Department survey documentation revealed that during the survey, September 28, 2021 to October 03, 2021, a copy of the job description of the current director of the food and dietetic services was requested and was not received.

Review of the personnel file for staff #1 on September 28, 2021 at 2:30 pm revealed no evidence that staff #1 had training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients.

Staff #7 confirmed in an interview conducted on September 28, 2021 at 12:00 pm that the facility was unable to provide documentation that the current director of food and dietetic services had training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients.

By the time of the survey exit on October 05, 2021 at 11:30 am, no evidence had been provided by the facility documenting that the current director of food and dietetic services had training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients.

Based on review of Appendix A of the State Operations Manua (SOM), policies and procedures, documents, and interviews, it was determined that the facility failed to ensure facility staff implemented infection control practices as required by facility policy. This deficient practice poses a potential risk to the health and safety of patients, when infection control practices are not implemented by clinical staff.

Findings include:

Review of the SOM section §482.42(a)(2) revealed: "... The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings ...."

Review of a policy "Infection Control and Prevention" (PolicyStat ID: 9286500 Last Revised 01/2020) revealed: "...Adherence to the practice of Standard Precautions is expected of nursing staff. Nursing staff serves as a role model for all healthcare workers in the use of personal protective equipment and adhereance to established guidelines...."

Review of a policy "Rest periods and Meal Breaks" (PolicyStat ID: 8804589 Last Revised 01/2020), revealed: "..."No employee is to consume food or beverages in work areas...."

An observation of staff #05 conducted on September 29, 2021 at 10:00 am revealed staff #05 in the dining area behind the food preparation area. Staff #05 was observed eating in the food preparation area and then taking the vital signs of all patients in the dining area. Staff #05 was not observed to have performed hand hygiene after eating or between patient vital signs. Staff #05 was not observed to have cleaned the vital sign machine between patients.

Review of the personnel file for staff #05 revealed orientation and training in infection control practices and Standard Precautions.

Staff #05 confirmed in an interview conducted on September 29, 2021 at 10:30 am that they should have not been eating in the patient dining area, they should have performed hand hygiene between patients, and cleaned the vital sign machine between patients.