HospitalInspections.org

Based on document review and interview, the facility failed to:


(A) provide evidence of an integrated patient safety program. The facility failed to provide evidence of proactive strategies to eliminate or minimize the occurrence of errors as evidenced by a failed chart audit that was done by the facility's multidiscipline quality committee. The chart audit was initiated after receiving a complaint from patient #1 family member. The facility's multidiscipline quality committee failed to identify:

E. The Nursing Staff and Pharmacy Services did not the follow the facility's established policy and State Regulations when dispensing medications.

F. The patients input and output was not monitored and recorded in the medical record as ordered.

G. The patient was not weighted as ordered.

H. The dietary department could not accommodate the dietary request of patient #1 and the caregiver.


Refer to A286



(B) provide evidence of a comprehensive system that identifies problems and opportunities for improvement through monitoring and evaluation. The Quality Assurance/Performance Improvement Director and committee was not able to identify system failures and patient safety issues related to the care of 1 (#1) of 1 patients.

(A) The leaders and committee did not identify that patient #1 was not afforded the correct dose of medication (Zenpep) to aid in digestion of food. Nurses and Pharmacy Services dispensed and administered patient #1 medication without a correct order.

(B) The intake and output for patient #1was not consistently recorded and monitored.

(C) The Dietary Department was not able and equipped to provide dietary request to patient #1 that suffered with chronic pancreatitis. Chronic pancreatitis left the patient without the ability to produce enough enzymes to digest certain foods without the aid of the medication Zenpep (a combination of three enzymes). The patient's dietary intake was limited to a few food that would not cause the patient to have abdominal pain and diarrhea. Patient #1 was not weighted as ordered.


Refer to tag A309

Based on document review, the facility failed to provide evidence of an integrated patient safety program. The facility failed to provide evidence of proactive strategies to eliminate or minimize the occurrence of errors as evidenced by a failed chart audit on 1(#1) of 1 patients that was done by the facility's multidiscipline quality committee. The chart audit was initiated after receiving a complaint from patient #1 family member. The facility's multidiscipline quality committee failed to identify:

A.The Nursing Staff and Pharmacy Services did not follow the facility's established policy and State Regulations when dispensing medications.

B. The patients input and output was not monitored and recorded in the medical record as ordered.

C. The patient was not weighted as ordered.

D. The dietary department could not accommodate the dietary request of patient #1 and the caregiver.


A review of the document titled "QUALITY/HEALTH CARE IMPROVEMENT, CLINICAL RISK MANAGEMENT AND PATIENT SAFETY PLAN FY2017" revealed, "Scope: Patient Safety (PS) - Reduction of risk to patients by promoting a culture of safety which provides a systematic, proactive, coordinated, and continuous approach to the maintenance and improvement of patient safety. This is achieved through the establishment of an integrated patient safety program utilizing mechanisms such as policies, procedures and protocols to support effective responses to actual occurrences; ongoing proactive strategies to eliminate or minimize the occurrence of errors or the probability that those errors will reach the patients; and involvement of the medical staff, employees, patients, and their families."


A. A review of the facility's document titled "Medication Orders" revealed: "Procedures: 2. To be considered complete, all medication orders shall include the drug name, the dosage, the route and frequency of administration, and the time and date the order is written ..."

A review of the "Texas Administrative Code, Title 22: Examining Boards, Part 15: Texas State Board of Pharmacy, Chapter 29: Pharmacies, Subchapter D: Institutional Pharmacy (Class C), Rule 291.72: Definitions" revealed:
"The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Accurately as prescribed--Distributing and/or delivering a medication drug order:

(A) to the correct patient (or agent of the patient) for whom the drug or device was prescribed;

(B) with the correct drug in the correct strength, quantity, and dosage form ordered by the practitioner; and

(C) with correct labeling as ordered by the practitioner and required by rule."


A review of the document titled "BHCS Orders" revealed "Non Formulary Medication Request, start 04/18/2019, Stop 04/25/2016. Order as Zenpep. Give 3 capsules by mouth 3 times day with meals. Nursing Instructions: Zenpep capsule ***3." [sic].


A review of hand written document titled Physician Orders dated 04/22/2016 and timed 14:15 (2:15pm) revealed a telephone order that read: Non Formulary Medication Zenpep, please change to 3 capsules PO 3X daily with meals.


A review of hand written document titled Physician Orders dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read: "D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals.
Zenpep, 3 capsules PO 3X daily with meals."


A review of the document titled "Medication Administration Record" revealed Non Formulary Medication Request - order as Zenpep capsule. Give 3 capsule by mouth 3 times daily with meals.

On 04/18/2016 0800am Not Given: NPO, 12:00pm Not Given: NPO, 1702 (5:02pm) 1 capsule given by mouth.

On 04/19/2016 8:45am 1 capsule given by mouth, 12:45pm 1 capsule given by mouth. No documentation for the 3rd dose. (Not known if it was or was not given)

On 04/20/2016 8:55am 1 capsule given by mouth, 11:37pm 1 capsule given by mouth, 17:30 (5:30pm) not given, patient refused.

On 04/21/2016 8:00am not given, Duplicate Order, 9:56am 1 capsule given by mouth. Instructions per home meds give 3-4 tabs. 12:42 pm 1 capsule given by mouth, 16:59 (4:59pm) 1 capsule given by mouth.

On 04/22/2016 8:51am 1 capsule given by mouth, 12:40 pm 1 capsule given by mouth, 17:38 (5:38pm) 3 capsule given by mouth. The number of capsules given changed from 1 to 3, which was the correct dosage ordered on 4/18/16

On 04/23/2016 9:11am 3 capsule given by mouth, 12:25pm 3 capsule given by mouth, 18:30 (6:30pm) 3 capsule given by mouth.

On 04/24/2016 8:38am 3 capsule given by mouth, 13:01pm (1:01pm) 3 capsule given by mouth, 17:44 (5:44pm) 3 capsule given by mouth.

On 04/25/2016 8:00am not given, Medication not available, 12:00pm (1:01pm) not given, Medication Discontinued.

Evidence showed the patient's home medication was available to be given. The document titled "Physician Orders" dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read: D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals. New order Zenpep, 3 capsules PO 3X daily with meals.


B. A review of the document titled "Clinical Nursing Documentation" revealed

Policy:

1. Professional clinical documentation is based on the following:

a. Promote inter-professional communication
b. Promote a patient centered health record
c. Validate clinician accountability in provision of safe and appropriate care
d. Meet professional, statutory and regulatory requirements
e. Promote quality improvement ...


3. Nurses have a professional obligation to document an accurate, chronological and comprehensive health record through timely, clear and concise documentation...


4. Frequency of nursing documentation is consistent with identified nursing standards and professional judgment in relation to complexity, stability and acuity of the patient as well as organizational policy.


5. Nurses and UAPs (Unlicensed Assistive Personnel) providing direct patient care and/or management of the patient, document directly in the patient's health record.


a. Registered Nurses (RNs) - Document the nursing process to include: comprehensive assessments, Plan of Care, implementation of treatments and interventions, evaluation and re-assessment of patient outcomes, patient and family education and communication with members of the care team.


b. Licensed Vocational Nurses (LVNs) - Document collection of data and information for a Focused Assessment, changes in patient condition, interventions, altered patient responses, patient teaching and communication with members of the care team.


c. UAPs - document care they provide and data they collect.


A review of patient #1 medical record revealed the document titled "BHCS Orders" dated 04/18/2016 and timed 02:28am, "Intake and Output per unit routine."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:28 am revealed "NPO".

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27 am revealed "Diet Order, Regular Diet."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27 am revealed "Ensure, 3 times daily, flavor(s) vary 1 can."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 12:15 am revealed "Advance Diet as Tolerated, Once, Special Instructions: restart oral sips 2 hours after procedure, advance as tolerated. Patient had topical anesthesia intraoperative."

A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 2:08pm revealed "Restrict Fluids, PO Restrictions, Volume in ml 1000."

A review of a document titled "BHCS Orders" dated 04/23/2016 and timed 8:24am revealed "NS, 1000ml dispensed bag size -Administer a total ordered volume of: 1000ml then discontinue. Ordered as limited volume. Continuous IV, Run at 50ml/hr, Stop after 20 hours, time: 04:23. Nurse Instructions: Ordered as limited volume. Administer total volume of 1000ml. Then discontinue."

A review of a document titled "Shift Assessment Flowsheet" revealed on 04/19/2016 at 4:09 staff #4 documented "Additional Notes: pt requested for snack, offered graham crackers and juice and jello. Pt. consumed a piece of graham cracker, cup of apple juice and half cup of jello, no swallowing difficulty noted, pt. assisted in feeding."


A review of a document titled Intake and Output (I&O) Flowsheet, Shift Total revealed:

04/18/2016 7:00pm, No oral intake was recorded. Staff recorded no urine output from the indwelling urethral catheter.

04/19/2016 7:00am Staff did not recorded oral intake.

04/19/2016 7:00pm Staff did not recorded intake.

04/20/2016 7:00am Staff did not recorded intake.

04/20/2016 7:00pm Staff did not documented intake or output.

04/21/2016 7:00am Staff did not documented intake or output.

04/22/2016 7:00pm Staff did not documented oral intake.

04/23/2016 7:00am Staff did not documented no oral intake.

04/24/2016 7:00pm No intake or output was documented.

04/25/2016 7:00am No intake or output was documented.


C. A review of patient #1 medical record revealed a document titled "BHCS Orders". The order read "Weight, start 04/20/2016, Routine, 1 time weekly, Special Instructions: Once Weekly."
A review of patient #1 medical record revealed the order was not implemented by the nursing staff. There was no evidence the patient was weighed.


D. A review of the document titled History and Physical revealed Chief Complaint: Fall, History of Present Illness: 73 y/o female with a past medical history of hypertension who presents with falls. History is taken from the patient and her brother, both of whom are poor historians. They report that she has fallen 2-3 times over the last few weeks. She normally walks with a cane, but has had increasing difficulty doing this. She reports longstanding history of abdominal pain with eating for which she is on many "supplements". Brother reports that she has been 70 pounds for quite a while, but her weight has been as high as 90 pounds.


A review of a document titled Consult Note revealed History of Present Illness: This is a 73 y/o Sri Lankan female pt. who migrated to this country in 1998, did not visit Sri Lanka till 2011. Now comes in with complaint of wt. loss and cachexia (a condition that causes extreme weight loss as well as muscle wasting) and falls.


A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:28am revealed the patient was NPO (nothing by mouth).


A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:35am revealed "Evaluate and Treat Speech Therapy (ST), ST to Order: Diet as Appropriate/ Dysphagiagram as Appropriate/ FEES (if available) as appropriate, Evaluate For: Clinical/Bedside Swallow Evaluation."


A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:35am revealed "Nutrition Consult, Routine, Consult Reason: Nutrition Assessment."


A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27am revealed "Diet Order, Common Diet: Regular" ordered by physician #1.


A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27 am revealed "Ensure, 3 times daily, flavor(s) vary 1 can" ordered by physician #1.


A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 12:15 am revealed "Advance Diet as Tolerated, Once, Special Instructions: restart oral sips 2 hours after procedure, advance as tolerated. Patient had topical anesthesia intraoperative."


A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 18:17pm revealed "Diet Order, Common Diet: Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- (CARD)." Ordered by the Dietitian #1.


A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 07:22am revealed "Nutrition Consult, Routine, Consult Reason: Nutrition Assessment." Ordered by physician #2.


A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 12:58pm revealed "Diet Order, Common Diet: Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- (CARD) Lactose Restricted- Thin Liquids/ No Liq Restrictions- Mechanical Soft, Chopped. Nurse to Nurse Communication: no ice in drinks: pt. prefers warm drink; no dairy." Diet ordered by Speech Therapist #1.


A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 13:00pm revealed "Nepro 3 times daily Flavor: Vanilla 1 can." Ordered by Dietitian #1


A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 13:26pm revealed "Nepro 2 times daily Flavor: Vanilla 1 can." Ordered by Dietitian #1


A review of a document titled "BHCS Orders" dated 04/21/2016 and timed 15:23pm revealed "Ensure, 3 times daily, Flavor Other: Vary 2 cans Special Instructions: Recommend 2 Ensure Clear with every meal."


A review of a document titled "BHCS Orders" dated 04/22/2016 and timed 15:30pm revealed "Diet Order Common Diet: Soft- Lactose Restricted- Thin Liquids/No Liq Restrictions- Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- Mechanical Soft, Chopped, Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Lo, Radiation Disposable."


A review of a document titled "BHCS Orders" dated 04/24/2016 and timed 9:58am revealed "Food Service Communication, Special Instruction: Soft and/or thin flat chicken or chopped, not just cut into pieces with gravy, Mashed potatoes and green beans well cooked."


A review of a document titled "BHCS" Orders dated 04/25/2016 and timed 13:53pm revealed "Diet Order Lactose Restricted- Mechanical Soft, Chopped, Radiation Disposable."



An interview with staff #5 revealed the dietary department had difficulty getting the food trey correct for the patient and the brother would complaint when the trey was not correct. The interviewee stated the request was for the patient to have thin chopped chicken, mashed potatoes and green beans well done, no milk products for lunch and dinner, every meal. The patient had chronic pancreatitis and did not produce the enzymes to digest fats. This diet along with her prescribed enzymes (Zenpep) to be taken with meals would not cause abdominal pain and diarrhea in the patient. The interviewee revealed the dietary order system would not accommodate patients ordering specific items for diet and if she was not in the dietary department to check the patient's food trey the dietary personnel would send ordered common diet. Example Order Common Diet: Soft- Lactose Restricted- Thin Liquids/No Liq Restrictions- Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- Mechanical Soft, Chopped, Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Lo, Radiation Disposable

Based on document review and interview, the facility failed to provide evidence of a comprehensive system that identifies problems and opportunities for improvement through monitoring and evaluation. The facility was able to provide evidence that Grievances are reviewed as part of quality improvement and/or Risk Management with appropriate leaders and committees but, the leaders and committee was not able to identify system failures and patient safety issues.

(A) The leaders and committee did not identify patient #1 was not afforded the correct dose of medication (Zenpep) to aid in digestion of food. Nurses and Pharmacy Services dispensed and administered patient #1 medication without a correct order.

(B) The intake and output for patient #1was not consistently recorded and monitored.

(C) The Dietary Department was not able and equipped to provide dietary request to patient #1 that suffered with chronic pancreatitis. Chronic pancreatitis left the patient without the ability to produce enough enzymes to digest certain foods without the aid of the medication Zenpep (a combination of three enzymes). The patient's dietary intake was limited to a few food that would not cause the patient to have abdominal pain and diarrhea. Patient #1 was not weighted as ordered.

A review of the document titled "QUALITY/HEALTH CARE IMPROVEMENT, CLINICAL RISK MANAGEMENT AND PATIENT SAFETY PLAN FY2017" revealed:

"Scope: Quality/Health Care Improvement (Quality/HCI - The primary function of Quality/HCI is the evaluation of the performance of functions, processes and outcomes of care applicable to various clinical, support, ancillary, and administrative hospital/clinic departments, services and practitioners. Quality/HCI provides integration of a multidisciplinary, comprehensive health care delivery system that identifies problems and opportunities for improvement through monitoring and evaluation. Improvement methods provide a mechanism for information flow between and among teams for patient-related activities and functions to coordinate efforts toward the resolution of identifiable problems or performance improvement opportunities."

A review of the document titled "Patient Complaint and Grievances" revealed: "Quality Improvement: Concerns/Complaints, and Grievances are reviewed as part of quality improvement and/or Risk Management with appropriate leaders and committees."

(A) A review of the facility's document titled "Medication Orders" revealed: "Procedures: 2. To be considered complete, all medication orders shall include the drug name, the dosage, the route and frequency of administration, and the time and date the order is written ..."

A review of the Texas Administrative Code, Title 22: Examining Boards, Part 15: Texas State Board of Pharmacy, Chapter 29: Pharmacies, Subchapter D: Institutional Pharmacy (Class C), Rule 291.72: Definitions revealed:
"The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Accurately as prescribed--Distributing and/or delivering a medication drug order:

(A) to the correct patient (or agent of the patient) for whom the drug or device was prescribed;

(B) with the correct drug in the correct strength, quantity, and dosage form ordered by the practitioner; and

(C) with correct labeling as ordered by the practitioner and required by rule."


A review of the document titled "BHCS Orders" revealed "Non Formulary Medication Request, start 04/18/2019, Stop 04/25/2016. Order as Zenpep. Give 3 capsules by mouth 3 times day with meals. Nursing Instructions: Zenpep capsule ***3." [sic].

A review of hand written document titled "Physician Orders" dated 04/22/2016 and timed 14:15 (2:15pm) revealed a telephone order that read:
"Non Formulary Medication Zenpep, please change to 3 capsules PO 3X daily with meals."

A review of hand written document titled "Physician Orders" dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read:
"D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals.
Zenpep, 3 capsules PO 3X daily with meals."

A review of the document titled "Medication Administration Record" revealed Non Formulary Medication Request - order as Zenpep capsule. Give 3 capsule by mouth 3 times daily with meals.

On 04/18/2016 0800am Not Given: NPO, 12:00pm Not Given: NPO, 1702 (5:02pm) 1 capsule given by mouth.

On 04/19/2016 8:45am 1 capsule given by mouth, 12:45pm 1 capsule given by mouth. No documentation for the 3rd dose. (Not known if it was or was not given)

On 04/20/2016 8:55am 1 capsule given by mouth, 11:37pm 1 capsule given by mouth, 17:30 (5:30pm) not given, patient refused.

On 04/21/2016 8:00am not given, Duplicate Order, 9:56am 1 capsule given by mouth. Instructions per home meds give 3-4 tabs. 12:42 pm 1 capsule given by mouth, 16:59 (4:59pm) 1 capsule given by mouth.

On 04/22/2016 8:51am 1 capsule given by mouth, 12:40 pm 1 capsule given by mouth, 17:38 (5:38pm) 3 capsule given by mouth. The number of capsules given changed from 1 to 3, which was the correct dosage ordered on 4/18/16

On 04/23/2016 9:11am 3 capsule given by mouth, 12:25pm 3 capsule given by mouth, 18:30 (6:30pm) 3 capsule given by mouth.

On 04/24/2016 8:38am 3 capsule given by mouth, 13:01pm (1:01pm) 3 capsule given by mouth, 17:44 (5:44pm) 3 capsule given by mouth.

On 04/25/2016 8:00am not given, Medication not available, 12:00pm (1:01pm) not given, Medication Discontinued.
Evidence showed the patient's home medication was available to be given. The document titled "Physician Orders" dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read: D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals. New order Zenpep, 3 capsules PO 3X daily with meals.


(B) A review of the document titled Clinical Nursing Documentation revealed

Policy:

1. Professional clinical documentation is based on the following:

a. Promote inter-professional communication

b. Promote a patient centered health record

c. Validate clinician accountability in provision of safe and appropriate care

d. Meet professional, statutory and regulatory requirements

e. Promote quality improvement ...

3. Nurses have a professional obligation to document an accurate, chronological and comprehensive health record through timely, clear and concise documentation...

4. Frequency of nursing documentation is consistent with identified nursing standards and professional judgment in relation to complexity, stability and acuity of the patient as well as organizational policy.

5. Nurses and UAPs (Unlicensed Assistive Personnel) providing direct patient care and/or management of the patient, document directly in the patient's health record.

a. Registered Nurses (RNs) - Document the nursing process to include: comprehensive assessments, Plan of Care, implementation of treatments and interventions, evaluation and re-assessment of patient outcomes, patient and family education and communication with members of the care team.

b. Licensed Vocational Nurses (LVNs) - Document collection of data and information for a Focused Assessment, changes in patient condition, interventions, altered patient responses, patient teaching and communication with members of the care team.

c. UAPs - document care they provide and data they collect.

A review of patient #1 medical record revealed the document titled "BHCS Orders" dated 04/18/2016 and timed 02:28am, "Intake and Output per unit routine."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:28 am revealed "NPO".

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27 am revealed "Diet Order, Regular Diet."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27 am revealed "Ensure, 3 times daily, flavor(s) vary 1 can."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 12:15 am revealed "Advance Diet as Tolerated, Once, Special Instructions: restart oral sips 2 hours after procedure, advance as tolerated. Patient had topical anesthesia intraoperative."

A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 2:08pm revealed "Restrict Fluids, PO Restrictions, Volume in ml 1000."

A review of a document titled "BHCS Orders" dated 04/23/2016 and timed 8:24am revealed "NS, 1000ml dispensed bag size -Administer a total ordered volume of: 1000ml then discontinue. Ordered as limited volume. Continuous IV, Run at 50ml/hr, Stop after 20 hours, time: 04:23. Nurse Instructions: Ordered as limited volume. Administer total volume of 1000ml. Then discontinue."

A review of a document titled "Shift Assessment Flowsheet" revealed on 04/19/2016 at 4:09 staff #4 documented "Additional Notes: pt requested for snack, offered graham crackers and juice and jello. Pt. consumed a piece of graham cracker, cup of apple juice and half cup of jello, no swallowing difficulty noted, pt. assisted in feeding."

A review of a document titled Intake and Output (I&O) Flowsheet, Shift Total revealed:

04/18/2016 7:00pm, No oral intake was recorded. Staff recorded no urine output from the indwelling urethral catheter.

04/19/2016 7:00am Staff did not record oral intake.

04/19/2016 7:00pm Staff did not record intake.

04/20/2016 7:00am Staff did not record intake.

04/20/2016 7:00pm Staff did not document intake or output.

04/21/2016 7:00am Staff did not document intake or output.

04/22/2016 7:00pm Staff did not document oral intake.

04/23/2016 7:00am Staff did not document no oral intake.

04/24/2016 7:00pm Staff did not document intake or output.

04/25/2016 7:00am Staff did not document intake or output.


(C) A review of the document titled History and Physical revealed Chief Complaint: Fall, History of Present Illness: 73 y/o female with a past medical history of hypertension who presents with falls. History is taken from the patient and her brother, both of whom are poor historians. They report that she has fallen 2-3 times over the last few weeks. She normally walks with a cane, but has had increasing difficulty doing this. She reports longstanding history of abdominal pain with eating for which she is on many "supplements". Brother reports that she has been 70 pounds for quite a while, but her weight has been as high as 90 pounds.

A review of a document titled "Consult Note" revealed "History of Present Illness: This is a 73 y/o Sri Lankan female pt. who migrated to this country in 1998, did not visit Sri Lanka till 2011. Now comes in with complaint of wt. loss and cachexia (a condition that causes extreme weight loss as well as muscle wasting) and falls."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:28am revealed the patient was NPO (nothing by mouth).

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:35am revealed "Evaluate and Treat Speech Therapy (ST), ST to Order: Diet as Appropriate/ Dysphagiagram as Appropriate/ FEES (if available) as appropriate, Evaluate For: Clinical/Bedside Swallow Evaluation."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 02:35am revealed "Nutrition Consult, Routine, Consult Reason: Nutrition Assessment."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27am revealed "Diet Order, Common Diet: Regular" ordered by physician #1.

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 04:27 am revealed "Ensure, 3 times daily, flavor(s) vary 1 can" ordered by physician #1.

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 12:15 am revealed "Advance Diet as Tolerated, Once, Special Instructions: restart oral sips 2 hours after procedure, advance as tolerated. Patient had topical anesthesia intraoperative."

A review of a document titled "BHCS Orders" dated 04/18/2016 and timed 18:17pm revealed "Diet Order, Common Diet: Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- (CARD)." Ordered by the Dietitian #1.

A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 07:22am revealed "Nutrition Consult, Routine, Consult Reason: Nutrition Assessment." Ordered by physician #2.

A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 12:58pm revealed "Diet Order, Common Diet: Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- (CARD) Lactose Restricted- Thin Liquids/ No Liq Restrictions- Mechanical Soft, Chopped. Nurse to Nurse Communication: no ice in drinks: pt. prefers warm drink; no dairy." Diet ordered by Speech Therapist #1.

A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 13:00pm revealed "Nepro 3 times daily Flavor: Vanilla 1 can." Ordered by Dietitian #1

A review of a document titled "BHCS Orders" dated 04/19/2016 and timed 13:26pm revealed "Nepro 2 times daily Flavor: Vanilla 1 can." Ordered by Dietitian #1

A review of a document titled "BHCS Orders" dated 04/21/2016 and timed 15:23pm revealed "Ensure, 3 times daily, Flavor Other: Vary 2 cans Special Instructions: Recommend 2 Ensure Clear with every meal."

A review of a document titled "BHCS Orders" dated 04/22/2016 and timed 15:30pm revealed "Diet Order Common Diet: Soft- Lactose Restricted- Thin Liquids/No Liq Restrictions- Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- Mechanical Soft, Chopped, Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Lo, Radiation Disposable."

A review of a document titled "BHCS Orders" dated 04/24/2016 and timed 9:58am revealed "Food Service Communication, Special Instruction: Soft and/or thin flat chicken or chopped, not just cut into pieces with gravy, Mashed potatoes and green beans well cooked."

A review of a document titled "BHCS" Orders dated 04/25/2016 and timed 13:53pm revealed "Diet Order Lactose Restricted- Mechanical Soft, Chopped, Radiation Disposable."


(D) A review of patient #1 medical record revealed a document titled "BHCS Orders". The order read "Weight, start 04/20/2016, Routine, 1 time weekly, Special Instructions: Once Weekly."

A review of patient #1 medical record revealed the order was not implemented by the nursing staff. There was no evidence the patient was weighed.

An interview on 3/15/2017 at approximately 1:30pm with staff #5 revealed the dietary department had difficulty getting the food tray correct for the patient and the brother would complain when the tray was not correct. The interviewee stated the request was for the patient to have thin chopped chicken, mashed potatoes and green beans well done, no milk products for lunch and dinner, every meal. The patient had chronic pancreatitis and did not produce the enzymes to digest fats. This diet along with her prescribed enzymes (Zenpep) to be taken with meals would not cause abdominal pain and diarrhea in the patient. The interviewee revealed the dietary order system would not accommodate patients ordering specific items for diet and if she was not in the dietary department to check the patient's food trey the dietary personnel would send ordered common diet. Example Order Common Diet: Soft- Lactose Restricted- Thin Liquids/No Liq Restrictions- Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- Mechanical Soft, Chopped, Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Lo, Radiation Disposable.

An interview on 3/15/2017 at approximately 12:00pm with staff #1, #2, and staff #3 revealed we feel the standard of care was met.

Base on document review, the facility failed to:

(A) to provide RN (Registered Nurse) supervision for 1 of 1 patients receiving care at the facility. The RNs failed to follow physician's orders, policy and the procedure for documentation.

(a)The RNs failed to ensure the patients input and output was not monitored and recorded in the medical record.

(b)The RNs failed to record and monitor 1 of 1 patient's weight as ordered.

Refer to tag A395


(B) follow the established facilty policy and State regulations when dispensing the medication Zenpep with an incomplete order. ZENPEP is a prescription medicine for people who cannot digest food normally because their pancreas does not make enough enzymes.

Refer to tag A405

Based on document review, the facility failed to provide RN (Registered Nurse) supervision for 1 of 1 patients receiving care at the facility. The RNs failed to follow physician's orders, policy and the procedure for documentation.

A. The RNs failed to ensure the patients input and output was monitored and recorded in the medical record.

B. The RNs failed to record and monitor 1 of 1 patient's weight as ordered.


A review of the document titled "Clinical Nursing Documentation" revealed:

Policy:

1. Professional clinical documentation is based on the following:

a. Promote inter-professional communication

b. Promote a patient centered health record

c. Validate clinician accountability in provision of safe and appropriate care

d. Meet professional, statutory and regulatory requirements

e. Promote quality improvement ...


3. Nurses have a professional obligation to document an accurate, chronological and comprehensive health record through timely, clear and concise documentation...


4. Frequency of nursing documentation is consistent with identified nursing standards and professional judgment in relation to complexity, stability and acuity of the patient as well as organizational policy.


5. Nurses and UAPs (Unlicensed Assistive Personnel) providing direct patient care and/or management of the patient, document directly in the patient's health record.

a. Registered Nurses (RNs) - Document the nursing process to include: comprehensive assessments, Plan of Care, implementation of treatments and interventions, evaluation and re-assessment of patient outcomes, patient and family education and communication with members of the care team.

b. Licensed Vocational Nurses (LVNs) - Document collection of data and information for a Focused Assessment, changes in patient condition, interventions, altered patient responses, patient teaching and communication with members of the care team.

c. UAPs - document care they provide and data they collect."



(A). A review of patient #1 medical record revealed the document titled BHCS Orders dated 04/18/2016 and timed 02:28am, "Intake and Output per unit routine."

A review of a document titled BHCS Orders dated 04/18/2016 and timed 02:28 am revealed: "NPO".

A review of a document titled BHCS Orders dated 04/18/2016 and timed 04:27 am revealed: "Diet Order, Regular Diet."

A review of a document titled BHCS Orders dated 04/18/2016 and timed 04:27 am revealed: "Ensure, 3 times daily, flavor(s) vary 1 can."

A review of a document titled BHCS Orders dated 04/18/2016 and timed 12:15 am revealed: "Advance Diet as Tolerated, Once, Special Instructions: restart oral sips 2 hours after procedure, advance as tolerated. Patient had topical anesthesia intraoperative."

A review of a document titled BHCS Orders dated 04/19/2016 and timed 2:08pm revealed: "Restrict Fluids, PO Restrictions, Volume in ml 1000."

A review of a document titled BHCS Orders dated 04/23/2016 and timed 8:24am revealed: "NS, 1000ml dispensed bag size -Administer a total ordered volume of: 1000ml then discontinue. Ordered as limited volume. Continuous IV, Run at 50ml/hr, Stop after 20 hours, time: 04:23. Nurse Instructions: Ordered as limited volume. Administer total volume of 1000ml. Then discontinue."

A review of a document titled Shift Assessment Flowsheet revealed on 04/19/2016 at 4:09 staff #4 documented "Additional Notes: pt requested for snack, offered graham crackers and juice and jello. Pt. consumed a piece of graham cracker, cup of apple juice and half cup of jello, no swallowing difficulty noted, pt. assisted in feeding.

A review of a document titled Intake and Output (I&O) Flowsheet, Shift Total revealed:

04/18/2016 7:00pm, No oral intake was recorded. Staff recorded no urine output from the indwelling urethral catheter.

04/19/2016 7:00am Staff did not record oral intake.

04/19/2016 7:00pm Staff did not record intake.

04/20/2016 7:00am Staff did not record intake.

04/20/2016 7:00pm Staff did not document intake or output.

04/21/2016 7:00am Staff did not document intake or output.

04/22/2016 7:00pm Staff did not document oral intake.

04/23/2016 7:00am Staff did not document no oral intake.

04/24/2016 7:00pm Staff did not document intake or output.

04/25/2016 7:00am Staff did not document intake or output.


(B). A review of patient #1 medical record revealed a document titled BHCS Orders. The order read Weight, start 04/20/2016, Routine, 1 time weekly, Special Instructions: Once Weekly.

A review of patient #1 medical record revealed the order was not implemented by the nursing staff. There was no evidence the patient was weighed.

Based on document review, the facility failed to follow the established policy and State regulations when dispensing the medication Zenpep with an incomplete order. Nursing staff medicated 1 of 1 patients without a complete medication order. The nursing staff did not act on behalf of the patient and question the incomplete order. ZENPEP is a prescription medicine for people who cannot digest food normally because their pancreas does not make enough enzymes.

A review of the facility's document titled "Medication Orders" revealed: " Procedures: 2. To be considered complete, all medication orders shall include the drug name, the dosage, the route and frequency of administration, and the time and date the order is written ..."


A review of the Texas Administrative Code, Title 22: Examining Boards, Part 15: Texas State Board of Pharmacy, Chapter 29: Pharmacies, Subchapter D: Institutional Pharmacy (Class C), Rule 291.72: Definitions revealed:

"The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Accurately as prescribed--Distributing and/or delivering a medication drug order:

(A) to the correct patient (or agent of the patient) for whom the drug or device was prescribed;

(B) with the correct drug in the correct strength, quantity, and dosage form ordered by the practitioner; and

(C) with correct labeling as ordered by the practitioner and required by rule."


A review of the document titled "BHCS Orders" revealed "Non Formulary Medication Request, start 04/18/2019, Stop 04/25/2016. Order as Zenpep. Give 3 capsules by mouth 3 times day with meals. Nursing Instructions: Zenpep capsule ***3. [sic]."


A review of hand written document titled "Physician Orders" dated 04/22/2016 and timed 14:15 (2:15pm) revealed a telephone order that read: "Non Formulary Medication Zenpep, please change to 3 capsules PO 3X daily with meals."

A review of hand written document titled "Physician Orders" dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read: "D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals.
Zenpep, 3 capsules PO 3X daily with meals."


A review of the document titled "Medication Administration Record" (MAR) revealed "Non Formulary Medication Request - order as Zenpep capsule. Give 3 capsule by mouth 3 times daily with meals." Further review of the MAR revealed the following:


On 04/18/2016 0800am Not Given: NPO, 12:00pm Not Given: NPO, 1702 (5:02pm) 1 capsule given by mouth.

On 04/19/2016 8:45am 1 capsule given by mouth, 12:45pm 1 capsule given by mouth. No documentation for the 3rd dose. (Not known if it was or was not given)

On 04/20/2016 8:55am 1 capsule given by mouth, 11:37pm 1 capsule given by mouth, 17:30 (5:30pm) not given, patient refused.

On 04/21/2016 8:00am not given, Duplicate Order, 9:56am 1 capsule given by mouth. Instructions per home meds give 3-4 tabs. 12:42 pm 1 capsule given by mouth, 16:59 (4:59pm) 1 capsule given by mouth.

On 04/22/2016 8:51am 1 capsule given by mouth, 12:40 pm 1 capsule given by mouth, 17:38 (5:38pm) 3 capsule given by mouth. The number of capsules given changed from 1 to 3, which was the correct dosage ordered on 4/18/16

On 04/23/2016 9:11am 3 capsule given by mouth, 12:25pm 3 capsule given by mouth, 18:30 (6:30pm) 3 capsule given by mouth.

On 04/24/2016 8:38am 3 capsule given by mouth, 13:01pm (1:01pm) 3 capsule given by mouth, 17:44 (5:44pm) 3 capsule given by mouth.

On 04/25/2016 8:00am not given, Medication not available, 12:00pm (1:01pm) not given, Medication Discontinued.

Evidence showed the patient's home medication was available to be given. The document titled "Physician Orders" dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read: D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals. New order Zenpep, 3 capsules PO 3X daily with meals.

Based on document review and interview, the facility failed to follow national accepted standards, the established policy and State regulations when dispensing the medication Zenpep with an incomplete order. ZENPEP is a prescription medicine for people who cannot digest food normally because their pancreas does not make enough enzymes.

A review of the facility's document titled Medication Orders revealed "Procedures: 2. To be considered complete, all medication orders shall include the drug name, the dosage, the route and frequency of administration, and the time and date the order is written ... "

A review of the AMA defines drug doses revealed:

Drug doses are expressed in conventional metric mass units (eg, milligrams or milligrams per kilogram), rather than in molar SI units. Moreover, certain drugs (such as insulin or heparin) may be prepared as mixtures and have no specific molecular weight, thereby precluding their expression in mass units. Although other drug dose units such as drops (for ophthalmologic preparations), grains (for aspirin), and various apothecary system measurements (eg, teaspoonful, ounces, and drams) may be encountered clinically, these units generally are not used.


A review of the Texas Administrative Code, Title 22: Examining Boards, Part 15: Texas State Board of Pharmacy, Chapter 29: Pharmacies, Subchapter D: Institutional Pharmacy (Class C), Rule 291.72: Definitions revealed:

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Accurately as prescribed--Distributing and/or delivering a medication drug order:

(A) to the correct patient (or agent of the patient) for whom the drug or device was prescribed;

(B) with the correct drug in the correct strength, quantity, and dosage form ordered by the practitioner; and

(C) with correct labeling as ordered by the practitioner and required by rule.


A review of the document titled BHCS Orders revealed Non Formulary Medication Request, start 04/18/2019, Stop 04/25/2016. Order as Zenpep. Give 3 capsules by mouth 3 times day with meals. Nursing Instructions: Zenpep
capsule ***3. [sic].


A review of hand written document titled Physician Orders dated 04/22/2016 and timed 14:15 (2:15pm) revealed a telephone order that read: Non Formulary Medication Zenpep, please change to 3 capsules PO 3X daily with meals.


A review of had written document titled Physician Orders dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read: D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals.
Zenpep, 3 capsules PO 3X daily with meals.


A review of the document titled Medication Administration Record revealed Non Formulary Medication Request - order as Zenpep capsule. Give 3 capsule by mouth 3 times daily with meals.

On 04/18/2016 0800am Not Given: NPO, 12:00pm Not Given: NPO, 1702 (5:02pm) 1 capsule given by mouth.

On 04/19/2016 8:45am 1 capsule given by mouth, 12:45pm 1 capsule given by mouth. No documentation for the 3rd dose. (Not known if it was or was not given)

On 04/20/2016 8:55am 1 capsule given by mouth, 11:37pm 1 capsule given by mouth, 17:30 (5:30pm) not give patient refused.

On 04/21/2016 8:00am not given Duplicate Order, 9:56am 1 capsule given by mouth. Instructions per home meds give 3-4 tabs, 12:42 pm 1 capsule given by mouth, 16:59 (4:59pm) 1 capsule given by mouth.

On 04/22/2016 8:51am 1 capsule given by mouth, 12:40 pm 1 capsule given by mouth, The number of capsules changed from 1 to 3 no evidence of order change on the MAR 17:38 (5:38pm) 3 capsule given by mouth.

On 04/23/2016 9:11am 3 capsule given by mouth, 12:25pm 3 capsule given by mouth, 18:30 (6:30pm) 3 capsule given by mouth.

On 04/24/2016 8:38am 3 capsule given by mouth, 13:01pm (1:01pm) 3 capsule given by mouth, 17:44 (5:44pm) 3 capsule given by mouth.

On 04/25/2016 8:00am not given, Medication not available 12:00pm (1:01pm) not given Medication Discontinued. Evidence shows the patient's home medication was available to be given and the medication was not stopped. The document titled Physician Orders dated 04/25/2016 and timed 13:24 (1:24pm) revealed a telephone order that read: D/C Non Formulary Medication Zenpep, 3 capsules PO 3X daily with meals. New order Zenpep, 3 capsules PO 3X daily with meals.

Based on document review and interview, the facility failed to provide 1 of 1 patient (patient #1) with the dietary request that would have decreased the incidence of abdominal pain and diarrhea and increase the likelihood of increasing the patient's nutritional intake.


A review of the document titled History and Physical revealed Chief Complaint: Fall, History of Present Illness: 73 y/o female with a past medical history of hypertension who presents with falls. History is taken from the patient and her brother, both of whom are poor historians. They report that she has fallen 2-3 times over the last few weeks. She normally walks with a cane, but has had increasing difficulty doing this. She reports longstanding history of abdominal pain with eating for which she is on many "supplements". Brother reports that she has been 70 pounds for quite a while, but her weight has been as high as 90 pounds.


A review of a document titled Consult Note revealed "History of Present Illness: This is a 73 y/o Sri Lankan female pt. who migrated to this country in 1998, did not visit Sri Lanka till 2011. Now comes in with complaint of wt. loss and cachexia (a condition that causes extreme weight loss as well as muscle wasting) and falls."


A review of a document titled BHCS Orders dated 04/18/2016 and timed 02:28am revealed the patient was NPO (nothing by mouth).


A review of a document titled BHCS Orders dated 04/18/2016 and timed 02:35am revealed "Evaluate and Treat Speech Therapy (ST), ST to Order: Diet as Appropriate/ Dysphagiagram as Appropriate/ FEES (if available) as appropriate, Evaluate For: Clinical/Bedside Swallow Evaluation."


A review of a document titled BHCS Orders dated 04/18/2016 and timed 02:35am revealed "Nutrition Consult, Routine, Consult Reason: Nutrition Assessment."


A review of a document titled BHCS Orders dated 04/18/2016 and timed 04:27am revealed "Diet Order, Common Diet: Regular" ordered by physician #1.


A review of a document titled BHCS Orders dated 04/18/2016 and timed 04:27 am revealed "Ensure, 3 times daily, flavor(s) vary 1 can" ordered by physician #1.


A review of a document titled BHCS Orders dated 04/18/2016 and timed 12:15 am revealed "Advance Diet as Tolerated, Once, Special Instructions: restart oral sips 2 hours after procedure, advance as tolerated. Patient had topical anesthesia intraoperative."


A review of a document titled BHCS Orders dated 04/18/2016 and timed 18:17pm revealed "Diet Order, Common Diet: Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- (CARD)." Ordered by the Dietitian #1.


A review of a document titled BHCS Orders dated 04/19/2016 and timed 07:22am revealed "Nutrition Consult, Routine, Consult Reason: Nutrition Assessment." Ordered by physician #2.


A review of a document titled BHCS Orders dated 04/19/2016 and timed 12:58pm revealed "Diet Order, Common Diet: Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- (CARD) Lactose Restricted- Thin Liquids/ No Liq Restrictions- Mechanical Soft, Chopped. Nurse to Nurse Communication: no ice in drinks: pt. prefers warm drink; no dairy." Diet ordered by Speech Therapist #1.


A review of a document titled BHCS Orders dated 04/19/2016 and timed 13:00pm revealed "Nepro 3 times daily Flavor: Vanilla 1 can." Ordered by Dietitian #1.


A review of a document titled BHCS Orders dated 04/19/2016 and timed 13:26pm revealed "Nepro 2 times daily Flavor: Vanilla 1 can." Ordered by Dietitian #1.


A review of a document titled BHCS Orders dated 04/21/2016 and timed 15:23pm revealed "Ensure, 3 times daily, Flavor Other: Vary 2 cans. Special Instructions: Recommend 2 Ensure Clear with every meal."


A review of a document titled BHCS Orders dated 04/22/2016 and timed 15:30pm revealed "Diet Order Common Diet: Soft- Lactose Restricted- Thin Liquids/No Liq Restrictions- Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- Mechanical Soft, Chopped, Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Lo, Radiation Disposable."


A review of a document titled BHCS Orders dated 04/24/2016 and timed 9:58am revealed "Food Service Communication, Special Instruction: Soft and/or thin flat chicken or chopped, not just cut into pieces with gravy, Mashed potatoes and green beans well cooked."


A review of a document titled BHCS Orders dated 04/25/2016 and timed 13:53pm revealed "Diet Order Lactose Restricted- Mechanical Soft, Chopped, Radiation Disposable."


An interview with staff #5 revealed the dietary department had difficulty getting the food tray correct for the patient and the brother would complain when the tray was not correct. The interviewee stated the request was for the patient to have thin chopped chicken, mashed potatoes and green beans well done, no milk products for lunch and dinner, every meal. The patient had chronic pancreatitis and did not produce the enzymes to digest fats. This diet along with her prescribed enzymes (Zenpep) to be taken with meals would not cause abdominal pain and diarrhea in the patient. The interviewee revealed the dietary order system would not accommodate patients ordering specific items for diet and if she was not in the dietary department to check the patient's food tray, the dietary personnel would send ordered common diet. Example Order Common Diet: Soft- Lactose Restricted- Thin Liquids/No Liq Restrictions- Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Low Fat- Mechanical Soft, Chopped, Heart Healthy 3-4 Gram Sodium, Low Cholesterol, Lo, Radiation Disposable.