HospitalInspections.org

Based on interview and record review, the facility failed to complete the "Registered Dietician Consult Form" in 3 of 30 records reviewed (Patient's #6, #21 and #29) in a sample of 30 records reviewed.

Findings include:

The facility policy, titled "Nutrition Intervention," dated 5/28/2021, revealed: "I. Nutrition Assessments: Admissions Nurse-If there are any dietary needs or modifications found during the initial assessment, the nurse will fill out the Diet Modification form and send it to dietary. Food Services Supervisor-Submit nutritional questionnaire to Consultant Dietician. Dietician-Interview patient or resident in person or by telephone within 48 hours. Chart assessment and give recommendations to nurse or physician. (sic) III. Recording in Medical Record: Dietician-Record diet consultations and instructions. Review any food intake done by direct-care staff."

A review of Patient #21's closed medical record revealed Patient #21 was admitted to the facility on 2/27/2022. The "Registered Dietician Consult Form" dated 2/27/2022, was blank.

A review of Patient #29's closed medical record revealed Patient #29 was admitted to the facility on 1/13/2022. The "Registered Dietician Consult Form" dated 1/13/2022, was blank.



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A review of Patient #6's open medical record revealed Patient #6 was admitted to the facility on 03/19/2022. The "Registered Dietician Consult Form" dated 03/19/2022 was blank.

During an interview on 03/23/2022 at 9:17 AM, the medical record review findings were discussed with, and confirmed by, Nurse Manager E. Nurse Manager E stated that the nursing staff were expected to complete the "Registered Dietician Consult Form" as part of each patient's nursing admission assessment, and stated nursing staff, "Should have it in the chart that it was completed."

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0225 - Stairway
K- 0521 - HVAC

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0225 - Stairway
K- 0521 - HVAC

Based on record review and interview, the facility staff failed to document a thorough screening neurological examination, including gross testing of cranial nerves, in 23 of 28 patients (Patients #1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 20, 21, 22, 24, 25, 28, 29, 30) with completed physical examinations in a total universe of 30 medical records reviewed.

Findings include:

A review of the facility's policy titled, "Physical Examination on Admission," dated April 30, 2021 revealed, "Each patient admitted ...shall receive a history and physical examination ...and documentation be placed in the patient's medical record within 24 hours of admission. This exam shall include a complete neurological examination ..."

A review of Patient #6's open medical record revealed Patient #6 was admitted to the facility on 03/19/2022. The "Psychiatric Admission History and Physical Examination" form completed on 03/20/2022 revealed in the "Screening Neurological Exam" section, 5 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #7's open medical record revealed Patient #7 was admitted to the facility on 03/22/2022. The "Psychiatric Admission History and Physical Examination" form completed on 03/22/2022 revealed the "Cranial Nerve" section was blank.

A review of Patient #8's open medical record revealed Patient #8 was admitted to the facility on 03/21/2022. The "Psychiatric Admission History and Physical Examination" form completed on 03/22/2022 revealed in the "Screening Neurological Exam" section, 7 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #9's open medical record revealed Patient #9 was admitted to the facility on 03/03/2022. The "Psychiatric Admission History and Physical Examination" form completed on 03/04/2022 revealed in the "Screening Neurological Exam" section, 5 of the 10 sections were left blank. In the "Cranial Nerve" section, 10 of the 12 cranial nerves were not documented as assessed.

A review of Patient #10's open medical revealed Patient #10 was admitted to the facility on 03/20/2022. The "Psychiatric Admission History and Physical Examination" form completed on 03/21/2022 revealed in the "Screening Neurological Exam" section, 9 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #11's open medical record revealed Patient #11 was admitted to the facility on 03/02/2022. The "Psychiatric Admission History and Physical Examination" form completed on 03/03/2022 revealed the "Screening Neurological Exam" section was blank. The "Cranial Nerve" section was blank.

A review of Patient #22's closed medical record revealed Patient #22 was admitted to the facility on 01/29/2022. The "Psychiatric Admission History and Physical Examination" form completed on 01/29/2022 revealed in the "Screening Neurological Exam" section, 6 of the 10 sections were left blank. In the "Cranial Nerve" section, 6 of the 12 cranial nerves were not documented as assessed.

A review of Patient #24's closed medical record revealed Patient #24 was admitted to the facility on 11/11/2021. The "Psychiatric Admission History and Physical Examination" form completed on 11/11/2021 revealed the "Screening Neurological Exam" section was blank. The "Cranial Nerve" section was blank.

A review of Patient #25's closed medical record revealed Patient #25 was admitted to the facility on 08/17/2021. The "Psychiatric Admission History and Physical Examination" form completed on 08/17/2021 revealed in the "Screening Neurological Exam" section, 2 of the 10 sections were left blank. The "Cranial Nerve" section was blank.






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A review of Patient #1's closed medical record revealed Patient #1 was admitted to the facility on 02/25/2022. The "Psychiatric Admission History and Physical Examination" form, completed on 02/25/2022 revealed the "Cranial Nerve" section was blank.

A review of Patient #3's closed medical record revealed Patient #3 was admitted to the facility on 03/16/2022. The "Psychiatric Admission History and Physical Examination" form, completed on 03/16/2022 revealed the "Cranial Nerve" section was blank.

A review of Patient #5's closed medical record revealed Patient #5 was admitted to the facility on 12/13/2021. The "Psychiatric Admission History and Physical Examination" form, completed on 12/14/2021 revealed the "Cranial Nerve" section was blank

A review of Patient #28's closed medical record revealed that Patient #28 was admitted to the facility on 07/26/2021. The "Psychiatric Admission History and Physical Examination" form, completed on
07/27/2021 revealed the "Cranial Nerve" section was blank.





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A review of Patient #12's closed medical record revealed Patient #12 was admitted to the facility on 04/25/2021. The "Psychiatric Admission History and Physical Examination" form completed on 04/26/2021, revealed in the "Screening Neurological Exam" section, 6 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #13's closed medical record revealed Patient #13 was admitted to the facility on 12/09/2021. The "Psychiatric Admission History and Physical Examination" form completed on 12/10/2021, revealed in the "Screening Neurological Exam" section, 7 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #14's closed medical record revealed Patient #14 was admitted to the facility on 08/26/2021. The "Psychiatric Admission History and Physical Examination" form completed on 08/26/2021, revealed in the "Screening Neurological Exam" section, 5 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #16's closed medical record revealed Patient #16 was admitted to the facility on 01/04/2021. The "Psychiatric Admission History and Physical Examination" form completed on 01/05/2021, revealed in the "Screening Neurological Exam" section, 10 of the 10 sections were left blank. The "Cranial Nerve" section was blank.


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A review of Patient #17's closed medical record revealed Patient #17 was admitted to the facility on 05/11/2021. The "Psychiatric Admission History and Physical Examination" form completed on 5/11/2021, revealed the "Cranial Nerve" section was blank.

A review of Patient #18's closed medical record revealed Patient #18 was admitted to the facility on 08/09/2021. The "Psychiatric Admission History and Physical Examination" form completed on 08/09/2021 revealed in the "Screening Neurological Exam" section, 3 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #20's closed medical record revealed Patient #20 was admitted to the facility on 10/28/2021. The "Psychiatric Admission History and Physical Examination" form completed on 10/29/2021 revealed in the "Screening Neurological Exam" section, 6 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

A review of Patient #21's closed medical record revealed Patient #21 was admitted to the facility on 02/27/2022. The "Psychiatric Admission History and Physical Examination" form completed on 02/28/2022 revealed in the "Screening Neurological Exam" section was blank. The "Cranial Nerve" section was blank.

A review of Patient #29's closed medical record revealed Patient #29 was admitted to the facility on 01/13/2022. The "Psychiatric Admission History and Physical Examination" form completed on 01/14/2022 revealed in the "Screening Neurological Exam" section was blank. The "Cranial Nerve" section was blank.

A review of Patient #30's closed medical record revealed Patient #30 was admitted to the facility on 02/14/2022. The "Psychiatric Admission History and Physical Examination" form completed on 02/15/2022 revealed in the "Screening Neurological Exam" section, 1 of the 10 sections were left blank. The "Cranial Nerve" section was blank.

During an interview on 03/23/2022 at 9:13 AM, the medical record review findings were discussed with and confirmed by Nurse Manager E who stated, "The providers are supposed to be doing neuro exams," and confirmed the physicians were expected to document the cranial nerve assessments.