HospitalInspections.org

Based on medical record review, policy and document review and staff interview, it was determined that the hospital failed to inform the durable power of attorney (DPOA) or patient representative of the patients' rights at the time of admission for 3 of 5 patients (Patient #'s 1, 3 and 4) in the sample. Findings include:

The hospital policy entitled "Patient Rights and Responsibilities Procedure" stated, "...Health System upholds the rights of all recipients to be fully informed during the admission process of their rights and responsibilities as a patient...On admission...legally authorized individual for dependent adult or surrogate is provided with a copy of the patient rights statement ('Patient Rights & Responsibilities')...patient rights statement...read to...legally authorized individual for dependent adult or surrogate...social worker checks the medical record to ensure that the acknowledgement of receipt has been signed...social worker assists...power of attorney of a dependent adult patient...or surrogate in signing unsigned consents or answering additional questions regarding patient rights..."

Medical record review revealed the following:
A. Patient #1 - Admitted 11/24/13 with admitting diagnosis of dementia with behavioral disturbances1. The hospital document entitled "Advance Directives..." included documentation by staff on 11/24/13 that Patient #1 had a durable power of attorney (person appointed to direct medical care). 2. There was no documented evidence in the medical record that Patient #1's DPOA had received the patient rights information.B. Patient #3 - Admitted 12/3/13 with an admitting diagnosis of dementia with behavioral disturbances1. The hospital document entitled "Advance Directives..." included no documentation by staff on 12/3/13 that Patient #3 had a DPOA or legal guardian. 2. The hospital's "...Intake Sheet" identified Patient #3's adult child as an "emergency contact".3. Patient #3 refused to sign an attestation of the receipt of "Notification of Patient's Rights" and ...Notice of Privacy Practices". - Staff documented on the form dated 12/3/13, "Pt (patient) has dementia & is unable to sign".- There was no documented evidence in the medical record that Patient #3's adult child (responsible party) had received the patient rights information. C. Patient #4 - Admitted on 12/7/13 with an admitting diagnosis of dementia with behavioral disturbances1. The hospital document entitled "Advance Directives..." included documentation by staff on 12/7/13 that Patient #4 had a DPOA.2. There was no documented evidence in the medical record that the DPOA had received the patient rights information.During an interview with Director of Nursing (DON) A and Director of Performance Improvement/Risk Management on 12/13/13 at 1:20 PM, DON A confirmed that staff should have:

- contacted the responsible parties for Patient #'s 1, 3 and 4
- reviewed the patients' rights with the appointed individuals
- documented the acknowledgement of the review in their medical records

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #1) in the sample admitted to the hospital, staff failed to promptly notify the family member or representative of the admission. Findings include:

The hospital policy entitled "Surrogate Decision-Making for Adults" stated, "...Where a durable power of attorney or appointed agent for healthcare decisions is in place, this individual is clearly identified and provides any necessary consents for patient treatment...To the extent possible, designated individual must be involved in...Initial consent to treatment..."

Medical record review revealed the following:

A. Patient #1
1. The "Registration Admission" document revealed Patient #1 was admitted on 11/24/13 at 2:40 AM with a diagnosis of dementia with behavioral disturbances.
2. The hospital document entitled "Advance Directives..." included documentation by staff on 11/24/13 that Patient #1 had a durable power of attorney (DPOA - person appointed to direct medical care).

3. The "Coordination of Care Communication" document included the following entries:

11/25/13 (no time of medical record entry)
- unsuccessful attempt to reach Patient #1's DPOA (message left)
- spoke with wife and completed bio (patient history); discharge planning initiated

4. The "Psychosocial Assessment" completed by Social Worker A during a phone conversation with Patient #1's DPOA was dated 11/25/13 at 11:10 AM.

5. Review of the medical record revealed that the first documented contact between the hospital and Patient #1's DPOA was 31.50 hours after Patient #1's admission.

Interview with Director of Nursing A on 12/6/13 at 2:45 PM, confirmed that Patient #1's DPOA was not contacted within 24 hours of admission, which was the hospital's expectation.

I. Based on medical record review, policy and job description review and staff interview, it was determined that nursing staff failed to report physical assessment findings to the physician for 1 of 5 patients (Patient #1) in the sample. Findings include:

The hospital policy entitled "Required Information and Order of the Medical Record" stated, "...Document the course of care...Promote continuity of care among healthcare providers...Clinical observations..."

The hospital job description entitled "Registered Nurse" stated, "...Communicates promptly to attending, on-call physician, medical consultant...significant changes in patient status..."

Medical record review revealed the following:

A. Patient #1

1. "Daily Nursing Assessment" documentation revealed the following:

11/24/13 at 3:00 PM
- choked when assisted to eat
- refer to medical for further evaluation

11/25/13 at 3:00 PM
- assisted with all activities of daily living including feeding

11/26/13 at 3:30 PM
- during lunch let food and fluid run out of mouth

2. During interviews with the following staff, it was determined that Patient #1 experienced the following nutritional barriers throughout the hospitalization: a. Registered nurse (RN) B on 12/6/13 at 3:30 PM:- On pureed diet- Staff fed Patient #1- Some trouble with swallowing; did well on pureed diet- Intake poor- Would keep food in mouth and hesitate to swallow, but eventually swallowedb. RN A on 12/9/13 at 10:30 AM:- On pureed diet and did well- Staff fed Patient #1- Spoke with Medical Director A regarding patient holding food and fluid in mouth - letting food and fluid run out of mouthc. Licensed Practical Nurse (LPN) A on 12/13/13 at 9:15 AM:- Staff fed Patient #1- Parkinsonian-like movements of arms affected ability to feed self - Couldn't eat regular food when sent up from kitchen; did well on pureed dietd. Aide A on 12/13/13 at 1:54 PM:- On pureed diet- Difficult to feed- Would not open mouthDuring an interview on 12/13/13 at 8:26 AM, Medical Physician A confirmed:
- staff concerns related to choking and/or swallowing had not been reported to him/her during the hospitalization
- any concerns related to eating, choking or swallowing would have been investigated by the medical physician if they had been reported

II. Based on medical record review, policy and job description review and staff interview, it was determined that nursing staff failed to follow physician's orders for 1 of 5 patients (Patient #1) in the sample. Findings include:

The hospital job description entitled "Registered Nurse" stated, "...Assessment of Patients...Obtains urines and other tests from patients in a timely fashion when ordered & (and) plays an active role in tracking lab work..."

The hospital policy entitled "Required Information and Order of the Medical Record" stated, "...Assessment documents including...test results...laboratory reports..."

Medical record review revealed the following:

A. Patient #1

1. Review of the "Medication Reconciliation Form" completed by the RN on 11/24/13, revealed that prior to hospital admission, Patient #1 had been prescribed coumadin (blood thinner) at bedtime.

2. "Physician's Orders" dated 11/23/13 at 7:45 PM included an order for a PT/INR (prothrombin time/international normalized ratio - used to check whether medicine to prevent blood clots is working) to be drawn STAT (immediately) in the morning of 11/24/13.

3. Review of the medical record revealed no evidence to support that the 11/24/13 stat blood specimen for the PT/INR blood level was obtained as ordered.

Interview with RN A on 12/9/13 at 10:30 AM confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #1) in the sample, nursing staff failed to revise the interdisciplinary care plan to reflect current patient care needs. Findings include:

The hospital policy entitled "Treatment Planning" stated, "...treatment plan will be individualized and identify the specific needs and goals of the patient and the specific interventions..."The hospital policy entitled "Required Information and Order of the Medical Record" stated, "...Treatment plan...All updates, re-assessments and revisions of the treatment plan..."I. Patient #1
Medical record review revealed the following:

A. Bowel and bladder incontinence (unable to control urine and/or bowel movements).1. Review of the "CNA (certified nurse assistant) Flow Sheet" documentation revealed periods of bowel and bladder incontinence on the following dates:11/24/13Evening shift - Incontinent of urineNight shift - Incontinent of urine 11/25/13Night shift - Incontinent of urine11/26/13Night shift - Incontinent of urine11/27/13Day shift - Incontinent of urine Night shift - Incontinent of urine 11/28/13Day shift - Incontinent of urine and bowels2. Review of the "Intake/Output Record" included the following documented output information (the section combined bowel and bladder output):11/24/135:00 PM - 6:00 PM - Incontinent x 111/25/1312:00 AM - 1:00 AM - Incontinent x 15:00 AM - 6:00 AM - Incontinent x 1
7:00 AM - 8:00 AM - Incontinent x 15:00 PM - 6:00 PM - Incontinent x 28:00 PM - 9:00 PM - Incontinent x 111/26/137:00 AM - 8:00 AM - Incontinent x 1 7:00 PM - 8:00 PM - Incontinent x 111/27/1311:00 PM - 12:00 AM - Incontinent x 15:00 AM - 6:00 AM - Incontinent x 11:00 PM - 2:00 PM - Incontinent x 18:00 PM - 9:00 PM - Incontinent x 13. The "Treatment Plan Co-Morbid (Medical)" failed to include:- Bowel and bladder incontinence as a current problem- Interventions currently in place - Attainable goalsDuring an interview on 12/9/13 at 10:30 AM, registered nurse (RN) A reported that Patient #1 was both continent and incontinent during the hospitalization. RN A reported that in an effort to prevent incontinence, staff was trying to toilet Patient #1 on a regular basis. RN A confirmed that the treatment plan had not been revised to include Patient #1's identified incontinence problem. B. Difficulty eating
1. "Daily Nursing Assessment" documentation revealed the following:

11/24/13 at 3:00 PM
- choked when assisted to eat
- refer to medical for further evaluation

11/25/13 at 3:00 PM
- assisted with all activities of daily living including feeding

11/26/13 at 3:30 PM
- during lunch let food and fluid run out of mouth

2. During interviews with the following staff, it was determined that Patient #1 experienced the following nutritional barriers throughout the hospitalization: a. RN B on 12/6/13 at 3:30 PM:- On pureed diet- Staff fed Patient #1- Some trouble with swallowing; did well on pureed diet- Intake poor- Would keep food in mouth and hesitate to swallow, but eventually swallowedb. RN A on 12/9/13 at 10:30 AM:- On pureed diet and did well- Staff fed Patient #1- Spoke with Medical Director A regarding patient holding food and fluid in mouth - letting food and fluid run out of mouthc. Licensed Practical Nurse (LPN) A on 12/13/13 at 9:15 AM:- Staff fed Patient #1- Parkinsonian-like movements of arms affected ability to feed self - Couldn't eat regular food when sent up from kitchen; did well on pureed dietd. Aide A on 12/13/13 at 1:54 PM:- On pureed diet- Difficult to feed- Would not open mouth
3. The "Treatment Plan Co-Morbid (Medical)" failed to address Patient #1's difficulty eating and necessary interventions.During an interview on 12/13/13 at 1:25 PM, Director of Nursing A reported that the treatment plan should have been revised to address Patient #1's difficulty eating and interventions in place.

I. Based on medical record review, policy and document review and staff interview, it was determined that entries in the medical record were not timed for 3 of 5 patients (Patient #'s 1, 3 and 5) in the sample. Findings include:

The hospital policy entitled "Required Information and Order of the Medical Record" stated, "...medical record and documentation within are to be...accurate, timely..."

The hospital policy entitled "Focus Documentation and Legal Guidelines" stated, "...Include the...time..."

Medical record review revealed the following:

A. Patient #1

The "Coordination of Care Communication" document contained the following untimed entries:

- 11/25/13 - (4) entries
- 11/27/13 - (1) entry

B. Patient #3

The "Coordination of Care Communication" document contained the following untimed entries:

- 12/4/13 - (1) entry
- 12/5/13 - (1) entry

C. Patient #5

The "Coordination of Care Communication" document contained the following untimed entries:

11/21/13 - (3) entries
11/25/13 - (1) entry
11/27/13 - (1) entry
12/2/13 (1) entry

Interview with Director of Performance Improvement and Risk Management A and Director of Nursing (DON A) A on 12/13/13 at 1:26 PM confirmed these findings.

II. Based on medical record review, policy review and staff interview, it was determined that nursing staff failed to document communication with the physician for 1 of 5 patient's (Patient #1) in the sample. Findings include:

The hospital policy entitled "Required Information and Order of the Medical Record" stated, "...Document the course of care...Promote continuity of care among healthcare providers...Clinical observations...Patient's response to care, treatment and services..."

Medical record review revealed the following:

A. Patient #1

a. The "Daily Nursing Assessment" dated 11/24/13 at 3:00 PM included the following clinical assessment:

- involuntary jerking movement
- choked when assisted to eat
- refer to medical for further assessment

b. The "History & Physical" dictated on 11/25/13 at 12:55 PM included no documented reference related to staff reporting the 11/24/13 observation of involuntary jerking or choking when being fed to the medical physician

c. The "Integrated Progress Note" and other medical record documentation:

- included no documented evidence that staff reported the observation of involuntary jerking to the medical physician on the day of discovery or prior to Medical Physician A's physical examination of Patient #1
- included no documented evidence that staff reported the observation of choking or other ingestion problems to the medical physician during the hospitalization

Medical Physician A confirmed the following during an interview on 12/13/13 at 8:26 AM:

- involuntary jerking was not observed during the 11/25/13 admission physical examination and staff concerns related to involuntary jerking had not been reported to him/her prior to the physical examination
- choking was not observed during the 11/25/13 admission physical examination and staff concerns related to choking and/or swallowing had not been reported to him/her during the hospitalization
- any reported concerns related to eating, choking or swallowing would have been investigated

Interview with DON A on 12/6/13 at 3:45 PM confirmed that there was no documentation in the medical record to support that the information related to choking had been communicated to the medical physician. In addition, DON A confirmed that there was no documentation in the medical record to support that the information related to Patient #1's involuntary jerking had been communicated to the medical physician on the day of discovery or prior to Medical Physician A's initial examination of Patient #1.

III. Based on medical record review, policy and document review and staff interview, it was determined that the medical record did not include medication consents for 1 of 5 patients (Patient #1) in the sample. Findings include:

The hospital policy entitled "Required Information and Order of the Medical Record" stated, "...Each patient's medical record contains...Evidence of informed consent for treatment and for psychopharmacological treatment..."

The hospital document entitled "Medication Consent" stated, "...By signing this consent for medication, I acknowledge that my...rights regarding medication administration and education about the indication for use of medication has [sic] given to me..."

Medical record review revealed the following:

A. Patient #1

- Admitted 11/24/13 with admitting diagnosis of dementia with behavioral disturbances- The hospital document entitled "Advance Directives..." included documentation by staff on 11/24/13 that Patient #1 had a durable power of attorney (DPOA - person appointed to direct medical care).
- No evidence of a medication consent signed by Patient #1's DPOA

Interview with DON A on 12/13/13 at 1:26 PM confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that the medical record for 1 of 1 patients (Patient #1) in the sample with a dietary consult, failed to contain an ordered consultative evaluation. Findings include:

The hospital policy entitled "Nutritional Assessment of High Risk Patients" stated, "...Physician orders a consult...Timeliness for dietary consultation of inpatients completed by the Dietitian...Within 72 hours after notification of a consult request...Registered Dietitian completes the consultation form or records his or her assessment in the progress note."Medical record review revealed the following:

A. Patient #11. "Geriatric Admission Orders" dated 11/24/13 at 5:30 AM included a physician's order for a dietary consult.2. There was no documented evidence of a completed dietary consult.
Interview with Director of Nursing A on 12/9/13 at 11:15 AM confirmed this finding.

Based on medical record review, policy and job description review and staff interview, it was determined that for 1 of 5 patients (Patient #1) in the sample, the medical record failed to include reports of all lab results necessary to monitor the patient's condition. Findings include:
The hospital job description entitled "Registered Nurse" stated, "...Assessment of Patients...Obtains urines and other tests from patients in a timely fashion when ordered & (and) plays an active role in tracking lab work..."

The hospital policy entitled "Required Information and Order of the Medical Record" stated, "...documentation is necessary to monitor the patient's condition...Assessment documents including...test results...laboratory reports..."

A. Patient #1

1. Review of the "Medication Reconciliation Form" completed by the registered nurse (RN) on 11/24/13, revealed that prior to hospital admission, Patient #1 had been prescribed coumadin (blood thinner) at bedtime.

2. "Physician's Orders" dated 11/23/13 at 7:45 PM included an order for a PT/INR (prothrombin time/international normalized ratio - used to check whether medicine to prevent blood clots is working) blood level to be drawn STAT (immediately) in the morning of 11/24/13.

3. Review of the medical record revealed no evidence to support that the 11/24/13 stat blood specimen for the PT/INR blood level was obtained as ordered.

Interview with RN A on 12/9/13 at 10:30 AM confirmed this finding.