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Based on record review and interview, the facility failed to ensure admission orders covered all diagnoses for one patient (Patient #4) of 36 medical records reviewed. The facility census was 106.

Findings included:

1. Review of the facility's document titled, "Medical Staff Rules and Regulations", approved 03/30/09, gave direction, in part, to include the following:"A Medical Staff member with admitting privileges shall be responsible for the medical care and treatment of each patient he or she admits to the Hospital".

2. Review of discharged Patient #4's medical record on 02/17/10 at 10:55 a.m. showed he/she was a Medicaid patient admitted on 12/29/10 with alcohol intoxication and acute pancreatitis (inflammation of the pancreas). The patient had gone to another hospital for treatment of alcoholism and found to be thrombocytopenic (low blood platelet count, which can cause bleeding or delay in clotting) and intoxicated. The patient was transferred to SSM St Joseph Hospital West for acute care treatment. Patient #4 arrived in the ED (emergency department) at 5:00 p.m. A blood test showed the patient had a blood alcohol level of 469 (0 is normal or when no alcohol is detected). Documentation showed that on 12/29/10 at 8:10 p.m., ED physician, staff LL, wrote admission orders but did not include orders for detoxification and possible DT's (delirium tremens [alcohol withdrawal]).

Review of Patient #4's medical record showed that he/she was transferred to the medical/surgical floor on 12/29/09 at 8:09 p.m. There was no documentation of detoxification orders being written until after the patient experienced a seizure on 12/30/09 at 11:13 a.m. The patient was subsequently transferred to ICU (intensive care unit).

Review of Patient #4's intensivist (ICU physician) consult note written 12/30/09 at 1:13 p.m. showed, "Assessment and Plan: 1. Seizure: Almost certainly alcohol related."

Review of Patient #4's discharge summary written 01/11/10 at 11:20 p.m. showed, "The patient developed DT, associated with seizure. The patient developed ataxia (lack of muscle coordination), unable to walk, he was very weak, we treated him with Librium (medication used for the anxiety and withdrawal symptoms of alcoholism), and ativan (medication used for anxiety), his symptoms were improving, however, he remains very weak, he had Neurology consult and CT scan (cat scan [diagnostic test]) and MRI (magnetic resonance imaging [diagnostic test]) of the head, which showed severe cerebral atrophy (loss of cells in the brain or shrinking of the brain) ...".

3. During an interview on 02/17/10 at 11:25 a.m., Director of Nursing, staff BB, stated that he/she had spoken with the ED physician, staff LL, after learning of this situation. Staff BB stated that there is a detoxification (alcohol detoxification) protocol available to physicians in their computerized ordering system. Staff BB stated that the ED physician was not familiar with the on-line detoxification protocol.

4. During an interview on 02/18/10 at 11:20 a.m., Risk Team Leader, staff P, confirmed there were no admitting orders written for alcohol detoxification.

5. During an interview on 02/18/10 at 1:45 p.m., Vice President of Medical Affairs and physician, staff MM, stated that the admitting orders are written by the ED physician. Staff MM stated that ED physician, staff LL, should have written the detoxification orders. Staff MM stated that a peer review had not been accomplished but was in the queue.

Based on observation, medical record review and facility policy, the facility failed to follow facility policy to obtain a physician order for restraints prior to initiating the restraints, and failed to follow their internal policy to obtain physician orders every 24 hours for the use of restraints for one patient out of one current medical record reviewed of a patient with restraints. (Patient #26). The facility census was 106 patients.

Findings included:

Facility policy titled, "Restraint Utilization Non-Violent, Non-Self Destructive", last revised 03/09, stated in part on page 1 of 6, "After restraint alternatives have been determined to be ineffective, the risk of injury or re-injury is noted and the nurse's assessment indicates the patient requires restraints, the physician will be contacted for an order to restrain the patient and the patient then placed in restraints", and on page 2 of 6, "Physician order to include the following: Time limitation (maximum of 24 hours). If restraint is required beyond 24 hours, a new order (including all criteria) is to be obtained".

1. During observation of nursing care to Patient #26 on 02/17/10 at 10:00 a.m. showed Patient #26 with bilateral soft wrist restraints.

Medical record review conducted on 02/17/10 at 3:00 p.m. on Patient #26 of restraint monitoring (an assessment/monitoring tool used by the facility and completed by nursing staff when a patient is in a restraint), showed the patient had been placed in bilateral wrist restraints on 02/11/10 at 2:00 a.m.

There was no physician order found in the medical record for bilateral wrist restraints until 02/11/10 at 10:50 a.m. (Ten hours and 50 minutes after the restraint was initiated).

2. Restraint monitoring from 02/11/10 - 02/12/10 showed the patient had been in bilateral wrist restraints continuously during that time.

The physician order found in the medical record for bilateral wrist restraints for 02/11/10 was timed at 10:50 a.m.

The physician order for bilateral wrist restraints for 02/12/10 was timed at 10:36 p.m. (More than thirty-six hours following the restraint order written on 02/11/10).

3. Restraint monitoring from 02/14/10 - 02/15/10 showed the patient had been in bilateral wrist restraints continuously during that time.

The physician order for bilateral wrist restraints for 02/14/10 was timed at 8:21 p.m. The physician order for bilateral wrist restraints for 02/15/10 was timed at 9:16 p.m. (More than twenty-four hours following the restraint order written on 02/14/10).

4. This was confirmed by Risk Management, staff P, on 02/18/10 at 2:00 p.m.

Based on record review and interviews, the facility failed to follow facility policy and ensure that patient care staff were trained on the use of restraints and restraint first aid for two (Staff JJ and Staff KK) of eleven staff training records reviewed. The facility census was 106 patients.

Findings included:

1. Review of facility policy titled, "Completion of Required Inservices, Training, & Other Work Related Expectations," effective date 01/08 showed the following (in part):
- "Failure on the part of an employee to complete a required inservice/training program or other work related expectations in the expected time frame will result in the removal from the work schedule without pay until completion";
- "Employees are expected to complete the required work at the first available opportunity to access the service and/or training";
- "In the event the employee fails to access the service and/or training at the first opportunity once removed from the work schedule, the employee will be considered to have resigned their position within SSM Health Care as the employee has not met required job expectations".

2. Review of staff training files and interview of Director of Education, Staff X, on 02/18/10 at approximately 10:30 a.m. showed the following:
- Both employees (Staff JJ and staff KK) missed the annual staff "Blitz Training" conducted 10/01/09 and were given "make up" training packets to complete;
- The deadline for completion of "make up" training for restraints and restraint first aid was 12/31/09, however, neither employee had completed the training as of 02/18/10;
- Staff X stated that the supervisor of employees who miss training are responsible for ensuring that the training is completed by the due date, and the reason why the training had not been completed was unknown.

3. During interview on 02/18/10 at approximately 1:00 p.m., Human Resources Director, Staff Y, stated that:
- Restraint and restraint first aid training is required annually
- The facility had been lenient about completion of the training because both employees had been "off duty extensively for FMLA."

4. Review of Timecards for both employees showed:
- Staff JJ worked 18 shifts between 01/01/10 and 02/18/10
- Staff KK worked 21 shifts between 01/01/10 and 02/18/10.

Based on facility policy review, observation and interview, the facility failed to follow nursing standards of practice related to the care of indwelling urinary catheters and failed to implement the facility policy to secure urinary catheters to prevent movement and to prevent tissue injury to the urethra (a canal for the discharge of urine extending from the bladder to the outside).
for five patients (#21, #22, #1, #3, #26) out of six current patients observed with urinary catheters; failed to follow professional standards of care and facility policy regarding Peripherally Inserted Central Catheter (PICC) line dressing changes for one patient (Patient #2); and failed to ensure nurses utilized critical thinking skills to notify a physician of a change in the patient's condition for one patient (Patient #4) of 36 medical records reviewed. The facility census was 106.

Findings included:

1. Review of facility policy, "Indwelling urinary catheter: assessment of need, insertion and maintenance", last reviewed 11/09 showed in section IV, F, "Secure catheter to the upper thigh to prevent tension on the catheter. The catheter may be secured to the lower abdomen in male patients."

Record review of current Patient #21 showed the patient entered the facility 02/15/10 for treatment of congestive heart failure. Review of the physician's orders showed an order dated 02/15/10 for a Foley catheter (a tube inserted into the bladder to provide for a continuous flow of urine) to gravity, insert and maintain.

Observation on 02/17/10 at 9:20 A.M. showed Patient #21 in bed with a Foley catheter. Nursing staff had not secured the catheter tubing to the patient.

Record review of current Patient #22 showed the patient entered the facility 02/10/10 for treatment of pneumonia. Review of the physician's orders showed an order dated 02/10/10 for a Foley catheter to gravity, insert and maintain.

Observation on 02/17/10 at 9:40 A.M. showed Patient #22 in bed with a Foley catheter unsecured to the abdomen or the thigh.

During an interview Staff nurse I said that staff used to anchor Foley catheters to the leg of the patient but they are trying something new and they no longer anchor the catheters. Staff I said he/she did not know what the facility is trying that is new instead of anchoring the catheters.



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During observation of nursing care to Patient #1 on 02/16/10 at 3:30 p.m. showed the patient with an indwelling foley catheter (rubber tubing introduced into the bladder to provide for a continuous flow of urine from the bladder). The foley catheter tubing was not secured to the patient.

During observation of medication administration to Patient #3 on 02/17/10 at 9:15 a.m., showed the patient with an indwelling foley catheter. The foley catheter tubing was not secured to the patient.

During observation of nursing care to Patient #26 on 02/17/10 at 10:00 a.m. by RN, Staff II, showed the patient with an indwelling foley catheter. The foley catheter tubing was not secured to the patient.

During an interview with on 02/17/10 at 10:15 a.m., staff II said that he/she did not know whether the foley catheter tubing should be secured.

2. The facility policy titled Central Venous Catheters: Adult Short Term Catheter Care and Management, dated 01/2010, stated in part, "Transparent occlusive dressing is changed every seven (7) days or more frequently if soiled or loose".

During an interview with Patient #2 on 02/16/10 at 3:25 p.m. showed the patient had a PICC line with a transparent dressing in the right upper arm. The date on the PICC line dressing was 02/05/10.

Review of Patient #2's medical record on 02/17/10 showed the patient had been admitted to the facility on 01/20/10 and discharged on 02/08/10. The patient was readmitted to the facility on 02/10/10 with the PICC line.

Registered Nurse (RN) and Clinical Support Nurse (CSN), staff A, confirmed on 02/16/10 at 3:30 p.m. the date on the PICC line dressing and said the dressing should have been changed.



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3. Review of discharged Patient #4's medical record on 02/17/10 at 10:55 a.m. showed he/she was admitted on 12/29/10 with alcohol intoxication and acute pancreatitis (inflammation of the pancreas). The patient had gone to another hospital for treatment of alcoholism and found to be thrombocytopenic (low blood platelet count, which can cause bleeding or delay in clotting) and intoxicated. The patient was transferred to SSM St Joseph Hospital West for acute care treatment. Patient #4 arrived in the ED (emergency department) at 5:00 p.m. A blood test showed the patient had a blood alcohol level of 469 (0 is normal or when no alcohol is detected). Documentation showed that on 12/29/10 at 8:10 p.m., ED physician, staff LL, wrote admission orders but did not include orders for detoxification and possible DT's (alcohol withdrawal).

Review of Patient #4's medical record showed that Patient #4 was transferred to medical/surgical floor on 12/29/09 at 8:09 p.m. There was no documentation of detoxification orders being written until after the patient experienced a seizure on 12/30/09. The patient was subsequently transferred to ICU (intensive care unit).

Review of Patient #4's nursing flowsheet showed that on 12/30/09 at 8:30 a.m., the registered nurse documented "tremorous" under the heading "Neuromuscular", "Right Upper Extremity" and "Left Upper Extremity". At 11:13 a.m. nursing documentation showed "patient seizing".

During an interview on 02/18/10 at 11:20 a.m., Risk Team Leader, staff P, stated there was no notification made to the physician when the tremors started and a physician was not called until the patient had a seizure.

During an interview on 02/18/10 at 11:55, Registered Nurse, Director of Medical/Surgical, staff NN, stated that the nurse who was assigned to Patient #4 and didn't notify the physician was no longer employed at the facility. Staff NN stated that he/she would expect a nurse to notify the physician when the tremors started as this was part of the DT's.

Based on observation, medical record review, facility policy review and interview, the facility failed to follow the facility's internal policy regarding administration of patients' home medications brought into the facility for one patient (Patient #3) out of six patient's observed during medication administration. The hospital census was 106 patients.

Findings included:

Facility policy titled "Medication Administration", last reviewed 01/10 states in part on page 2, "If using a patient's home medication while in the hospital, please refer to the pharmacy policy pertaining to home medications".

Facility policy titled "Medication Distribution System", last revised 01/09 states in part on page 2, "Home medications which are to be continued during the hospital stay, and which the pharmacy is unable to obtain through its usual sources, may be brought in from the patient's home. The drug product must be identified by a pharmacist before any doses are administered. A bar coded label is placed on the medication/bottle. The pharmacist needs to document in the chart that medications were verified".

1. During observation of medication administration on 02/17/10 at 9:10 a.m. to Patient #3, Registered Nurse (RN), staff M, opened the medication box in the patient's room and retrieved a bottle of medication. The bottle had a label from another pharmacy, but did not have a label from the facility pharmacy.
Staff M administered the Salagen (cholinergic, used to increase secretions of the salivary glands to eliminate dry mouth) 5 mg. tablet from the bottle to the patient.

Observation of the medication on 02/17/10 at approximately 1:30 p.m. showed the bottle in a plastic bag, with an appropriate label with a bar code.

Review of Patient #3's medical record on 02/17/10 at approximately 2:00 p.m. showed the patient had received the medication on 02/14/10 at 9:00 p.m., on 02/15/10 at 9:00 a.m. and 9:00 p.m., on 02/16/10 at 9:00 a.m. and 9:00 p.m., and on 02/17/09 at 9:00 a.m. without the drug having been identified by the pharmacy.
The medical record contained no documentation which stated the pharmacy had identified the medication.

RN, Team Leader, staff B, confirmed this and said that he/she had called pharmacy that morning (02/17/10) to identify and label the medication.

During an interview on 02/17/10 at 2:00 p.m., Pharmacist, staff H stated that he/she had verified the medication that morning after Staff B called. If physician writes an order for the patient to take a home medication, then pharmacy would ask nursing if the medication was on the unit to identify. Staff H did not know how this medication had been missed.

Based on observation, facility policy review, record review, and interview, the facility failed to ensure medications were administered as ordered by the physician for one (Patient #24) of six patients observed during medication administration. The census was 106 patients.

Findings included:

1. Review of facility policy titled, "Network Clinical Practice Policy - Medication Administration", effective date 01/10, showed the following (in part):
- "Medications should be given within 30 minutes before or after the scheduled time".

2. Observation of Registered Nurse (RN), staff K, on 02/17/10 showed the following medications were administered to Patient #24 at 10:07 a.m.:
- Cilostazol (PLETAL) (widens arteries that supply blood to the legs and improves circulation by keeping platelets in the blood from sticking together and clotting) 100 mg (milligrams);
- Clopidrogel (PLAVIX) (keeps platelets in blood from coagulating (clotting) to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions) 75 mg;
- Famotidine (PEPCID) (decreases the amount of acid the stomach produces) 20 mg;
- Gabapentin (NEURONTIN) (anticonvulsant, and also used to treat some types of nerve pain) 200 mg.

Review of the Medication Administration Record (MAR) for 02/17/10 showed:
- The above listed medications were to be given at 9:00 a.m.
- Administration instructions for Cilostazol were to " take 30 minutes before meals or 2 hours after a meal; avoid grapefruit juice. "

In an interview on 02/17/10 at 10:15 a.m., RN, staff K, stated administration of all morning medications for Patient #24 were delayed to allow the appropriate amount of time to lapse between breakfast and Cilostrazol administration.

Based upon record review, interview, and review of facility policies, the facility failed to have accurate weights for seven (#35, 34, 4, 7, 9, 36, 12) of ten patients reviewed for weights; and failed to have complete documentation for one (#35) of one patient reviewed for calorie counts, in a total sample of 36, including a current census of 106.

Finding included:

1. Review of facility policy "Clinical Practice and Outcome Guidelines: Patient Weights (700-430) showed, in part:
"A. Patients are weighed on admission." "Type of scale utilized is documented in the patient's medical record."
"E. If a discrepancy of 5 or more pounds is noted, patient is re-weighed immediately. Bed may be re-zero-ed by nursing or re-calibrated by Clinical Engineering Services as needed." "a. If weight discrepancy is accurate, report to Physician/Clinical nutrition Services along with other relevant clinical data."

2. Review of current Patient #35, admitted 02/10/10 and receiving renal dialysis, showed an admission weight of 228 pounds, no method of weighing noted. On 02/14/10, Patient #35 weighed 245 pounds; and 2/17/10, Patient t#35 weighed 288 pounds, 8 ounces. The Registered, Licensed Dietitian (RDLD) assessment of 02/10/10, recorded in the Progress Notes section, indicated an assumption that the admission weight was a stated weight; and may not be an actual weight. On 02/16/10, the RLDL note mentioned that Patient #35 is 9 liters above normal fluid balance, per intake and output record.
No further action was taken in relation to the patient's weight discrepancy.

3. Review of current Patient #34's medical record showed the patient was admitted 2/14/10 for renal insufficiency, pressure sores and dehydration. The review showed that Patient #34 was identified at high nutritional risk on 02/15/10, and seen by the RDLD on 02/17/10. At that time, the RDLD noted the admission weight of 180 pounds was a stated weight; and requested an accurate weight to be done. During an interview on 02/18/10 at 10:00 a.m., the Registered Dietitian stated that the nursing staff had not yet weighed the patient. The patient was identified at high nutritional risk related to protein deficiency evidenced by Albumin of 2.5 (Normal = 3.5 - 5.0 milligram per deciliter (mg/dl)), pressure ulcers, renal insufficiency and history of poor meal intake. The RDLD was currently assessing the patient's meal intake by monitoring a calorie count of all foods consumed.

4. Review of discharged Patient #4's medical record showed the patient had been admitted 12/29/09 for acute pancreatitis and chronic alcohol abuse. On admission, Patient #4's weight was recorded as 140 pounds. The RDLD assessment was provided on 01/03/10 and noted the physician diagnosis of malnutrition with related encephalopathy. The RDLD requested a current weight be taken. On 01/05/10, Nursing Services weighed the patient as 195 pounds. The RDLD requested a recheck on the weight, which was done on 01/06/10 as 199 pounds.
No further attention was given to the weight change or discrepancy by the day of discharge 01/11/10.

5. Review of discharged Patient #7's medical record showed the patient was admitted 12/27-29/09 for delivery of a baby. The patient's weight was documented as stated.

6. Review of discharged Patient #9's medical record showed the patient was admitted for delivery of a baby; and the patient's weight was documented as stated.

7. Review of Patient t#36's medical record showed the patient was admitted for delivery of a baby; and the patient ' s weight was documented as stated.

8. Review of discharged Patient #12's medical record showed the patient was admitted for Caesarian delivery of a baby; and the patient's weight was documented as stated.

9. In interview on 02/16/10, the RDLD stated that the nutritional services monitors and assesses obstetric patients, as well as other patients. RDLD, staff Z, stated that all of the hospital beds are capable of weighing the patients.
The accurate body weight for patients is essential to accurate Medical Nutrition Therapy assessments for all patients.

In regards to calorie counts:
10. Review of current Patient #35's medical record, showed the RDLD had begun a calorie count for 02/18-02/19/10. In interview on 02/17/10, the RDLD stated the calorie count had to be extended because the initial count was incomplete for meal consumption, to be documented by nursing.

11. Review of current Patient #33's medical record, showed the RDLD began a calorie count to assess meal intake for 02/04-06/10. On 02/7/10, the RDLD assessment showed the calorie count discontinued because no records were kept and tube feedings were beginning. On 02/13/10, a new calorie count was begun; and for the report on 02/14/10, the RDLD noted that only one meal intake was recorded for an intake of 160 calories and 4 grams of protein. The tube feedings had been interrupted because the tube had been pulled out over the night hours. On 02/15/10, the RDLD documentation showed the calorie count had to be extended because there was a "lack of documentation saved to adequately assess pt (patient) po (oral) intake to determine changes in tf (tube feeding) regimen."

12. In interview on 02/16/10 at 10:00 a.m., the RDLD, staff Z, stated that the calorie count information is often missing meal consumption.

Based on observation, facility policy review and interview, the facility failed to follow their internal policy in regard to reporting medication errors for two patients (Patient #3 and Patient #24). The facility census was 106.

Findings included:

1. Review of facility policy titled, "Occurrence Reporting Policy," policy number 54, effective date 09/11/02, on page 2 at B. "Reportable Occurrences" states, "Occurrences that must be reported include, but are not limited to: Medication occurrences"; and states on page 8 at H. Definitions, "Occurrence Report - a formal, written report of a variance that has been standardized across SSMHC. Medication Occurrences - any occurrence at any point in the medication process from the time a drug is ordered until the patient receives it, or fails to receive it."

2. During observation of medication administration on 02/17/10 at 9:10 a.m. to Patient #3, the nurse administered medications to the patient which included Salagen 5 milligrams (mg.) tablet. (Cholinergic, used to increase secretions of the salivary glands to eliminate dry mouth).

Review of the medication administration record (MAR) showed that the patient did not receive the medication the evening of 02/12/10; did not receive the medication at all on 02/13/10; and did not receive the medication on the morning of 02/14/10. The nursing note in the medication administration record (MAR) stated the medication was not administered because the medication was not available.

During an interview on 02/18/10 at approximately 10:00 a.m., Risk Management, staff P, said that no occurrence reports had been completed for these omitted medications.



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3. Observation of Registered Nurse (RN) K on 02/17/10 showed the following medications were administered to Patient #24 at 10:07 a.m.:
- Cilostazol (PLETAL) (widens arteries that supply blood to the legs and improves circulation by keeping platelets in the blood from sticking together and clotting) 100 mg (milligrams);
- Clopidrogel (PLAVIX) (keeps platelets in blood from coagulating (clotting) to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions) 75 mg;
- Famotidine (PEPCID) (decreases the amount of acid the stomach produces) 20 mg;
- Gabapentin (NEURONTIN) (anticonvulsant, and also used to treat some types of nerve pain) 200 mg.

Review of the Medication Administration Record (MAR) for 02/17/10 showed:
- The above listed medications were to be given at 9:00 a.m.
- Administration instructions for Cilostazol were to "take 30 minutes before meals or 2 hours after a meal; avoid grapefruit juice."

In an interview on 02/17/10 at 10:15 a.m., RN ,staff K, stated administration of all morning medications for Patient #24 were delayed to allow the appropriate amount of time to lapse between breakfast and Cilostrazol administration.

In an interview 02/18/10 at approximately 11:30 a.m., Executive Director of Nursing, staff BB, confirmed that medications that were administered late or were missed entirely should be considered an "occurrence" and reported.

In an interview on 02/18/10 at 3:35 p.m., Director of Quality Management, staff Q, stated an "Occurrence Report" associated with late medications for Patient #24 was not done.

Based upon record review, interview, and review of facility policy, the facility failed to assure complete and comprehensive Medical Nutrition Therapy for four (#34, 4, 35, 6) of five patients reviewed for this concern. The current census was 106; and the total sample was 36.

Finding included:

1. Review of facility policy, "Hospitality & Clinical Nutrition Policy #9093.12, Subject: Nutrition Assessment" stated in part:
B. "Nutrition assessments are completed on all acute inpatient status patients identified at nutrition risk.
C. Consults and assessments are completed within 2 days of notification or detection."

2. Hospital Regulations for the State of Missouri at 19CSR 30-20.021 090 4(C) require, "Comprehensive nutritional assessments within twenty-four (24) hours after screens on patients at nutritional risk, including height, weight and pertinent laboratory tests; "

3. Record review for current Patient #34, admitted 02/14/10, and identified at nutritional risk for renal insufficiency and pressure ulcers of the skin on 02/15/10 was not seen by the Registered, Licensed Dietitian (RDLD) until 02/17/10.

4. Record review for discharged Patient #4, admitted 12/30/09 for pancreatitis and alcohol addiction was identified at high nutritional risk on 12/31/09 with a note that the patient was "in care and to be seen". The nutritional assessment was not completed until 01/03/10, day 6 of the patient's admission.

5. Record review for discharged Patient #35, admitted 01/02/10 to 01/05/10 was identified at high nutritional risk for weight loss; but was not seen for Medical Nutrition Therapy during the entire hospital admission.

6. Record review for discharged Patient #6, admitted 01/03/10 for pancreatitis and weight loss was identified at high nutritional risk on 01/03/10; but was not seen by the RDLD until 01/05/10.

7. During an interview on 02/17/10 at 10:00 a.m., the Chief Clinical Dietitian, staff Z, stated that the facility expectation by their policy expected the dietitians to provide a nutritional assessment within 48 hours of identification of patient nutritional risk. Staff Z also stated that the facility had recently (September, 2009) increased the hours allocated for the RDLDs by an additional ? person (or 20 hours per week).
Staff Z has kept quality monitoring on the ability of the RDLDs to meet the nutritional needs of the patients and the Quality Assurance reports have indicated the failure to meet the assessment expectation for nutritional assessment for more than 17.8% of the patients as a total average of the patients in 2009, or a total number of 1493 cases not seen for the year of 2009. This quality tracking, however, was based upon the expectation of nutritional assessment within 48 hours of identification of nutritional risk, not the required 24 hours after identification of nutritional risk. For the month of December, SJHW (St. Joseph Hospital West) Clinical Nutrition Department, January 2010, Review and Analysis showed that 80 consults were not done, "mostly due to the New Year Holiday staffing."