HospitalInspections.org

29578

Based on review of hospital policies and procedures, review of medical records, and staff interviews, it was determined the hospital's administrator failed to ensure that the medical record contained re-assessment after administration of pain medications for two (2) of two patients (Patient #7 and 27) which has the potential to increase the risk of patients not receiving adequate pain control in the patient population.

Findings include:

Review of facility's policy titled: " Nursing Services Age Appropriate Pain Assessment Tools And Management " requires: " ...Determine patient ' s age and developmental level ...assess the amount of pain the patient is feeling and treat accordingly...If there is not...an order for pain medication call the physician...Administer medication...Reassess patient ' s pain level after 30 minutes if IV medication is given, and 60 minutes if PO pain medication given...If patient is still in pain, consider other interventions...notify doctor of continued pain .... "

Patient # 7's medical record revealed that pain was not re-assessed for the following dates and times.

On 4/24/15 at 2135, Patient #7 had complaints of pain of "8" on the pain scale ( pain scale is documented from 1-10, with 1 being the least pain and 10 being the most pain). The patient received Oxycodone IR 5 mg. There was no documentation of the pain re-assessment in the medical record.

On 4/25/15 at 0246, Patient #7 had complaints of pain of "6" on the pain scale. The patient received Oxycodone IR 5 mg. There was no documentation of the pain re-assessment in the medical record.

On 5/01/15 at 2300, Patient #7 had complaints of pain of "7" on the pain scale. The patient received Oxycodone IR 5 mg. The documentation of the pain re-assessment in the medical record revealed it was completed on 5/2/15 at 0148. This was almost three hours after the administration of the medication.

On 5/3/15 at 2005, Patient #7 had complaints of pain of "5" on the pain scale. The patient received Tylenol. There was no documentation of the pain re-assessment in the medical record.

The Clinical Care Coordinator # 16 confirmed in interview conducted on 6/4/15, that the re-assessment was not completed on the dates of 4/24, 4/25, and 5/3/15. She also confirmed that the re-assessment for pain was almost three hours after administration of the pain medication on 5/1/15.

Patient # 27's medical record revealed that pain was not re-assessed and/or not reassessed in the time allotment required per hospital policy for the following dates and times.

On 4/11/14 at 2256 hours, Patient #27 had complaints of pain of "8" on the pain scale. Patient received Oxycodone 2 mg. There was no documentation of the pain re-assessment in the medical record.

On 4/12/14 at 1820 hours, Patient #27 had complaints of pain of "8" on the pain scale. Patient received Oxycodone 2 mg. The patient was re-assessed at 2007 hours for a pain scale of "0", however, reassessment was completed after the required 60 minute time frame.

On 4/16/14 at 2210 hours, Patient #27 had complaints of pain of "8" on the pain scale. The patient received Oxycodone 2 mg. The patient was re-assessed at 2345 hours for a pain scale of 2, however, reassessment was completed after the required 60 minute time frame.

The Clinical Care Coordinator # 16 confirmed during an interview conducted on 6/5/15, that the re-assessment was not completed, or was not completed in the time frame required per hospital policy.

Based on review of policy and procedure, staff interviews, and observations, it was determined the administrator failed to ensure a current diet manual approved by the medical staff is available as evidenced by lack of the facility to provide documentation of the manual being approved by Medical Staff.

Findings:

Review of hospital policy titled "Dietetic Service Therapeutic Diets/Menus" dated 10/13, reviewed 2/2015 revealed: "... A current diet manual shall be readily available to attending physicians, food service personnel. and licensed nursing personnel...."

Observation on 6/3/15, in the hospital kitchen/food preparation area revealed the Simplified Diet Manual,11th Edition, Iowa Dietetic Association. copyright 2012.

Dietician # 14 confirmed in an interview conducted on 06/04/2015, confirmed the Simplified Diet Manual, Iowa Dietetic Association, copyright 2012 was the current diet reference used by the staff for patient meals and diets.

Employee # 15 confirmed during an interview conducted on 06/03/15, that the ' Simplified Diet Manual, Iowa Dietetic Association', copyright 2012 is the reference sources for patient meals and diets.

The Director of Nursing confirmed during an interview conducted on 06/05/2015, the 'Simplified Diet Manual, Iowa Dietetic Association,' copyright 2012 is the most current diet reference used by the staff for patient meals and diets.

The facility could not provide documentation while the surveyors were on site that the most current diet manual was approved by the medical staff.

The Director of Nursing confirmed during an interview conducted on 06/05/2015, there was no documentation that the 'Simplified Diet Manual, Iowa Dietetic Association,' copyright 2012 was approved by the Medical Staff.

Based on review of the hospital Infection Control Plan, hospital policy/procedure, observations on tour, and staff interviews it was determined the hospital's infection control officer failed to establish, document and implement policies that identified the following deficiencies which have the potential to increase the risk of infection in the patient population:

1. Visitors not donning gowns or gloves prior to entering a contact isolation room or;

2. Visitors not performing hand hygiene when exiting a contact isolation room.

Findings include:

Review of facility's Infection Control Plan Policy #14.4.1.5 revised 03/10/13, revealed: " ...object of the Infection Control Plan is to prevent and control the spread of infections and communicable/contagious diseases...provide and maintain a sanitary environment for patients, personnel, visitors and the general public...precautions will be on each patient's door to alert hospital staff, visitors, patients, family members, physicians, volunteers... Post Contact Precautions sign on the patient's door...wear gown and gloves when entering room. Remove gown and gloves and clean hands prior to leaving the room...."

1. During a tour of the facility 06/02/15, at 0930 hours, this surveyor observed Room #1 with signage of contact Isolation. An adult male and female child was observed performing hand hygiene prior to entering the Isolation room. This surveyor observed a total of 6 visitors in the isolation room without wearing gowns or gloves.

2. The above observation revealed two adults and two children exiting the isolation room without performing hand hygiene and walking down the hall and entering the family kitchen area.

RN # 10 confirmed during an interview conducted 06/02/15 at 0945 hours, that the facility does not require families to gown and glove prior to entering a contact isolation room of a family member; however, staff is expected to follow contact isolation protocols.

The Assistant Director of Nursing confirmed during an interview conducted 06/02/15 at 0950 hours, that the virus was inside the infant's mouth. The Assistant Director confirmed that the hospital cannot constantly monitor all family members or visitors visiting patients in the hospital.

The contracted Infectious Disease Physician confirmed during an interview conducted 06/03/15 at 1030 hours, that the infant was completing the ordered anti-viral medication course. The Physician confirmed during the same interview that the risk in the infant transferring the disease is low. The Physician also confirmed that it would be difficult to "find any hospital to comply 100%" with family compliance of contact isolation protocols.

Based on review of hospital policy and procedure, hospital documents, observation on tour, patient interviews, and staff interviews, it was determined the facility failed to provide specific diet menus which has resulted in two patients not receiving diets as ordered by the physician for two of two patients (Patient #'s 5 and 6).

Findings include:

Review of hospital policy titled "Dietetic Service Therapeutic Diets/Menus" dated 10/13, reviewed 2/2015 revealed: "...Diets shall be provided for each patient as prescribed...A copy of the meal selections and dates prepared/ offered will be kept in the patient's chart...."

Review of the job description for Registered Dietician revealed: "... assist in planning practical basic...meals and nourishment lists...coordinate menu planning...."

Review of the facility consulting agreement for corporate dietitians revealed: "...Services to be provided by consultant: Consultant agrees to provide services to Facility as specifically requested, including but not limited to...monthly observation and recommendations regarding shopping and menu selection...approval of all menu selections...assessing and counseling patients and/or their families concerning regular and therapeutic diets...."

Observation on tour of the kitchen on 6/3/15, and 6/5/15, revealed the presence of a dietary manual not approved by the medical staff, and a freezer containing commercial frozen foods available in grocery stores: commercial prepackaged frozen waffles, box of white castle burgers, box of corn dogs, individual pizzas, dinosaur shaped chicken nuggets, vegetables, and peanut butter sandwiches. The refrigerator was observed to contain individual containers of juices and milk. Direct observation of the food supplied routinely did not identify designated meals for therapeutic purposes.

Patient # 5 medical record revealed the following. Patient # 5 was admitted on 10/15/14, with a diagnoses of high-output cardiac failure secondary to severe anemia and malnutrition and protein C deficiency and for diet education.

Admission orders revealed orders for Dietary consult and a 3 gram sodium, cardiac diet.

Review of the medical record further revealed that the dietary consult was completed on 10/17/14 with nutritional education given to patient regarding low sodium food choices, choose better food options to prevent anemia, malnutrition,and protein C deficiency. Patient was educated on food choices that were low in sodium and foods to avoid due to high sodium. There was no evidence in the chart of a therapeutic diet for a 3 gram sodium, cardiac diet.

Patient # 5's medical record revealed that the foods that were served as follows:

Breakfast 10/16/14: eggs, hash browns, bacon, and yogurt; 10/17/14: bagel with cream cheese and water; 10/18/14: eggs, corn, carrots, bacon and cheese with Kool-Aid; 10/19/14: egg beaters, cheese and Kool-Aid; 10/20/14: Pancakes and fruit with water.

Lunches were as follows: 10/16/14: pork, carrots, apples and strawberries with Gatorade; 10/17/14: carrots, banana, yogurt, pork and bread with Gatorade; 10/18/14: toast x 2, mayo, turkey, cheetos, and banana with water; 10/19/14: instant mashed potatoes, chicken nuggets, and a banana with Kool-Aid; 10/20/14: instant mashed potatoes, chicken nuggets, and corn with Kool-Aid. PM snacks were as follows: 10/18/14: cheetos; 10/19/14: ice cream x 2 and strawberries; 10/20/14: cheetos. There was no documentation of PM snacks given to the patient for 10/15/14 through 10/17/14.

Dinners were as follows: 10/15/14: chicken noodle soup (from a can), corn, apples and yogurt; 10/16/14: hot dog, yogurt, cookies, and pizza hot pocket;10/17/14: turkey, cheetos, cheesecake, bread, mayo and grapes; 10/18/14: Reese peanut butter cup, cheesecake, taquitos, strawberries and a potato with butter and sour cream with water; 10/19/14: thin bagel, mayo, turkey. cheetos, and cucumber slices with Kool-Aid. Hour of Sleep snacks were as follows: 10/15/14: bagel and cream cheese; 10/17/14: chips; 10/18/14: bread,cheese, potatoes, cucumber slices and a shake made with strawberries, milk and ice cream; 10/19/14: hot pocket, chips and a shake.

RN #8 and #17 confirmed in interviews conducted on 6/4/15, that the sodium needed to be calculated for Patient #5 from reading the labels on the food packages. RN #8 and # 17 confirmed that there is no specific 3 gram Sodium, Cardiac diet menu to follow.

Dietician #14 confirmed in an interview conducted on 6/4/15, that some of food choices documented in the Patient # 5's record did not follow a therapeutic diet for 3 gram sodium cardiac diet.

Employee # 15 confirmed there is no written meal plan for a patient on a 3 gram sodium cardiac diet. She also confirmed that the facility buys the pre-packaged food according to the requests of the patient and staff. She also confirmed that patients are given food choices based on what is available in the refrigerator, freezer and cupboards.

Patient # 6 medical record revealed the following: Patient # 6 was admitted on 3/29/15 with diagnoses of multiple fractures after a car accident; pulmonary contusions and liver and spleen lacerations. Patient admitted primarily for physical therapy and occupational therapy. Patient was non-weight bearing on the right side.

Review of physician's orders revealed that patient was ordered a regular diet.

There was no evidence in the chart of a therapeutic diet for a regular diet. Patient # 6's medical record revealed that the foods that were served and consumed were as follows:

Breakfast meals that were served and consumed are: 3/30/15: yogurt and breakfast scrambles; 4/1/15: no specific foods documented for breakfast; 4/2/15: waffles, eggs, bacon, hash browns and juice; and 4/3/15: breakfast sandwich and a granola bar with Gatorade. The medical record did not contain documentation of breakfast items served and consumed on 3/31/15.

Lunch meals that were served and consumed are: 3/30/15: pizza, hot pocket, and peanut butter crackers with Gatorade; 3/31/15: hot pocket and fruit with Gatorade; 4/1/15: pizza, vegetables, and fruit with soda from Mom; and 4/2/15: chicken nuggets, corn, brownie and apple with Gatorade.

Dinner meals that were served and consumed are: 3/30/15: chicken nuggets, corn, apple sauce, and fruit snacks with juice; 3/31/15: chicken, fruit and vegetables with water; 4/1/15: pizza, corn, yogurt, and banana; and 4/2/15: peanut butter and jelly sandwich, carrots and yogurt with juice.

Morning snacks that were served and consumed were only documented on 3/30/15, of a Halo orange, and ice cream with Gatorade. Evening snacks that were served and consumed are documented for 3/31/15: goldfish crackers; and for 4/2/15: chicken nuggets, and apple sauce with Gatorade.

Employee # 15 confirmed there is no written meal plan for a patient on a regular diet.

Dietician #14 confirmed in an interview conducted on 6/4/15, that some of food choices documented in the Patient # 6's record, who was on a regular diet was the same foods documented in Patient # 5's record, who was on a 3 gram sodium cardiac diet.

Dietician # 14 in an interview conducted on 6/4/15, the meals are heated in the microwave in the kitchen area and served on disposable plates or bowls. Eating utensils are plastic disposable, and drinking cups are Styrofoam and disposable. Dietician # 14 also confirmed that there were no menu plans provided to the staff for preparation of food. She also confirmed that the staff have the food pyramid to assist them in preparing diets for the patients. The Registered Dietician also confirmed that the registered dietician provides oversight for meal plans.

RN # 8 confirmed in an interview conducted on 6/4/15, that the nurses have to choose the food from what is available and calculate the right amount of calories, sodium if ordered, and portions for the patient. She also confirmed that the diet manual that is located in the kitchen only has a few diet menus and that they are aimed at adults.

RN # 17 confirmed in an interview conducted on 6/4/15, that the nurses have to prepare the foods for the patient. She confirmed that therapeutic diet menus are not available for staff and patients to review.

MD # 2 confirmed in an interview conducted on 6/4/15, that she was not aware that the facility did not have documented diet menus for the staff to follow to provide specific diets.

Assistant Director of Nursing confirmed in an interview conducted on 6/3/15, that the facility prepares food in a microwave. She confirmed that specific diet menus are not available to staff and patients. She stated that the staff just follow the food pyramid for food choices and portions.

The Director of Nursing confirmed in an interview conducted on 6/5/15, that specific diet menus are not available to staff and patients. She stated that the staff just follow the food pyramid for food choices and portions.

The staff do not have menu plans, do not document all available food choices and selections, and follow guidelines from a diet manual not approved by the medical staff.