HospitalInspections.org

Based on record review and interview, the hospital failed to ensure consent for treatment for one (Patient #8) of twenty patients.

This failed practice has the likelihood to place patients at risk of not understanding treatment options, thereby reducing their capacity to participate in treatment planning and in the request or refusal of treatment.

Patient #8

A review of a document titled "Conditions for Admission-Permission for Treatment" read in part, "Items in this Authorization for Medical Treatment have been fully explained to me and I certify that I understand its contents; therefore permission is hereby granted for examinations and treatment deemed necessary and advisable during the visit. I have received the Grady Memorial Hospital's "Patient Information & Visitor's Guide," which explains my patient rights."

A review of the medical record showed the patient was admitted to the hospital on 06/12/20. Documentation showed no signed Conditions for Admission-Permission for Treatment consent form.

On 09/23/20 at 10:02 AM, Staff H reviewed the medical record for Patient #8 and stated a Conditions for Admission-Permission for Treatment consent should have been obtained to show the patient agreed to care at this hospital and was aware of their rights.

Based on record review and interview, the hospital failed to ensure further interventions were in place after initial interventions failed to achieve a self-identified performance improvement goal for one (Food and Nutrition Services) of one performance improvement projects.

This failed practice has the likelihood place patients at risk of receiving quality of care identified by the hospital as in need of improvement.

A review of a document titled "Quality Assessment, Performance Improvement, and Patient Safety Plan" read in part, "The QAPI and Patient Safety Council is comprised of key members ...These key members work directly and openly to improve quality by ...acting on recommendations ...The QAPI and Patient Safety Council ...is comprised of: CEO, VP of Patient Care Services, QAPI/Risk/Patient Safety Director ...The work groups/teams discuss data analysis and determine what actions must be implemented to attain the desired outcome. Analysis usually involves numerous reviews to examine different aspects of the performance issue ...Implementation of actions and re-measurement occurs with refinement in actions if the desired outcome is not achieved ...Evaluations of performance improvement activities will be reviewed annually by the QAPI and Patient Safety Council."

A review of a document titled "Food and Nutrition Services QI [Quality Improvement] Initiative" showed a goal for patients to receive at least 90% of the ordered volume of enteral nutrition. The document showed a result of 0% achievement for the months of February, April, June, July, and August of 2020.

On 09/21/20 from 2:33 PM to 3:00 PM, Staff G stated the following:
1. He or she had previously reached out to Staff A about the role nursing documentation might have had in the PI project falling short of goal.
2. This had been a PI project for fourteen years.

On 09/23/20 at 11:20 AM, Staff C stated the following:
1. He or she didn't think interventions to reach the PI project goal were documented.
2. His or her role in PI projects was to sit in with them every fall.
3. He or she reviewed PI data monthly or every other month to make sure it had been reported and sometimes would analyze the PI project data.
4. They were getting a team together to address reaching the PI project goal to make sure patients get the calories they need.
5. He or she would provide the PI project annual reviews to this surveyor. Staff C never returned with these.

On 09/23/20 at 11:40 AM, Staff A stated the following:
1. He or she was not familiar with the Food and Nutrition Services PI project until yesterday.
2. He or she had a meeting scheduled for the following Monday, 09/28/20, to assemble a team to address the PI project and what seemed to be a "disconnect" with nursing documentation of tube feeding.

Based on record review and interview, the hospital failed to ensure its written instruction was followed to provide nutrition as ordered for 1 (Patient #1) of 20 patients.

This failed practice has the likelihood place patients at risk of receiving care inconsistent with the hospital's standard of care, thereby placing the patient at risk of skin, muscular, cognitive, digestive, urinary, and cardiac impairment or death.

Patient #1

A review of a policy titled "Enteral Tube Feeding Administration and Monitoring" read in part, "Nursing: Will administer the TF [tube feeding] as ordered."

A review of a document titled "Review Patient's Orders" showed the patient was to receive 1200 mL of Glucerna 1.2 per day starting on 09/11/20.

A review of a document titled "Extra PCI Database Source" showed the 24-hour tube feeding intake for 09/14/20 was 720 mL. (480 mL short).

On 09/22/20 at 11:56 AM, Staff H reviewed the medical record for Patient #1 and stated the following:
1. The patient did not receive the ordered amount of Glucerna on 09/14/20
2. The risk of inadequate nutrition was delayed healing or skin breakdown

Based on observation and interview, the hospital failed to maintain a sanitary environment, increasing the risk of infections by failing to assess the surgical area and ensure control of possible infectious exposures.

Findings:

During tour of surgical department in surgical bays 1, 2, and 3 chairs non-continuous, pourous coverings was being used by the staff members adminstering anesthesia.

On 09/21/20 at 1:16 pm, Staff O stated the chairs were not able to be disenfected due to the seams in the covering.