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Based on review of facility policies and procedures, observation, and staff interview, it was determined that the center failed to maintain the confidentiality of records against unauthorized usage in the Emergency Room (ER) area.

Findings were:

Review of facility policy, entitled Confidentiality (A.5- Protecting Health Information), reviewed 02/25/03, revealed that patient records ...would not be left unattended.

Observation in the ER at 2:30 p.m. on 07/13/2010, in the company of the director of medical records, revealed that an area noted as a clean utility room contained clinic medical records. The door to this clean utility room was unlocked. Patients and visitors had unlimited access to this area, as patient rooms were located directly across the hall from this clean utility room. The director of medical records stated that the door would be immediately secured.

Observation of the same area at 9:30 a.m. on 07/14/2010, in the company of the supervisor of the ER, again revealed that the same clean utility room door remained open and medical records remained accessible to unauthorized persons. The supervisor of the ER stated that the door would be secured.

Observation of the ER's clean utility room at 11:00 a.m. on 07/14/2010, in the company of the facility's maintenance director, revealed that the door to the clean utility room was locked and secured and could only be opened with a key.

Based on review of facility policies and procedures, job descriptions, medical records, and staff interviews, it was determined that the facility failed to provide criteria as to when the dietician was to be notified regarding a patient's nutritional needs.

Findings were:

Review of facility policy and procedure, entitled Nutritional Assessment, no policy number, last revised 07/6/10, indicated that a nutritional assessment and dietary history would be completed by the Certified Dietary Manager (CDM)/RD (Registered Dietician) obtained by information gathered by nursing service on all patients who were moderate to high risk. The policy continued to indicate that the CDM/RD would determine the patient's level of nutrition risk.

Review of the facility's Admission Assessment document indicated that the
assessment included whether the patient was a swing bed patient, was receiving TPN (intravenous fluids mixed with nutritional supplements/vitamins/medications), was receiving tube feedings, was on special diets, had unintentional weight loss, had a pressure ulcer (non healing wounds), had swallowing or chewing problems, appeared malnourished, or had multiple food allergies or intolerances. How the list was answered determined the assignment of a specific score.

Review of the CDM job description failed to reveal any specific training regarding nutritional assessment nor were there any requirements related to when and under what circumstances the CDM was required to notify the Dietician.

During an interview while on tour of the dietary department at 3:10 p.m. on 7/13/2010 and during an interview at 10:30 a.m. on 7/15/2010 in the facility's conference room, the Certified Dietary Manager (personnel file # 5) stated that any patient that received a score of twenty (20), a patient on TPN, or a swing bed patient would automatically trigger a dietary consult. The CDM stated that there were no specific triggers or indicators regarding patient lab values, and was really unsure at times when the dietician needed to be contacted. The CDM stated that the dietician visited the facility one day per month and would review medical records and visit patients while at the facility. When the CDM was asked about the assessment scoring process, he/she was unsure about the scores, but stated that when the nurses completed the patient's admission assessment, the computer automatically totaled the patient's nutritional score.

Review of the facility's dietician job description indicated that he/she would review the Dietary Department and make recommendations to the CDM, but there was no specific criteria noted regarding when the dietician would be contacted.

During a phone interview at 4:10 on 7/14/2010, the dietician (staff interview # 1) stated that he/she reviewed all patient charts, especially swing bed patients or any special concerns. The dietician stated that he/she handled consults throughout the month, and visited the facility once per month. The dietician stated that, if the CDM had any trouble, he/she would consult the dietician, but confirmed there was no specific criteria for the CDM to follow. The dietician further stated that any patient on TPN, on a tube feeding, having poor intake, nausea, vomiting, or diarrhea, was assigned points. If the patient had twenty (20) points or greater, then the the CDM would handle that assessment. The dietician stated that if lab values were out of range, he/she was supposed to be contacted.

Review of medical record # 30 revealed that the patient had been readmitted into the facility less than 24 hours after discharge, but according to the initial assessment, did not require a nutritional consult, even though the patient had a history of diabetes with an admitting blood glucose level of 930 (normal range 60/70-120/130), a diabetic wound, low hemoglobin and hematocrit (7.8 and 22.5), total protein in the blood of 5.0 (Normal range 6-8.3) and a serum albumin level of 1.6 (normal range greater than 4). The patient received two units of blood on day 2 of hospitalization to treat his/her low hemoglobin and hematocrit.