HospitalInspections.org

Based on findings from medical record (MR) review and staff interview, in 2 of 4 MRs reviewed (Patients A and B), documentation of the patients' dietary intake/nutritional status was not complete.

Findings include:

-- Review of Patient A's MR on 4/14/15 at 3:35 pm revealed admission on 4/9/15 with a cardiac diet order. The MR lacked documentation of receiving meals, snacks and of the percentage of meals consumed over a 96 hour period from 4/10/15 through 4/13/15.

An interview with Patient A on 4/14/15 at 3:30 pm revealed he/she had been receiving meals.

During interview with RN #1 (Manager of Progressive Care Unit) on 4/14/15 at 4:00 pm regarding Patient A's MR, he/she acknowledged the above findings.

-- Review of Patient B's MR on 4/14/15 at 10:02 am revealed admission on 4/4/15 with a diet order of liquids that was advanced to a diabetic diet on 4/7/15. On 4/9/15 after midnight Patient B was ordered NPO (nothing by mouth) due to surgery. An order to resume an oral diet was written later that day at 5:37 pm. However, the MR lacked documentation of the percentage of meals consumed from 5:37 pm on 4/9/15 to 8:23 am on 4/13/15.

Interview of Patient B on 4/14/15 at 11:30 am revealed he/she was receiving meal trays.

During interview of RN #2 on 4/14/15 at 12:40 pm regarding Patient B's MR, he/she confirmed there was inconsistent documentation of meals and snacks and percentage of meals eaten.

-- During interview of RN #3 on 4/14/15 at 11:45 am, he/she reported meal documentation was done by dietary.

During interview of Dietary Aide #1 on 4/14/15 at 11:50 am, he/she reported that dietary aides pick up meal trays from patient rooms and document the percentage of the meal eaten by the patient on a paper list. Then this list is given to staff in the dietary department to enter into patients' MRs within 60-90 minutes after meals.

During interview of Nurse's Aide #1 on 4/14/15 at 12:00 pm, he/she reported the dietary aide documents the percentage of each meal eaten by the patient.

During interview of Nurse's Aide #2 on 4/14/15 at 12:43 pm, he/she reported the dietary aides pick up patients' meal trays after eating, making note of the amount consumed. The dietary department enters this information into patients' MRs.

During interview of the Director of Food & Nutrition on 4/15/15 at 9:00 am, he/she confirmed that the catering associates (dietary aides) are responsible for noting the percentage of a meal eaten when removing trays from patients' rooms during the routine meal times. This documentation is then entered into the electronic MR by another Food & Nutrition Department staff member. Nursing is responsible for documentation when meals are served outside the regular mealtimes and when a patient is on isolation. The Dietary Department would become aware of insufficient documentation of nutrition when a Registered Dietician is ordered for consult or during the Dietary Department's random chart audits. He/she indicated there is no written policy regarding these procedures for meal documentation.

Based on findings from medical record (MR) review, facility document review, and interview, in 2 of 6 MRs reviewed (Patients C & D) verbal /telephone orders were not cosigned by the provider within 48 hours as required by the facility's medical staff rules and regulations.

Findings include:

-- Per MR review, Patients C and D lacked provider signatures for verbal/telephone orders within 48 hours. For example:

Patient A - a telephone order from a physician on 4/8/15 at 3:15 pm for "creatinine body fluid" remained unsigned 6 days later, and

Patient B - a telephone order from a physician on 4/11/15 at 07:30 am for "type and screen" remained unsigned 3 days later.

-- The facility's "Rules and Regulations of The Medical Staff of Our Lady of Lourdes Memorial Hospital," last reviewed 12/2013, stated "Verbal orders must be authenticated within 48 hours."

-- During interviews on 4/14/15 with RN #4 at 10:30 am, and RN #5 at 3:30 pm, the above findings were acknowledged.

-- During interview on 4/15/15 with the Medical Director at 8:50 am, he/she acknowledged that medical staff are using telephone/verbal orders routinely.

Based on findings from document review and interview, 2 out of 4 endoscopic patients' medical records (MRs) (Patients A and B) lacked current history and physicals (H&Ps) completed within 30 days before admission.

Findings include:

-- Per review of Patient A's MR on 4/14/15 at 3:30 pm, he/she had an H&P completed on 3/5/15. Patient A underwent a surgical procedure on 4/14/15, greater than 30 days later. Even though the H&P form indicated the H&P was reviewed with no changes noted, it was not current as it had been completed greater than 30 days prior.

-- Per review of Patient B's MR on 4/14/15 at 3:45 pm, he/she had an H&P completed on 2/26/15. Patient B underwent a surgical procedure on 4/14/15, greater than 30 days later. Even though the H&P form indicated the H&P was reviewed with no changes noted, it was not current as it had been completed greater than 30 days prior.

-- During interview with the Interim Operating Room Director and RN #2 on 4/14/15 at 4:00 pm, the above 2 findings were confirmed.