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Based on patient interviews, policy/procedure review, medical record review, and staff interviews the Hospital staff failed to ensure that information regarding the use of monitoring cameras, located in every patient room, was given to 6 of 6 patients on admission to the Psychiatric Care Unit (PCU) (Patients # 1, 2, 3, 4, 5 and 6). The hospital staff also failed to inform patients of locations in their room where privacy is available. On 11/1/10, Hospital administrative staff reported a PCU census of 6.

Failure to provide PCU patients with information regarding cameras in patient rooms could potentially violate patient ' s right to privacy if patients were unaware of the camera locations in their rooms and/or where patients could go to ensure privacy when performing personal hygiene, toileting, and/or bathing.
Findings include:

1. During an interview, on 11/1/10 at 2:30 PM, Patient #5 reported that he/she was admitted on 10/31/10 and that nursing staff discussed patient rights at that time. Patient #5 stated that he/she was not aware that a camera was located in his/her patient room nor did nursing staff inform him/her that the camera is monitored at the nurses' station.

2. During an interview, on 11/2/10 at 9:30 AM, Patient #2 reported that he/she was admitted on 10/29/10 and that nursing staff discussed patient rights at that time. Patient #2 stated that he/she was not aware that a camera was located in his/her patient room nor did nursing staff inform him/her that the camera was monitored at the nurses' station.

3. On 11/2/10 at 1:30 PM, review of Hospital policy/procedure titled "Patient Rights", reviewed 2/2010, revealed: "Other Rights: A. The right to reasonable privacy including periods and place of privacy."

4. Review of medical records revealed that 6 of 6 open PCU medical records (patients #1, 2, 3, 4, 5, and 6) lacked evidence that the patients received any notification/information regarding the use of cameras in the patient's rooms or that the cameras are monitored in the nurses' station.

5. During an interview, on 11/1/10 at 2:00 PM, Staff A reported that all patient rooms in the PCU are monitored by a camera. The monitor, located in the nurses' station, is used to ensure patient and staff safety. Staff A also reported that patients are informed about the cameras on admission but that "we do not document this in the patients' medical record".

6. During an interview, on 11/2/10 at 9:00 AM, the PCU Nurse Manager reported that "I am not sure if the nurses document that patients are told about the cameras but, I am sure that the nurses are telling patients about the cameras and where to go in there room for privacy."

The PCU Nurse Manager acknowledged that 6 of 6 open medical records (patients #1, 2, 3, 4, 5, and 6) lacked evidence that patients are informed about the patient room cameras at admission or that the cameras are monitored in the nurses' station.

Based on medical record review and staff interview, the hospital failed to ensure the patient ' s medical record included hemodialysis treatment flowsheets that documented the patients ' progress and status during the hemodialysis treatment.
Failure to maintain the hemodialysis treatment flowsheets in the patient ' s medical record could potentially prevent hospital staff from assessing the patient ' s dialysis treatment and providing the care the dialysis patient requires to receive optimal post dialysis care.
The hemodialysis treatment flowsheet is a reflection of the patient ' s hemodialysis treatment and how the patient tolerated the treatment. It includes information regarding the hemodialysis machine safety checks, pre and post patient assessments, treatment prescription, medications given, and the patient ' s status during the treatment (blood pressure, pulse, fluid removed, arterial and venous pressures, blood flow rates, dialysate flow rates, ultrafiltration rates), patient concerns, and hemodialysis staff comments.
The hospital had no current hemodialysis patients at the time of the survey. Findings for 4 of 4 closed medical records reviewed (Patient # ' s 1,2, 3, & 4) include:
1. Review of Patient #1 ' s medical record showed the patient required hospitalization on 7/28/10, and the patient received hemodialysis treatments while hospitalized on 7/30/10 and 8/2/10. Further review showed the patient required hospitalization a second time on 8/19/10 and required hemodialysis treatments while hospitalized on 8/20/10 and 8/21/10.
Review of 4 documents, each titled " DIALYSIS ORDERS " , dated 7/30/10, 8/2/10, 8/20/10, and 8/21/10 respectively, showed the physician ordered the patient to receive hemodialysis on those days.
Further review of the medical record showed documentation of communication between the RN (Registered Nurse) from the hospital and the RN from the dialysis unit indicating the patient received dialysis those days. Information on the communication form included a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient ' s current condition and level of consciousness post treatment. However, the medical record failed to include the hemodialysis treatment flowsheets.
2. Review of Patient #2 ' s medical record showed the patient required hospitalization on 4/6/10, and the patient received hemodialysis treatments while hospitalized on 4/7/10, 4/9/10, 4/12/10, and 4/14/10.
Review of 4 documents, each titled " DIALYSIS ORDERS " , dated 4/7/10, 4/9/10, 4/12/10, and 4/14/10 respectively, showed the physician ordered the patient to receive hemodialysis on those days.
Further review of the medical record showed documentation of communication between the RN (Registered Nurse) from the hospital and the RN from the dialysis unit indicating the patient received dialysis those days. Information on the communication form included a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient ' s current condition and level of consciousness post treatment. However, the medical record failed to include the hemodialysis treatment flowsheets.
3. Review of Patient #3 ' s medical record showed the patient required hospitalization on 4/19/10, and the patient received one hemodialysis treatment while hospitalized on 4/21/10.
Review of a document titled " DIALYSIS ORDERS " , no date or time available, showed the physician ordered the patient to receive hemodialysis.
Further review of the medical record showed documentation of communication between the RN (Registered Nurse) from the hospital and the RN from the dialysis unit on 6/4/10 indicating the patient received dialysis those days. Information on the communication form included a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient ' s current condition and level of consciousness post treatment. However, the medical record failed to include the hemodialysis treatment flowsheets.
4. Review of Patient #4 ' s medical record showed the patient required hospitalization on 6/3/10, and the patient received one hemodialysis treatment while hospitalized on 6/4/10.
Review of a document titled " DIALYSIS ORDERS " , dated 6/4/10, and showed the physician ordered the patient to receive hemodialysis on that day.
Further review of the medical record showed documentation of communication between the RN (Registered Nurse) from the hospital and the RN from the dialysis unit on 6/4/10 indicating the patient received dialysis those days. Information on the communication form included a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient ' s current condition and level of consciousness post treatment. However, the medical record failed to include the hemodialysis treatment flowsheets.
5. During an interview on 11/2/10 at 11:35 AM, the CNE (Chief Nursing Executive) reported a lack of knowledge regarding the need for dialysis treatment flowsheets in hospital records. The CNE stated, " We were audited to death a few years ago and no one ever told us that. We don ' t send inpatient records with them to dialysis. "

Based on medical record review and staff interview the hospital failed to ensure:
1. Nursing staff consistently included the amount of fluid removed during the dialysis treatment when calculating the patients I&O (Intake and Output) at the end of the shift.
2. The written dialysis orders signed by the physician had no areas left blank.
Failure to ensure an accurate account of the dialysis patient ' s output could potentially result in the hospital staff not identifying a patient with too much or too little fluid removed. Too much fluid removed could potentially cause low blood pressure, cramping, and/or dizziness. Too little fluid removed could cause volume overload, fluid retention, and shortness of breath.
Failure to ensure physician orders in regards to fluid removal are complete could potentially allow staff to administer a dialysis treatment that could be harmful or even fatal to the patient.
The hospital had no inpatients receiving hemodialysis at the time of the survey. Findings for 4 of 4 closed medical records reviewed (Patient # ' s 1, 2, 3, and 4) include:
1. Review of Patient #1 ' s medical record revealed the following:
a. Review of a document titled " DIALYSIS ORDERS " , signed by Physician D on 7/30/10, showed an area titled " UF (Ultrafiltration) Profile " and " UF Amount " . The Uf Profile may better preserve blood volume and reduce the incidence of hypotensive episodes. The UF Amount indicates the amount of fluid removed throughout the course of the dialysis treatment. Further review showed these areas remained blank.
b. Review of a document titled " HEMODIALYSIS FLOWSHEET " , dated 7/30/10, showed staff did not use a UF Profile during the treatment. The amount of fluid removed (UF Amount), based on the patient ' s pre and post weight, equaled 0.8 kg (kilograms).
c. Review of a document titled " PHYSICIAN ' S ORDER SHEET " , dated 7/30/10, showed the physician failed to order Contracted Services A staff to remove 0.8 kg (UF Amount) and not to use a UF Profile.
d. Review of a document titled " DIALYSIS ORDERS " , signed by Physician D on 8/20/10, showed an area titled " Dialysate " with lines for the physician to write in the ordered amount of K+ (potassium), Ca (Calcium), and Na (sodium). Further review showed these lines remained blank. Additionally, the physician failed to order the UF Profile.
e. Review of a document titled " HEMODIALYSIS FLOWSHEET " , dated 8/20/10, showed the patient received a 3k/2.5Ca/140Na bath during the dialysis treatment, and no UF Profile.
f. Review of a document titled " PHYSICIAN ' S ORDER SHEET " , dated 8/20/10, failed to show an order for a 3k/2.5Ca/140Na bath and failed to show an order directing staff to not use a UF Profile.
g. Review of a document titled " DIALYSIS ORDERS " , signed by Physician D on 8/21/10, showed an area titled " Dialysate " with lines for the physician to write in the ordered amount of K+ (potassium), Ca (Calcium), Na (sodium), Bicarb, Na Model, and dialysate temperature. Further review showed this area remained blank. In addition, review showed an area titled " DFR (dialysate flow rate) " which also remained blank.
h. The facility was unable to provide a copy of the hemodialysis flowsheet dated 8/21/10.
2. Review of Patient #4 ' s medical record revealed the following:
a. Review of a document titled " DIALYSIS ORDERS " , signed by Physician D on 6/4/10 at 9:10 AM, showed an area titled " UF (Ultrafiltration) Profile " and " UF Amount " . Further review showed these areas remained blank.
b. Review of a document titled " HEMODIALYSIS FLOWSHEET " , dated 6/4/10, showed staff did not use a UF Profile during the treatment, and the amount of fluid removed (UF Amount), based on the patient ' s pre and post weight, and equaled 2.7 kg (kilograms).
c. Review of a document titled " PHYSICIAN ' S ORDER SHEET " , dated 6/4/10, failed to show an order to remove 2.7 kg (UF Amount), and failed to show an order from the physician not to use a UF Profile.
d. Review of a document titled " DIALYSIS ORDERS " , signed by the physician on 6/4/10 at 9:10 AM, showed a box that included " Date " , " Time " , " AM " , and " PM " (regarding when the orders were written). Further review showed this box remained blank.
3. Review of Patient #2 ' s medical record showed the patient required hospitalization on 4/6/10 and during that stay received hemodialysis services on 4/7/10, 4/9/10, 4/123/10, and 4/14/10.
a. Review of a document titled " HEMODIALYSIS FLOWSHEET " , dated 4/9/10, showed the patient ' s weight prior to dialysis equaled 42.7 kg (kilograms) and the post treatment weight equaled 52.2 kg and the amount of fluid removed 0.5 kg.
b. Review of a document titled " VITAL SIGNS/DAILY CARE FLOWSHEET " , dated 4/9/10, reflected documentation regarding the patient ' s daily weight, the amount of urine the patient voided, and the amount of fluids taken orally. However, further review of the document failed to show the amount of fluid removed during the dialysis treatment.
4. Review of Patient #3 ' s medical record showed the patient required hospitalization on 4/19/10 and during that stay received hemodialysis services on 4/21/10.
a. Review of a document titled " HEMODIALYSIS FLOWSHEET " , dated 4/21/10, showed the patient ' s weight prior to dialysis equaled 59.7 kg (kilograms) and the post treatment weight equaled 58.5 kg and the amount of fluid removed 1.2 kg.
b. Review of a document titled " VITAL SIGNS/DAILY CARE FLOWSHEET " , dated 4/21/10, reflected documentation regarding the patient ' s daily weight, the amount of urine the patient voided, and the amount of fluids taken orally. However, further review of the document failed to show the amount of fluid removed during the dialysis treatment.
5. During an interview on 11/2/10 at 11:30 AM, the CNE (Chief Nursing Executive) acknowledged and agreed that the written hemodialysis orders, signed by the physician, contained blank areas and that hospital staff did not consistently document the fluid removed from the patient during dialysis on the hospital flowsheet.

Based on medical record review and staff interview, the hospital staff failed to obtain a properly executed informed consent for hemodialysis services received outside of the hospital during their inpatient stay.
Failure to obtain an informed consent from the patient regarding the dialysis procedure and transport to the dialysis facility could potentially prevent the patient from receiving knowledge regarding the anticipated benefits, material risks, and alternative therapies.
The hospital had no inpatients receiving hemodialysis at the time of the survey. The hospital had 5 admissions for 4 patients (one patient admitted twice) in which the patient received hemodialysis services during their inpatient stay. Findings for 4 of 4 closed medical records reviewed (Patient # ' s 1, 2, 3, and 4) include:
1. The hospital had a contracted service to provide hemodialysis to their inpatients. When a patient requiring hemodialysis is in the hospital, staff reportedly transport patients via wheelchair or stretcher outside to Contracted Services A chronic dialysis unit located approximately one block east of the hospital. Upon completion of the dialysis treatment, hospital staff transport the patients back to their hospital room.
2. Review of Patient #1 ' s medical record showed the patient required hospitalization on 7/28/10, and while in the hospital the patient received hemodialysis treatments on 7/30/10 and 8/2/10. Further review showed the patient required hospitalization a second time on 8/19/10. While in the hospital the patient received hemodialysis treatments on 8/20/10 and 8/21/10.
Review of 2 documents, each titled " CONSENTS AND AUTHORIZATIONS " , dated 7/28/10 and 8/19/10 respectively, showed a form, signed and dated by the patient, which stated in part, " ...CONSENT FOR TREATMENT ...authorize KAH (Keokuk Area Hospital),the attending physician and any consulting physicians, and other practitioners designated by them to prescribe treatment, to administer medications, and to perform such procedures and tests as may be deemed advisable or necessary in the diagnosis of this patient during this hospitalization ...PATHOLOGIST SERVICES ...RADIOLOGIST SERVICES ... " However, further review failed to show the consent for treatment included hemodialysis services. Hemodialysis is a special procedure for patients already diagnosed with ESRD (End-stage Renal Disease) and is not covered under general consent for treatment.
3. Review of Patient #2 ' s medical record showed the patient required hospitalization on 4/6/10, and while in the hospital the patient received hemodialysis treatments on 4/7/10, 4/9/10, 4/12/10, and 4/14/10.
Review of a document titled " CONSENTS AND AUTHORIZATIONS " , dated 4/6/10, showed a form, signed and dated by the patient, which stated in part, " ...CONSENT FOR TREATMENT ... authorize KAH (Keokuk Area Hospital),the attending physician and any consulting physicians, and other practitioners designated by them to prescribe treatment, to administer medications, and to perform such procedures and tests as may be deemed advisable or necessary in the diagnosis of this patient during this hospitalization ...PATHOLOGIST SERVICES ...RADIOLOGIST SERVICES ... " However, further review failed to show the consent for treatment included hemodialysis services. Hemodialysis is a special procedure for patients already diagnosed with ESRD (End-stage Renal Disease) and is not covered under general consent for treatment.
4. Review of Patient #3 ' s medical record showed the patient required hospitalization on 4/19/10, and while in the hospital, the patient received a hemodialysis treatment on 4/21/10.
Review of a document titled " CONSENTS AND AUTHORIZATIONS " , dated 4/21/10, showed a form, signed and dated by the patient, which stated in part, " ...CONSENT FOR TREATMENT ... authorize KAH (Keokuk Area Hospital),the attending physician and any consulting physicians, and other practitioners designated by them to prescribe treatment, to administer medications, and to perform such procedures and tests as may be deemed advisable or necessary in the diagnosis of this patient during this hospitalization ...PATHOLOGIST SERVICES ...RADIOLOGIST SERVICES ... " However, further review failed to show the consent for treatment included hemodialysis services. Hemodialysis is a special procedure for patients already diagnosed with ESRD (End-stage Renal Disease) and is not covered under general consent for treatment.
5. Review of Patient #4 ' s medical record showed the patient required hospitalization on 6/3/10, and while in the hospital, the patient received a hemodialysis treatment on 6/4/10.
Review of a document titled " CONSENTS AND AUTHORIZATIONS " , dated 6/3/10, showed a form, signed and dated by the patient, which stated in part, " ...CONSENT FOR TREATMENT ... authorize KAH (Keokuk Area Hospital),the attending physician and any consulting physicians, and other practitioners designated by them to prescribe treatment, to administer medications, and to perform such procedures and tests as may be deemed advisable or necessary in the diagnosis of this patient during this hospitalization ...PATHOLOGIST SERVICES ...RADIOLOGIST SERVICES ... " However, further review failed to show the consent for treatment included hemodialysis services. Hemodialysis is a special procedure for patients already diagnosed with ESRD (End-stage Renal Disease) and is not covered under general consent for treatment.
6. During an interview on 11/2/10 at 11:35 AM, the CNE (Chief Nursing Executive) reported lack of knowledge regarding the need for dialysis consent forms in hospital records. The CNE stated, " We ' ve never had to have them before. We always used the general consent for treatment. We are not doing the treatment as an inpatient. "

Based on medical record review and staff interview, the hospital staff failed to ensure a nutritional assessment by the dietician occurred when indicated on the admission nutrition screening.
Failure to perform a nutritional assessment on a patient with ESRD (End Stage Renal Disease) could potentially allow the patient to remain on a diet inappropriate to their medical needs. Nutrition-related concerns include maintenance of acceptable weight, fluid balance, and serum proteins, as well as prevention of renal osteodystrophy and reduction of cardiovascular risk related to increased fluid volume.
The hospital had no inpatients receiving hemodialysis at the time of the survey. The hospital had 5 patient admissions (one patient admitted twice) since 5/1/10. Findings for 1 of 4 closed medical records reviewed include:
1. Review of Patient #4 ' s medical record showed the following:
Review of a document titled " ED ADMITTING ORDERS FOR AT " , signed by the physician on 6/3/10, showed the patient presented to the emergency room and required admission to the hospital with a diagnosis of bronchitis, ESRD, and pulmonary edema. Further review of the document showed an area that had a box with a checkmark in it and stated in part, " Diet: Low sodium diet ADA (American Diabetic Association) 1500 calories ... "
Review of a document titled " ADMISSION NUTRITION SCREENING " , signed and dated 6/3/10 by a Registered Nurse, showed an area which stated in part, " ...Policy: Nutritional screening is used to identify patients at nutritional risk ...All patients admitted ...Procedure: Nursing will complete the nutritional screening ...Any check in high or moderate nutritional categories will trigger a nutritional assessment by the dietician ...dietary staff will pick up the screen copies ...and forward to dietician ... " Further review of the document showed a box with a checkmark in it next to the words " Moderate Nutritional Risk ...Moderate Risk Diagnosis ...Renal Disease ... "
Further review of the medical record failed to show a nutritional assessment by a dietician occurred at any time during the hospitalization.
Review of a document titled " PHYSICIAN ' S ORDER SHEET " , dated 6/6/10, showed the physician ordered a renal diet for the patient.
2. During an interview on 11/2/10 at 11:45 AM, the Chief Nursing Executive acknowledged and agreed, in this instance, staff failed to assure a nutritional assessment by a dietician occurred.