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Based on observation, interview and record review, the facility failed to ensure that all medical staff (Physician 1) was accountable for the quality of care and services provided to all patients (Patient 7) and that Psychiatrist 1 followed the bylaws. This failure created the risk of substandard healthcare for Patient 1.

Findings:

A record review, on September 11, 2012 at 10:55 AM, revealed that Patient 7 was admitted to the facility on August 23, 2012, with diagnoses which included Major Depressive Disorder (a condition characterized by a long-lasting saddened mood or marked loss of interest or pleasure in all or nearly all activities) and dementia (a loss of brain function that occurs with certain disease processes. It affects memory, thinking, language, judgment and behavior). Patient 7 weighed 98 pounds on admission.

A record review on September 11, 2012 at 10:55 AM, revealed that on August 24, 2012, a Registered Dietician (RD 1) documented on a "Multidisciplinary Progress Note" on August 24, 2012, that Patient 7 "...triggered for possible weight change..." and possible poor oral intake. RD 1 included recommendations to obtain "...weekly weights to monitor trends..."

A record review, on September 11, 2012, at 10:55 AM, of Physician 1's orders from August 24, 2012, revealed that there were no orders for "weekly weights" as RD 1 recommended for monitoring for changes in Patient 7's weight. There were no orders written to obtain strict intake and output (I & 0) measurements after RD 1 identified that Patient 7 could possibly have poor oral intake.

A record review, on September 11, 2012, at various times, revealed that from August 24, 2012, when RD 1 recommended obtaining weekly weights, to September 11, 2012, weekly weights were not obtained for Patient 7.

A record review, on September 11, 2012, at various times, revealed that from August 24, 2012, when RD 1 documented that Patient 7 triggered for possible poor oral intake to September 11, 2012, there was no continuous monitoring of all of Patient 7's intake and outputs throughout each day.

A record review, on September 11, 2012 at 3 PM, revealed that a nurse documented, on August 29, 2012, that Patient 7's blood pressure dropped to 64/35 (normal 120/80). The patient had no urine output since midnight and was not eating or drinking well.

A record review, on September 11, 2012 at 3 PM, revealed that on August 29, 2012 at 2:15 PM, a nurse obtained a telephone order from Physician 1 to transfer Patient 7 to a local emergency department "due to failure to thrive (a decline) and dehydration." On August 30, 2012, Patient 7 returned to the facility after receiving treatment for dehydration. No additional orders were documented by a physician to address the dehydration or to monitor Patient 7's I & O.

A record review, on September 11, 2012 at 3 PM, revealed that on September 4, 2012 Patient 7 weighed 95 pounds (a three pound weight loss since admission). The record review also revealed that from August 30, 2012 (after Patient 7 returned from the emergency department to obtain treatment for dehydration) to September 11, 2012 no additional monitoring was done to ensure that Patient 7 did not develop dehydration again.

During an interview, on September 11, 2012 at 3:50 PM, with the Patient Care Manager of Adult Services, he stated that the physician did not write an order to obtain weekly weights for Patient 7 but that it was a standard practice of the facility to obtain weekly weights on all patients. The manager stated that for Patient 7, no weekly weights were obtained and that the physician also did not order to obtain strict intakes and output measurements for Patient 7. He stated that the nurses could have provided closer monitoring of Patient 7's I & O and that the nurses' documentation "wasn't good," (referring to the I & O documentation). When the manager was asked if there had been any additional monitoring of Patient 7's I & O after the patient returned from the emergency department to ensure that the patient did not get dehydrated again, he stated "No."

A record review, on September 11, 2012 at 3:50 PM, of Patient 7's meal consumption from September 5, 2012 to September 10, 2012, indicated that Patient 7's intake had decreased.

On September 11, 2012 at 4 PM, an interview was conducted with Psychiatrist 1. After she reviewed Patient 7's meal consumption from September 5, 2012 to September 10, 2012, she verified that the meal percentages which were documented demonstrated that Patient 7's intake had decreased. Psychiatrist 1 stated that it was the same pattern noted prior to the patient being transferred to the emergency department for dehydration and that orders to monitor intake and outputs were not ordered after Patient 7 returned from the emergency department because she was medically cleared. Psychiatrist 1 was asked how she could ensure that Patient 1 did not develop dehydration again and was being monitored for the risk of possible dehydration, she responded, "The internist (Physician 1) sees her (referring to Patient 7)."

An interview and a concurrent record review was conducted on September 12, 2012 at 8:40 AM (of Patient 7's meal consumption records from September 5, 2012 to September 10, 2012), with the Patient Care Manager of Adult Services. He stated that Patient 7 had poor intake and that the intake & outputs and the weekly weights had not been consistently documented.

On September 12, 2012 at 9:50 AM, RD 1 was interviewed (RD 1 was the dietician who recommended weekly weights and identified that Patient 7 triggered for poor oral intake). She stated that she can only make the recommendations and that it is up to the physician to write the orders to measure the patient's weight and I & O.
On September 12, 2012 at 10:10 AM, Physician 1 was interviewed regarding Patient 7's dehydration status, its monitoring and the measurements of the patient's weekly weights. He stated, "I can't reassure you that it won't happen again, it will. It's something that happens here often. My hands are tied. I can only do so much. We can't put in a Foley (a catheter inserted into the bladder to provide close observation of a patients urine output) or an IV (intravenous line which could be used to provide hydration) and we can't put in a PEG-tube (a tube inserted into the stomach to provide nutrition) the facility does not provide these treatments. She's a chronic dementia patient and nobody will but in a PEG. We have to wait until she (Patient 7) drops her blood pressure then transfer her out. I can't prevent the dehydration." Physician 1 stated that he had to wait until the patient starves to death and "I know it sounds bad but I can't do anything else. Give me a solution (surveyor told him that it was not possible to provide a solution and that the facility needed a plan to prevent the dehydration from occurring again or to provide closer monitoring of the patient), he stated, "Well I can't do that. We are keeping her sedated, that's all we can do and comfort measures because if we ease up on the medications, she becomes more alert and combative. There is nothing more we can do because she has chronic dementia." Physician 1 was asked about RD 1's recommendations to address the I & O and weekly weight measurements to monitor Patient 7's oral intake and possible weight changes. He stated, "They can write all the recommendations they want to, it doesn't mean I am going to write orders for them ..." He also stated that the nurses informed him that Patient 7 was eating. Physician 1 was asked why he did not feel it was necessary to monitor Patient 7's I & O and weight. He stated, "It's too difficult because she's combative and has chronic dementia." He was asked if he had attempted to measure the patient's I & O or weight, he responded that "there's no point."

During an interview, with the Governing Body members, on September 12, 2012 in the afternoon, the Medical Director stated that Physician 1 was "highly emotional" and that it was "not our standard of practice to dismiss the Dietician's recommendations" and that the nurses track I & O but do not always document them. The Medical Director stated that Physician 1 was the consultant for Patient 7 but that Psychiatrist 1, was the patient's attending physician who had the "Ultimate responsibility" of the patient. The Medical Director also stated that they "Absolutely never just let patients starve to death or wait until they lose their blood pressure to transfer them out" and that they do not have recurrent dehydration cases that get transferred out to the emergency department. The Medical Director stated that it was a documentation issue and that they know they can do a better job of documenting I & Os. He stated that the facility never allows patients to deteriorate before treatment is provided and that the facility realized that they could have provided closer monitoring of the patient but that the patient was not harmed. The Medical Director stated that once a month, they perform random reviews of consultations but they had not done so for this particular case.

A record review, on September 13, 2012 at 3:15 PM, of the facility's "2012 - 2013 Medical Staff Rules and Regulation, approved by the Governing Board on May 16, 2012" documented the following, "...Overall responsibility for the treatment plan rests with the attending physician ..."



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