HospitalInspections.org

Based on observation, interview, and record review, the facility failed for three of thirty patients, to ensure information necessary to monitor the patients' condition was documented completely. The facility failed:

1. to ensure CIWA and COWS forms were completed for Patient 200 and a COWS form was completed for Patient 205. This failure resulted in the potential for the patients' detoxification status to go unevaluated and the failure to establish an appropriate treatment plan; and

2. to follow physician's orders to complete a PSA following Patient 206's admission. This failed practice placed the patient at risk for having an inaccurate medical record and at risk for not receiving needed services.

Findings:

1. The facility policy titled, "CIWA/COWS," with a revision date of June 2008, was reviewed on July 6, 2010. The policy indicated the following:

a. the CIWA was designed to be an objective rating scale that provided a detailed evidence based measure for alcohol withdrawal status;

b. the COWS Scale was developed and designed to objectively evaluate criteria associated with opiate withdrawal;

c. daily assessment of withdrawal symptoms was required to evaluate the patient's detoxification status, to establish an appropriate treatment plan, and to provide clinical information to the treatment team;

d. the Charge Nurse would complete a current CIWA/COWS based on a face to face assessment of detoxification symptoms for each patient and the scale would be placed in each patient's medical record for physician review; and,

e. the higher the score, the more severe the symptoms, "which suggests a greater risk of complications, i.e. seizures, hallucinations, confusion, DT's."

a. On July 6, 2010, at 11 a.m., Patient 200 was observed standing in the hall, outside the medication room. Patient 200 was asking the medication nurse for a pill to help her relax.

The record for Patient 200 was reviewed on July 6, 2010. Patient 200 was admitted to the facility on June 27, 2010, with diagnoses that included alcohol and opiate dependence.

Patient 200's record contained a form titled, "Opiate Withdrawal Assessment Flowsheet." The form included a place to document the substances used by the patient in addition to opiates. Across the top of the page were places to document the day (of detox), date, time, blood pressure, pulse, respirations and temperature. The body of the document was used to evaluate criteria such as GI upset, sweating, tremors, restlessness, yawning, pupil size, anxiety, bone aches, gooseflesh, runny nose, and tearing.

Patient 200's Opiate Withdrawal Assessment Flowsheet indicated scores were documented on June 27, 28, and 29, 2010 (1st, 2nd and 3rd day of detox). The next documented score was dated July 3, 2010, and identified as the 7th day of detoxification. There was no documentation of daily COWS scores for June 30 or July 1 or 2, 2010.

Patient 200's record contained a form titled "Alcohol Withdrawal Assessment Flowsheet." The form included a place to document the substances used by the patient in addition to opiates. Across the top of the page were places to document the day (of detox), date, time, blood pressure, pulse, respirations and temperature. The body of the document was used to evaluate criteria such as nausea/vomiting, tremors, anxiety, agitation, paroxysmal (sudden onset) sweats, tactile, auditory, and visual disturbances, and headaches.

Patient 200's Alcohol Withdrawal Assessment Flowsheet indicated scores were documented on June 27, 28, and 29, 2010 (1st, 2nd and 3rd day of detox). The next documented score was dated July 3, 2010, and identified as the 7th day of detoxification. There was no documentation of daily CIWA scores for June 30 or July 1 or 2, 2010.

During an interview with RN 201 on July 6, 2010, at 2 p.m., RN 201 stated withdrawal assessments were to be completed daily, but she did not believe the flowsheets had to be completed every day. RN 201 stated the assessment was completed to evaluate the patient's subjective information

During an interview with the DON on July 6, 2010, at 2:30 p.m., the DON stated the withdrawal assessment and flowsheet should be completed daily and left for physician review, as the physicians made treatment decisions based on the patient's score.

b. The record for Patient 205 was reviewed on July 7, 2010. Patient 205 was admitted to the facility on June 14, 2010, with diagnoses that included major depression. On June 15, 2010, a diagnoses of opioid dependence was added as the patient admitted a past history of substance abuse and taking 10 Vicodin tablets the day prior to admission.

Patient 205's record contained a form titled "Opiate Withdrawal Assessment Flowsheet." The form included a place to document the substances used by the patient in addition to opiates. Across the top of the page were places to document the day (of detox), date, time, blood pressure, pulse, respirations and temperature. The body of the document was used to evaluate criteria such as GI upset, sweating, tremors, restlessness, yawning, pupil size, anxiety, bone aches, gooseflesh, runny nose, and tearing.

Patient 205's Opiate Withdrawal Assessment Flowsheet indicated scores were documented on June 15 at 6 a.m., and 6 p.m. This was documented as the first day of detox. There was no documentation of daily COWS scores for June 16, 17, 18, and 19, 2010. Patient 205 was discharged on June 19, 2010.

2. The record for Patient 206 was reviewed on July 7, 2010. Patient 206 was admitted to the facility on June 5, 2010, with diagnoses that included bipolar disorder. Patient 206's inpatient admit orders dated June 5, 2010, indicated the patient was to have a, "Psychosocial Assessment."

Patient 206's record contained a document titled "Psychosocial Assessment." The document consisted of a mental status examination, memory test, evaluation of the patient's appearance and self care, attitude, stressors, weaknesses/skill deficits, word recall, substance and trauma history, risk assessment, personal/educational information, employment history, and other issues. Patient problems and goals for treatment were identified on the document. The document concluded with an initial discharge plan and diagnostic summary/case formulation. Patient 206's Psychosocial Assessment was not completed. There was no evidence in the record the PSA for Patient 206 was completed during his hospitalization between June 5, 2010 through June 11, 2010.

During an interview with RN 202, on July 8, 2010, the RN stated the PSA was a document completed by LCSWs. RN 202 stated if the patient was a recent readmission, it would not have to be redone.

During an interview with MFT 200, on July 8, 2010, at 11:30 a.m., MFT 200 stated the PSA should be completed within 24 hours of the patient's admission. MFT 200 stated if it was unable to be completed immediately, they should at a minimum determine SI or HI risk. MFT 200 stated if the patient was a recent readmit, a copy of the previous PSA was placed in the record and an update completed. MFT 200 reviewed Patient 206's record and was unable to find evidence a PSA or PSA update was completed for the patient.

Based on observation, interview, and record review, the facility failed to control and distribute medications in accordance with standards of practice and state law, and in a manner that was safe to patients, by failing to ensure:

1. medications used for emergency situations were kept in a portable container that was immediately accessible;

2. implementation of policies and procedures for restocking and sealing of the emergency drug supply;

3. emergency drugs were kept in a clearly marked, portable container with a seal that must be broken to gain access;

4. internal drugs were stored separately from external drugs; and,

5. a high alert medication list was readily available in the medication room.

Findings:

1. On July 6, 2010, at 1 p.m., during inspection of the facility's medication room, it was noted the facility did not have an emergency drug supply for immediate use in case of a life threatening emergency.

During a concurrent interview with Staff 301, she stated the facility did not keep an emergency drug supply in a portable container. She stated they removed the portable container and placed all of the emergency drugs in the ADC.

During an interview with the PIC on July 7, 2010, at 11:45 a.m., the PIC stated the facility got rid of the portable emergency drug container and placed all of the emergency drugs in the ADC. He stated he was not aware of the state regulation regarding the emergency drug supply.

The facility policy titled, Emergency Drugs," was reviewed on July 7, 2010. The policy indicated the following:

a. emergency drug boxes would be prepared by the pharmacy and stored in a designated area;

b. the boxes would contain the drugs approved by the medical staff, with directions for use;

c. the contents of the box would be listed on the outside, with expiration dates of the drugs;

d. the pharmacy would use a numbered, breakable seal designed to assure the continued security and integrity of the contents between periods of use;

e. a separate seal of another color would be stored inside the container for use by the nursing staff to reseal the box after use to indicate the box was awaiting restocking and not patient ready; and,

f. seals, when used, would be controlled by the pharmacy and would not be available to nursing and others who used the drugs.

According to CCR, Title 22, § 71233:

(f) Supplies of drugs for use in medical emergencies only shall be immediately available at each nursing unit or service area.

(2) The emergency drug supply shall be stored in a clearly marked portable container which is sealed by the pharmacist in such a manner that a seal must be broken to gain access to the drugs. The contents of the container shall be listed on the outside cover and shall include the earliest expiration date.

2. On July 6, 2010, at 1 p.m., during inspection of the facility's medication room, medications for external use were observed stored on the same shelves as medications for internal use as follows:

a. the second shelf contained one 100 count bottle of naproxen (pain medication) 200 mg tablets (for internal use), one jar of tucks (for treatment of hemmorhoids) (for external use), and three boxes of nicotine patches of various strengths (for external use); and,

b. the bottom shelf contained one 12 ounce bottle of aloe vera 100 percent gel (for external use) and one opened bottle of 100 count excedrin (pain medicine) caplets (for internal use).

During a concurrent interview, Staff 301 stated the internal use drugs should have been stored separately from the external use drugs.

According to CCR, Title 22, §71233(q)(5), external use drugs in liquid, tablet, capsule or powder form shall be segregated from drugs for internal use.

3. On July 6, 2010, at 1 p.m., during inspection of the facility's medication room, no high alert or LASA drug lists were observed.

During a concurrent interview, Staff 301 stated the list was posted on the wall, but had been removed recently. Staff 301 was unable to locate a high alert or LASA drug list in the medication room.

During an interview with the PIC on July 7, 2010, at 1:30 p.m., the PIC stated the list had been removed from the medication room.

(High risk, high alert medications are those medications involved in a high percentage of medication errors and/or sentinel events. They carry a higher risk for abuse, errors, or other adverse outcomes. LASA medications are an example of high risk, high alert medications).

The facility policy titled, "LASA Medications," was reviewed on July 7, 2010. The policy indicated an LASA list would be readily available in all medication rooms and on each nursing unit, and would be reviewed and revised by the pharmacist at least annually.

Based on observation, interview, and record review, the facility failed to ensure unusable medications were not available for patient use, resulting in the potential for medication errors and spread of infection.

Findings:

On July 6, 2010, at 1 p.m., during inspection of the facility's medication room, a portable wheeled medication cart contained the following:

1. over the counter topical tubes (for external use) that were labeled as, "House Supply," and were visibly squeezed and used. The medications included:

a. one 28.35 gram tube of 0.5 percent hydrocortisone cream (to relieve itching and rash);
b. one 28 gram tube of one percent cortizone 10 cream (to relieve itching and rash;
c. one 28 gram tube of two percent benadryl cream (to relieve itching and rash);
d. two 28.4 gram tubes of triple antibiotic cream;
e. one 28 gram tube of anti itch cream; and,
f. one 3.5 gram tube of refresh p.m. lubricant eye ointment with an expiration date of January 2010.

2. prescription topical medications that were no longer used by patients because they had been discharged. The medications included:

a. one 30 gram tube of 2.5 percent hydrocortisone cream;
b. one 45 gram tube of 0.75 percent metronidazole cream (to treat fungal infections); and,
c. one 30 gram tube of 0.05 percent clobetasol (to relieve itching and rash).

During a concurrent interview, Staff 301 stated the discontinued and expired medications, and medications of discharged patients, were kept in the cart or in the ADC until the pharmacist came once a week (on Mondays) to remove them. She was not able to explain how the over the counter topical medications were used for patients at the facility, but they were, "more than likely," used for multiple patients, and that was not a good practice.

During an interview with the PIC on July 7, 2010, at 11:30 a.m., the PIC stated he did not know how the over the counter topical medications were used or if they were used on multiple patients. He stated the topical medications should have been labeled with patient names to prevent use on multiple patients and spread of infection. He stated the expired topical medications and the topical medications for the discharged patients should have been removed from the cart.

The facility policy titled, "Administration of Drugs: General," was reviewed on July 7, 2010. The policy indicated the following:

1. discontinued drugs should be removed from the patient's drug supply and placed in the pharmacy pick up container or returned to the pharmacy; and,

2. when a patient was discharged, the drugs should be removed from the patient's storage container and placed in the pharmacy pickup container or returned to the pharmacy.

Based on observation, interview and record review, the facility failed to ensure the dietetic service administrative and support staff were competent in duties related to cooking methods, implementation of therapeutic diets, and food storage. This failed practice resulted in the storage, preparation, and distribution of foods in an unsafe manner.

Findings:

1. On July 7, 2010, at 12:15 p.m., during observation of the lunch trayline, there was the service of limp mixed vegetables in which all green vegetables had turned yellow-green.

During a concurrent interview, DSS 1 stated she was unaware of the guidelines for cooking the previously frozen vegetables, but she knew the vegetables had been "steamed."

A review of the recipe for California Blend Vegetables on July 8, 2010, at 4:45 p.m., indicated the vegetables were to be boiled, but no cooking time was specified to ensure appeal, textural quality, or nutrient retention.

2. On July 7, 2010, at 12:20 p.m., during observation of the lunch trayline, a review of Patient 401's profile card revealed he was to be on a CCD, NAS diet with large portions, snacks between meals, lowfat milk, and egg substitute.

During a concurrent interview, DSS 1 stated she did not follow any portioning guidelines to achieve the intended diet and Patient 401, "could receive seconds." She stated Patient 401 received only one half of the planned dessert at each meal, but there were no other restrictions.

3. On July 7, 2010, at 12:24 p.m., during observation of the lunch trayline, a review of Patient 402's profile indicated she was on a regular diet with six small meals.

During a concurrent interview with DSS 1, she stated the information on the profile card indicated Patient 402 would receive three regular meals (of comparable size to other patients on a regular diet) "plus six small meals, actually snacks, in between the meals." She stated in addition to, "cheese and crackers," Patient 402 could receive other foods as snacks, "but not as big as a meal."

The record for Patient 402 was reviewed on July 8, 2010. The record indicated Patient 402 was five feet five inches tall, weighed 223 pounds, was morbidly obese, and had a history of gastric bypass surgery (a procedure to make the stomach smaller, resulting in the need to eat small frequent meals).

DSS 1 failed to recognize the profile card indicated Patient 402 should receive six small meals a day.

4. During inspection of the dry food storage room on July 8, 2010, at 9:50 a.m., accompanied by the DSM, the DSM stated there should be two dates on the open food items, one to indicate when the item was received, and one to indicate when it was opened.

The following food items were observed:

a. an opened 5 lb box of blueberry muffin mix with a date of January 26, 2010, which the DSM stated was the receipt date. There was no date indicating when the box was opened;

b. an opened 25 lb bag of pinto beans with a receipt date of August 1, 2009. There was no date indicating when the bag was opened;

c. an opened 5 lb jug of honey with a handwritten open date of, " 2/26." There was no date indicating when the jug was received; and,

d. a 25 lb bag of non fat dry milk (powder) which had not been opened with a receipt date of March 12, 2009.

The DSM stated she did not know the shelf life of these foods.

The facility policy titled, "Safe Food Handling and Storage,", was reviewed on July 8, 2010. The policy indicated all foods in dry storage, unopened, were good for 6 months or per manufacturer's guidelines." The policy did not indicate how long opened items were good for.

The muffin mix, pinto beans, and dry milk were on the shelf for longer than six months, and there was no way to ascertain how long the honey had been on the shelf. These storage practices led to uncertainty as to freshness, nutritional quality, and safety of the food items.

Based on interview and record review, the facility failed to ensure:

1. the physician reviewed and considered recommendations made by the RD for two of 34 patients (Patients 200 and 202); and,

2. a timely assessment was completed by the RD for 4 of 4 patients at risk for nutritional problems (Patients 206, 207, 209, and 211).

These failed practices resulted in the potential for inadequate nutrition.

Findings:

1a. The record for Patient 200 was reviewed on July 6, 2010. Patient 200 was admitted to the facility on June 27, 2010, with diagnoses that included alcohol dependence, hypertension, and dyslipidemia (abnormal lipid levels). Patient 200 was still an inpatient in the facility on July 6, 2010.

According to the initial history and physical, Patient 200's lipid levels (total cholesterol, LDL, HDL, and triglycerides) were to be checked on June 28, 2010. Patient 200 was on a NAS diet.

The report of laboratory results for Patient 200 indicated on June 28, 2010, the triglyceride level was 648 MG/dl (normal 35-160 MG/dl). A second report of laboratory results indicated on July 2, 2010, the patient's triglyceride level had increased to 651 MG/dl.

According to the initial "Medical Nutrition Therapy," evaluation dated July 2, 2010, Patient 200 was a high nutrition risk due to abnormal lab values, severe depression, and history of substance use. The form indicated a patient at high risk would have a nutritional evaluation and plan. The form, signed by the RD on July 2, 2010, included the following entry "Resident eating well. TG's very high. Recommend 4 grams of fish oil per day."

On July 6, 2010, at 2 p.m., RN 201 was interviewed. RN 201 was unable to find evidence in the record the RD's recommendations were acted upon. RN 201 stated the RD should have followed up with the patient's physician to obtain orders. RN 201 stated she was unaware Patient 200's triglycerides were elevated and the RD had made recommendations.

During an interview with the RD on July 7, 2010, at 11 a.m., the RD stated follow up for RD recommendations should be conducted by the nursing staff. The RD stated he was unaware the recommendation for Patient 200 had not been communicated to the patient's physician.

A review of the facility document titled, "Food Services Policy," was reviewed on July 7, 2010. The subject of the document was the "Division of Labor." In the section for the dietitian, it indicated the dietitian would record assessment findings, recommendations, and follow-up plan, and alert other team members to any part of the nutritional care plan needing their cooperation.

1b.The record for Patient 202 was reviewed on July 6, 2010. Patient 202 was admitted to the facility on June 24, 2010, with diagnoses that included Schizophrenia, dehydration, and protein-calorie malnutrition. Patient 202 was still an inpatient on July 6, 2010.

According to the patient's history and physical, dated June 24, 2010, Patient 202 had been experiencing weight loss and was dehydrated. In addition, the patient was being treated for protein-calorie malnutrition with Ensure (an oral dietary supplement).

The "Medical Nutrition Therapy," evaluation form dated June 30, 2010, indicated the patient was on a regular diet with Ensure three times daily. Patient 202 was identified as at moderate risk and required a nutritional evaluation and plan. House (regular) diet was marked in the section under moderate risk. In addition, a check mark was placed in the box for a multivitamin with minerals. The following was documented: "eating 30-100% of meals last 2 days. Drinking Ensure daily. Add MVI with min."

During an interview with RN 203, on July 8, 2010, at 10:30 a.m., RN 203 stated she was unable to find information in the record that the RD's recommendation was communicated to the patient's physician. RN 203 stated the RD would speak with the patient's physician if the physician was in the building, otherwise the RD would communicate to the nurse. RN 203 was unable to explain why the RD recommendations for Patient 202 were not acted upon in the last seven days.

2a. The record for Patient 206 was reviewed on July 7, 2010. Patient 206 was admitted to the facility on June 5, 2010, at 6:36 p.m., with diagnoses that included bipolar disorder, methamphetamine abuse and migraines. Patient 206 was discharged from the facility on June 11, 2010.

Patient 206' s initial physician's orders included a regular diet, Depakote 500 mgs twice daily and Abilify 20 mgs every night at bedtime. The Comprehensive Assessment and Screening form indicated the patient had frequent migraine headaches, his last meal was on June 4, 2010, at 8 a.m., (30 hours prior to his admission), and he had consumed only 8 ounces of fluid in the last 24 hours.

According to the "Nursing Services Initial Nutrition Screening," no risk factors were identified for Patient 206. There was no evidence an assessment had been completed by the RD during Patient 206's six day hospitalization.

b. The record for Patient 207 was reviewed on July 7, 2010. Patient 207 was admitted to the facility on July 4, 2010 with diagnoses that included HTN and drug abuse.

Patient 207's initial physician's orders included a regular diet. The Comprehensive Assessment and Screening form indicated the patient had a poor appetite and impaired skin integrity due to skin popping (using drugs by injecting or placing them under the skin). In the area for Care Concerns, Patient 207 was identified as having an alteration in nutrition.

According to the "Nursing Services Initial Nutrition Screening," Patient 207 was five feet ten inches tall, weighed 276 pounds, and had a poor oral intake for more than three days. Although HTN and poor oral intake for more than three days were listed on the form as risk factors to be reported to the kitchen, the nurse doing the screening did not identify any risk factors. There was no evidence an assessment had been completed by the RD during Patient 207's hospitalization.

c. The record for Patient 209 was reviewed on July 7, 2010. Patient 209 was admitted to the facility on May 28, 2010, with diagnoses that included opiate dependency, abscesses, and indigestion and gastritis secondary to drug abuse. According to the "Intake Screening Documentation," Patient 209 had vomiting and diarrhea and a 20 pound weight loss in the last two years. Patient 209 reported his appetite was poor.

Patient 209's initial physician's orders included a regular diet. The Comprehensive Assessment and Screening form indicated the patient had a poor appetite and he was not sure how much fluid he had in the prior 24 hours.

According to the "Nursing Services Initial Nutrition Screening," Patient 209 had no risk factors. There was no evidence an assessment had been completed by the RD during Patient 209's 10 day hospitalization.

d. The record for Patient 211 was reviewed on July 7, 2010. Patient 211 was admitted to the facility on May 17, 2010 with diagnoses that included liver cirrhosis and alcohol abuse. Patient 211 was transferred to the psychiatric service on May 20, 2010, and was discharged on June 6, 2010.

The Comprehensive Assessment and Screening form indicated the patient had a poor appetite, had not eaten since the day prior to admission, and fluid intake was poor. In the area for "Care Concerns," Patient 211 was identified as having an alteration in nutrition.

According to the "Nursing Services Initial Nutrition Screening," Patient 211 had poor oral intake in the last three days and liver cirrhosis. There was no evidence an assessment had been completed by the RD during Patient 211's 20 day hospitalization.

During an interview with RN 203 on July 8, 2010, at 10 a.m., the RN stated, of the thirteen patients currently in house, only one (an insulin dependent diabetic with labile blood sugars) would need a referral to the dietitian. RN 203 stated she completed the "Nursing Services Initial Nutrition Screening," during the admission process and would submit the information to the dietary department. RN 203 stated the only medication she would report to the dietitian was a MAO inhibitor. RN 203 stated she had never been in serviced by the dietary department about the referral process.

A review of the facility document titled "Food and Nutritional Services Indicators of Care," was reviewed on July 7, 2010. The document indicated nutritional assessment would be performed within seven days of admission by a Registered Dietitian. "High Risk patients are assessed within 72 hours."

A review of the facility documented titled "Risk Factor Levels-see assessment form attached," included recommended criteria for nutritional risk. The policy indicated, "High Risk," were those patients with three or more factors from a list that included:

a. tube feeders;
b. dialysis;
c. significant weight changes;
d. protein and/or calorie malnutrition;
e. refusal to eat;
f. advanced disease;
g. alcohol and drug abuse;
h. wounds;
i. dehydration;
j. inadequate nutrient intake >5 days;
k. liquid diet > 3 days;
l. NPO > 3 days;
m. IV solution > 5 days; and
n. weight changes of 5% or > in one month, 7.5 % in 3 months, 10 % in 6 months, or 2-3 % in one week.

During an interview with the RD on July 7, 2010, at 10 a.m., the dietitian stated he was in the facility three days per week and completed patient assessments at that time. The RD stated he would see "High Risk," patients within 72 hours, but would not need to see other patients for 30 days. The RD stated he received referrals from the nursing staff.

Based on observation and interview, the facility failed to ensure the kitchen walk-in refrigerator had a reliable internal thermometer for surveillance of safe food temperatures. This failed practice resulted in the potential for undetected malfunction of the refrigerator and serving of unsafe foods.

Findings:

On July 8, 2010, at 11:18 a.m., during inspection of a kitchen walk-in refrigerator, accompanied by the DSM, the following was observed:

1. the temperature gauge on the refrigerator registered 39 degrees F (two degrees below the maximum for the safe chilling of potentially hazardous foods);

2. an egg salad sandwich prepared on July 7, 2010, was at 39.9 degrees F; and,

3. the internal thermometer registered 20 degrees F (12 degrees below the freezing point of water).

The DSM stated, "We need a new thermometer. This one is not working...."