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Based on record review and interview, the hospital's Governing Body failed to ensure the Medical Staff was accountable for services and treatment provided to patients. This failed practice is evidenced by the Governing Body's failure to ensure S7MD completed consultation reports and/or medical assessment/progress notes relative to patient care and services for 3 (#3-current patient, #5-current patient, #2) of 3 patients' records reviewed for consultation reports and medical assessment/progress notes from a total sample of 5.
Finding:

Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital on 1/19/16 for a suicide attempt by overdosing on Klonopin and Synthroid. Her medical diagnoses included: Primary Biliary Cirrhosis, Asthma, Anemia, and Hypothyroid. Review of the Physician's order for 1/22/16 revealed a medical consult for a low TSH (Thyroid Stimulating Hormone) lab value. Review of the lab value for TSH on 1/20/16 revealed a result of .02 (normal range is 0.36 to 3.74 uIU/ml). Review of the medical record revealed no documentation of a medical consult being performed on Patient #3 for her low TSH lab value.

In an interview with S7MD on 1/26/16 at 8:30 a.m., he was unable to determine if he was aware of the patient's low TSH lab value. S7MD reported when he did the patient's history and physical he continued the patient on her home medication of Synthroid. S7MD further reported the TSH lab values were not available when he conducted his History and Physical.

Patient #5
Review of the medical record revealed Patient #5 was a 50 year old female admitted to the hospital on 1/16/16 for an Overdose, Violent behavior and Self-inflicted Lacerations. Review of Patient #5's Physician's orders revealed an order for an Internal Medicine Consult for right hip pain on 1/20/16. Review of the medical record revealed no evidence of an internal medicine consult being conducted on Patient #5 for her complaints of right hip pain.

An interview was conducted with S7MD on 1/26/16 at 8:30 a.m. S7MD reported he receives so many consults from the hospital he is unable to document on the consults. S7MD further reported he was doing well just to complete the patients' history and physical. S7MD stated on the patient's history and physicals, he writes the plan of care, and the nurses enter his orders into the computer due to his time constraints. S7MD went on to report the nurses text or call him on his consults at the hospital. S7MD reported he makes his rounds at the hospital in the evenings. S7MD stated he had spoken on the phone to S6Psy/MD of the need to decrease the amount of medical consults being generated, that some of the patient's issues could be handled over the phone, such as a runny nose. When the surveyor questioned S7MD on Patient #5's medical consult on 1/20/16 for right hip pain, S7MD reported he was unaware of the consult after reviewing his phone texts and phone log. S7MD stated he had no way of knowing if the nurses notified him of the consult. (Review of the Nurse's notes from 1/20/16 at 6 p.m. revealed S13RN documented she notified S7MD of the medical consult on Patient #5 for right hip pain.)

Patient #2
Review of the medical record for Patient #2 revealed she had been admitted to the hospital on 12/29/15 with an Axis I Diagnosis of Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified; and an Axis III Diagnosis of Type 2 Diabetes Mellitus without complications, Pure Hyperglyceridemia, and Essential (primary) Hypertension. Documentation revealed Patient #2 was discharged on 01/12/16. Record review revealed the H&P was completed on 12/30/15. Documentation revealed a consultation was ordered on 01/01/16 by S6Psy/MD. Review of the medical record revealed no evidence to indicate that the consultation was completed as ordered. There was no documented evidence of Progress Notes by S7MD for care and management of Patient #2 while in the hospital.

In an interview on 01/26/16 at 10:25 a.m., S6Psy/MD (Psychiatrist/ Medical Director) indicated that she was not aware that S7MD was not documenting his consultation and/or progress notes. S6Psy/MD indicated that she would look at the orders and based on the orders written, she was certain that he was providing care (consult & treatment) to the patients. She indicated the Administrative Staff never communicated to her that S7MD was not documenting his Consultation Reports and/or Progress Notes.

Based on record review and interview, the hospital failed to ensure that the notice of rights was met as evidence by the failure of notification of the patient's responsibility party of change in condition and/or transfer to a level of higher care for 1 (#2) of 5 sampled patients.
Findings:

Review of the Hospital's Policy & Procedure titled Patient Discharges or Transfers presented as current (01/16) by S1Adm. read in part: 16. When the hospital determines the patient's discharge or transfer needs, it promptly shares this information with the patient, also with the patient's family...

Review of the Hospital's Policy & Procedure titled Changes in a Patient's Condition presented as current (09/15) by S1Adm. read in part: The hospital informs the patient and family how to seek assistance when they have concerns about a patient's condition.

Review of the Hospital's Policy & Procedure titled Medical Emergencies presented as current (09/15) by S4PI/Edu. read in part: Notify the patient's family.

Review of the EMR for Patient #2 revealed she had been admitted to the hospital on 12/29/15 with Axis I Dx. Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified; Axis III Dx. Type 2 Diabetes Mellitus without complications, Pure Hyperglyceridemia, and Essential (primary) Hypertension and discharged on 01/12/16.

Review of the Nurses Notes for Patient #2 on 01/03/16, written byS9RN at 5:00 p.m. read in part: "Notified S8PNP, along with S1Adm., S2DON of order to transfer patient to the Emergency Room."

Review of the Nurses Notes for Patient #2 on 01/12/16 , written by S9RN at 2:43 a.m. & 3: 10 a.m. read in part: " S8PNP, S1Adm., S2DON notified of S7MD order to send out to emergency room." 3:10 a.m. " Notified S6Psy/MD of change in patient's status and that she had been sent to the emergency room."

Further review of Patient #2's EMR revealed no documented evidence that the patient's responsible party (mother) had been notified of changes in the patient's condition and the need for transfer on 01/03/16 & 01/12/16 to Hospital "A".

In an interview on 01/26/16 at 8:45 a.m., S9RN indicated that she was the nurse on duty on 01/03/16 & 01/12/16 and she failed to notify the patient's mother of the change in her condition and transfer to Hospital "A".

In an interview on 01/26/16 at 9:00 a.m., S2DON confirmed that Patient #2' s mother was not notified during the 2 ED visits.

Further review of Patient #2's EMR revealed no documented evidence that the patient's responsible party (mother) had been notified of change in condition and need for transfer on 01/03/16 & 01/12/16.

Based on observation, record review and interview, the hospital failed to ensure the patients received care in a safe setting as evidenced by failing to ensure MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for 1 of 1 patients (#1) reviewed with 1:1 observation level physician's orders.
Findings:

Review of the hospital policy, PC 36-Provision of Care, Treatment, and Services, Patient Observation revealed in part, Category I: One-to-One Constant Supervision 1) Patient is in imminent danger of harm to self or others. 3) Nursing intervention: a) 1:1 constant observation (at arm's length) twenty-four (24) hours a day or seclusion/restraints.

Review of the medical record revealed Patient #1 was a 20 year old male admitted on 1/12/16 on a PEC (Physician Emergency Certificate) from an emergency room for psychosis and substance abuse. Review of the Initial Psychiatric Evaluation, dated 1/13/16, revealed Patient #1 is a poor historian due to his altered thought processes. His delusions are grandiose, illogical and religious in content. He is disorientated to person, place and time and easily agitated. Review of Patient #1's physician orders revealed he had an order for 1:1 observation level on 1/22/16.

An observation was conducted on 1/22/16 at 11:00 a.m. of Patient #1, in his room, asleep in his bed, which was located on the wall furthermost from the door to his room. S14MHT was sitting in a chair, in the hallway, at the entrance of Patient #1's room. S14MHT was not within arms reach of Patient #1.

An interview was conducted with S14MHT on 1/22/16 at 11:00 a.m. S14MHT reported Patient #1 was on 1:1 observation level and she was assigned to monitor him.

An observation was conducted on 1/22/16 at 11:40 a.m. of Patient #1, in his room, asleep in his bed, which was located on the wall farthermost from the door to his room. S15MHT was sitting in a chair, in the hallway, at the entrance of Patient#1's room.

An interview was conducted with S15MHT on 1/22/16 at 11:40 a.m. S15MHT reported she was assigned to observe Patient #1, while he was asleep, since he was on 1:1 observation level. S15MHT was not within arms reach of Patient #1.

A second interview was conducted with S15MHT on 1/26/16 at 1:45 p.m. She reported while a patient is asleep in their bed and they are on 1:1 observation level, the MHTs watch the patient from the hallway at the entrance to their room.

An interview was conducted with S4PI/Edu on 1/25/16 at 11:30 a.m. S4PI/Edu reported if a patient is on 1:1 observation level, the MHTs are suppose to be within arm's length of the patient at all times. S4PI/Edu further reported the MHT sitting in the hallway, at the entrance to Patient #1's room is not considered at arm's length.

Based on record review and interview, the hospital's medical staff failed to provide quality care to patients as evidenced by failing to provide documented evidence that consultations were conducted as ordered for 3 (#3-current patient, #5-current patient, #2) of 3 patients reviewed for medical consultations.
Findings:

Review of the Medical Staff Rules and Regulations revealed in part, Consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient, the consultant's opinion and recommendations. This report shall be made a part of the patient's record. Any qualified attending medical staff member with clinical privileges in the hospital may be called for consultation. The consultant must be qualified to give an opinion in the field in which his opinion and consultation is sought. The attending medical staff member is responsible for the care of the patient and shall be responsible for judgments as to the serious nature of the illness and the question or doubt as to diagnosis and treatment.


Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital on 1/19/16 for a suicide attempt by overdosing on Klonopin and Synthroid. Her medical diagnoses included: Primary Biliary Cirrhosis, Asthma, Anemia, and Hypothyroidism. Review of the Physician's order for 1/22/16 revealed a medical consult for a low TSH (Thyroid Stimulating Hormone) lab value. Review of the lab value on TSH for 1/20/16 revealed a result of .02 (normal range is 0.36 to 3.74 uIU/ml). Review of the medical record revealed no documentation of a medical consult being performed on Patient #3 for her low TSH lab value.

In an interview with S7MD on 1/26/16 at 8:30 a.m., he was unable to determine if he was aware of the patient's low TSH lab value. He reported when he did the patient's history and physical he continued the patient on her home medication of Synthroid. TSH labs were not available when he conducted his History and Physical.

Patient #5
Review of the medical record revealed Patient #5 was a 50 year old female admitted to the hospital on 1/16/16 for an Overdose, Violent behavior and Self-inflicted Lacerations. Review of Patient #5's Physician's orders reveals an order for an Internal Medicine Consult for right hip pain on 1/20/16. Review of the medical record revealed no evidence of an internal medicine consult being conducted on Patient #5 for her complaints of right hip pain.

An interview was conducted with S7MD on 1/26/16 at 8:30 a.m. He reported he receives so many consults from the hospital he is unable to document the consults. He further reported he was doing well just to complete the patient's history and physical. He reported the nurses text or call him on his consults at the hospital. When the surveyor questioned S7MD on Patient #5's medical consult on 1/20/16 for right hip pain, he reported he was unaware of the consult after reviewing his phone texts and phone log. S7MD stated he had no way of knowing if the nurses notified him of the consult. (Review of the Nurse's notes from 1/20/16 at 6 p.m. revealed S13RN documented she notified S7MD of the medical consult on Patient #5 for her right hip pain.)

Patient #2
Review of the medical record for Patient #2 revealed she had been admitted to the hospital on 12/29/15 with an Axis I Diagnosis of Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified; and an Axis III Diagnosis of Type 2 Diabetes Mellitus without complications, Pure Hyperglyceridemia, and Essential (primary) Hypertension. Documentation revealed Patient #2 was discharged on 01/12/16. Record review revealed the H&P was completed on 12/30/15. Documentation revealed a consultation was ordered on 01/01/16 by S6Psy/MD for elevated blood glucose levels. Review of the medical record revealed no evidence to indicate that the consultation was completed as ordered. There was no documented evidence of Progress Notes by S7MD for care and management of Patient #2 while in the hospital.

In an interview on 01/26/16 at 10:25 a.m., S6Psy/MD (Psychiatrist/ Medical Director) indicated that she was not aware that S7MD was not documenting his consultation on patients.








31206

31206

Based on record review and interview, the hospital's registered nurses failed to ensure the supervision and evaluation of care provided to patients as evidenced by :

1) Failing to ensure I & O (intake & output), calorie counts and weight orders were monitored and documented for 2 of 5 sampled patients (#1, #2).

2) Failing to ensure that diets are ordered for patients upon admission for 2 of 5 sampled patients (#2, #4).

3) Failing to ensure skin assessments were conducted for 2 of 2 patients (#4, #5) reviewed for skin assessments.

4) Failing to ensure the physician was aware of Patient #3's low nutritional intake with a 6 pound weight loss within 6 days of admission.

Findings :

1) Failing to ensure I&O's, calorie counts, and weights were monitored and documented.

Patient #1
Review of the medical record revealed Patient #1 was a 20 year old male admitted on 1/12/16 on a PEC (Physician Emergency Certificate) from an emergency room for psychosis and substance abuse. Review of Patient #1's Physician's order on admission revealed an order for daily weights and heights. Review of the medical record revealed no weights were recorded on the patient from admission (1/12/16) thru the time of this record review on 1/22/16.

An interview was conducted with S4PI/Edu on 1/22/16 at 2:00 p.m. She reported there were no weights documented for the patient in the medical record, she reported she assumes the patient refused since he has been combative in the hospital. She reported there was no documentation in the medical record of the patient refusing to be weighed.


Patient #2
Review of the medical record for Patient #2 revealed she had been admitted to the hospital on 12/29/15 with an Axis I Diagnosis of Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified; and an Axis III Diagnosis of Type 2 Diabetes Mellitus without complications, Pure Hyperglyceridemia, and Essential (primary) Hypertension. Documentation revealed Patient #2 was discharged on 01/12/16. Review of the physician's orders revealed an order (12/30/15) for height & weight every day.
Further review of the record revealed a telephone order from S8PNP (Psychiatric Nurse Practitioner) for strict I & O.

Review of the height & weight and I & O sheets revealed the following:
Height & weight- admission (12/29/15) height- 5 ft. 7 in. & weight- 192 lbs. (pounds). Weight- 192 lbs. ( no date). I & O sheets revealed no documented evidence of intake and output monitoring.

In an interview on 01/25/16 at 1:40 p.m., S4PI/Edu. (Performance Improvement/Education) confirmed that only 2 weights were documented and there was no documentation of intake and output monitoring.

In a telephone interview on 01/16/16 at 8:45 a.m., S9RN (Registered Nurse) indicated that the MHTs (Mental Health Technicians) should be documenting weights weekly and I & O's as ordered. S9RN indicated that it is the responsibility of the RN to make certain these tasks are completed.

In an interview on 01/26/16 at 12:30 p.m., S13RN indicated that the MHTs were responsible for documenting the vital signs, heights weights and I & O of all patients. S13RN indicated that it was the responsibility of the RN to check and make certain that the MHTs document the results and she failed to do so.


2) Failing to ensure diets are ordered upon admission.

Patient #2
Review of the medical record for Patient #2 revealed she was admitted to the hospital on 12/29/15. Review of the admission orders for Patient #2 revealed no diet order. A diet order was written by S6Psy./MD on 01/01/16 for 1800 calorie diabetic diet.

In an interview on 01/25/16 at 12:55 p.m., S2DON indicated that Patient #2 had no order for a diet upon admission (12/29/15) and was provided a Regular Diet and glucerna 3 cans a day. She indicated the RN should have contacted the physician for a diet order at the time of admission.

In an interview on 01/25/16 at 2:20 p.m., S4PI/Edu. indicated that diets should be ordered at the time of admission to the hospital.

Patient #4
Review of the medical record revealed Patient #4 was admitted to the hospital on 11/12/15 for Aggressive Behavior. Her medical diagnoses included: Diabetes Mellitus, Hypertension, Post CVA (Cerebral Vascular Accident), Mediport insertion. Patient #4 was discharged on
11/18/15. Review of the Physician Orders for Patient #4 revealed a diet was not ordered by the physician until 11/17/15 which was 5 days after admission to the hospital.

An interview was conducted with S4PI/Edu on 1/25/16 at 2:20 p.m. S4PI/Edu. indicated that diets should be ordered at the time of admission to the hospital.

An interview was conducted with S3PI/IC on 1/25/16 at 2:25 p.m. She confirmed the patient's specific diet was not ordered until 11/17/15, 5 days after admission.



3) Failing to ensure skin assessments were conducted.

Patient #4
Review of the medical record revealed Patient #4 was admitted to the hospital on 11/12/15 for Aggressive Behavior. Her medical diagnoses included Mediport insertion. Documentation revealed that Patient #4 was discharged on 11/18/15. Review of the Physician's History and Physical, dated 11/14/15, revealed the patient had a mediport. Review of the medical record during the patient's hospital stay (11/12/15- 11/18/15) revealed no documentation of the location and site appearance of the mediport.

An interview was conducted with S3PI/IC on 1/25/16 at 2:25 p.m. She reported there was no documentation in the nursing notes or the skin assessments during the patient's hospital stay of the location of the mediport or of the appearance of the mediport site.

Patient #5
Review of the medical record revealed Patient #5 was a 50 year old female admitted to the hospital on 1/16/16 for an Overdose,Violent behavior and Self-inflicted Lacerations. Review of Patient #5's Treatment Plan revealed Laceration without foreign body of wrist. Review of the medical record from 1/16/16 until 1/23/16 (discharge date) revealed no assessment of her self-inflicted lacerations to her wrist.

An interview was conducted with S3PI/IC on 1/26/16 at 10:00 a.m. She verified that there was no documentation of an assessment during her hospital stay of the self inflicted lacerations on the wrist.


4) Failing to ensure the physician was aware of Patient #3's low nutritional intake with a 6 pound weight loss within 6 days of admission.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital on 1/19/16 for a suicide attempt by overdosing on Klonopin and Synthroid. Her medical diagnoses included: Primary Biliary Cirrhosis, Asthma, Anemia, and Hypothyroidism. Further review of the Initial Psychiatric Evaluation, dated 1/20/16, revealed the patient's appetite was decreased and she reported she did not feel like eating. Review of her physician's orders revealed she had orders for strict I & O's, calorie count, and Ensure 3 times a day. Further review revealed on admission (1/19/16) her weight was 137 pounds, her weight on 1/25/16 was documented as 131 pounds (6 pound lost within 6 days).

Review of the MHT's (Mental Health Technicians) handwritten Close Observations Sheets revealed nutritional percentage and Intake and Output information.
1/20/16- Breakfast 10% consumed, Lunch 10%, Dinner 20%.
Intake was 18 oz, 1 cup Ensure 1 biscuit. Output 6 oz. of urine.
1/21/16-Breakfast 10% Lunch and Dinner in hospital receiving blood.
Intake 24 oz, 1 cup Ensure,1 Sausage and 1 bacon. Output 12 oz of urine.
1/22/16-Breakfast 0%, Lunch %, Dinner 0% Snack 25%
Intake- 24 oz., 1 cup Ensure, Output: 6 oz. of urine
1/23/16-Breakfast 100%, Lunch 5%, Dinner 25%
Intake- 24 oz of liquid, bowl cereal, sausage, 3 bites of pizza, 1 cup of Ensure Output 12 oz of urine.
1/24/16-Breakfast 25%, Lunch 0%, Dinner 0%, Snack 50%
Intake-1 desert peach cobbler, 24 oz. of liquid, Output: 6 oz. of urine.

An interview was conducted with S13RN on 1/25/16 at 1:35 p.m. She reported Patient #3 had a poor appetite and was receiving Ensure three times a day. She further reported the MHTs monitor the patient's calorie counts.

An interview was conducted with S12MHT on 1/25/16 at 1:40 p.m. He reported the MHTs document the patients' intake and output, but he wasn't sure how to conduct a calorie count.

An interview was conducted with S17LPN/DM on 1/26/16 at 12:00 p.m. She reported she was not aware Patient #3 was on strict Intake and Output, a calorie count and she was not aware of her 6 pound weight loss since her admission.

An interview was conducted with S6Psy/MD on 1/26/16 at 11:00 a.m. She reported she was not aware of Patient #3's weight loss and she should have been notified.

31206


Based on record review and interview, the hospital failed to ensure drugs and biological's were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care and as directed by hospital policy for 2 of 2 patients (#2, #4) reviewed for medication administration out of a total sample of 5. Findings:

Review of the hospital policy, MM 24-Medication Management, Subject Medication Administration revealed in part, Sliding scales are followed as written... Each dose of medication administered is properly recorded in the patient's medical record on the Medication Administration Record.

Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted to the hospital on 12/29/15. Review revealed her Axis I diagnoses included Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified.

Review of the orders for Patient #2 revealed the following medication orders:
12/30/15-Zyprexa 10 mg (milligrams) tab (tablet) at bedtime.
01/01/16- Ativan 2 mg IM (intramuscular) at bedtime. ("give with zyprexa IM if have pt. refuses to take po zyprexa").

Review of the MAR (Medication Administration Record) for Patient #2 revealed on 01/01/16, she refused Zyprexa 10 mg by mouth at bedtime. The MAR indicated that Ativan 2 mg IM was overlooked.

In an interview on 01/25/16 at 1:30 p.m., S2DON indicated according to the MAR Patient #2 refused the Zyprexa tablet and the Zyprexa and Ativan was not administered IM as ordered by the physician. She indicated this was a medication error and had not been identified by the Nursing Staff.


Patient #4
Review of the medical record revealed Patient #4 was admitted to the hospital on 11/12/15 for Aggressive Behavior. Her medical diagnoses included Diabetes Mellitus.

Review of the Physician Orders, dated 11/14/15, revealed an order for sliding scale insulin. The order was for the following: Novolog 100 units/ml Sub-Q per sliding scale
1-180= 0 units
181-250= 2 units
251-300= 4 units
301-350= 6 units
351-400= 8 units
<80 or>400 call md.

Review of the Blood glucose flowsheet for 11/16/15 at 6:55 a.m. revealed Patient #4's blood glucose was 184. Review of the blood glucose flowsheet and the patient's MAR (Medication Administration Record) revealed no documentation that 2 Units of Novolog was administered to the patient as per the physician's sliding scale order.

Review of the Nurse's note for 11/16/16 at 0800 revealed the only evidence of documentation the patient received insulin for her elevated blood glucose level. The Nurse's Note revealed, Pt observed in dayroom eating breakfast, insulin given as ordered, a.m. meds taken, no complaints.

An interview was conducted with S3PI/IC on 1/25/16 at 2:15 p.m. S3PI/IC reported the only documentation of the insulin being administered to the patient was in the nurse's note for 11/16/16. She further reported the nurse did not document the amount of insulin that was administered and the insulin was not documented on the blood glucose flowsheet or MAR as per hospital policy. S3PI/IC was unable to locate in the medical record how much insulin was administered to the patient for her glucose reading of 184.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Dietetic Services as evidenced by:

1) Failing to ensure there was a qualified individual who was responsible for the daily management of the dietary services within the hospital. (See findings in A0620)

2) Failing to have a qualified dietitian supervise the nutritional aspects of patient care as evidenced by:
a. the dietician failing to review and approve the patients' menus.
b. the dietician failing to perform a nutritional consult within 48 hours on a patient at high risk for nutritional problems.
c. the dietician failing to evaluate laboratory testing and follow-up on a nutritional consultation of patient (#2) who was refusing to eat.
(See findings in A0621)

3) Failing to ensure the nutritional needs of the patients were met as evidenced by failing to ensure therapeutic diets were ordered at the time of admission to the hospital for 2 (#4-current patient, #2) of 2 patients who's medical record was reviewed for dietary orders from a total sample of 5. (See findings in A0629)

Based on record review and interview, the hospital failed to ensure there was a qualified individual who was responsible for the daily management of the dietary services within the hospital. Findings:

Review of the Dietary Manager specific responsibilities and duties revealed the following;
1. Ensure special diets are provided in accordance with the dietary manual. Consults contract Dietician with special concerns and questions.
2. Ensure food is palatable and attractive, diets are served accurately, and substitutions are appropriate.
3. Reviews nutritional assessments on each patient.
4. Monitors food and fluid intake and plate waste.
5. Alerts dietitian, physician, nurse and others to problems noted.
6. Designs menus and obtain Dietician input and approval.
7. Reviews food temperature logs.
8. Provides staff education regarding nutritional changes and trends as hospital deems appropriate.

S17LPN/DM signed the job description for Dietary Manager on 1/22/16 which was the first day of this survey.

An interview was conducted with S1Adm on 1/26/16 at 11:00 a.m. She reported S17LPN/DM was appointed as the dietary manager of the hospital on 1/22/16 (first day of the complaint survey). S1Adm further reported the former dietary manager S18RN/former DM resigned from her position at the hospital on 11/11/15. She confirmed the hospital did not have a dietary manager from 11/11/15 thru 1/22/16.

An interview was conducted with S17LPN/DM on 1/26/16 at 12:00 p.m. S17LPN/DM reported she was appointed dietary manager on 1/22/16. S17LPN/DM further reported the dietician did a basic review of her job responsibilities and demonstrated how to perform food temperatures. S17LPN/DM indicated that she has had no other training and/or education relative to the job duties of a dietary manager within a hospital.

Based on observations, record review and interview, the hospital failed to have a dietitian who supervised the nutritional aspects of patient care as evidenced by:

1. the dietician failing to review and approve the patients' menus.
2. the dietician failing to perform a nutritional consult within 48 hours of being ordered on a patient at high risk for nutritional problems for 1 (#3-current patient) out of 2 (#2, #3) patients reviewed for a nutritional consult.
3. the dietician failed to evaluate laboratory testing and follow-up on a nutritional consultation of a patient (#2) who was refusing to eat.
Findings:

Review of the hospital policy, PC 76-Provision of Care, Treatment, and Services; Nutritional Assessment of Patients by Registered Dietician revealed in part, Nutritional assessments shall include a review of Clinical information: diagnosis, diet order, medical history, age, sex, clinical laboratory data, medications including potential food-drug interactions. Anthropometrical measure: height, weight, desirable weight etc. Diet information: diet history, eating habits (number and content of meals, location of meals, assistance needed in cooking and shopping, economic factors), food preferences, cultural, ethnic, and religious background. Difficulties chewing, swallowing, nausea, vomiting or diarrhea are documented.

1. Dietician failing to review and approve patients' menus.

An interview was conducted with S1Adm on 1/26/16 at 12:55 p.m. She reported the dietician (S5RD) had not reviewed and approved the menus. S1Adm reported she was not aware the registered dietician needed to review and approve the menus.


2. Nutritional consult not done within 48 hours of being ordered.

Review of the hospital policy, PC 10-Provision of Care, Treatment, and Services, Patient Assessment and Reassessment, 5. When warranted by the patient's needs or conditions, the Registered Nurse will obtain orders from the physician for consults from the following licensed patient care providers contracted by the hospital. Registered Dietitian; If the contracted Registered Dietitian is consulted, the Nutritional Assessment will be completed within 48 hours of receipt of the physician's order.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 29 year old female admitted to the hospital on 1/19/16 for a suicide attempt via overdosing on synthroid and Klonopin. Patient #3's medical diagnoses included: Primary Biliary Cirrhosis, Seizures, Hypothyroidism, Anemia, and Asthma. Review of the Initial Psychiatric Evaluation on 1/20/16 revealed Patient #3 had a poor appetite and did not feel like eating. Review of the Physician Orders revealed an order for a dietary consult on 1/20/16. Review of the Nutritional Assessment/Consult revealed the consult was conducted on 1/25/16 (5 days after the dietary consult was ordered). Further review of the nutritional assessment revealed Patient #3 had lost 6 pounds since her admission 6 days prior.

An interview was conducted with S3PI/IC on 1/26/15 at 10:30 a.m. She confirmed the dietary consult was performed 5 days after the dietary consult was ordered.


3. Failing to evaluate laboratory testing and follow-up on a nutritional consultation of a patient who was refusing to eat.

Patient #2
Review of the medical record for Patient #2 revealed she had been admitted to the hospital on 12/29/15 with an Axis I Diagnosis of Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified; and an Axis III Diagnosis of Type 2 Diabetes Mellitus without complications and Essential (primary) Hypertension.

Review of the Nutritional Assessment (01/03/16 at 2:30 p.m.) performed by S5RD (Registered Dietician) revealed: Labs Glucose, BUN, Creatinine, Hgb, Hct, Albumin, and cholesterol "(01/02/16 unavailable at present time)." Recommendations: 1. diet change to 2000 calorie diabetic diet with 1 can COLD glucerna with meals. 2. Honor food preferences as feasible. 3. Provide feeding assistance and encouragement. 4. Encourage physical activity as tolerated.

Review of the Patient #2's lab results revealed the following were performed at 6:45 a.m. on 01/03/16 and the results received and signed off by S13RN at 12:40 p.m.:
Test Results Reference range
glucose 328 (H) 74- 106 mg/dL
BUN 29(H) 7-18 mg/dL
Creatinine 1.1 12.0 -20.0
Albumin 3.9 3.4- 5.0 mg/dL
Cholesterol level- not available at the time of the nutritional consult

Further review of Patient #2's laboratory testing results revealed lab from Hospital "A" performed on 12/29/15 were available at the time of the Nutritional Assessment which included Hct. & Hgb. There was no evidence to indicate that the dietician followed up on patient's nutritional status or the abnormal lab values.

In a telephone interview on 01/26/16 at 10:02 a.m., S5RD indicated that a nutritional assessment was performed (not certain of date) on Patient #2. S5RD reported that laboratory results were not available for review at the time of the nutritional assessment and recommendations were made for diet order with supplements, Nutritional intake monitoring/documentation, and staff to assist patient with meals. S5RD indicated that after the initial assessment she provided no follow-up care to Patient #2. S5RD indicated that she was never informed that the patient was not eating, had uncontrolled blood sugars, or that laboratory results were abnormal. S5RD indicated that there was no follow up on her part after conducting the original nutritional assessment.




31206

Based on record review and interview, the hospital failed to ensure the nutritional needs of the patients were met as evidenced by failing to ensure therapeutic diets were ordered at the time of admission to the hospital for 2 (#2, #4) of 2 patients who's medical record was reviewed for dietary orders from a total sample of 5. Findings:

Patient #2
Review of the medical record for Patient #2 revealed she had been admitted to the hospital on 12/29/15 with an Axis I Diagnosis of Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified; and an Axis III Diagnosis of Type 2 Diabetes Mellitus without complications, Pure Hyperglyceridemia, and Essential (primary) Hypertension. Review of the admission orders for Patient #2 revealed no diet order. A diet order was written by S6Psy/MD on 01/01/16 for 1800 calorie diabetic diet (3 days after admission to the hospital).

In an interview on 01/25/16 at 12:55 p.m., S2DON verified that Patient #2 had no order for a diet upon admission (12/29/15) and was provided a Regular Diet and glucerna 3 cans a day.


Patient #4
Review of the medical record revealed Patient #4 was admitted to the hospital on 11/12/15 for Aggressive Behavior. Her medical diagnoses included: Diabetes Mellitus, Hypertension, Post CVA (Cerebral Vascular Accident), and Mediport insertion. Review of the physician orders revealed a diet was not ordered until 11/17/15 (5 days after admission to the hospital).

An interview was conducted with S4PI/Edu on 1/25/16 at 2:20 p.m. She verified that individual diets should be ordered for the patients at the time of admission.

An interview was conducted with S3PI/IC on 1/25/16 at 2:25 p.m. She verified the patient specific diet was not ordered until 11/17/15 which was 5 days after admission.




31206

Based on record review and interview, the hospital failed to ensure each patient had an individualized, comprehensive treatment plan as evidenced by failure to include identified medical problems for which the patient was being treated and failure to individualize the interventions planned for each patient to address the patient's identified problems for 3 (#1, #3, #4) of 5 sampled patients. Findings:

Review of the hospital's policy PC 74- Provision of Care, Treatment, and Services, Plan of Care revealed 1. Every patient shall have an individualized comprehensive plan of care...4. Every patient's plan of care shall identify patients goals and associated objectives and interventions necessary to meet the identified goals...4. The plan of care, treatment and services includes, but may not be limited to: defined problems and needs statements. Measurable goals and objectives based on the assessed needs, strengths and the patient's limitations. Objectives are sufficiently specific to evaluate the patient's progress...the frequency of care, treatment and services...

Patient #1
Review of the medical record revealed the patient was a 20 year old male admitted on 1/12/16 on a PEC (Physician Emergency Certificate) from an emergency room for psychosis and substance abuse. Review of the Initial Psychiatric Evaluation, dated 1/13/16, revealed Patient #1 is a poor historian due to his altered thought processes. His delusions are grandiose, illogical and religious in content. He is disorientated to person, place and time and easily agitated. Review of Patient #1's Close Observation Sheets revealed he was on 1:1 observation level from 1/13/16 until 1/24/16 due to his violent behaviors. Review of his treatment plan revealed the only intervention documented for his identified Problem of at Risk for violence to others was Group Psychotherapy (45 minutes) to explore insight and increase coping, life skills, and rational thoughts.

An interview was conducted with S3PI/IC on 1/22/16 at 1:15 p.m. She reported his treatment plan was not individualized for Patient #1's violent behaviors or for the need for 1:1 observation level.


Patient #3
Review of the medical record revealed the patient was admitted to the hospital on 1/19/16 for a suicide attempt by overdosing on Klonopin and Synthroid. Her medical diagnoses included: Primary Biliary Cirrhosis, Asthma, Anemia, and Hypothyroidism. Review of the physicians orders revealed the patient had to be sent to a local hospital for a blood transfusion due to her low hemoglobin and hematocrit lab values and was returned to the current hospital after the blood transfusion was completed. Review of the Initial Psychiatric Evaluation, dated 1/20/16, revealed the patient's appetite was decreased and she reported she did not feel like eating. Review of the physician orders revealed she had orders for strict I & O's, calorie count, and Ensure 3 times a day. Review of the MAR revealed no documentation of how much of the Ensure she was consuming. Review of Input and Output revealed no entries. Review of the medical record revealed on admission her weight was 137 pounds, her weight on 1/25/16 was documented as 131 pounds (6 pound lost).

Review of her Treatment Plan revealed no indication the patient received a blood transfusion due to her low hematocrit and hemoglobin values during her hospitalization. Further review of the Treatment Plan revealed no problems, goals or interventions for the patient's lack of appetite, decrease caloric intake or weight loss.

An interview was conducted with S3PI/IC on 1/25/16 at 1:00 p.m. She verified the treatment plan did not include specific interventions for her anemia, such as her blood transfusion. She further reported the Treatment Plan did not address her decreased appetite or weight loss.


Patient #4
Review of the medical record revealed the patient was admitted to the hospital on 11/12/15 for Aggressive Behavior. Her medical diagnoses include Diabetes Mellitus, Hypertension, Post CVA (Cerebral Vascular Accident), Mediport insertion. Review of the Treatment Plan revealed no problems, goals or specific interventions for Patient #4's diagnosis of Diabetes Mellitus. Review of Patient #4's Physician's orders revealed she was receiving insulin per sliding scale to regulate her glucose levels while in the hospital.

An interview was conducted with S3PI/IC on 1/25/16 at 2:25 p.m. She verified the patient's Treatment plan did not address her medical diagnosis of Diabetes Mellitus.

Based on record review and interview, the Medial Director failed to provide adequate medical oversight to ensure quality medical services were provided by failing to ensure consultation reports and progress notes were documented by S7MD for all patients whose care he managed while in the hospital.
Finding:

Patient #2
Review of the medical record for Patient #2 revealed she had been admitted to the hospital on 12/29/15 with an Axis I Diagnosis of Schizoaffective Disorder, Unspecified and Major Depressive Disorder, Single Episode, Unspecified; and an Axis III Diagnosis of Type 2 Diabetes Mellitus without complications, Pure Hyperglyceridemia, and Essential (primary) Hypertension. Documentation revealed Patient #2 was discharged on 01/12/16. Record review revealed the H&P was completed on 12/30/15. Documentation revealed a consultation was ordered on 01/01/16 by S6Psy/MD. Review of the medical record revealed no evidence to indicate that the consultation was completed as ordered. There was no documented evidence of Progress Notes by S7MD for care and management of Patient #2 while in the hospital.

In an interview on 01/26/16 at 10:25 a.m., S6Psy/MD (Psychiatrist/ Medical Director) indicated that she was not aware that S7MD was not documenting his consultation and/or progress notes.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the hospital on 1/19/16 for a suicide attempt by overdosing on Klonopin and Synthroid. Her medical diagnoses included: Primary Biliary Cirrhosis, Asthma, Anemia, and Hypothyroid. Review of the record revealed orders dated 1/22/16 for a medical consult for the patient's low TSH (Thyroid Stimulating Hormone) lab value. Review of the lab value for TSH on 1/20/16 revealed a result of .02 (normal range is 0.36 to 3.74 uIU/ml). Review of the medical record revealed no documentation of a medical consult being performed on Patient #3 for her low TSH lab value.

In an interview with S7MD on 1/26/16 at 8:30 a.m., he was unable to determine if he was aware of the patient's low TSH lab value. He reported when he did the patient's history and physical he continued the patient on her home medication of synthroid. He further reported the TSH lab values were not available when he conducted his History and Physical.

Patient #5
Review of the medical record revealed Patient #5 was admitted to the hospital on 1/16/16 for an Overdose, Violent behavior and Self-inflicted Lacerations. Review of the record revealed orders dated 1/20/16 for an Internal Medicine Consult for right hip pain. Review of the medical record revealed no evidence of an internal medicine consult being conducted on Patient #5 for her complaints of right hip pain.

An interview was conducted with S7MD on 1/26/16 at 8:30 a.m. He reported he receives so many consults from the hospital he is unable to document on the consults. When the surveyor questioned S7MD on Patient #5's medical consult on 1/20/16 for right hip pain, he reported he was unaware of the consult after reviewing his phone texts and phone log. S7MD stated he had no way of knowing if the nurses notified him of the consult. (Review of the Nurse's notes from 1/20/16 at 6 p.m. revealed S13RN documented she notified S7MD of the medical consult on Patient #5 for her right hip pain.)

Based on record review and interview, the hospital failed to have a Therapeutic Activities Director to provide comprehensive therapeutic activities according to the patients' active treatment programs. Findings:

Review of the hospital's policy on Therapeutic Recreational Activities revealed in part the hospital provides individualized therapeutic activities. Therapeutic activities focus upon the development and maintenance of adaptive skills that will improve the patient's functioning.
Leisure activities provide the patient with individualized opportunities to acquire knowledge, skills and attitudes about meaningful leisure involvement and experience. Procedure: The number of qualified therapists, support staff and consultants are adequate to provide comprehensive therapeutic activities consistent with each patient's active plan of care.

An interview was conducted with S19COO on 1/25/16 at 3:30 p.m. S19COO verified that the hospital did not have a Therapeutic Recreational Activities Director at this time.