HospitalInspections.org

Based on record review and interviews with hospital staff, the governing body failed to ensure that personnel providing services by contract are oriented, trained and evaluated to ensure competence and meet the same health requirements of employees of the hospital.

Findings:

1. One of one agency contract nurse which the hospital used for patient care did not have any orientation or compentencies specific for Rolling Hills Psychiatric hospital. Hospital staff stated on 03/27/13 in the afternoon that the employment agency provided all orientation and training for the nurse. The hospital did not conduct any orientation or training or document health histories for contract services.

2. Pharmaceutical services are provided by contract. There was no documentation of health histories for the two pharmacy contract personnel.

3. Dietitian services are provided by contract. There was no documentation of a health history for the contract dietitian.

Based on record review and interviews with hospital staff, the governing body failed to ensure that adverse events such as medication errors are identified, tracked, analyzed and preventative actions taken. Medication errors were not tracked and analyzed as part of an ongoing Quality Assurance/Performance Improvement (QA/PI) program.

Findings:

1. There was no documentation of the analysis and trending of medication errors and incident reports by hospital staff as part of an ongoing QA/PI program.

2. Staff (B) stated on 03/27/13 that there was no trending and analysis of medication errors.

Based on clinical record review, policy and procedure review, observation and staff interview, it was determined the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for five (#11, 14, 15, 16 and #17) of five records reviewed for nursing care. Findings:

On 03/26/13 and 03/27/13, the clinical records for five patients were reviewed. The records documented the following deficiencies:

1. Nursing staff did not weigh patients upon admission and weekly/daily thereafter as ordered by the physician.

2. Nursing staff did not perform an initial nutritional screen for every patient. Patient #16 did not have a completed nursing nutritional screen.

3. Nursing staff did not assess patients as required by the hydration and anorexia protocols. After the protocols were implemented, the nursing staff did not reassess the patients daily or follow all requirements of the protocol.

4. Nursing staff did not document percentages of meals consumed and amounts of fluids taken for each meal time. When these were recorded, the RN did not review the documentation and intervene when indicated, i.e., provide additional nutrition or fluids.

Additional entrees, alternate meals and snacks were not documented. If a patient consumed one of these, the amount was not recorded.

5. On a tour of the geriatric unit, it was observed the patients were provided fluids in large cups with lids. The cups were not clear and the liquid inside the cup could not be seen. The cups were not graduated with cc's or ounces. Staff stated they "estimated" how much fluid the patient consumed.

There was no policy and procedure for establishing how much fluid a patient was provided on each shift. For example, there was no policy that stated techs provided "X" amount of water, juice, etc. at the beginning of the shift and measured and recorded an amount consumed at the end of the shift.

6. Nursing staff did not regularly assess all patients for signs and symptoms of dehydration. When dehydration was documented, there was no evidence of intervention by the nursing staff unless ordered by the physician.

7. Supplements were not always recorded. If they were recorded, the documentation did not include how much was consumed.

8. Nursing care plans did not reflect patient food and fluid preferences.

9. Nursing staff did not ensure patients were bathed or showered regularly and had other hygiene daily:

Patient #11 had no documentation of bathing and hygiene on ten of 26 days. The record also documented the patient "refused" bathing and hygiene on another five times in 26 days. This indicated the patient had no bathing and hygiene on 15 out 26 days.

Patient #14 had no documentation of bathing and hygiene on 16 of 22 days. The record documented the patient "refused" the other six days.

Patient #15 had no documentation of bathing and hygiene on 21 of 23 days.

Patient #16 had no documentation of bathing and hygiene on 21 of 33 days.

10. On 03/27/13, the DON stated there was a problem with documentation. She stated the hospital had not considered a problem with recording fluid intake using the cups provided.

She stated no one from nursing leadership was reviewing documentation of basic activities of daily living and meal and fluid intake records.

Based on employee record review, policy and procedure review and staff interview, it was determined the hospital failed to develop and implement a job description for the dietary manager and failed to include dietary services in the QAPI program. Findings:

On 03/26/13, the dietary services policy and procedure manual had no job description for the dietary manager. There was no policy that described the integration of roles between the dietary manager and the dietitian.

There was no documentation the dietitian evaluated the services provided by the dietary manager.

On 03/27/13, the dietary manager was asked how dietary services participated in the quality program. She stated she was not sure.

She was asked if anyone evaluated whether the hospital's hydration and anorexia protocols were implemented appropriately. She stated she did not know.

She was asked if anyone evaluated documentation of weights, meal intake and fluid intake. She stated she did not think so.

There was no documentation dietary services submitted data and evaluation to the QAPI committee.

Based on clinical record review, staff file review and staff interview, it was determined the hospital failed to ensure the dietitian provided adequate oversight of the nutritional needs of patients and oversight of the hospital's entire nutritional services program.

Findings:

1. On 03/27/13, the dietitian's employment file was reviewed. There was no signed job description found in the file.

A review of dietary services policies and procedures had no documentation of a policy that addressed the comprehensive nutritional screen performed by the dietitian. The only policy available addressed a brief nutritional screen performed by the nursing staff.

The nursing nutritional screening form, developed by the dietitian, did not require the nursing staff to enter an actual height and weight for the patient. The nursing staff could write in a "stated" height and weight.

The form did not address skin breakdown, non-healing wounds, loss of appetite, medical conditions such as diabetes, or the patient's need staff assistance with hydration and nutrition.

The dietitian was not required to evaluate the nurses' nutritional screening.

There were no policies and procedures that required the dietitian to do special monitoring of the geriatric patients' nutritional status.

There was no documentation the dietitian was required to monitor and evaluate the hospital's special hydration and anorexia protocols.

2. On 10/10/12, patient #11, a geriatric patient, was admitted from another hospital with a therapeutic diet order, the inability to use one arm due to a fracture, dementia, and a need for assistance with all activities of daily living. The physician ordered the patient to be weighed upon admission and weekly thereafter.

The nursing staff performed a nutritional screen and documented the patient's "stated" height was 70 inches, and his "stated" weight was 214 pounds. There was no documentation the staff actually weighed the patient to verify the patient's height and weight.

The screening form documented the patient had chewing and swallowing difficulty, needed a special diet, was over 65 years of age, and that a dietitian consultation was required.

On 10/12/12, the nursing staff documented on the treatment plan that the patient was fragile physically and needed full assistance with eating.

There were multiple nutritional interventions ordered by the physician including vitamin and mineral supplements, changes in diet type and texture, and extra hydration monitoring.

On 10/13/13, the dietitian performed a nutritional assessment. After this assessment, no other documentation by the dietitian was found in the clinical record.

On 10/22/12, the physician ordered daily weights for the patient. The first weight documented by the nursing staff was on 11/01/12. The patient's weight was 168 pounds. This would indicate the patient had a weight loss of 46 pounds in 12 days.

The next weight was documented on 11/02/12. The patient's weight was 164 pounds.

There was no documentation that indicated the dietitian reviewed the patient's weights, meal intake percentages, fluid intake, the provision of supplements and relevant laboratory results. There was no documentation the dietitian evaluated the patient's severe weight loss for validity.

3. Patient #14, a geriatric patient, was admitted on 01/10/13 with a "stated" weight of 190 pounds. The patient was ordered to have weekly weights. The first actual weight taken by the staff was recorded on 01/29/12 as 162 pounds. There was no documentation the dietitian evaluated the patient's severe weight loss of 28 pounds in 19 days.

The facility did not have a mechanism in place for the dietitian or dietary manager to monitor weekly weights for the patients.

4. Patient #15, a geriatric patient, was admitted with orders to weigh on admission and then weekly. There was no documentation the patient was actually weighed by the nursing staff. Two documents recorded on the same day, had two different weights. One weight record was documented as a "stated" weight.

Two days later, the dietitian evaluated the patient. The consultation form documented, "... Patient eating poorly... if [oral] intake less than 75 %, offer nutritional health shake... encourage fluids... consider daily [multivitamin with minerals]..."

Four days later, the physician instituted standing dietary orders for poor nutritional status.

The clinical record had inconsistent documentation of meal percentages consumed. When it was documented, the percentage was always less than 75%. A supplemental health shake was documented only once during the patient's admission.

The clinical record also documented the patient consumed between 16 and 40 ounces of fluids daily - far less than a minimum requirement of 72 ounces per day.

There was no documentation the dietitian reviewed the patient's weights, meal percentages, supplements provided and fluid intake.

5. Patient #16, a geriatric patient, was admitted with no nutritional screening done by the nursing staff. Throughout the patient's stay, there was no documentation of meal intake or fluid intake.

6. Patient #17, a geriatric patient, was admitted with a diagnosis of Alzheimer's disease. There was a physician's order for weight on admission and weekly thereafter.

The nurses requested a dietitian consult for the patient at the time of admission. The dietitian documented on the consult, "... Scales not working. No weight on admission..."

There was no documentation of weekly weights.

Nine days after admission, the physician documented the patient was not eating and was not producing adequate urine. He ordered "anorexia protocol" to be implemented for the patient.

The hospital's "Anorexia Protocol," documented, "... to assure that patients receive adequate nutrition... and to address signs and symptoms of nutritional deficiency... The Hydration Protocol is cross-referenced if the patient also shows signs and symptoms of dehydration...

If the patient is 65 or older, patient will be provided with a Second Choice Entree at meals. This entree will be bland (not spicy) and easy to chop...

If patient is age 65 or older and eats less than 75% at a regular meal, the patient will be provided a 4 ounce nutritional supplement following the meal...

If a patient eats less than 50% at three consecutive meals, or averages less than 50% consumption of meals over 72 hours, the RN shall assess the patient for signs and symptoms of dehydration as described in the Hydration Protocol...

In addition, the RN shall place a Nutrition Consult for the patient unless a consult has been performed during the preceding 72 hours...

The RN shall follow the Anorexia Protocol set forth below... Initiate the Hydration Protocol if the patient meets criteria... Provide the patient with a 4 to 8 ounce nutritional supplement with each meal, [every night at bedtime and as needed]..."

A review of the patient's clinical record indicated when the patient ate less than 75%, he was not offered a nutritional supplement shake. There was no documentation a second entree was offered. There was no documentation the patient was offered and consumed between meals snacks.

The record documented the patient consumed between 24 and 64 ounces of fluid per day, well below the 100 ounces recommended per day.

There was no documentation the dietitian was consulted again for this patient.

On 03/27/13, the dietary manager stated unless the nursing staff notified the dietitian of further nutritional problems or of another consultation request, the dietitian did not initiate follow-up on her own.

She stated there was no process in place for dietary services to review weight and nutritional monitoring and documentation (or lack of ) by the nursing staff.

The dietary manager stated that other than doing a kitchen evaluation, she was not aware the dietitian evaluated any other aspects of the nutritional services program.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure patients were assessed, reassessed and were provided nutritional interventions when indicated for five (#11, 14, 15, 16 and #17) of five patient records reviewed for nutritional care. Findings:

On 03/26/13 and 03/27/13, five clinical records were reviewed for nutritional screening, reassessment and the provision of nutritional interventions.

All five records had nutritional screening by the nursing staff utilizing the tool provided by the dietitian. However, the tool did not trigger critical nutritional assessment indicators such as patients with:

~recent hospitalization
~recent peripheral nutrition
~current infections
~alterations in ability to ingest, absorb or digest nutrients as a result of medical or surgical conditions
~diagnosis or signs and symptoms that indicate a compromised nutritional status, such as anorexia, bulimia, electrolyte imbalances, malabsorption and end stage organ diseases (common in the elderly), or
~patients with medical conditions that can be adversely affected by their nutritional intake, such as diabetes, congestive heart failure, patients taking certain medications, renal diseases, non-healing wounds, etc. (also common in the elderly)

There was no policy and procedure for advanced nutritional evaluation by the dietitian. There were no special requirements for assessment and intervention of the geriatric patients.

The records documented that when special protocols were implemented, such as the hydration or anorexia protocol, there was not documentation of reassessment by the nurses or the dietitian.

When the protocols required supplementation of the patients' diet with extra foods, substitutions, snacks, shakes or fluids, the nursing staff did not document these were provided to the patient or that they were refused.

Based on emergency plan review and staff interview, it was determined the hospital failed to fully develop and implement a comprehensive emergency preparedness plan. Findings:

On 03/26/13, the hospital's emergency preparedness plan was reviewed. The following deficiencies were noted:

1. The plan had not been reviewed and approved by the hospital's safety officer.

2. The staff call back phone number list was last updated in June 2008 and did not list current staff.

3. There was no documentation the hospital ever participated in a community-wide disaster drill. The safety officer stated this was planned for April 2013.

4. The plan documented emergency water supply would be provided by the City of Ada. The safety officer stated the water supply would come from a commercial vendor.

5. A hospital "Disaster Policy" was last updated in June 2008. The plan did not describe all disaster codes used in other policies, such as "Code Cobra" and "Code Orange".

On 03/27/13, the CEO and the safety officer stated the disaster preparedness program was in the process of revision.

Based on policy and procedure review, personnel record review and staff interview, it was determined the hospital failed to ensure all employees were appropriately immunized and tested as necessary for communicable diseases for 12 (J, F, C, K, L, G, M, N, O, P, Q, and R) of 13 records reviewed. Findings:

1. On 03/26/13 and 03/27/13, staff employee health files were reviewed for evidence of immunity to communicable diseases, acceptance or declination of annual flu vaccination, and evidence of regular TB skin testing as required.

Staff J was not administered a two step TB skin test as required by state TB control requirements, had no documentation of immunity or vaccination to hepatitis B, and had no evidence of vaccination to hepatitis A as required by hospital policy for this employee's job category.

Staff F had no documentation of flu immunization or declination.

Staff C had no documentation of flu immunization or declination, did not receive a two step TB skin test as required, and had no documentation of immunity or vaccination for hepatitis B.

Staff K had no documentation of hepatitis B immunity or vaccination, no evidence of immunity to varicella and no documentation of vaccination to hepatitis A.

Staff L had no documentation of immunity to varicella.

Staff G had no documentation of a two step TB skin test, and no evidence of vaccination or immunity to hepatitis B, measles, mumps, rubella, and varicella.

Staff M had no documentation of a two step TB skin test, and no documentation of immunity or vaccination for hepatitis B.

Four agency staff files (N, O, P and Q) had no documentation of any immunizations or TB skin testing.

The contracted dietitian file had no documentation of immunizations or TB skin testing.

2. The hospital's bloodborne pathogen exposure control plan was reviewed. Forms and documents used to guide staff on the administration of the program were dated 1997 and did not reflect current standards. None of the documents used by the hospital reflected testing for hepatitis C.

Records were reviewed for those employees who had an exposure in the last 12 months. The files had no documentation employees were evaluated and counseled by a qualified medical person immediately after exposure.

There was no documentation the employees were offered post-exposure blood testing and vaccination if needed. Records were not kept of the lab results for each employee. There was no documentation employees were follow-up post-exposure as required by the bloodborne pathogen standard.

There was no documentation in the records to identify the source patient involved in the exposure event.

The infection control practitioner was made aware of the findings. No comment was made.