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Based on observation, interview and record review, the hospital failed to update the nursing care plan to reflect the need for isolation for three of 14 sampled patients(1, 3, and 6) which had the potential to result in unidentified patient needs.

Findings:

1. During an observation on 5/16/12 at 10:15 AM, the wall next to the door of Patient 1's room had a sign posted which indicated strict contact precautions were to be used by all persons entering the room.

The clinical record for Patient 1 was reviewed on 5/16/12. The Interdisciplinary Care Plan, last updated on 5/15/12, did not indicate the need for isolation. The record indicated contact isolation was initiated on 4/29/12.

During an interview with Nurse Manager A, on 5/16/12 at 10:45 AM, she reviewed the care plan and was unable to find documentation of patient care needs resulting from isolation.

2. During an observation on 5/16/12 at 11:25 AM, the wall next to the door of Patient 3's room had a sign posted which indicated strict contact precautions were to be used by all persons entering the room.

The clinical record for Patient 3 was reviewed on 5/16/12. The Interdisciplinary Care Plan, last updated on 5/16/12, did not indicate the need for isolation. The record indicated contact isolation was initiated on 5/10/12.

During an interview with Registered Nurse A, on 5/16/12 at 12:10 PM, she reviewed the care plan and was unable to find documentation of patient care needs resulting from isolation.

3. During an observation on 5/16/12 at 12:20 PM, the wall next to the door of Patient 6's room had a sign posted which indicated strict contact precautions were to be used by all persons entering the room.

The clinical record for Patient 6 was reviewed on 5/16/12. The Interdisciplinary Care Plan, last updated on 5/16/12, did not indicate the need for isolation. The record indicated contact isolation was initiated on 4/30/12.

During an interview with Infection Control Coordinator, on 5/16/12 at 12:10 PM, she reviewed the care plan and was unable to find documentation of patient care needs resulting from isolation.

The facility policy and procedure titled "Interdisciplinary Care Plan", dated 1/09, indicated "The Interdisciplinary Care Plan is updated when there is a change in condition or additional patient care needs are identified by nursing and other appropriate disciplines."

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Based on interview and record review, the hospital failed to ensure that the nutritional needs for one of 14 (14) sampled patients were identified timely.

Findings:

The clinical record for Patient 14 was reviewed on 5/16/12. The "Review of the Visit Information" form, dated 5/14/12, indicated Patient 14's chief complaint was "abd (abdominal) pain with N/V (nausea and vomiting) x (times) 1 week."

According to the hospital nutrition screening criteria, a patient is considered to be at nutritional risk if the patient experienced diarrhea for three days or more. Review of the admission dietary screening form showed the patient had not been identified as being at high nutritional risk based on her admitting screening form completed by the admitting nurse.

Patient 14 was screened by the admitting nurse and to the question of diarrhea she indicated "N" implying that the patient did not have any problems with diarrhea. The admitting nurse was not available for interview.

When this error was brought to the attention of Registered Dietitian A and Nursing Manager B, they both indicated the question asked in the nurse's screen was different and specific to a kind of diarrhea, intractable diarrhea. This is diarrhea that is unstoppable even with medication.

This difference in the way the screening questions were asked resulted in the inaccurate assessment and identification of nutritional risk. Diarrhea and vomiting could result in nutrient losses that can lead to malnutrition and other complications if it continues for at least three days.

Nutritional intervention was delayed for at least a day. The registered dietitian conducted a nutritional assessment on Patient 14 because of another nutrition related risk factor of low albumin.

Based on observation, interview, and record review, the hospital failed to ensure the hospital's diet manual reflected diets served in the hospital.

Findings:

According to Registered Dietician A, the hospital utilizes both an online and paper diet manuals. The online diet manual was the American Dietetic Association Care manual. The hard copy (paper) manual was not a printed version of the online manual. The paper diet manual included information on some of the diets served. Neither manual reflected all the diets provided in the hospital.

According to an undated document titled "Diets Available in Medi-tech", the hospital physician could order among other diets a Hepatic Diet. Review of the diet manual did not include the description of the hepatic diet. In addition, the kitchen did not have a hepatic diet menu.

There had been modifications made to the hospital menu that had been approved by the medical staff. These modifications were not reflected in the description of the diet. For example, a nutritional supplement had been added to the clear liquid diet to improve the nutritional content of the diet. The approval was a document added to the manual. Nursing and food service staff that are not familiar with the modification that was made would not get an accurate description of the diet if the diet manual is being used as a reference source.

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Based on observation and interview, the hospital failed to identify the proper air flow for one room and have sufficient supply of masks readily available for use which had the potential to result in a lack of observance of proper isolation practices.

Findings:

1. During an observation on 5/16/12 at 10:55 AM, patient Room 216 had a sign posted on the wall next to the door which indicated this room was a negative air flow room (a room used to keep germs from moving outside the room). There was a large red sign secured to the door of this room indicating this room was a positive air flow room (a room used to keep germs from moving into the room).

During an interview with Maintenance Engineer A, on 5/16/12 at 11:15 AM, he stated Room 216 had originally been designated as a negative air flow room but was changed to a positive air flow room in the past based on patient needs. He stated the original negative air flow sign was not removed when the room was switched to positive air flow.

2. During an observation on 5/16/12 at 11:20 AM, Patient 2's room had a sign posted on the wall outside the room indicating droplet precautions were in place and anyone working within 3 feet or upon entering the room was to wear a mask. The supply cupboard next to the room contained gowns but the box for masks was empty.

During an interview with Nurse Manager B, on 5/16/12 at 11:20 AM, she viewed the empty mask box and stated there should be masks available for staff and visitors use in the cupboard.