HospitalInspections.org

Repeat deficiency
A. Based on medical record review and staff interview, it was determined in 1 of 4 ( Pt #6) medical records reviewed for completion of nutritional screening and subsequent referral to RD, if indicated, the CAH failed to ensure the nutritional screening was completed.

Findings include:

1. The medical record of Pt #6 was reviewed on 5/29/12. Pt #6 was admitted to the CAH on 5/16/12 with the diagnoses CHF and COPD and was discharged home on 5/18/12. There was no documentation to indicate a nutritional screening was completed during Pt #6's hospitalization.

2. During a staff interview, conducted with the DON on 5/29/12 at 9:30 AM, the Nutritional Screening process was discussed. It was verbalized the RN was to complete the nutritional screen upon admission. If any of the indicators are marked with a positive response, a referral to the Dietary Manager is automatically triggered. The Dietary Manager then completes an evaluation/ data collection of the patient and faxes the information to the RD for ongoing nutritional guidance. There was no documentation to indicate the Dietary Manager and/or the RD had evaluated Pt #6. The DON confirmed that no nutritional screening and/or evaluation had been completed on Pt #6.

Repeat Deficiency
A. Based on medical record review and staff interview, it was determined in 2 of 11 (Pts #3, #11) medical records reviewed, the CAH failed to ensure care was provided in accordance with physician orders.

Findings include:

1. The medical record of Pt #3 was reviewed on 5/29/12. Pt #3 was admitted to the CAH on 5/24/12 with the diagnosis CHF. On 5/24/12, there was a physician order for daily weights and vital signs every 4 hours. There was no documentation to indicate a weight was obtained on 5/25/12. There was no documentation to indicate vital signs were taken every 4 hours on 5/25/12.

2. The medical record of Pt #11 was reviewed on 5/29/12. Pt #11 was presented to the ED on 5/19/12 with the CC Right Sided Weakness. There was a physician order for Rapid Drug Screen and Magnesium level. There was no documentation to indicate these were completed. ED nursing documentation indicated "Nubain 10 milligrams IM given 2240, Phenergan 25 milligrams IM given 2245, and 0.9 Normal Saline 1000 milliliters at 100 ml/hour at 2300." There was no physician order for these medications.

3. During a staff interview, conducted with the DON on 5/29/12 at 4:00 PM, the above findings were confirmed.

Repeat deficiency
A. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 3 of 11 (Pts #3, #4, #6) medical records reviewed, the CAH failed to ensure all entries in the medical record were dated and timed.

Findings include:

1. The CAH policies titled "Inpatient (Medical Surgical and Observation) Physician Orders" (revised 2/15/12) was reviewed. It indicated "All orders for medications/ treatments shall include the date and time..."

2. The medical record of Pt #3 was reviewed on 5/29/12. Pt #3 was admitted to the CAH on 5/24/12 with the diagnosis CHF. There was no documentation to indicate the time the MSE was completed or the date and time as to when the ED orders were written.

3. The medical record of Pt #4 was reviewed on 5/29/12. Pt #4 was admitted to the CAH on 5/25/12 with the diagnoses Hyponatremia and CHF. There was no documentation to indicate when the ED orders were written 1 of 4 physician progress notes failed to indicate the date it was written.

4. The medical record of Pt #6 was reviewed on 5/29/12. Pt #6 was admitted to the CAH on 5/16/12 with the diagnoses CHF and COPD. There was no documentation to indicate the time the MSE or the date and time as to when the ED orders were written. 1 of 3 physician progress notes failed to include the date and time as to when it was completed.

5. During a staff interview, conducted with the DON on 5/29/12 at 4:00 PM, the above findings were confirmed and it was verbalized that the expectation is that all entries in the medical record are to be dated and timed.