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Based on interview and record review, the hospital failed to ensure verbal or telephone physician's orders were authenticated within 48 hours of when the orders were given to the hospital staff for 11 of 30 sampled patients (2, 4, 8, 10, 13, 14, 15, 17, 19, 21, and 22), which had the potential for transcription errors to adversely affect patient safety.

Findings:

1. During a concurrent clinical record review for Patient 2 and interview with the Chief Nursing Officer (CNO), on 3/6/12, at 3:40 PM, she confirmed the physician for Patient 2 had not authenticated the following verbal/telephone orders within 48 hours: one order dated 2/28/12, one order dated 3/2/12.

2. During a concurrent clinical record review for Patient 4 and interview with the CNO, on 3/7/12, at 12:50 PM, she confirmed the physician for Patient 4 had not authenticated the following verbal/telephone orders within 48 hours: two orders dated 2/8/12, one order dated 2/17/12, three orders dated 2/21/12, one order dated 2/23/12, one order dated 2/25/12, two orders dated 3/1/12, one order dated 3/2/12, one order dated 3/3/12, and one order dated 3/4/12.

3. During a concurrent clinical record review for Patient 8 and interview with the Manager of Accreditation (MA), on 3/8/12, at 10 AM, she confirmed the physician for Patient 8 had not authenticated the following verbal/telephone orders within 48 hours: one order dated 2/25/12, and one order dated 2/26/12.

4. During a concurrent clinical record review for Patient 10 and interview with the MA, on 3/8/12, at 10 AM, she confirmed the physician for Patient 10 had not authenticated the following verbal/telephone orders within 48 hours: two orders dated 3/3/12.



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5. During a concurrent clinical record review for Patients 14 and 22 and interview with the CNO, on 3/6/12, at 2:50 PM, she confirmed the physician for Patients 14 and 22 had not authenticated the following verbal/telephone orders within 48 hours: For Patient 14: three orders dated 3/1/12 and one order dated 3/4/12, and for Patient 22: one order dated 2/16/12 and two orders dated 2/17/12.

6. During a concurrent clinical record review for Patient 13 and interview with the Registered Nurse (RN) 2, on 3/7/12, at 2:50 PM, she confirmed the physician for Patient 13 had not authenticated the following verbal/telephone orders within 48 hours: one order dated 2/21/12, and one order dated 2/22/12.

7. During a concurrent clinical record review for Patient 15 and interview with RN 3, on 3/7/12, at 3:05 PM, she confirmed the physician for Patient 15 had not authenticated the following verbal/telephone orders within the 48 hours: one order dated 2/17/12, and one order dated 2/23/12.

8. The clinical record for Patient 17 was reviewed on 3/7/12, at 4:15 PM. The verbal/telephone order written on 3/4/12 at 4:16 PM had not been authenticated by the physician.

9. The clinical record for Patient 19 was reviewed on 3/8/12, at 8:55 AM. Two verbal/telephone orders dated 3/4/12 were not authenticated by the physician within 48 hours.

10. The clinical record for Patient 21 was reviewed on 3/8/12, at 10 AM. The verbal/telephone order written on 3/2/12 at 11:25 AM was not authenticated by the physician within 48 hours.

The hospital policy and procedure titled "Authentication of Verbal and Telephone Orders", dated 1/18/12, indicated, "It is the responsibility of the practitioner to authenticate verbal/telephone orders within 48 hours."

Based on observation, review of clinical records, hospital documents and patient and staff interviews, the hospital failed to ensure the nutritional needs of one of 30 sampled patients (18) was met. The hospital's policy for Patient 18 excluded him from selecting food preferences from the menu. This resulted in poor meal intake for Patient 18, who was already severely nutritionally compromised.

Findings:

Patient 18 was admitted to the hospital on 3/2/12 with diagnoses including severe anemia and generalized pain. He also had a history of bilateral above knee amputation, paraplegia (spinal cord injury resulting in loss of the use of two limbs), chronic renal disease, colostomy (an opening of a portion of the large intestine through the abdominal wall to the skin surface that allows the drainage of stool), and extensive, stage III pressure ulcers (pressure ulcers - an injury usually caused by unrelieved pressure that damages the skin and underlying tissue; stage III, a measurement scale for pressure ulcers, a full thickness of skin loss with exposed underlying tissue that presents as a deep crater), measuring 15 centimeters (cm) x 20 cm.

The clinical record review indicated a registered dietitian (RD) conducted an initial nutritional assessment on 3/3/12, based on his diagnoses and referral by the nursing staff. The RD documented Patient 18 had decreased appetite on admission and his appetite had remained poor. The patient was documented as 121.92 cm tall and weighing 56.82 kilograms (kg). The RD described his physical appearance as " underweight" and assessed the patient's weight as 82% of his ideal body weight. The RD calculated his nutritional needs at the higher level due to increased need for "wound healing" and "HD (hemodialysis - the use of an artificial kidney to clear waste products from the body) treatment".

The nutritional goal set by the RD included PO (oral) intakes of 75%. Review of Patient 18's intake from 3/2/12 through 3/5/12, showed his intake averaged less than 50%. The RD recommended Nepro, a nutritional supplement for patients with renal disease, and increased dosage of an appetite stimulant. On 3/5/12, he was reassessed by another RD, who recommended PEG (percutaneous endoscopic gastrostomy - a tube placed into the stomach) tube feeding for long term nutritional support. Her rationale was due to the patient's four stage III pressure ulcers.

On 3/6/12, at 11 AM, an interview was conducted with Patient 18 in the presence of the clinical nutrition manager (CNM), who promised to follow up. The patient was cachectic (an appearance of ill health, malnutrition, and wasting) looking with eyes bulging and very little fat pads around his eyes and cheeks. Cachexia is physical wasting with weight loss and muscle mass loss as a result of a chronic disease. He indicated he did not have a poor appetite but he just did not like the food that was being served. He requested specific food items he would eat if served. He further stated he did not like the nutritional supplement for patients with kidney disease, which the physician had ordered, and he preferred the taste of the regular supplement instead. The CNM promised to follow-up on the patient's requests.

In a subsequent interview with the Interim Director of Nutritional Services (IDNS), on 3/6/12, at 1:30 PM, she indicated the inmate-patients, which Patient 18 was, were not allowed to receive other food items not offered to them on the menu because of contractual obligations (with the California Department of Corrections - CDC). A copy of the contract was requested.

A follow-up entry in Patient 18's medical record on 3/6/12, indicated the patient's request for alternative food choices was denied. The rationale was "not within CDC care policy." The physician also denied a request to change oral nutritional supplement to the regular supplement.

A review of the CDC contract was conducted on 3/7/12. There was no language in the contract that precluded the hospital from offering inmate patient choices of food offered to other patients in the hospital. This observation was shared with the IDNS at 4:15 PM on 3/7/12. She stated in an interview at 4:25 PM, the hospital policy which speaks to the lack of choice with meals was not in the nutrition services department policy and procedure manual but in nursing policies.

A copy of the nursing policy, dated 1/24/07, and reviewed January 2010, titled, "Care of Inmate", was reviewed on 3/8/12. It indicated the policy had been established to be used as a guideline for the procedures which stated, "Do not order special food items for the inmate. Check with the correctional officer first."

An interview with the hospital administrative staff and consultants was conducted on 3/7/12, at 4:35 PM. The ICNS stated the hospital had a Hostess Program which utilized the hostesses to help patients with meal selection off the menu in order to improve patient satisfaction. She also stated the determination was made (unclear by whom) that certain groups or population of patients were not offered the Hostess Program. She stated these groups included patients from the ICU (intensive care units), ER (emergency room), maternity care, cardiac catherization lab and CDC (inmate patient wing). She stated in the years she had worked in the hospital, CDC patients were never allowed to have food choices off the menu.

An internal memorandum from the hospital administrator was reviewed on 3/8/12. The memorandum (memo) clarified the "no special food" policy, and indicated the inmate patients were to be treated the same way as any other patient in the hospital including the choice of food. The IDNS stated changes would be made based on the clarification that was received in the memo.

During a concurrent interview with the IDNS, on 3/8/12, at 8:30 AM, regarding Patient 18's double portion servings and lack of menu selection, she stated Patient 18 was not interviewed on food preferences and should not have been offered double portions when his appetite was poor.



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