HospitalInspections.org

Based on medical record review and interview it was determined the Hospital failed to ensure medications and/or biologicals were administered in accordance with physician orders for 3 patients in a sample of 48 patients.

Findings include:

1.) Patient #9's medication administration record (MAR) indicated Patient #9 was administered 1 milligram (mg) of Dilaudid (narcotic pain medication) intravenously (IV) at 4:00 AM on 12/1/10. A review of Patient #9's Physician Orders did not reveal an order for this dose of Dilaudid. Nursing Director #3 was interviewed in person during a tour of the ED conducted on 12/1/10 from 9:30 to 10:20 AM. Nursing Director #3 confirmed there was no order for the dose of Dilaudid.

2.) Patient #20's MAR indicated Patient #20 was administered Dilaudid 1 mg IV at 7:00 PM on 11/30/10. A review of Patient #20's Physician Orders revealed only 1 Order for Dilaudid and the Order was for 0.5 mg IV.

3.) Patient #21's 11/20/10 Flowsheet indicated a Duoderm (hydrocolloid) dressing was applied to a right buttock pressure ulcer. A review of Patient #21's Physician's Orders did not reveal an Order for the Duoderm dressing.

Based on documentation review, it was determined Hospital Nursing Staff failed to document complete pressure ulcer assessments for 1 of 30 applicable patients in a sample of 48 patients.

Findings included (but were not limited to):

1.) A Skin Assessment performed on Patient #21 between 8:00 AM and 3:59 PM on 11/19/10 identified: a Stage II pressure ulcer on the left buttock measuring 3 centimeters (cms) in length; a Stage I pressure ulcer on the right buttock measuring 2 cms in length and; a Stage II pressure ulcer on the left outer ankle measuring 2 cms in length. The Skin Assessment did not include descriptions of the pressure ulcers, width measurements and/or descriptions of the surrounding skin.

2.) An Assessment of Patient #21's Stage II left buttock pressure ulcer documented on 11/21/10 indicated the pressure ulcer measured 3X4 cms. The Assessment did not include a description of the pressure ulcer and/or a description of the surrounding skin.

3.) An Assessment of Patient #21's Stage II left outer ankle pressure ulcer documented on 11/23/10 did not include a description of the pressure ulcer, measurements and/or a description of the surrounding skin.

Based on documentation review it was determined the Hospital failed to ensure medical record entries were legible, authenticated, dated and/or timed in 4 medical records in a sample of 48 medical records.

Findings included:

1.) The ED Physician signature dated 12/1/10 and timed 10:10 AM on Physician Orders in Patient #8's medical record was illegible.

2.) The ED Physician signature dated 12/2/10 and timed 8:20 AM on Physician Orders in Patient #14's medical record was illegible.

3.) Nursing signatures on Patient #9's MAR timed 6:40, 6:42, 7:30 and 10:32 AM were illegible.

4.) The signatures on 2 Orders written in Patient #40's medical record on 12/2/10 were illegible.

5.) The signature on Patient #40's History and Physical was illegible.

6.) The signature on the Post Operative Note section of Patient #40's Short Stay Record Form was illegible.

7.) The 11/30/10 Cardiology Note in Patient #25's medical record was not timed.

8.) Two Orders dated 12/2/10 in Patient #40's medical record were not timed.

Based on documentation review it was determined the Hospital failed to ensure all Orders were properly authenticated in 1 medical record in a sample of 48 medical records.

Findings included:

Orders written in Patient #25's medical record on 11/30, 12/1 and 12/2/10 were signed, but the signature did not include the person's credential.

Based on documentation review it was determined the Hospital failed to ensure all orders were authenticated within 48 hours in 3 medical records in a sample of 48 medical records.

Findings included:

The Hospital policy that addressed verbal and telephone orders indicated verbal and telephone orders must be authenticated with a date and time within 48 hours.

1.) Telephone Transfer Orders dated 11/20/10 in Patient #15's medical record were not authenticated as of 12/3/10.

Telephone Orders for Patient #15 given at 2:30 and 7:30 PM on 11/19/10, 7:20 PM on 11/21/10, 6:10 and 10:55 PM on 11/28/10, and 12:30 AM on 11/30/10 were not authenticated as of 12/3/10.

2.) Telephone Orders for Patient #19 given at 7:20 PM on 11/13/10, 7:05 PM on 11/14/10 and 4:40 PM on 11/27/10 were not authenticated as of 12/2/10.

3.) A Telephone Order for Patient #25 given at 5:10 PM on 12/1/10 was not authenticated as of 12/6/10.

Based on documentation review it was determined the Hospital failed to ensure the time of consent was documented on 2 surgical procedure Consent Forms in a sample of 7 surgical/invasive procedure Consent Forms.

Findings included:

1.) Patient #27's 11/22/10 surgical Consent Form did not include the time of consent.

2.) Patient #40's 11/22/10 surgical Consent Form did not include the time of consent.

Based on record review and interviews, the hospital failed to complete timely and comprehensive nutritional assessments and/or reassessments for 2 of 28 applicable patients in a sample of 48 patients.

Findings included:

The Hospital's policy titled "Nutrition Services" indicated all patients are to be evaluated for nutritional risk by a dietician and the assigned level of nutritional risk determines the time frame for the initiation of a comprehensive assessment of the patient's nutritional status and need for reassessment or follow-up. The two levels of risk include Level I or high nutritional risk and Level II; a lower risk. High risk patients are assessed within 24 to 48 hours of admission. Level II risk patients are to be seen on a priority need basis based on the dietician's screening data information and an assessment to be completed by day five as indicated. Risk criteria may include food & nutrient intake patterns, psychological and social factors, physical/medical condition with disease level, abnormal laboratory values, drug-nutrient interactions and information from medical interdisciplinary rounds.

1.) Medical record documentation indicated Patient #19 was admitted on 11/11/10 with diagnoses including respiratory distress, metabolic derangement and encephalopathy and was intubated and admitted to the ICU. A Nutrition Consult for TF (tube feeding) was ordered on 11/13/10.

Patient #19 was assessed by the dietician on 11/13/10 and the Dietician estimated Patient #19's daily energy needs to be 2200 calories and 91 grams protein to maintain nutritional status. The recommendation included to advance the formula feeding from 10 ml to 60 ml per hour to provide 2160 calories and 98 gram protein. Patient #19's medical condition included several Level I high risk criteria factors that required a comprehensive nutritional evaluation. The Initial Nutrition Consult did not include the patient's weight, prior nutrition status or medical history, clinical laboratory values, daily fluid needs, and need for nutrient supplementation needs.

A nutrition follow up note dated 11/15/10 indicated Patient #19 was discussed at Rounds with reported laboratory result for prealbumin at 7 (an indicator of protein status with normal range values above 20). The Dietician recommended a protein (Prostat 30 ml) supplement be provided and the supplement was ordered by the physician. There was no further nutritional assessment revisions documented (i.e. dietary supplements including thiamine, folate and a multivitamin prescribed by the physician).

Patient #19's Nutrition Progress note dated 11/18/10 indicated Patient #19 continued on enteral feedings with (Prostat) a protein supplement. The plan was to follow and recheck the prealbumin level.

A Medical Progress Note dated 11/18/10 indicated Patient #19 weighed 94 kilograms (approximately 206 pounds) and had a fluid intake and output of 1700 and 2575 milliliters (mls); respectively. Documentation indicated Patient #19's nasogastric tube was removed and the diet was advanced to a mechanical soft (ground) with nectar thickened liquids based on a bedside Swallowing Evaluation. Patient #19 was at risk for aspiration and required 1:1 feeding assistance.

A Nutrition Follow-Up note dated 11/19/10 acknowledged the diet order change and abnormal prealbumin (6.7). Patient #19 exhibited high nutritional risk criteria, but there was no evidence of a reassessment of dietary needs when the feeding route changed. The Dietician recommendation included a "Magic Cup" (high protein ice cream) supplement once a day. The nutritional plan did not address many of Patient #19's nutritional needs such as hydration needs (i.e. 20-35 cc /kg body weight), protein needs and meal intake.

Patient #19 received intermittent IV fluids based on laboratory results and poor hydration status. Documentation on Patient #19's Flowsheet indicated Patient#19's daily total oral fluid intake ranged from 100 to 393 mls/day on 11/20, 11/21, 11/22 and 11/23/10 (an inadequate volume to maintain hydration needs) and Patient #19 required IV fluid administration. Medical Progress Notes indicated Patient #19's condition was further complicated by decreased mental status, akathisia (motor restlessness) and medication sensitivity.

A Nutrition Progress Note dated 11/23/10 indicated nursing staff were aware Patient #19 was eating poorly and Patient #19 was identified as at nutritional risk due to poor meal intake with weight loss from 190 to 178 pounds (weight status was questioned as to actual body weight loss or fluid related). The Nutritional Plan remained unchanged except the "Magic Cup" was increased to twice/day. There was no assessment of Patient #19's daily calorie intake or lack of.

Documentation indicated that over the next few days, Patient #19 required feeding and had meal intakes ranging from 0 to 25 %. There was no Nutritional Reassessment of Patient #19's dietary needs by the Dietician until 11/27/10. At that time, the Dietician informed the physician of a 13 pound weight loss since admission and severe protein-calorie malnutrition. Patient #19's albumin level was 2.4 g/dl (normal range values above 3.5g/dl). The Nutrition recommendation was to continue the "Magic Cup" at all meals and to add "Mighty Shake" supplements at meal times. There was no evidence of alternative meal plans (i.e. between meal supplementation) and no documentation as to whether Patient #19 was consuming the "Magic Cups".

The Nutrition Progress Note dated 12/1/10 acknowledged Patient #19's poor meal intake and recommended enteral support.

Observation of Patient #19 on 12/2/10 revealed no 1:1 meal assistance until inquiry by the Surveyor.

In an interview on 12/2/10, Dietician #1 and Nursing Director #1 indicated Patient #19 refused to eat at times. There was no evidence that alternative nutrition interventions were attempted and failed until weight loss was evident.

Interview with the Director of Clinical Nutrition Services on 12/2/10 confirmed Patient #19's hydration needs and an alternative plan for continued poor food intake were not clearly addressed in Patient #19's ongoing Nutritional Assessments. Further interview revealed that although hydration is an important component of health status, screening and nutritional assessments did not consistently address daily fluid requirements. Additionally, meal tray supplementation such as "Magic Cups" and "Mighty Shakes" were not specifically identified or tracked as accepted or refused in order to determine whether there was a need to change nutrition care approaches.

2.) Medical record documentation indicated Patient #28's was admitted to the Hospital on 11/25/10 with diagnoses of new, subacute infarct, hyponatremia and hypokalemia and Patient #28's medical history included a recent CVA and an intestinal infection treated with antibiotic therapy.

Patient #28's Initial Nutrition Assessment dated 11/26/10 indicated Patient #28 had a previous CVA, hypertension, and chronic (stage III) kidney and that Patient #28 was not available at the time of Dietician's visit, and nutrition education materials were left in the room.

Documentation indicated Patient #28 experienced hematemesis (the vomiting of blood) and required gastroendoscopy diagnostic testing, blood transfusions and medication changes. A Nutrition Note dated 11/29/10 indicated Patient #28 was ordered NPO (nothing by mouth) for question of Mallory-Weiss tear (a tear in the mucosa of the esophagus or gastroesophageal junction). Laboratory testing revealed Patient #28's protein albumin level was abnormal at 2.5 (normal values range above 3.5 g/dl). The Nutrition Plan was to advance diet as tolerated and to hold off on nutrition education.

Patient #28 had identified nutritional risk factors that were not assessed timely according to the Hospital's Nutrition Services policy for Nutrition Assessment. There was no evidence of a nutritional reassessment to address the patient's altered electrolyte and hydration status, abnormal protein levels, or dietary needs.

During an interview conducted on 12/2/10 at 11:30 AM, Dietician #2 had no explanation as to why Patient #28's nutritional assessment was not previously completed.

On 12/2/10; 7 days after Patient #28's admission to the Hospital, a comprehensive Nutritional Assessment was conducted. At that time, Patient #28 was noted to have a Stage I pressure ulcer and skin tear on a lower extremity. Patient #28's albumin level remained low at 2.4 g/dl. The assessment indicated Patient #28 was at high nutritional risk, preferred vegetarian foods, and still received a full liquid diet. At that time, the Dietician recommended a protein supplement at each meal to improve protein-calorie intake.

The Director of Clinical Nutrition Services confirmed that the Initial Nutrition Assessment for Patient #28 was not conducted in a timely or comprehensive manner.

Based on observations and staff interview, it was determined the Hospital failed to ensure that staff consistently implemented infection prevention and control protocols during the performance of 3 fingerstick blood sugar (FSBS) testing procedures in a sample of 8 observed FSBS testing procedures.

Findings include:

1.) Certified Nursing Assistant (CNA) # 1 was observed performing a FSBS procedure on Nursing Unit #1 at 11:40 AM on 12/1/10. At the completion of the procedure, CNA #1 failed to clean the glucometer (a device to measure blood sugar) prior to returning the glucometer to the carrying case and making it available for use on other patients.

2.) CNA #2 was observed performing a FSBS procedure in the Multipurpose Room on Nursing Unit #2 at 12:00 PM on 12/2/10. CNA #2: utilized the barcode scanner; prepped Patient A's finger with an alcohol pad; wiped the finger with a sterile gauze; discarded the alcohol and gauze pads in the cover of the open glucometer carrying case; pricked the finger (with a single-use retractable lancet); squeezed a drop of blood onto the glucometer test strip; obtained the blood sugar reading; removed the test strip from the glucometer and discarded it in the cover of the open glucometer case; wiped the glucometer with an alcohol pad and; placed the glucometer in the (open) carrying case. CNA #2 did not have gloves on at any time during this observation and did not perform handwashing after the procedure.

3.) Once CNA #2 completed the FSBS procedure on Patient A (see above), CNA #2 carried the open glucometer case to Patient #10 who was also in the Multipurpose Room, and: wiped the glucometer with a (new) alcohol pad; utilized the barcode scanner; prepped Patient 10's finger with an alcohol pad; wiped the finger with a sterile gauze; discarded the alcohol and gauze pads in the cover of the open glucometer carrying case; pricked the finger (with a single-use retractable lancet); squeezed a drop of blood onto the glucometer test strip; failed to obtain a blood sugar reading; removed the test strip from the glucometer and discarded it in the cover of the open glucometer case; utilized the barcode scanner; prepped Patient 10's finger with an alcohol pad; wiped the finger with a sterile gauze; discarded the alcohol and gauze pads in the cover of the open glucometer carrying case; pricked Patient #10's finger (with a single-use retractable lancet); squeezed a drop of blood onto the glucometer test strip; obtained the blood sugar reading; removed the test strip from the glucometer and discarded it in the cover of the open glucometer case; discarded the contents of the (open) cover of the carrying case in an open trash container; closed the carrying case; placed the glucometer on top of the carrying case; left the Multipurpose Room with the glucometer and closed carrying case; opened the carrying case in the Nursing Station Area and placed the glucometer inside and; stored the glucometer making it available for use on other patients. CNA #2 did not have gloves on at any time during this observation and did not: dispose of the test strips in the glucometer carrying case in an appropriate manner; clean the carrying case after disposing of the test strips/trash; clean the glucometer and/or; perform handwashing after the procedure.

CNA #2 was interviewed in person at 1:30 PM on 12/2/10. CNA #2 confirmed that she did not wear gloves while performing FSBS testing on Patients A and #10.

Based on documentation review it was determined the Hospital failed to ensure a History and Physical Examination performed more than 30 days prior to the performance of a surgical procedure was updated prior to the performance of the procedure for 1 of 5 applicable patients in a sample of 48 patients.

Findings included:

Patient #40 was admitted on 12/6/10 for a surgical procedure. A History and Physical Examination dated 11/22/10 included in Patient #40's medical record was stamped to indicate the Patient was examined and that there were no changes since the 11/22/10 History and Physical, but lines for the date and time of this examination were not filled in.

Based on documentation review it was determined the Hospital failed to ensure a properly executed Informed Consent Form was present in the medical record for 2 of 5 applicable patients in a sample of 48 patients.

Findings include:

Refer to Tag # 0466