HospitalInspections.org

CO #IL00083963/162210
A. Based on document review and interview, it was determined for 1 of 2 (Pt. #1) clinical records reviewed after a fall, the Hospital failed to ensure a post fall risk reassessment was completed as required.

Findings include:

1. On 8/30/16 at approximately 1:00 PM, the Hospital's policy titled, "Fall Reduction Program" (revised 1/29/14) required, "... 3. Assessment of fall risk on admission, immediately after a fall..."

2. On 8/30/16 at approximately 1:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 50 year old female admitted on 10/02/15 with a diagnosis of ascites (fluid collection in the peritoneal cavity). Pt. #1 fell while in the hospital on 10/04/15. However, a fall risk reassessment for 10/04/15 was documented not until 10/13/15 (11 days after the fall).

3. On 8/30/16 at approximately 3:00 PM, finding was discussed with the Director of Nursing acknowledged that a post fall risk reassessment for 10/04/15 was documented not until 10/13/15.


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CO #IL00087587/162690
B. Based on document review and interview, it was determined for 1 of 1 (Pt. #1) on calorie count, the Hospital failed to ensure all menus documenting patient's meal consumption were saved and collected as required by policy.

Findings include:

1. The Hospital policy titled, "Calorie Count for Patients (Adult and Pediatric)" (Rev. 7/1/16) required, "to systematically observe, evaluate and record the food consumption of a patient so that the daily intake of calories and protein can be calculated and documented in patients medical record. ... The dietician should place an envelope on the patient's room door for the collection of all the patient's menu.... The patient's daily menu should be saved by the nursing personnel in the envelopes... The amount of each food item eaten should be recorded on each menu by a member of the nursing staff collecting the tray. Calculation of daily intake of calories and protein based on menus saved.."

2. The clinical record for Pt. #1, was reviewed on 8/30/16. Pt. #1 was an 81 year old female admitted to the Psychiatric-Gero unit on 7/24/16 with diagnoses of dementia and psychosis. Pt. #1's included "presents with worsening behavior, paranoia, refusing to eat." On 7/31/16 at 7:30 PM, a dietician consult and calorie count was ordered by physician. The calorie count for the following dates were as follows:
- 7/31/16 = 416
- 8/1/16 = 981
- 8/2/16 no documentation
- 8/3/16 = 1846 (breakfast menu was "not saved")
- 8/4/16 = 240 (breakfast and lunch menu was "not saved")
- 8/5/16 = 1084 (lunch menu "not saved")
- 8/6/16 =483 (breakfast and lunch menu "not saved")

3. The above findings were discussed with the Quality during an interview on 9/2/16 at approximately 1:30 PM who stated that there was no documentation of calorie count on 8/2/16.

4. The DON interviewed by phone on 9/2/16 at approximately 2:10 PM stated that the staff, either a Nurse or Tech who observed the patient eating fills out the menu on the patients tray and documents the percentage of what was eaten. They then place that menu in the the envelop that the dietician provides, who then collects and calculates the patient's intake.