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VIBRA HOSPITAL OF WESTERN MASS - CENTRAL CAMPUS
PATIENT RIGHTS
Tag No.: A0115
The Hospital was out of compliance for the Condition of Participation for Patient Rights.
Findings include:
The Hospital failed to inform, for one Patient (#1) out of a sample of 10 patients, of his or her health status and involve Patient #1 in care planning and treatment, and of being able to request or refuse treatment. Patient #1 had a significant, unplanned weight loss of 24.7 pounds (lbs) between 6/20/22 and 8/26/22.
Refer to TAG: A-0131.
QAPI
Tag No.: A0263
The Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was out of compliance.
Findings include:
The Hospital failed, for one Patient (#1) out of a sample of 10 patients, to investigate, analyze, and provide system wide implementation of preventative actions that would address the identification of patients with nutritional care plan needs and experienced a significant weight loss in the Hospital.
Refer to TAG: A-0286.
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on record review, policy review and interviews, the Hospital failed to inform Patient #1 of his/her health status and involve Patient #1 in care planning and treatment, and of being able to request or refuse treatment. Patient #1 had a significant, unplanned weight loss of 24.7 pounds (lbs) between 6/20/22 and 8/26/22.
Findings include:
Review of Hospital's Policy titled, Nutrition Care Process - Nutrition Assessment, dated January 2023, indicated that patients assessed and identified as moderate risk level would be reassessed no less than every 14 days. The Policy indicated that the total nutritional care process included developing a nutrition care plan which included identifying problems, goals, and interventions.
Patient #1 was admitted to the Facility in June 2022, with a diagnosis of Mitochondrial Disease, weighing approximately 210 lbs and received a bolus tube feeding to meet his/her nutritional needs.
Further review of Patient #1's medical record indicated that there was no documentation to support the Hospital discussed the significant weight loss with Patient #1 or developed a plan of care and/or developed and implemented interventions regarding the unintentional weight loss. The medical record indicated that during the 67 days of Patient #1's admission, his/her weight decreased from 210.7 lbs to 186 lbs, a 24.7 lbs total weight loss.
During an interview on 5/23/23 at 2:28 P.M., Dietitian #1 and during a separate interview on 5/24/23 at 12:29 P.M., the Chief Clinical Officer indicated Patient #1 had significant weight loss during his/her time in the Hospital, and they acknowledged the Hospital's Policies were not followed for Patient #1's nutritional care planning and treatment during his/her admission.
PATIENT SAFETY
Tag No.: A0286
Based on interviews and records reviewed, the Hospital failed, for one Patient (#1) out of a sample of 10 patients, to investigate, analyze, and provide system wide implementation of preventative actions that would address the identification of patients with nutritional care plan needs and experienced a significant weight loss in the Hospital.
Findings include:
Review of Hospital's Policy titled, Documentation of Oral Intake, dated January 2023, indicated nursing services would observe a patient's oral intake of meals and snacks and document the intake percentages, and registered dietitians and physicians would utilize oral intake data to evaluate a patient's nutrient intake, response to nutrition interventions, and to devise alterations in patient nutrition interventions and nutrition care plans as needed.
Patient #1 was admitted to the Facility in June 2022, with a diagnosis of Mitochondrial Disease, and experienced a significant weight loss of 210.7 pounds (lbs) to 186 lbs, a total of 24.7 lbs
Further review of Patient #1's medical record indicated that there was no documentation to support the Hospital identified and addressed the missing PRN documentation, gaps in oral nutritional intake and weight documentation, and the delay in completing nutritional re-assessments for patients identified with moderate nutritional risk.
During an interview on 5/24/23 at 12:29 P.M., the Chief Clinical Officer said Patient #1 had significant weight loss during his/her admission, and said Patient #1's electronic medical record had missing clinical documentation of his/her nutritional needs and care.
During an interview on 5/24/23 at 1:38 P.M., the Director of Patient Safety said the Hospital had identified inaccurate and missing documentation throughout Patient#1's electronic medical record. The Director of Patient Safety said there was no formal system or improvement plan in response to the lack Patient #1's nutritional plan of care documentation as the Hospital was unaware of Policy violations until the time of the Survey.