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SELECT SPECIALTY HOSPITAL-NORTHEAST OHIO, INC
SUPERVISION OF CONTRACT STAFF
Tag No.: A0398
Based on medical record review, policy review and interview, the facility failed to ensure staff documented and/or administered tube feedings in accordance with physician orders and the facility's policy for one (Patient #8) of one patient's medical record reviewed with bolus tube feedings. The facility's active census was 21.
Findings include:
The facility's Guidelines and Protocols, Clinical policy (#S05-G, Revised 10/01/23) included the purpose was to outline clinical routines, guidelines and protocols of patient care. The policy was to ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. Two patient identifiers will be used when providing care, treatment, and services. The patient's room number will not be used as a method of identification. A specific physician order will supersede the minimum frequencies noted below.
The medical record for Patient #8 contained an order on 03/22/24 at 9:00 AM for Pivot 1.5 tube feeding bolus 240 milliliters (ml) every four hours with a 300 ml water flush every four hours. The medical record contained an order on 03/26/24 at 10:20 AM for continuous tube feedings.
The medical record review revealed nursing staff documented and/or administered tube feedings as follows:
03/22/24 10:43 AM, 4:03 PM, and 8:00 PM, on 03/23/24 12:00 AM, 4:00 AM, 8:00 AM, and 8:00 PM, on 03/24/24 12:00 AM, 4:00 AM, 8:00 AM, and 8:00 PM, on 03/25/24 4:00 AM, 6:46 PM, 8:00 PM, and 10:36 PM, and on 03/26/24 4:00 AM.
On 03/23/24, the 12:00 PM and 4:00 PM feeds were not documented and/or administered. On 03/24/24, the 12:00 PM and 4:00 PM feeds were not documented and/or administered. On 03/25/24, the 12:00 AM, 8:00 AM and 12:00 PM feeds were not documented and/or administered. On 03/26/24, the 4:00 AM feed was not documented and/or administered.
The findings were shared with Staff A on 04/24/24 at 12:42 PM and confirmed.
This deficiency represents non-compliance investigated under Complaint Number OH00152498.