HospitalInspections.org

Based on policy and procedure review, document review, medical record review, and interview, the chief nursing officer failed to ensure that nursing personnel implemented the facility policy related to documentation of meals for 5 of 5 patients (pts. #1 through #5); failed to ensure the documentation of daily baths for 4 of 5 patients (pts. #2 through #5), as per facility expectation/protocol; and failed to ensure that patient call lights were answered within the expected time frame, as per the March 2014 training program, for 4 of 5 patients (pts. #1, #2, #4 and #5).

Findings:
a. Review of the policy and procedure, "Documentation Of Food And fluid Intake", policy number H-NS 09-013, with a date of 02/2012, indicated:
A. Under "Policy", it read: "It is Kindred's policy to document food and fluid intake for all patients to screen for inadequate nutrient intake.".
B. Under "Procedure", it read: "1. Each meal and supplement is observed and the percentage eaten is recorded for each patient...".

b. Review of patient medical records indicated:
A. Pt. #1 lacked documentation from 5/13/14 to 5/31/14 for:
I. all three meals on 5/13/14, 5/15/14, and 5/18/14.
II. breakfast or dinner on 5/17/14.
III. dinner on 5/19/14, 5/27/14, 5/28/14, and 5/29/14.
IV. lunch or dinner on 5/22/14.
V. breakfast or lunch on 5/24/14.
VI. breakfast on 5/30/14.
B. Pt. #2 lacked documentation from 5/20/14 to 6/6/14 for:
I. breakfast or dinner on 5/22/14.
II. breakfast on 5/23/14.
III. dinner on 5/24/14 and 6/4/14.
IV. lunch on 5/30/14.
C. Pt. #3 lacked documentation from 5/17/14 to 6/4/14 (day of discharge) for:
I. all three meals on 5/13/14 and 5/15/14.
II. lunch on 5/16/14, 5/19/14, and 5/22/14.
III. breakfast on 5/17/14.
IV. dinner on 5/18/14 and 5/25/14.
V. breakfast and dinner on 5/23/14 and 5/26/14.
VI. lunch or dinner on 5/27/14 and 6/3/14.
D. Pt. #4 lacked documentation from 5/17/14 to 6/7/14 for:
I. dinner on 5/17/14 and 6/5/14.
II. lunch on 5/18/14, 5/24/14, 5/30/14, 5/31/14, and 6/3/14.
III. breakfast or dinner on 5/22/14.
IV. breakfast or lunch on 5/23/14.
V. lunch or dinner on 5/27/14 and 6/4/14.
VI. all three meals on 6/7/14.
E. Pt. #5 lacked documentation from 5/13/14 to 5/29/14 for:
I. dinner on 5/17/14, 5/18/14, 5/21/14, 5/25/14, and 5/28/14.
II. all three meals on 5/19/14, 5/20/14, and 5/26/14.
III. breakfast or lunch for 5/29/14 (day of discharge which was after dinner and was documented)

c. Interview with staff member #53, the nurse manager, at 9:45 AM on 6/11/14, indicated:
A. The facility policy (as listed in a. above) indicates nursing staff are to document all food and fluid intake.
B. Each meal is to be documented as to percentage eaten, if patient refuses the meal, or some other reason a meal is not provided or consumed.
C. Patients #1 through #5 lacked documentation of meals as listed in b., above.

d. Review of patient medical records indicated:
A. For the period of 5/20/14 to 6/6/14, pt. #2 lacked documentation of having received a bath on 5/24/14 and 5/27/14.
B. For the period of 5/13/14 to 6/4/14, pt. #3 lacked documentation of having received a bath on 5/17/14, 5/19/14, 5/25/14, 5/29/14, 6/2/14, 6/3/14, and 6/4/14.
C. For the period of 5/17/14 to 6/7/14, pt. #4 lacked documentation of having received a bath on 5/21/14, 5/24/14, 5/28/14, 5/29/14, 5/30/14, 6/2/14, 6/6/14, and 6/7/14.
D. For the period of 5/8/14 to 5/29/14, pt. #5 lacked documentation of having received a bath on 5/8/14, 5/16/14, 5/17/14, 5/20/14, 5/22/14 (nursing did document that the patient "refused gown change"), and 5/24/14.

e. At 9:45 AM on 6/11/14, interview with staff member #53, the nurse manager, indicated:
A. Patients #2 through #5 were lacking documentation of baths as listed in d. above.

f. At 11:40 AM on 6/11/14, interview with staff member #50, the chief executive officer, indicated:
A. There is no specific policy stating that baths are to be given daily, but that is the facility expectation, as per standards of practice.

g. Review of the document titled "Mandatory Annual Retraining" (for all nursing staff in March 2014), indicated the expectation for responding to call lights is "within 3 minutes".

h. Review of the Nurse Call System "Summary Patient Activity Report" indicated:
A. Between 5/11/14 and 5/24/14, pt. #1 had:
I. 31 events where their call light was answered between 4 minutes and 2 seconds and 22 minutes and 48 seconds.
II. 6 events where their pulse oximeter (equipment alarm--not ventilator) was responded to between 4 minutes and 8 seconds and 6 minutes and 36 seconds.
III. 1 event where their ventilator alarmed and was not responded to for 5 minutes and 32 seconds.
B. Between 5/13/14 and 5/24/14, pt. #2 had:
I. 16 events where their call light was answered between 4 minutes and 56 seconds and 19 minutes and 49 seconds (voice response was at 17 minutes and 41 seconds).
C. Between 5/11/14 and 5/24/14, pt. #4 had:
I. 20 events where their call light was answered between 4 minutes and 6 seconds and 16 minutes and 7 seconds (at 9 minutes and 5 seconds, voice response was noted).
II. The documentation indicated the patient's call light was "cord out" on 5/16/14 for 11 minutes and 8 seconds before nursing response, and on 5/21/14 for 9 minutes and 14 seconds before nursing response.
D. Between 5/11/14 and 5/24/14, pt. #5 had:
I. 23 episodes where their call light was answered between 4 minutes and 7 seconds and 23 minutes and 58 seconds (voice response was 19 minutes and 41 seconds).
II. 1 event where their "equipment" (pulse oximiter) alarm activated for 23 minutes and 36 seconds before nursing response (voice response was at 21 minutes and 35 seconds).
III. one "cord out" episode that was 4 minutes and 10 seconds.
IV. 2 "staff emergency"(bathroom call light) episodes that were 4 minutes and 56 seconds and 23 minutes and 17 seconds (voice response was 17 minutes and 35 seconds).

i. Interview with staff member #50, the chief executive officer, at 11:40 AM on 6/11/14 indicated:
A. There is no specific call light policy.
B. Per the March 2014 Mandatory retraining, call light expectation is that they are responded to within 3 minutes.
C. Review of the Nurse Call System "Summary Patient Activity Report" indicates that nursing is failing to respond to call lights as per facility and corporate expectations.

Based on medical record review and interview, the speech therapy staff failed to follow their care plan for one patient. (pt. #5)

Findings:
1. Review of patient medical records indicated that a SLP (speech language pathologist) saw patient #5 on 5/13/14 and indicated that the treatment plan was for the "patient to be seen daily 5X/wk for 4 weeks.". However, Tuesday, 5/20/14; Wednesday, 5/21/14; and Thursday, 5/22/14, had no documentation that the patient was seen by SLP on those days.

2. Interview with SLP #56 at 12:15 PM on 6/11/14, indicated that after review of the patient's medical record for pt. #5, it is unknown why there was no documentation of therapy on 5/20/14, 5/21/14, or 5/22/14. If a patient is unable to participate, is out of the building, or for some other reason does not receive speech therapy, a notation should still be made in the medical record. This was not done for 3 consecutive days for pt. #5, as stated in 1. above.