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Based on record review and interview, the hospital failed to ensure the use of restraints were in accordance with a written modification to the patient's plan of care for 1 (#1) of 3 (#1, #2, #3) patients sampled with restraints out of a total sample of 5..

Review of the hospital's policy on Restraints, Policy Number: II.K.11.)7, revealed in part, Care Plan: The patient's care plan will be modified to reflect the need for restraints.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 57 year old female admitted to hospital on 06/27/15 with diagnoses of Respiratory Failure with Ventilator/Tracheostomy, Renal Failure with Hemodialysis, Sepsis, Anemia, Malnutrition, Morbid Obesity, S/P (Status Post) Exploratory Laparotomy with Enterocutaneous Fistula.

Review of the physician orders from 06/27/15 to 07/26/15, and review of the Restraint Management Documentation Forms from 06/27/15 to 07/26/15 revealed wrists restraints were used for Patient #1 due to the patient was pulling at medical devices.

Review of the LTAC (Long Term Acute Care) Interdisciplinary Plan of Care initiated on 06/27/15 revealed no documented evidence of a nursing diagnosis, goals or interventions identified related to the use of restraints.

In an interview on 07/27/15 at 2:37 p.m. S5RN, Charge Nurse reviewed the medical record for Patient #1 and confirmed the plan of care was not updated with the restraints and there were no goals or interventions identified for the use of restraints. She confirmed the patient had been restrained since 6/27/15 up until yesterday, when they realized they did not have signed physician's orders to restrain the patient.

Based on record review and staff interview, the hospital failed to ensure the use of restraints was in accordance with the order of the physician as evidence by failing to ensure the physician authorized the continued use of restraints after 24 hours for 3 of 3 (#1, #2, #3) sampled patients reviewed for the use of restraints out of a total sample of 5 (#1-#5).

Findings:

Review of the hospital's policy on Restraints, Policy Number II.KI.1107, revealed in part, Continuation of Restraint Orders: The attending physician or other licensed independent practitioner who is responsible for the care of the patient will perform in-person assessments of a restrained patient at least once every 24 hours, at which time restraint will either be reordered or discontinued as indicated.
Patient #1
Review of the medical record for Patient #1 revealed the patient was a 57 year old female admitted to hospital on 06/27/15 with diagnoses of Respiratory Failure with Ventilator/Tracheostomy, Renal Failure with Hemodialysis, Sepsis, Anemia, Malnutrition, Morbid Obesity, S/P (Status Post) Exploratory Laparotomy with Enterocutaneous Fistula.

Review of the physician's orders dated 06/27/15 at 8:10 p.m. revealed wrist restraints were ordered due to the patient was pulling at medical devices.
Review of the Restraint Order Sheets dated 6/29/15 and 6/30/15 for wrist restraints revealed the physician signed the orders, but did not date or time his authentication.
Review of the Restraint Order Sheets dated 07/01/15 to 07/26/15 revealed telephone orders for wrist restraints were documented, but none of the restraint orders had been signed by the physician.

Review of the Restraint Management Documentation Forms dated 06/27/15 through 07/26/15 revealed wrist restraints had been used continuously during this time frame.

In an interview on 07/27/15 at 2:37 p.m. S5RN, Charge Nurse stated the physician had refused to sign the restraint orders. S5RN stated they realized this yesterday and discontinues the patient's restraints because the physician had not signed the orders. S5RN confirmed the patient had been restrained since 06/27/15 until yesterday (07/26/15) and they did not have signed physician's orders to restrain patient.

Patient #2
Review of the medical record for Patient #2 revealed he was a 56 year old male admitted to the hospital on 7/14/15 with the following diagnoses: MRSA (Methicillin Resistant Staphylococcus Aureus) Sepsis, Hepatic Encephalopathy, Moderate Malnutrition, Anemia, ETOH (alcohol) Abuse, Liver Failure, COPD (Chronic Obstructive Pulmonary Disease) and Seizure Disorder
Review of the medical record for Patient #2 revealed he was placed in soft bilateral wrist restraints on 7/15/15 at 2000 due his confusion and inability to follow directions, climbing over the side rails, and trying to pull out his peripheral intravenous lines and Foley catheter.
Review of Patient #2's Restraint Order Sheets for the following dates; 7/16/15 at 0600, 7/21/15 at 0600, 7/22/15 at 0600 and 7/23/15 at 0600 revealed S8MD (as of 7/24/15 at 12:00 p.m.) had not signed the restraint orders for the above dates for Patient #2.
An interview was conducted with S2DON on 7/27/15 at 2:00 p.m. He verified the restraint orders had not been signed by the physician.


Patient #3
Review of the medical record for Patient #3 revealed the patient was an 83 year old male admitted to the hospital on 07/17/15 with diagnoses of Acute/Chronic Respiratory Failure, Metabolic Encephalopathy, Diabetes Mellitus Type 2, Chronic Obstructive Pulmonary Disease, Conjunctivitis, Glaucoma, Ruptured Globe Right Eye, Cachexia, and Pseudomonas in Tracheal Aspirate.

Review of the physician's orders dated 07/18/15 at 4:10 p.m. revealed a verbal order from S8MD as follows: "Ok to use bilateral wrist restraints." Further review of the Restraint Order Sheets dated 07/18/15 through 07/25/15 revealed S8MD had signed the order sheets, but had not dated or timed his authentication.

In an interview on 07/27/15 at 3:45 p.m., S5RN confirmed the physician had not dated or time his signature on the Restraint Order Sheets and confirmed there was no way to verify the orders were signed within the required time frame.

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

1) Failing to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's (LSBN) Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of a RN assessment at a minimum of every 24 hours for 1 (#4) current sampled patients out of a total sample of 5 (#1-#5) patients;

2) Failing to assess the patient's pain level and response to pain medication for 2 of 2 (#4, #5) sampled patients reviewed for pain management out of a total sample of 5;

3) Failing to obtain daily or weekly weights as ordered by the physician on 3 of 3 (#2, #4, #5) patients' records reviewed for daily weights from a sample of 5 (#1-#5) patients, and;

4) Failing to clarify the physician's orders for the specific dose of the medication and the parameters for titration for the use of a continuous infusion of Neosynephrine for 1 of 1 (#3) sampled patients reviewed for Vasoactive medication infusions out of a total sample of 5.

Findings:

1) Failing to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of a RN assessment at a minimum of every 24 hours:

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by a RN every 24 hours.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 64 year old male admitted to the hospital on 07/16/15 with diagnoses of VRE (Vancomycin Resistant Enterococcus) Bacteremia, Urinary Tract Infection with Sepsis, Congestive Heart Failure, Severe Protein Calorie Malnutrition, and Left Hip Wound. Review of the Daily Nursing Assessment Sheets for Patient #4 revealed no RN assessments were documented during the 24 hour shifts from 6:00 a.m. on 7/25/15 through 6:00 a.m. on 7/27/15. Review of the Daily Nursing Assessment Sheets for 07/25/15 and 07/26/15 revealed S17LPN and S18LPN had documented the nursing assessments on both days.

In an interview on 07/28/15 at 2:15 p.m., S2DON the 2 nurses assessing the patient on 07/25/15 and 07/26/15 were agency LPNs, S17LPN and S18LPN. He confirmed an assessment by the RN was not done for 2 days.


2) Failing to assess the patient's pain level and response to pain medication for 2 of 2 (#4, #5) sampled patients reviewed for pain management out of a total sample of 5.

Review of the hospital policy titled Pain Assessment and Management, Policy Number II.I.9.04, dated 09/04/12, revealed in part the following: Each patient admitted to the facility will be assessed to a pain history, current pain, sites of pain, if any, and an interdisciplinary treatment plan involving all disciplines will be established. This process is continuous and ever changing to meet the individual patient's needs....3. Continuous Pain Assessment and Effectiveness of Interventions - Completed by all disciplines participating in the care of the patient. Supporting documentation to be found in the following locations within the medical record: nurse notes, medication administration record (MAR)....

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 64 year old male admitted to the hospital on 07/16/15 with diagnoses of VRE (Vancomycin Resistant Enterococcus) Bacteremia, Urinary Tract Infection with Sepsis, Congestive Heart Failure, Severe Protein Calorie Malnutrition, and Left Hip Wound.

Review of the MARs and Daily Nursing Assessments revealed the following:
07/21/15 - Review of the MAR revealed Norco (Hydrocodone/Tylenol 5-325 mg) was administered at 2:00 p.m. Review of the medication notes on the back of the MAR revealed the reason for the Norco was "pain." The patient's response was documented as decreased (arrow indicating down) pain at 2:30 p.m. Review of the Daily Nursing Assessment revealed no documentation of an assessment of the patient's pain on the flow sheet or the narrative section. Further review of the MAR revealed Norco was administered at 2:15 a.m.(07/22/15). The reason was documented as pain left knee. There was no documentation of an assessment of the patient's pain on the flow sheet or narrative section of the Daily Nursing Assessment. Review of Daily Nursing Assessment revealed a section for documentation of pain including a pain rating scale and a section to document the location, description, precipitators, relief measures, and an evaluation of measures used.
07/22/15 - Review of the MAR revealed Norco was administered at 12:45 p.m. and 4:45 p.m. The reason was documented at pain to bilateral legs and right knee. The patient's response to the medication was left blank. Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (description, precipitators, rating scale) or the patient's response to the pain medication.
07/23/15 - Review of the MAR revealed Norco was administered at 8:25 p.m. and the reason was documented as "C/O (Complaint of) pain to hip." Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (description, precipitators, rating scale).
07/25/15 - Review of the MAR revealed Norco was administered at 10:00 a.m. Review of the MAR and the Daily Nursing Assessment revealed no documented evidence of an assessment (description, precipitators, rating scale) of the patient's pain, or the patient's response to the pain medication.
07/26/15 - Review of the MAR revealed Norco was administered at 12:13 p.m. and the reason was documented as, "C/O pain." Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (location, description, precipitators, rating scale).
07/27/15 - Review of the MAR revealed Norco was administered at 8:30 a.m. and the reason was documented as, "pain." Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (location, description, precipitators, rating scale).

In an interview on 07/28/15 at 2:15 p.m. with S2DON (Director of Nursing) the patient's pain should be assessed with location and a rating scale of the pain. He confirmed the nurse can document the assessment on the MAR or in the Daily Nursing Assessment. He confirmed the patient's response should have been documented.



Patient #5
Review of the medical record for Patient #5 revealed the patient was a 73 year old female admitted to the hospital on 07/01/15 with diagnoses Sepsis, Hemolytic Strep, S/P I & D (Status post incision & drainage), Wound Vac, and Stage 4 Decubitus. Review of the physician's orders and the MARs revealed the patient received Oxycontin 40 mg by mouth every 12 hours. The patient was also prescribed Oxycodone 10 mg. 1 and 1/2 tablet every 4 hours as needed for breakthrough pain.

Review of the MARs and Daily Nursing Assessments revealed the following:
07/22/15 - Review of the MAR revealed Oxycodone 10 mg. 1 tablet was administered at 11:00 a.m. and 3:00 p.m. The reason was documented as, "C/O pain." Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (location, description, precipitators, rating scale). Further review of the MAR revealed Oxycodone 10 mg. 1/2 tablet was administered at 1:30 a.m. and the reason was documented as, "C/O sacral pain." Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (description, precipitators, rating scale).
07/23/15 - Review of the MAR revealed Oxycodone 10 mg. 1/2 tablet was administered at 1:50 p.m., 6:36 p.m., 12:20 a.m.(07/24/15), and 5:12 a.m. Review of the MAR revealed the reason was documented as, "C/O pain" at 1:50 p.m. only. Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (location, description, precipitators, rating scale).
07/24/15 - Review of the MAR revealed Oxycodone 10 mg. 1/2 tablet was administered at 1:45 p.m. and 5:45 p.m. Review of the MAR revealed the reason was documented as, "pain." Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (location, description, precipitators, rating scale).
07/25/15 - Review of the MAR revealed Oxycodone 10 mg. 1/2 tablet was administered at 7:45 p.m. and 3:00 p.m. Review of the MAR revealed the reason was documented as, "C/O pain." Review of the Daily Nursing Assessment revealed no documented evidence of an assessment of the patient's pain (location, description, precipitators, rating scale). Further review of the MAR revealed Oxycodone 10 mg. 1 tablet was administered at 5:10 a.m. and there was no documentation of an assessment of the patient's pain on the MAR or in the Daily Nursing Assessment.
07/26/15 - Review of the MAR revealed Oxycodone 10 mg. 1 tablet was administered at 2:45 p.m. and 5:00 a.m.(07/27/15) The reason was documented as, "breakthrough pain" for the 2:45 p.m. dose only. There was no documented evidence of an assessment of the patient's pain (location, description, precipitators, rating scale) on the MAR or in the Daily Nursing Assessment.

In an interview on 07/28/15 at 12:55 p.m. S12RN reviewed the patient's medical record and confirmed there was no documentation of pain assessments as indicated above. She stated the first place they are to document a pain assessment is on the back of the MAR. She stated they are notified by administration when the pain assessment is not documented on the MAR. She stated there is a place to document on the Daily Nursing Assessment narrative section and on the flow sheet. S12RN stated pain assessments can be documented there, but at least it has to be documented on MAR.


3) Failing to obtain daily or weekly weights as ordered by the physician on 3 (#2, #4, #5) of 3 patients' records reviewed for daily weights from a sample of 5 (#1-#5) patients:


Patient #2
Review of the medical record for Patient #2 revealed he was a 56 year old male admitted to the hospital on 7/14/15 with the following diagnoses: MRSA(Methicillin Resistant Staph Aureus) Sepsis, Hepatic Encephalopathy, Moderate Malnutrition, Anemia, ETOH (alcohol) Abuse, Liver Failure, COPD (Chronic Obstructive Pulmonary Disease) and Seizure Disorder.

Review of the LTAC (Long Term Acute Care) Admit Physician Orders dated 7/14/15 at 1330 revealed an order for daily weights.

Review of Patient #2's Nutritional Assessment on 7/15/15 revealed the patient's current weight was 149.5 # (pounds) and he was 69 inches in height. His nutritional diagnosis was list as Malnutrition/Under Nutrition and his albumin was low likely related to malnutrition and liver disease. Boost TID (three times a day) was recommended with meals. S15RD signed the Nutritional Assessment.

Review of Patient #2's Vital Signs/ Intake and Output Records revealed the following weights for the patient:
7/15/15- 149.5#
7/16/15-weight not documented
7/17/15- 146.1#
7/18/15-144#
7/19/15-137.7#
7/20/15-139.8#
7/21/15-weight not documented
7/22/15-weight not documented
7/23/15-weight not documented
7/24/15- 137.8#
7/25/15-136.7#
7/26/15-135.6#
7/27/15-135.7#
The patient had a weight loss of 12.5 pounds in 13 days. 4 out of 13 days there is no evidence the patient's weight was obtained.

An interview was conducted with S2DON on 7/27/15 at 1:00 p.m. He reported the CNA (Certified Nursing Assistants) perform the daily weights on the 6 a.m. rounds and the daily weights are documented on the Vital signs and Graphic Sheet. S2DON confirmed Patient #2's weights were not done daily as ordered by the physician.


Patient #4
Review of the medical record for Patient #4 revealed the patient was a 64 year old male admitted to the hospital on 07/16/15 with diagnoses of VRE (Vancomycin Resistant Enterococcus) Bacteremia, Urinary Tract Infection with Sepsis, Congestive Heart Failure, Severe Protein Calorie Malnutrition, and Left Hip Wound.
Review of the physician's admitting orders dated 07/16/15 revealed weekly weights were ordered. Review of the Vital Signs/Intake & Output records from 07/16/15 to 07/27/15 revealed no documented evidence that the patient was weighed from 07/17/15 to 07/27/15. Further review of the record revealed the initial nursing assessment documented a weight of 366 pounds on 07/16/15. The patient's weight documented on 07/17/15 was 394.7 pounds (28.7 pound increase from the day before).

In an interview on 07/28/15 at 2:15 p.m., S2DON confirmed weights had not been done as ordered and he confirmed the weight on 7/17/15 was not accurate. He stated the patient was initially admitted to another bed and later transferred into a bariatric bed. He stated the bed was probably not zeroed before the patient was moved into the bariatric bed. S2DON confirmed the nursing staff had failed to assess the patient's weight as ordered by the physician. S2DON stated all patients are weighed at least weekly.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 73 year old female admitted to the hospital on 07/01/15 with diagnoses Sepsis, Hemolytic Strep, S/P I & D (Status post incision & drainage), Wound Vac, and Stage 4 Decubitus.
Review of the physician's admitting orders dated 07/01/15 revealed weekly weights were ordered. Review of the Vital Signs/Intake & Output records from 07/01/15 to 07/27/15 revealed no documented evidence that the patient was weighed from 07/06/15 to 07/27/15.

In an interview on 07/28/15 at 12:55 p.m. S12RN reviewed the patient's medical record and confirmed there was no documentation of weekly weights done the weeks of 07/13/15 and 07/20/15. S12RN stated the only place the weights were documented was on the Vital Signs/Intake & Output record. She stated weekly weights were done every Monday.


4) Failing to clarify the physician's orders for the specific dose of the medication and the parameters for titration for the use of a continuous infusion of Neosynephrine:

Review of the hospital policy titled, Use and Intravenous Infusion of Vasoactive Medications, Policy number II.K.11.82, dated 02/28/13 revealed in part the following: Vasoactive infusions will be administered at the rate prescribed. Infusions may be titrated for the desired effect as stated and ordered by the physician or LIP (Licensed Independent Practitioner). Vasoactive infusion orders will be considered complete when the following elements are included:
A. Dose minimum and maximum (e.g. 5-20 mcg/kg/min [micrograms/kilogram/minute])
B. Clinical parameters used for titration dose (e.g. maintain SBP [Systolic Blood Pressure] > 90)
C. Titration dose increments and frequency (e.g. increase by 2 mcg./kg/min every 5 min)
D. Clinical parameters that need to be reported to physician (e.g. Call MD if HR [Heart Rate] > 120, SBP < 90).


Patient #3
Review of the medical record for Patient #3 revealed the patient was an 83 year old male admitted to the hospital on 07/17/15 with diagnoses of Acute/Chronic Respiratory Failure, Metabolic Encephalopathy, Diabetes Mellitus Type 2, Chronic Obstructive Pulmonary Disease, Conjunctivitis, Glaucoma, Ruptured Globe Right Eye, Cachexia, and Pseudomonas in Tracheal Aspirate. Review of the record revealed the patient had a bradycardic episode with respiratory arrest on 07/25/15 and a Neosynephrine Intravenous infusion was initiated.

Review of the physician orders dated 07/25/15 at 11:49 a.m. revealed a verbal order to start Neosynephrine 40 mg./250 ml, titrate to keep SBP > 100. There was no documented evidence that the nurse clarified the order with the physician to include the dose minimum and maximum, the titration dose increments and frequency, or the clinical parameters to report to the physician as required by the hospital policy.

Review of the Cardiogenic Medication Flowsheets revealed the following:
07/25/15 at 11:50 a.m. Neosynephrine initiated at 100 mcg./kg/minute.
07/25/15 at 4:00 p.m. the dose was decreased to 50 mcg./kg/minute.
07/26/15 at 12:30 a.m. the dose was increased to 60 mcg/kg/minute.
07/26/15 at 12:45 a.m. the dose was increased to 100 mcg/kg/minute.
07/26/15 at 2:45 a.m. the dose was increased to 150 mcg/kg/minute.
07/26/15 at 5:45 p.m. the dose was decreased to 100 mcg/kg/minute.
07/26/15 at 6:00 p.m. the dose was increased to 150 mcg/kg/minute.
07/26/15 at 7:00 p.m. the dose was decreased to 100 mcg/kg/minute.

In an interview on 07/27/15 at 3:40 p.m. S5RN reviewed the physician's order for the Neosynephrine and confirmed there were no orders for titration increments and frequency. She stated they have their own policy for titrating Neosynephrine. The policy/protocol was requested for review. S5RN provided an IV medication book for review and stated the hospital did not have a policy and procedure. She stated they have unwritten agreement with the physicians that they don't go above 200 without calling the physician. When asked what the titration increments and frequencies were she stated 5-10 mcg would be the amount to titrate by. After reviewing the flowsheets for the amounts the medication was titrated, she confirmed increments of 50 mcg were done. S5RN confirmed the order did not specify an increment amount and the hospital did not have a written policy.




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26351



Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 3 of 3 (#1, #2, #5) sampled patients reviewed for plans of care. Findings:

Review of the hospital's policy, Plan of Care, Policy Number: II.I.9.02. revealed in part,
After a thorough nursing assessment is done, care plans are completed by an RN (Registered Nurse). The care plan will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals. All interventions should be specific. The admission assessment data and physician orders are the basis for the selection and individualization of the patient plan of care. Patients receive care based on documented assessment of their need.
a. The patient care plan will be personalized to meet individual patient care needs.
B. Additional problems unique to the patient may be included and reassessed whenever warranted by the patient's conditions...
3. Each patient's nursing care plan is based unidentified nursing diagnosis and are consistent with the therapies of other disciplines. The care plans are also base on patient care needs and standards.
Planning: a. These goals are based on the nursing assignment, reflect realistic expectations, are measurable and are consistent with prescribed medical therapy.
b. The care plan will be reviewed daily and revised as necessary and as indicated by the changing needs of the patient...
D. Evaluation:
1. Patients are evaluated on a regular basis as delegated by the RN. Patient outcomes and response to treatment/implementation of patient care planning is evaluated and documented daily.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 57 year old female admitted to hospital on 06/27/15 with diagnoses of Respiratory Failure with Ventilator/Tracheostomy, Renal Failure with Hemodialysis, Sepsis, Anemia, Malnutrition, Morbid Obesity, S/P (Status Post) Exploratory Laparotomy with Enterocutaneous Fistula.

Review of the LTAC (Long Term Acute Care) Interdisciplinary Plan of Care revealed the following patient problems were identified: Impaired mobility, Decline in ADLs, Ineffective Airway Clearance, Altered nutrition, Altered urine elimination, Impaired skin integrity, High risk for injury. There was no documented evidence of any interventions or goals identified for these problems.

In an interview on 07/27/15 at 2:37 p.m. S5RN, Charge Nurse, confirmed the care plan did not include goals and interventions for all the patient's problems that were identified.


Patient #2
Review of the medical record for Patient #2 revealed he was a 56 year old male admitted to the hospital on 7/14/15 with the following diagnoses: MRSA (Methicillin Resistant Staphylococcus Aureus) Sepsis, Hepatic Encephalopathy, Moderate Malnutrition, Anemia, ETOH (alcohol) Abuse, Liver Failure, COPD (Chronic Obstructive Pulmonary Disease) and Seizure Disorder.

Review of Patient's Plan of Care revealed on 7/14/15 the Nursing Diagnosis of Altered Nutrition less than required was initiated. The interventions were listed as provide diet as tolerated, administer antiemetics 30 minutes before meals, Consult dietician prn (as needed), and weigh as directed.

Review of Patient #2's medical record revealed a dietician assessed him and placed him on Boost TID (three times a day) on 7/15/15, the patient was having difficulty feeding his self, the patient had lost 12.5 pounds in 13 days, and his diet was changed from a regular diet to a finely chopped diet on 7/15/15. These interventions were not included on his plan of care and his significant weight loss was not addressed on the plan of care.

Further review of Patient #2's Plan of Care revealed Altered Urine Elimination related to incontinence; catheter was not marked as being applicable. Patient #2 had a Foley catheter inserted on 07/15/15.

Review the Patient #2's medical record revealed he developed a DVT (Deep Vein Thrombosis) in his left arm. The DVT was not addressed in his plan of care and interventions were not developed.

An interview was conducted with S2DON on 7/28/15 at 10:00 a.m. He confirmed the plan of care were not specific and individualized for Patient #2.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 73 year old female admitted to the hospital on 07/01/15 with diagnoses of Sepsis, Hemolytic Strep, S/P I & D (Status post incision & drainage), Wound Vac, and Stage 4 Decubitus.
Review of the admission orders dated 07/01/15 at 2:30 p.m. revealed an order for isolation precautions due to a history of VRE (Vancomycin Resistant Enterococcus). Further review of the orders revealed the contact precautions were discontinued on 07/16/15.
Review of the record revealed the patient had wounds on the sacrum, ear, and left arm. The record revealed the patient was receiving routine pain medication twice a day and as needed pain medication for breakthrough pain.

Review of the LTAC Interdisciplinary Plan of Care revealed no problem/goal/interventions related the the patient's infection and isolation precautions. The problems that were identified did not include individualized, measurable goals and the interventions were not individualized.
The goals/interventions related to pain and skin integrity were not individualized for the patient.

In an interview on 07/28/15 at 12:55 p.m. S12RN reviewed the patient ' s medical record and confirmed the care plan was not individualized with goals and interventions for identified problems and confirmed the care plan did not include the problem of infection and contact precautions. S12RN confirmed there was no specific goal for pain and the interventions were not individualized for pain or skin integrity.

26351


Based on record review and interview the hospital failed to ensure all patients' medical record entries were dated and timed by the person responsible for providing or evaluating the service provided for 3 (#2, #4, #5) out of 5 patients sampled. Findings:

Review of the hospital policy, Authentication, Policy Number: III.O.15.06, revealed in part, Practitioners must date and time their authentication when signing a verbal/telephone order.

Review of the hospital policy, Time Frames, Policy Number: III.O.15.15 revealed in part, The health record documentation shall be completed in an ongoing manner through the stay. Telephone Orders per state law, LA (Louisiana) 10 days (Completion Time).

Review of the Medical Staff Rules and Regulations revealed in part, 5.1.2. All medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided consistent with hospital policy and procedure.

Patient #2
Review of the medical record for Patient #2 revealed he was a 56 year old male admitted to the hospital on 7/14/15 with the following diagnoses: MRSA (Methicillin Resistant Staphylococcus Aureus) Sepsis, Hepatic Encephalopathy, Moderate Malnutrition, Anemia, ETOH (alcohol) Abuse, Liver Failure, COPD (Chronic Obstructive Pulmonary Disease) and Seizure Disorder

Review of the following orders revealed the orders were signed by S8MD, but not dated or timed when the orders were authenticated.
7/15/15 1830 Place Foley catheter.
7/15/15 2000 Change Haldol 5 mg (milligrams) IVP (intravenous push) q (every) 6h (hours) prn (as needed) agitation to Haldol 5 mg q 6h prn agitation. Bilateral soft wrist restraints to prevent harm to pt (patient).
7/15/15 0630 Stool for occult blood.
7/15/15 17:05 Boost - 1 can TID (three times a day) with meals
7/16/15 1830 Ativan 1 mg every 6 hours prn severe agitation IVP, CBC (Complete Blood Count), CMP (Complete Metabolic Profile), Ammonia, Magnesium in a.m. CXR (Chest x-ray) in a.m. Lotrisone cream to rash/red areas BID (twice a day).
7/20/15 0810 Magnesium Rider 3 grams IVPB (Intravenous Piggy Back) x 1
7/21/15 0935 Ultrasound to L (left) arm to r/o (rule out) DVT (Deep Vein Thrombosis) Dx (diagnosis) swelling of L arm.
7/21/15 1430 5000 units-Heparin bolus IV (intravenous), 500 Units/hr (hour) Heparin IV
Follow Heparin Protocol. CMP (Complete Metabolic Profile) today.

An interview was conducted with S2DON on 7/28/15 at 1:00 p.m. He confirmed the above orders were not dated and timed when they were authenticated by S8MD. S2DON further reported the dating and signing orders by the physician has been a problem.



Patient #4
Review of the medical record for Patient #4 revealed the patient was a 64 year old male admitted to the hospital on 07/16/15 with diagnoses of VRE (Vancomycin Resistant Enterococcus) Bacteremia, Urinary Tract Infection with Sepsis, Congestive Heart Failure, Severe Protein Calorie Malnutrition, and Left Hip Wound.

Review of the physician's admitting orders dated 07/16/15 revealed S16MD signed and dated the admission orders on 07/17/15, but did not time his authentication.

Further review of the physician's orders revealed the following verbal orders were not authenticated by S16MD within 10 days:
07/17/15 at 11:06 a.m. - Type & cross & transfuse 2 units packed red blood cells.
07/17/15 at 5:15 p.m. - Wound Care Clarification orders.
07/17/15 at 5:20 p.m. - Change oral supplement from Glucerna 1.2 - 1 can three times a day to Boost Glucose Control - 1 can three times a day with meals.
07/18/15 at 7:45 a.m. - Ciprofloxacin 400 mg. IVPB (infusion) every day. Urine culture, wound culture.

In an interview on 07/28/15 at 2:15 p.m. S2DON confirmed the physician orders had not been authenticated within 10 days and the physician had not timed his authentication on the admission orders.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 73 year old female admitted to the hospital on 07/01/15 with diagnoses Sepsis, Hemolytic Strep, S/P I & D (Status post incision & drainage), Wound Vac, and Stage 4 Decubitus.

Review of the physician's admitting orders dated 07/01/15 revealed S16MD signed and dated the admission orders on 07/12/15 (11 days), but did not time his authentication.
Review of the physician's orders revealed the following verbal orders were signed by S16MD, but the authentication was not dated or timed:
07/02/15 at 2:15 p.m. - Wound Vac Clarification....
07/13/15 at 3:30 p.m. - Wound Care Clarification....
Review of the physician's orders revealed the following verbal orders were not authenticated within 10 days of the order:
07/16/15 at 9:32 a.m. - D/C (Discontinue) contact precautions.
07/17/15 at 5:10 p.m. - Wound Care Clarification....
Further review of the physician's orders revealed the following order, written by S16MD, did not have the time of the order: 07/10/15 - Celebrex 200 mg.. PO BID (by mouth, twice a day).

In an interview on 07/28/15 at 12:55 p.m. S12RN reviewed the patient's medical record and confirmed the physician orders were not authenticated within 10 days and the physician did not time the admission orders or date/time the verbal orders that he signed. She confirmed the order written by S16MD on 07/10/15 did not have documentation of the time of the order.

26351


Based on record review and interview the hospital failed to ensure patients' individual nutritional needs were reassessed per hospital policy as evidenced by 4 (#1, #2, #4, #5) out of 5 patients reviewed for nutritional needs failed to be reassessed 7 days after the initial nutritional consult. Findings:

Review of the hospital's policy, Nutrition Assessment, Policy Number: IV.T.20.27. revealed in part, The dietitian will complete a nutritional assessment within 72 hours when the nutritional screening triggers a patient is at nutritional risk... The following guidelines are developed for nutritional assessment: 1. An assessment is performed by the Registered Dietitian and is documented on the Nutritional Assessment Form and may include but is not limited to diagnosis; height/weight; usual body weight; diet order; lab values; medications & interactions; diet history, comprehension, compliance, recommendations and plan. 2. A nutrition treatment plan will be documented. This includes nutrition related measurable goals and actions to achieve them. 3. Reassessment of the patient will be completed in seven days.

Patient #2:
Review of the medical record for Patient #2 revealed he was a 56 year old male admitted to the hospital on 7/14/15 with the following diagnoses: MRSA (Methicillin Resistant Staph Aureus) Sepsis, Hepatic Encephalopathy, Moderate Malnutrition, Anemia, ETOH (alcohol) Abuse, Liver Failure, COPD (Chronic Obstructive Pulmonary Disease) and Seizure Disorder.

Review of Patient #2's Nutritional Assessment on 7/15/15 revealed the patient's current weight was 149.5 # (pounds) and he was 69 inches in height. His nutritional diagnosis was list as Malnutrition/Under Nutrition and his albumin was low likely related to malnutrition and liver disease. Boost TID (three times a day) was recommended with meals. S15RD signed the Nutritional Assessment.

Review of Patient #2's Nutritional Care plan revealed Boost was order as a supplement for the patient, daily weights were checked off and the follow up date for the nutritional reassessment was listed as 7/22/15.

Review of Patient #2's Vital Signs/ Intake and Output Records revealed the following weights for the patient:
7/15/15- 149.5#
7/16/15-weight not documented
7/17/15- 146.1#
7/18/15-144#
7/19/15-137.7#
7/20/15-139.8#
7/21/15-weight not documented
7/22/15-weight not documented
7/23/15-weight not documented
7/24/15- 137.8#
7/25/15-136.7#
7/26/15-135.6#
7/27/15-135.7#

This was a 12.5# loss of weight in 13 days.

Review of Patient #2's medical record revealed no documented reassessment of the patient 7 days (7/22/15) after the initial nutritional assessment (as per hospital's policy) until the present date of 7/28/15, which was 13 days after the initial nutritional assessment.

A phone interview was conducted with S15RD on 7/28/15 at 12:15 p.m. She reported she had done the initial nutritional assessment of the patient on 7/15/15. She reported she was not aware of the patient's continued weight loss. She further reported she works as needed at the hospital and she has a limited time to work at the hospital. She reported she prioritized the patients and the newly admitted patients obtain first priority. She confirmed she had not done a nutritional reassessment on Patient #2.

An interview was conducted with S2DON on 7/28/15 at 12:30 p.m. He reported the hospital's full time dietician recently left employment and currently the hospital has 2 prn (as needed) dieticians working in the hospital.



Patient #1
Review of the medical record for Patient #1 revealed the patient was a 57 year old female admitted to hospital on 06/27/15 with diagnoses of Respiratory Failure with Ventilator/Tracheostomy, Renal Failure with Hemodialysis, Sepsis, Anemia, Malnutrition, Morbid Obesity, S/P (Status Post) Exploratory Laparotomy with Enterocutaneous Fistula.
Review of the record revealed the patient had wounds to the abdomen and the sacrum.

Review of the patient's record revealed a dietary consult was documented by the Registered Dietician (RD) on 07/02/15 at 8:00 a.m. Review of the RD's plan revealed a follow up evaluation was to be done on 07/09/15. There was no documented evidence of a follow-up evaluation.

In an interview on 07/28/15 at 1:00 p.m. S2DON confirmed the follow-up evaluation had not been done as directed in the hospital's policy.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 64 year old male admitted to the hospital on 07/16/15 with diagnoses of VRE (Vancomycin Resistant Enterococcus) Bacteremia, Urinary Tract Infection with Sepsis, Congestive Heart Failure, Severe Protein Calorie Malnutrition, and Left Hip Wound.

Review of the patient's record revealed a dietary consult was documented by the Registered Dietician (RD) on 07/17/15 at 5:20 p.m. There was no documented evidence of a follow-up evaluation.

In an interview on 07/28/15 at 1:00 p.m. S2DON confirmed the follow-up evaluation had not been done as directed in the hospital's policy.



Patient #5
Review of the medical record for Patient #5 revealed the patient was a 73 year old female admitted to the hospital on 07/01/15 with diagnoses Sepsis, Hemolytic Strep, S/P I & D (Status post incision & drainage), Wound Vac, and Stage 4 Decubitus.

Review of the patient's record revealed a dietary consult was documented by the Registered Dietician (RD) on 07/02/15 at 9:45 a.m. Review of the RD's plan revealed a follow up evaluation was to be done on 07/09/15. There was no documented evidence of a follow-up evaluation.

In an interview on 07/28/15 at 1:00 p.m. S2DON confirmed the follow-up evaluation had not been done as directed in the hospital's policy.