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Based on observation, interview and record review the facility failed to document consumption of a nutritional supplement (a drink added to the diet, usually to increase calories and/or protein to increase weight or the ability to heal wounds) for six patients (#4, #24, #26, #27, #28, and #10) of seven reviewed for documentation of consumption of a nutritional supplement This had the potential to affect 21 current patients, with orders for nutritional supplement, throughout the facility. The facility census was 62.

Findings included:

1. Record review of the facility's policy titled, "Supplemental, Enteral and TPN [Total Parenteral Nutrition-a complete liquid-type diet] Procedures," revised 05/12, showed the following:
-[Need for] supplements are communicated to the physician so the physician can write an order for the supplement.
-Food service initiates supplement based on the initiation of the Dietitian or physician order.
-Supplements are delivered as ordered.
-All oral supplements will be documented on the intake section of the IDD (Interdisciplinary Daily Documentation).

2. Record review of the facility's policy titled, "Wound Assessment, Prevention and Documentation," revised 11/12, showed the staff should encourage appropriate intake.

3. Record review of Patient #4's History and Physical (H & P) dated 07/18/13, showed the patient was admitted on 07/17/13 with decreased functional status and left side weakness. The patient was admitted with multiple pressure sores on her left side.

Record review of the patient's laboratory results dated 07/19/13 showed a low albumin (a level of protein in the blood) of 3.3 g/dL (grams per deciliter, normal=3.6-5.0). A 3.3 albumin level can be an indicator of poor nutritional status and decreased ability to heal wounds.

Record review of a Nutritional Assessment dated 07/18/13 showed the patient had inadequate oral intake, had wounds, and required education and a nutritional supplement to help heal her skin. The patient was considered a severe nutritional risk.

Record review of the patient's physician's order dated 07/31/13 showed the physician ordered three nutritional supplements per day, with meals.

Record review of the patient's Interdisciplinary Plan of Care (IPOC) dated 07/31/13 showed the patient should receive a nutritional supplement three times daily.

During an interview on 08/06/13 at 10:54 AM, Staff K, Registered Dietitian (RD), stated that the patient was to receive the nutritional supplements as recommended so as to improve her intake, as well as help heal her pressure sores. Staff K stated that nursing should document the consumption of the supplement so she could ascertain the supplement's efficacy (if the supplement was providing what was intended), or the need to make further recommendations.

Record review of the patient's IDD's from 08/02/13 through 08/05/13, showed staff failed to document the supplement intake for at least one meal per each day.

4. Record review of Patient #24's H & P dated 07/30/13 showed the patient was admitted on 07/30/13 with decreased functional status related to a right thigh bone fracture. The patient also had multiple abrasions on his right hip, thigh, and lower right leg.

Observation and concurrent interview on 08/06/13 at 2:30 PM showed the patient had three incisions with sutures/staples and other open skin areas (abrasions) on the right leg. There were four unopened cartons of nutritional supplement on his overbed table.

During an interview on 08/06/13 at 3:10 PM, Staff K, RD, stated that the supplements were sent from Dietary with each meal tray, not all at once.

Record review of a Nutritional Assessment dated 07/31/13 showed the patient had wounds on the right leg. The dietitian recommended a nutritional supplement, three times daily, to address his increased nutrient needs. The patient was considered a moderate nutritional risk.

Record review of the patient's physician's order dated 07/31/13 showed an order for a supplement three times daily.

Record review of the patient's IPOC dated 07/31/13 showed the patient should receive nutritional supplements.

Record review of the patient's IDD's from 07/31/13 through 08/05/13, showed staff failed to document any supplement intake on 07/31/13 and on 08/05/13.

5. During an interview on 08/07/13 at 8:25 AM, Staff T, Registered Nurse (RN), stated that supplements were delivered on meal trays. Staff T stated that nursing staff delivered the tray to the room and retrieved the tray after a meal was consumed. Staff T stated that nursing staff was responsible for documenting the amount of the supplement consumed in cubic centimeters (cc's-one carton =240 cc's). Staff T stated that if the patient refused the supplement, an "R" or the word "refused" should be documented. Staff T stated that, the patient technician (tech) usually documented the supplement consumption; however, the ultimate responsibility fell to the RN.

6. During an interview on 08/07/13 at 8:58 AM, Staff S, patient tech, stated that the tech assigned to the patient with a supplement was responsible for documenting its consumption in the record.

7. Record review of Patient #27's IDD dated 08/03/13 showed she was admitted to the facility on 08/02/13 with a gastrostomy tube (a tube into the stomach that liquid nutrition is put through) and an oral diet.

Record review of the patient's physician's order dated 08/03/13 showed an order for a supplement three times daily.

Record review of the patient's IDD's from 08/04/13 through 08/06/13, showed staff failed to document supplement intake once each day on 08/04/13 and on 08/06/13.

8. Record review of Patient #28's Physician Admission Orders dated 06/24/13, showed the patient was admitted on that date, with some paralysis (loss of mobility), and an order for a supplement three times daily.

Record review of the patient's physician's order dated 07/02/13 showed an order for a supplement three times daily.

Record review of the patient's IDD's from 07/04/13 through 08/06/13, showed staff failed to document supplement intake, one to three times per day, on most days.

9. Record review of Patient #10's H & P dated 07/27/13, showed the patient was admitted on that date with decreased functional status related to pelvic fractures (broken bones).

Record review of the patient's physician's orders dated 07/29/14 showed an order for a supplement three times daily.

Record review of the patient's IDD's from 07/29/13 through 08/05/13 showed staff failed to document supplement intake one to three times daily, on most days.

10. Record review of Patient #26's H & P dated 07/29/13, showed the patient was admitted on 07/26/13 for recovery following a blunt force trauma incident that damaged the left side of the brain.

Record review of the patient's laboratory results dated 07/29/13 showed an albumin level of 4.5 g/dL, which was within normal limits of 3.6-5.0. Laboratory results dated 08/05/13 showed the patient's albumin level had dropped to 3.5 g/dL.

Record review of a Nutritional Assessment dated 07/27/13 showed the patient to have difficulty with chewing and swallowing, was determined to be at severe risk of malnutrition and unplanned weight loss due to inadequate oral intake, and required a nutritional supplement.

Record review of a physician's order dated 07/31/13 showed the dietitian recommended, and the physician signed an order for a nutritional supplement three times daily, and to "start calorie count."

Record review of the patient's IPOC dated 08/01/13 showed the patient should receive a nutritional supplement three times daily and recommended weekly weights.

Record review of the patient's Daily Flowsheet/Treatment Records from 7/31/13 through 08/06/13, showed on 08/02, on 08/04, and on 08/06 staff failed to document supplement intake at least once on those days.

11. Record review of the facility's New Employee Orientation Agenda, dated 02/23/06, showed documentation education related to supplement consumption occurred on day two of the orientation.

Record review of the facility's New Employee Initial Competency Verification Document, undated, showed the employee was instructed on documentation of nutritional supplements.

12. Record review of the facility's Orientation Skills Check List for the Rehabilitation Technician, undated, showed the employee was to learn how to document nutritional supplements.






04467

Based on observation, interview and record review the facility failed to develop specific, individualized Interdisciplinary Plans of Care (IPOCs) for two patients (#25, and #4) of two patients reviewed who were receiving special protective status to prevent possible sexual and/or physical abuse by a visitor/family member while an inpatient. This had the potential to affect all patients on a protective status, currently two patients. The facility census was 62.

Findings included:

1. Record review of the facility's policy titled, "Protective Status Patients," revised 02/13, showed the policy's intent was to provide the safest environment for the patient, their visitors and the staff (if the patient was a victim of violence). The patient's name was kept confidential, and no information about the patient was to be given out without the permission of the patient. Visitors were screened and only allowed on the permission of the patient. There were two types of protective status, voluntary and involuntary. If the patient chooses protection, it was voluntary.

2. Record review of the facility's policy titled, "Interdisciplinary Plan of Care [IPOC]," revised 02/12, showed the following:
-The patient's IPOC will be based on his/her assessed individual needs, family/caregiver needs, physical, cognitive and functional impairments.
-The plan must include anticipated interventions required by the patient during the stay.
-Updates to the plan are documented in the plan.

3. Record review of Patient #4's History and Physical (H & P) dated 07/18/13, showed the patient was admitted on 07/17/13 with decreased functional status and left weakness. The patient was admitted on an involuntary protective status related to possible sexual/physical abuse prior to admission.

Record review of the patient's IPOC dated 07/31/13 showed staff failed to identify and address the patient's protective status in the IPOC.

During an interview on 08/06/13 at 9:55 AM, Staff H, Registered Nurse (RN) Manager, stated the patient came to the hospital as a victim of violence. Staff H confirmed that staff failed to care plan the patient's protective status.

4. During an interview on 08/07/13 at 8:25 AM, Staff T, RN, stated that the nurses were responsible for updating the IPOC with any event or change in status. Staff T stated that the protective status of a patient could be added to the safety problem.

5. Record review on 08/06/13 of Patient #25's medical record showed the patient was admitted to the facility on 7/17/13 and was sexually assaulted while a patient at the facility by a visitor on 7/29/13. Further review of the medical record showed emergency medical treatment, prophylactic medications, and psychiatric counseling in response to the sexual assault.

Review of the patient's IPOC showed staff failed to plan, assess and document ongoing care needs related to the sexual assault including safety needs/protective status, the medical needs, counseling needs, and prophylaxis medication regimen.

During an interview on 08/05/13 at 2:30 PM, Staff B, Director of Quality, stated that the patient was not placed in involuntary protective status (a physician's order) until 07/31/13.

Observation on 08/06/13 at 3:00 PM of the patient's room showed the patient was placed in involuntary protective status as noted by specific (confidential) secure room markings known to the facility staff. The observation was made to verify the patient was in protective status but that status had not been identified in the IPOC.





04467




17863

Based on observation, interview and record review, staff failed to follow facility policy and physician orders for medication administration for one discharged patient (#12) of one discharged patient reviewed and one current patient (#10) of 12 current patients reviewed. The facility also failed to investigate missed medication doses for one patient (#12) of one patient who had missed medications and implement process changes to reduce the risk of this occurring again. These deficient practices had the potential to affect all patients in the facility. The facility census was 62.

Findings included:

1. Record review of the facility's policy titled, "Medication Administration" revised 05/13, showed direction that all medications administered to patients required a physician's order. Further review showed all medications were transcribed to the Medication Administration Record (MAR) and confirmed by a licensed nurse.

2. Record review of Patient #12's History and Physical (H & P) showed the 49-year-old female was admitted on 06/06/13 for rehabilitation after care and treatment for bleeding on the brain. The physician's plan included medication (Nimodipine) to prevent vasospasm of brain blood vessels.

Record review of the patient's physician's admission orders dated 06/06/13 showed "Nimodipine 60 mg q 4 x 7 days" (the medication given in a specific dose every four hours, or six times a day, for seven days) and the first initial order review was signed by Staff X, Registered Nurse (RN).

Record review of Patient #12's medical record showed a handwritten MAR for 06/06/13 and 06/07/13 that included Nimodipine to be given every four hours. The handwritten scheduled dosing times were entered for four times per day (rather than the six times per day necessary to follow the every four hour order). Nurses recorded on the MAR as administering Nimodipine doses included Staff W, RN, and Staff Y, RN.

Record review the patient's medical consultation dated 06/08/13 showed the patient had new seizures, low blood pressure and was transferred to an Emergency Department.

3. During an interview on 08/06/13 at 2:10 PM, Staff R, Director of Pharmacy, stated that he was unaware of Patient #12's missed Nimodipine doses and that the patient should have received additional doses on 06/06/13 at Midnight and on 06/07/13 at 4:00 AM.

4. During a telephone interview on 08/07/13 at 9:25 AM, Staff W stated that she had not been told about the patient's missed Nimodipine doses and she did not recall the patient.

5. During a telephone interview on 08/12/13 (after surveyor exit from the facility) at 4:40 PM, Staff Y, RN, stated that she had not been told about the patient's missed Nimodipine doses and she did not recall anything about the patient's medications.

6. During a telephone interview on 08/12/13 (after surveyor exit from the facility) at 7:10 PM, Staff X, RN, stated that:
- She had not been told about the patient's missed Nimodipine doses;
- She did not recall the patient; and
- She had been instructed to review the scheduled dosing times when comparing medication orders to the MAR.

7. Record review of Patient #12's incident report dated 07/05/13 and completed by Staff B, Director of Quality, showed that:
- There were missed Nimodipine doses for the patient.
- Staff missed the doses because the order was transcribed incorrectly.
- The case had been sent to Physician Peer Review and Nursing Peer Review.

8. During an interview on 08/06/13 at 3:00 PM, Staff C, Interim Director of Nursing, stated that:
- She had not conducted an investigation of the missed Nimodipine doses because the case had gone to Nursing Peer Review.
- The Nursing Peer Review Committee was a subcommittee of the Nursing Quality Practice Council whose members were staff nurses.
- The committee met monthly and had met once to review the case.
- No process changes regarding MAR transcription had been implemented and no employee counseling had taken place regarding the error.
- She was waiting for the committee's recommendations before taking any actions.

9. During an interview on 08/07/13 at 10:15 PM, Staff V, Physician and facility Medical Director, stated that he was aware of the missed Nimodipine doses for the patient and he had been concerned that may have caused the new seizures. He was unaware that the staff involved had not been notified of the error or that no investigation had been done.

10. Record review of Patient #10's H & P dated 07/27/13, showed the patient was admitted on that date with decreased functional status related to pelvic fractures. The patient had a history of tobacco use and the physician planned smoking cessation via a nicotine patch (assists in the urge to smoke).

Record review of the patient's admission orders dated 07/27/13 showed the patient should receive a nicotine patch 14 mg topically daily for smoking cessation.

Observation and concurrent interview on 08/06/13 at 9:20 AM, showed the patient had two Nicotine patches on, one on each arm. Staff EE, RN, stated that someone forgot to take one of the patches off before placing another one (on a previous shift).

During an interview on 08/07/13 at 8:44 AM, Staff H, RN Manager, stated that she had been made aware a nurse put another patch on Patient #10 without removing the existing one first.

11. Record review of the Food and Drug Administration's website regarding Nicotine Patch use, on 08/19/13, showed one 14 mg patch was to be worn daily. Directions showed, "Do not wear more than one patch at a time."




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