HospitalInspections.org

Based on medical record review, policy review, and staff interviews the facility failed to ensure 1 (Patient 8) of 1 sampled patients with documented aggressive behaviors received a comprehensive behavioral care plan to protect the staff and patients per hospital policy. This failed practice has the potential to cause harm or negative outcomes to all inpatients who present to the hospital for care. The facility inpatient census at the time of entrance was 489.


16132

Findings are:

A. Medical Record review on (12/16/2024 at 1:48PM) revealed, 62-year-old, Patient 8 (Pt 8) was brought to the hospital on 10/15/2024 for persistent cough despite outpatient treatment by the patients physician. The patient was found to have pneumonia in the left lower lobe, and a history of non-small cell lung cancer. The patient was discharged on 10/17/2024.

Review of Pt 8's medical record identified:
-On 10/15/2024 at 8:39 PM the nursing note by RN-C revealed, "Patient refused lab draw for lactate at 2000 (8 PM). Patient educated on the importance of getting lab draw. Patient stated does not want to be poked until tomorrow morning. (Dr) notified."

-On 10/15/2024 at 11:01 PM the nursing note by RN-C revealed, "This RN entered patient's (room) due to complaining of pain." The patient received pain medication earlier in the shift and was educated that "it was too soon to give another one. Offered to reach out to (Dr) to get another order for a pain medication. Patient's voice escalated at this RN, the patients voice continued to escalate and started to swear at this RN. Pt started to throw blankets off and get out of bed. A Security assist was called. (A page is made that notifies Hospital Security and/or Armed Security to assist with any event at any time for assist with managing or controlling violent or aggressive behavior.) Security assist team helped deescalate the situation. Patient is now calm and resting in bed."

-On 10/15/2024 at 1:10 AM the nursing note by RN-C revealed, "This RN went to answer patient's call light. As this RN entered the room, the patient stated, "I don't want you. Get the (swear word) out." This RN left the room and notified charge nurse. Cares transferred to Charge Nurse."

-On 10/16/2024 at 7:02 PM the nursing note by RN D revealed, "This RN went into patient's room to administer a medication. Patient was willing to take (medication). Patient also expressed having pain with the infusion of the antibiotic and it's leaking. This RN assessed IV, no swelling or redness noted at IV site, but leaking was noted from IV dressing. Antibiotic infusion paused at this time. Patient continued to fixate on the IV. Patient's tone of voice escalated. RN reassured that IV would be addressed in that, RN would need to grab necessary supplied outside of the room. Patient started yelling. RN left room and patient escalated more by yelling at RN and staff. Security assist called."

-On 10/17/2024 at 11:56 AM the nursing note by RN-E revealed, "Pt left with shirt, pants, shoes, jacket, hat, cell phone and tub full of personal items including clothing. All discharge education complete and all questions answered."

Review of the Flowsheet charting for "History of Assaultive Behavior" identified:
-10/15/2024 at 2320 (11:20 PM), "Aggressive episode"
-10/16/2024 at 1830 (6:30 PM), "Aggressive episode"
-10/17/2024 at 1150 (11:50 AM), "Aggressive episode"

Review of Physician/Provider notes identified:
-On 10/16/2024 at 11:22 AM, the Pulmonary service note revealed, "Pt is evaluated in bed. Awake and alert, reports feeling tired today. Overnight, became agitated, threatened to leave AMA, refused lab draws."

-On 10/17/2024 at 11:46 AM, the Pulmonary Service Discharge Summary revealed, "Patient seen at bedside. Multiple security assists called overnight due to patient's agitation/anger. Is very anxious to discharge home today. Respiratory status remains stable on room air."

B. Review of the policy titled Caring for the Patient with Assaultive Behavior (effective 6/12/2023) revealed:

-"Assaultive behavior during current hospitalization:" If an incident occurs, staff should complete the Assaultive Behavior documentation in the Care/Safety Flowsheet which will place the 'history of Assaultive Behavior' banner in the record. The Assaultive Behavior FYI Flag should also be added with the approval of nursing leadership. Notify the clinical manager. Consider interventions techniques listed below. Document the incident in a B-Safe.

-"Request assistance from other available staff or contact Security:" Re-assess plan of care interventions at shift change; adjust as needed. If other intervention efforts have failed, consider convening a care conference to review options to prevent or manage future abusive, aggressive, or violent events.

-"Initiate a Care Conference to address patterns of assaultive behavior and develop an individualized care plan." A behavior treatment plan (behavior contract) may result fro the Care Conference for patients with capacity for understanding. Interventions resulting from the Care Conference should be documented by the Nurse Manager in the Assaultive Behavior documentation in the Care/Safety flowsheet and B-Safe.

-"Documentation:" Document plan of care in the electronic medical record. Complete the Assaultive Behavior documentation in the Care/Safety flowsheet.

C. Interview with RN-F on 12/18/2024 at 1:30 PM verified that Pt 8's 10/15/2024-10/17/2024 medical record lacked a care plan related to Aggressive Behavior. RN-F revealed, it is not in Epic (electronic medical record) Library, and would expect a care plan due to pneumonia, discharge plan, knowledge deficit, pain, fall, the medical things. When inquired from RN-F if could add an aggressive behavior care plan, stated "No it isn't in the Epic Library for this patient due to not having a psychiatric diagnosis. When inquired from RN-F that if having assaultive behavioral issues with a patient, would it not be beneficial for the nursing staff to have a care plan to guide the staff with this kind of behaviors? RN-F, stated, it was not part of this patients Epic Library for care plans. When inquired if the facility had the option to run the call light system for Pt 8 from 10/15-10/17/2024, RN-F said yes, will get it. [On 12/19/2024 at 9:15 AM, this surveyor was notified that the facility could only run 'Hourly Round Report' for that room in that time period and was unable to run the call light report related to the patient turning on the light and when it was answered. Per facility Pt 8's room was identified as the only room that would not be able to produce a call light report for the requested dates for an unknown reason to staff.]

D. Interview with Director of Safety and Security on 12/18/2024 at 8:49 AM stated, "I had been notified by the Nurse Manager (RN-F) on 10/15/2024 in the evening related to a patient with volatility and assaultive behavior, requiring Security support staff and to increase the Security rounding on this area. It was decided per the Caring for the Patient with Assaultive Behavior Policy that (Patient 8) would be presented a "Patient Cooperation Agreement" that would refer to the patient's rights and the staff rights to allow for the treatment plan goals to be met. We (Director of Safety & Security and RN-F) entered the patient's room with the Patient Cooperation Agreement Contract on 10/17/2024, at which time the patient was calm. As I read the contract to the patient, the patient became agitated and refused to sign the contract and would not leave AMA or leave until discharged by the doctor. We explained to the patient that if discharge by provider, refused to sign contract, and would not leave, the process would be to call LPD (Lincoln Police Department) to have the patient removed. The hospitalist gave the order already to discharge and were waiting on Pulmonary Services to round and discharge. The orders were received and the patient received the discharge instructions and left without further incident."

Based on policy review, medical record review and staff interviews the facility failed to ensure 1 (Patient 3) of 3 sampled patients diagnosed with malnutrition were ordered tube feeding recommended by the Registered Dietitian (RD), and the medical nutrition treatment plan of care was followed to monitor supplemental intake for effectiveness per hospital policy. This failed practice has the potential to cause negative outcomes for all inpatients who present to the hospital for care. The facility inpatient census at the time of entrance was 489.

Findings are:

A. Review of the policy titled Medical Nutrition Therapy (effective 3/30/2023) revealed:

1. A diagnostic driven medical nutrition treatment plan of care is developed and reassessed at regular intervals to evaluate outcomes or effectiveness of interventions by an RD.

2. Patients identified at nutritional risk for malnutrition, through the nutrition screen receive a comprehensive nutritional assessment and a diagnostic driven medical nutrition treatment plan of care by a RD or Licensed Medical Nutrition Therapist (LMNT) with 48 hours of notification and procedure for nutrition screen/rescreen.

3. Planning of the patient's care involves: individualized appropriate to age specific patient needs, inclusion of family, and interdisciplinary input.

4. The RD or LMNT write orders for tube feeding (TF) (liquid nutrition that either goes through a tube in the nose to the stomach or intestines, or abdomen to the stomach or intestines to provide life sustaining nutrition for a patient), or parenteral nutrition (PN) (liquid nutrition that goes through an intravenous (IV) line to provide life sustaining nutrition for a patient) in the physician's orders when a physician writes for or gives a verbal order for the RD to: start TF or PN per RD, or RD to see and write orders for TF or PN, or start TF per RD recommendations, or RD to adjust and order TF.

B. Review of the medical record (12/17/2024 at 7:51 AM) revealed Patient 3 was admitted to the hospital 9/29/2024 at 7:52 PM for shortness of breath, poor appetite, difficulty swallowing and extreme fatigue. Patient 3's past medical history included but not limited to Lupus with failed kidney transplant requiring hemodialysis (treatment that filters waste and extra water from the blood), and sepsis (infection).

Patient 3's nutrition care plan from 9/30/2024 revealed:
-Nutritional needs goal of eating greater than or equal to 75%.
-Encourage adequate protein at meals and snacks to aid in the maintenance of lean body mass.
-Supplement therapy interventions of send Ensure Clear (supplement) twice daily, and a protein shake in the afternoon for snack daily.
-Monitor by mouth intake, weight and diet tolerance.

Patients 3's medical record by mouth intake (meal) documentation confirmed by RD-A revealed:
-9/30/2024: 10% of meals (goal of 75%)
-10/1/2024: 10% of meals (goal of 75%)
-10/2/2024: lacked evidence of meal documentation.
-10/3/2024: 25% and 0% of meals (goal of 75%)
-10/4/2024: lacked evidence of meal documentation.
-10/5/2024: 10% of meals (goal of 75%)
-10/6/2024: 10% of meals (goal of 75%)
-10/7/2024: 10% of meals (goal of 75%)
-10/8/2024: 10% of meals (goal of 75%)
-10/9/2024: 0% of meals (goal of 75%)
-10/10/2024: 0% of meals (goal of 75%)
-10/11/2024: lacked evidence of meal documentation (Patient 3 discharged at 3:45 PM).

Patient 3's medical record lacked evidence of supplement intake documentation three times per day on 9/30/2024, 10/1/2024, and 10/4/2024 through 10/11/2024, confirmed by RD-A.

Patient 3's medical record revealed documentation on 10/3/2024 at 11:45 AM of vomiting, "pink from drinking berry ensure and strawberry yogurt," confirmed by Staff-A.

Patient 3's nutrition goals documented on 10/3/2024 at 2:56 PM revealed:
-maintain weight, goal not met, continue.
-weight down to 47.2 kilograms(kg) from admit weight of 53.1 kg.
-meet nutritional needs greater than or equal to 75%, goal not met, continue.
-by mouth intake of 0-25% at meals.
-vitamin/mineral intake goal not met, continue.
-intervention of continue three times per day supplements with meals and monitor by mouth intake and weight.

Patient 3's medical record revealed a documented nutrition assessment on 10/8/2024 at 2:00 PM that included:
-patient continues to eat minimally, 0-10% of meals (goal of 75%), threw up after breakfast.
-noted GI concern for achalasia (patient is unable to get food to the stomach) with plans for outpatient work up.
-weight down approximately 6 kg since admit.
-by mouth intake average of 11% of last 9 meals documented.
-Enteral Nutrition Recommendations revealed patient, "is severely malnourished.....previously okay with short-term TF but didn't want G-tube (a tube that requires surgery, and goes into the stomach) placed, may need to consider feeding tube placement (short term is a tube that goes through the nose into the stomach or intestines per a physician order) until patient is able to eat more by mouth and/or get work up for achalasia. TF recommendations: Osmolite 1.2, start at 20 milliliters per hour, advance 10 milliliters per hour every 8 hours with a goal of 60 milliliters per hour....TF regimen provides 1584 kcalories, 73 gram of protein." RD-A confirmed Patient 3's medical record lacked evidence of an order for the RD to start TF or PN on 10/8/2024 per hospital policy.

Patient 3's care plan documented on 10/8/2024 at 3:03PM revealed malnutrition interventions that included recommendations to monitor, adjust tube feedings, and parenteral nutrition based on nutritional status and assessed needs." RD-B confirmed Patient 3 did not receive any TF or PN from 9/29/2024 - 10/11/2024.

C. Interview (12/17/2024 at 1:03 PM) with RD-B revealed that a malnutrition score of 2 or greater from the nursing admit nutrition screen consults the RD to follow the patient. RD-B recalled Patient 3 had a malnutrition score of 3 on admit. RD-B recalled patient 3's initial assessment on 9/30/2024 with a conversation of the patient willingness for short term tube feeding, and parenteral nutrition was not discussed due to infection concerns. The RD can diagnose malnutrition and then the physician can agree or disagree and address in the progress note. RD-B revealed the RD recommendations are automatically sent via the electronic medical record to the physician to address in the progress note. The RD stated they utilized a secure chat that is not a part of the medical record to communicate patient 3's nutritional recommendations to the physician. The secure chat is no longer available to be viewed after 7 days. [The facility was unable to produce evidence of the physician being aware or addressing the RD tube feeding recommendation on 10/8/2024 in Patient 3's entire medical record, confirmed by RD-A.]