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Based on observation, interview and record review, the facility failed to have a process and procedure in place to adequately monitor and/or be alerted when patient call lights were activated on the second floor. The second floor staff cares for patients with severe stroke and brain injuries. The second floor census was 34 patients at the time of survey with a potential capacity of 41. The facility census was 80.

Findings included:

1. Observation on 04/28/14 at 9:30 PM showed the call light button activated in Patient #4's room by Staff I, Registered Nurse (RN). The call light button activated the light above the patient's door on the outside of the room in the hall but no sound was heard. Staff I activated the call light button a second time and confirmed that no sound could be heard to alert staff to a patient care need.

2. During an interview on 04/28/14 at 9:30 PM, Staff I stated that the patient call light was monitored at the nurses' station.

3. Observation on 04/28/14 at 9:35 PM showed no nursing staff at the nurses' station.

4. During an interview on 04/28/14 at 9:35 PM, Staff F, Plant Operations Manager, stated that the monitor at the nurses' station were on a 45-second delay. He explained that when a call-light button was activated in a patient's room that the system was programmed to delay monitor activation for 45-seconds at which time the monitor then beeps and shows the room number where the call light button was pressed. The call light alert can also be canceled or turned off at this monitor. He stated that there were two different call light buttons in the patient's room: One for a normal patient request that had a white light and one for an emergency request that activated a red light - both lights were located in the hallway above the patients' doors. Staff F stated that both buttons were programmed for the 45-second delay. He stated that the emergency call-light delay should probably be changed to no delay.

5. Observation on 04/28/14 at 9:40 PM showed no nursing staff at the nurses' station. Staff D, Chief Executive Officer (CEO,) also observed while Staff F activated the emergency call light button in vacant patient room #218. As before, there was a 45-second delay before the nurses' station monitor activated with a sound and it was one minute and 30 seconds before a nurse tech (technician) heard the monitor and responded to the emergency call light.

6. During a concurrent interview on 04/28/14 at 9:45 PM, Staff D and Staff F stated that the nursing staff on the second floor did not have Ascom (brand name) telephones (a nurse call system that connects the nursing care team directly to the patient via the telephone activated by the patients' call light). They stated that when nursing staff have these phones that they were immediately notified of a patient call light request and can answer the call light and talk with the patient no matter where they were on the floor, which facilitates patient communication and patient care requests/emergencies. They stated that the phones on the second floor had been lost, stolen or misplaced by employees and that the facility had recently ordered 39 new ones for the nursing staff but had not received them, but expecting delivery within the month. They stated that the phones had been off of the second floor for approximately two months but no changes to call light request procedures had been made. Staff F stated that he would contact the call light monitor company in the morning to discuss the 45-second delay and changes that could be made for improved responses to patient call light requests and potential emergencies.

7. Record review of a complaint submitted to the facility on 04/01/14 by discharged Patient #26 alleged that she needed help to the toilet and waited 45 minutes for nursing staff to respond to her call light. The complaint also stated that she needed help off of the toilet and waited an additional 20 minutes after pressing the call light button for assistance.

8. During an interview on 04/29/14 at 10:15 AM, Staff F stated that the monitoring company was at the facility and that the delay times for the call light response system had been set to zero for both the patient assistance and emergency call light buttons.

9. During an interview on 04/29/14 at 3:20 PM, Staff D, Chief Executive Officer (CEO), stated that the facility had no policy and/or written procedures in reference to patient call light responses. She stated that the facility's philosophy was, "a no pass zone" meaning that all staff was to respond to any patient request regardless if they were assigned to that patient.

10. During an interview on 04/30/14 at 9:30 AM, Staff F stated that until the phones (Ascom communication phones) were received and distributed that someone should be assigned at the nurses' station to monitor and answer the patient call requests.

11. During an interview on 04/30/14 at 9:35 AM, Patient #29 stated that he pressed his call light 20 minutes ago because he needed help getting ready to go to therapy but no one had come to help him.

12. During an interview on 04/30/14 at 1:50 PM, Staff D stated that an employee would be designated to sit behind the nurses' station on the second floor to answer, field and respond to patient call lights.

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 five current patients (#11, #24, #27, #31 and #32) and one discharged patient (#19) of nine patients reviewed for documentation of consumption of a nutritional supplement. This had the potential to adversely affect 25 current patients, with orders for nutritional supplement throughout the facility, with their nutritional needs, weight management and wound healing.
-Weigh, and/or supervise weekly and/or daily weights, as directed in their policy for two current patients (#12 and #33) and one discharged patient (#19) of six patients reviewed.
-Weigh, and/or supervise pre and post weights of patients receiving dialysis (a process by which blood is cleansed of toxins, and filters excess weight from the blood. For patients with kidney disease-a pre-weight gives dialysis staff an assessment of how much fluid can/should be removed during dialysis and a post weight verifies a therapeutic volume of fluid was removed. The number of times dialysis is needed per week is also determined, partially, by the weight of the patient) for four (#8, #12, #33, and #34) of four current dialysis patients reviewed, and for one (#19) of one discharged dialysis patients reviewed. The facility census was 80.

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 09/13, showed the following:
- Food service initiates supplement based on the initiation of the Dietician or per physician order.
- Supplements are delivered as ordered.
- All oral supplements will be documented on the intake section of IDD [Interdisciplinary Daily Documentation-a paper documentation sheet that is no longer used unless computer documentation is not operational].

Record review of the facility's policy titled, "Patient Weights," revised 06/11, showed each patient was weighed upon admission and weekly thereafter, unless ordered more frequently. The Registered Nurse (RN) supervisor was responsible for making sure the weights were completed and documented. The policy failed to address dialysis patients' weight requirements.

2. Record review of the facility document titled,"Types of Supplements available," dated 08/29/13, showed the following:
- Administer at time ordered. May be with meals or as a snack;
- Document quantity consumed under intake on daily flow sheet/treatment record section of IDD;
- Notify dietician or physician if patient is refusing supplement.

Record review of the facility document titled,"Quality Council" meeting minutes dated 04/28/14, showed the following:
- Nursing - 2nd floor target of 85% for improved documentation of supplements with a 23% result for 03/14;
- Nursing - 3rd floor target of 90% for improved documentation of supplements with a 23% result for 03/14;
- Nursing - 4th floor target of 90% for improved documentation of supplements with a 21% result for 03/14.

3. Record review of current Patient #11's History and Physical (H & P) dated 04/22/14, showed the patient was admitted on 04/22/14 with T6 paraplegia (injury or trauma that occurred at the 6th vertebrae resulting in paralysis from the waist down) ASIA A [American Spinal Injury Association-a classification system used for grading the severity of the injury] secondary to a gunshot wound. The plan was to focus on upper extremity and trunk strengthening to achieve independence in mobility and daily living skills from the wheelchair level and to prevent skin complications.

Review of the patient's order history dated 04/23/14 showed the physician ordered three nutritional supplements per day, with meals.

Record review of the patient's Electronic Medical Record (EMR) from 04/23/14 to 04/28/14 showed the staff failed to document the supplement intake for at least one meal per day with no documentation for two days.

4. Record review of current Patient #24's H & P dated 04/18/14, showed the patient was admitted on 04/17/14 with fractures of the sternum and ribs, traumatic brain injury, pulmonary (lung) contusions (bruising), and a right hip fracture with recent surgical repair.

Record review of the patient's laboratory results dated 04/26/14 showed a low albumin (a level of protein in the blood) of 3.2 g/dL (grams per deciliter, normal=3.6-5.0). A 3.2 albumin level can be an indicator of poor nutritional status and decreased ability to heal wounds.

Record review of the patient's order history dated 04/27/14 showed the physician ordered three nutritional supplements per day, with meals.

Record review of the patient's EMR from 04/27/14 to 04/29/14 showed staff failed to document the supplement intake for at least two meals per day with no documentation for one day.

5. Record review of current Patient #27's H & P dated 04/23/14, showed the patient was admitted on 04/23/14 with decreased independence with activities of daily living (ADL's), decreased mobility and decreased transfer status in relation to recent spinal fusion (a surgery to permanently join together two or more bones in the spine so there is no movement between them. (These bones that are joined are called vertebrae).

Record review of the patient's order history dated 04/23/14 showed the physician ordered three different kinds of supplements three times per day, with meals.

Record review of the patient's EMR from 04/25/14 to 04/30/14 showed staff failed to document any supplement intake for two of the three ordered supplements and failed to document supplement intake for at least one meal per day for three of the five days for one supplement.

6. Record review of current Patient #31's H & P, dated 04/26/14, showed the patient was admitted on 04/25/14 with a history of a pelvic and left lower leg fracture requiring an external stabilizing device (fixator-pins through skin into the bone creating open wounds at pin sites).

Record review of the EMR, showed an admission weight of 240 pounds. The physician ordered Ensure three times daily on 04/26/14. As of 04/27/14, the patient weighed 231 pounds, or a loss of nine pounds in two days. Staff failed to document the supplement intake one to two times daily from 04/26/14 through 04/29/14.

7. Record review of current Patient #32's H & P, dated 04/25/14, showed the patient was admitted on that date with a history of a stroke and other heart problems requiring some intensive therapy. The patient had a history of swallowing problems.

Record review of the patient's laboratory results, dated 04/28/14, showed a low plasma total protein (source of nutrition for the body tissues) of 6.2 g/dL (normal = 6.5-8.5 g/dL) and albumin of 3.3 g/dL (normal = 3.6-5.0 g/dL).

Record review of the EMR, showed an order for a supplement three times daily with meals on 04/26/14. Staff failed to document the supplement intake one to three times daily from 04/26/14 through 04/27/14.

8. Record review of discharged Patient #19's H & P, dated 04/04/14, showed the patient was admitted on that date with liver and kidney failure requiring dialysis three times weekly. The patient was six feet tall and weighed 141 pounds on admission. The patient was admitted for intensive therapy.

Record review of physician's orders showed the following:
- An order, dated 04/04/14, for a nutritional supplement called Ensure, three times daily with meals.
- An order for an appetite stimulant medication called Megace, dated 04/07/14.
- An order for a feeding tube (a tube placed into the stomach to provide nutrition) on 04/16/14.

Record review of Registered Dietitian (RD), notes showed the following:
- On 04/05/14, the patient had inadequate oral intake and a poor appetite. The patient's usual body weight was 165 pounds.
-On 04/10/14, the patient's meal intake ranged from 0-50%. There was,"no new weight noted."
- On 04/14/14, the patient did not have an appetite, and there was, "no new weight noted."

Record review of the EMR on 04/30/14, showed the staff failed to document the following:
- On 04/05/14, no supplement was documented as consumed.
- On 04/06/14 and 04/12/14, no supplement was documented at lunch or dinner.
- From 4/07/14 through 04/11/14 and on 04/15/14, no supplement was documented as consumed.
- On 04/14/14, no supplement was documented at breakfast, or dinner.
- On 04/16/14, no supplement was documented at dinner.
- Subsequent weekly weights for Patient #19, and pre and/or post dialysis weights.

Record review of a physician progress note, dated 04/17/14, showed the patient was emaciated (thin and wasted) appearing.

9. During an interview on 04/30/14 at 10:07 AM, Staff W, RN Manager, stated that Patient #19 did not eat well, responded poorly to feeding assistance, and was very thin. Staff W stated that nursing staff, either the RN or technician (tech), should document supplement percentage consumed in the EMR by showing the name of the supplement and the percentage as 25%, 50%, 75%, or 100%, or in milliliters.

10. During an interview on 04/29/14 at 2:15 PM, Staff N, RN, Infection Control, stated that the nutritional supplements were to be documented under the intake and output section of the EMR.

11. During an interview on 04/30/14 at 9:05 AM, Staff S, RN, stated that nursing staff was responsible to document the amount of nutritional supplements a patient consumes. She stated that whoever "pulled" [removed] the dining tray are responsible to document in the patient's EMR. Staff S stated that there were two different places (electronic screens) that the document could be recorded under the task list - the I & O (Input and Out take) screen or the assessment screen. She stated that there were a few reasons why the nutritional supplements would not be documented, a staff member not assigned to the patient pulled the patients tray or that she wasn't sure that nursing techs knew how to document that the nutritional supplement had been refused by the patient.

12. During an interview on 04/30/14 at 9:20 AM, Staff W, RN, Nurse Manager, stated that the nutritional supplements were to be documented under the intake and output section under nutrition. Staff W stated that if documented under only one of these the documentation should show up in both places. Staff W stated that he was aware of the low percentage of documentation of the nutritional supplements reported in the quality council meeting for 03/14.

13. During an interview on 04/30/14 at 9:30 AM, Staff T, RN, stated that all nutritional supplements were documented in the EMR under the Task List. He stated that it was the responsibility of the nurse or the nurse's tech assigned to the patient to ensure the nutritional supplements were documented. He stated that if he saw that a supplement had not be documented on the patient that he would go ask the patient how much of the supplement they had consumed.

14. During an interview on 04/30/14 at 9:40 AM, Staff I, RD, Lead Dietitian, stated that nutritional supplements were to be documented under the Assessment portion of the patient's EMR. She stated that the nutritional supplement documentation by the nursing staff was not one of her audits. She stated that the nutritional supplement documentation was audited by Staff E, Director of Quality. Staff I stated that she did not know how the audit was compiled or what EMR screens were used to pull the supplement documentation information. She stated that she did not review the results of the audit. Staff I stated that she had been employed at the facility since October 2013 and had not conducted any inservices to staff since she had been there. She stated that she knew that some inservices were conducted prior to her employment but was unaware of the content. She was also unaware that nursing staff were documenting the supplement consumption on different EMR screens. Staff I stated that nutritional supplements were given with patient meals and not in between meals and was not concerned that a patient may be too full to drink the supplement or choose to drink the supplement and not the meal.

15. During an interview on 04/30/14 at 10:38 AM, Staff G, RN Chief Nursing Officer (CNO), stated that the staff should document the supplemental feedings in the intake and output section of the chart and they can select a drop down box to choose the type of supplement then comment how much was consumed by the patient. Staff G stated that Staff I, RD, Lead Dietitian, received the data from the Quality Council meeting minutes quarterly and should review it.

16. During an interview on 04/30/14 at 10:58 AM, Staff Z, tech, stated the following:
- The techs get a list of patients that are to receive supplements from dietary at 6:45 PM each day, for the next day.
- The techs were supposed to document the percentage consumed and type in the name of the supplement.
- If the patient does not drink the supplement, but says they will later, the tech reports unconsumed supplement to the next tech as appropriate. The supplement is documented at time of consumption, not with tray pick-up (contrary to other interviews).
- The RN was supposed to follow-up to see if the supplement had been documented appropriately.

17. According to the most current dialysis regulations, CFR 494.90, V543, showed the following:
- The interdisciplinary team must decide the necessary care and services to manage the patient's volume status.
- Volume status is measured in terms of the dialysis patient's "target weight," or what the patient would weigh if not symptomatic of kidney disease.
- Excess fluid accumulation may have adverse effects (high blood pressure, and other heart problems).
- Removal of too much fluid or removing it too fast in one dialysis treatment, or going below the patient's target weight may cause low blood pressure, muscle cramping, and clotting of the dialysis access.
- Each patient should be weighed before and after each treatment.
- With successful fluid management, the number of medications to treat blood pressure control may be reduced.

18. Record review of current Patient #12's H & P, dated 04/10/14, showed the patient was admitted on 04/09/14 for intensive therapy after injuries from a fall. The patient also received dialysis.

Record review of physician's orders showed an order for daily weights on 04/19/14.

Record review of Patient #12's weight history showed staff failed to weigh the patient on 04/23/14, and 04/24/14. Staff also failed to weigh Patient #12 prior to and after dialysis throughout his stay.

19. Record review of current Patient #33' H & P, dated 03/19/14, showed the patient was admitted on 03/18/14 for therapy related to an oxygen depriving brain injury. The patient also received dialysis.

Record review of physician's orders showed an order for daily weights on 04/20/14.

Record review of Patient #33's weight history showed staff failed to weigh the patient on 03/25/14, 04/16/14, 04/22/14, 04/23/14, 04/24/14, 04/25/14, and 04/29/14. Staff also failed to weigh Patient #33 prior to and after dialysis throughout his stay.

20. Record review of current Patient #8's H & P, dated 04/14/14, showed the patient was admitted on 04/13/14 for therapy related to a recent hip fracture. The patient also received dialysis three times weekly.

Record review of the patient's EMR, on 04/30/14, showed facility staff failed to weigh Patient #8 prior to and after dialysis throughout his stay.

21. Record review of current Patient #34's H & P, dated 04/26/14, showed the patient was admitted on 04/01/14 for therapy related to a recent hip fracture. The patient also received dialysis three times weekly.

Record review of the patient's EMR, on 04/30/14, showed facility staff failed to weigh Patient #34 prior to and after dialysis throughout his stay.

22. During an interview on 04/30/14 at approximately 1:30 PM, the CNO confirmed that it was not a facility practice to weigh dialysis patients prior to, or after dialysis.



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