HospitalInspections.org

Based on a review of policies and procedures, medical records, and staff interviews, the hospital failed to ensure the therapeutic diets were meeting the needs of the patients.


Findings:

1. Patient #8's medical records did not contain a request for a dietary consult although the patient was admitted with dehydration, electrolyte imbalance, frequent diarrhea, diabetic. Orders on admission included daily weights, aspiration precautions. Documentation on the nursing assessment/nutritional screen stipulates "dietary consult required" and the box was checked "no". There was no documentation as to why a dietary consult was not provided.

Glucerna was ordered three times a day as a supplement. The "medication administration "record included two entries during the stay where the patient refused the supplement. No other documentation of staff administering the supplement was noted on the medication administration record. On a separate electronic form titled "medication history" documentation indicated all Glucerna supplements were administered. Staff F and G were asked where the nursing staff are instructed to document supplements and refusal, both told surveyors the supplements should be documented in the "medication administration" record.

On 11/28 surveyors asked Staff F (medical records) and Staff H (pharmacy) why the documentation did not show on the medication administration record. Both staff members did not know why/or how the supplement documentation was in one area of the electronic record but not in the "medication administration" area. Staff F and G verified the supplement was not documented in the medication administration area.


2. Patient #13's medical record contained a request for dietary consult. There was no dietary consult included in the record. There was no documentation why the patient did not receive a dietary consult.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. Three of three licensed nursing personnel (Staff L, M and O), whose personnel files were reviewed, did not have documented training and competencies performed by the respiratory therapist. The training was performed by the Director of Nursing. This finding was reviewed and verified by administrative staff on 11/28/2011.