HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patients' rights, the right of the patient to receive, at the time of admission, information about the hospital's patient rights policy(ies) and the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care.

Four (4) of 6 patients (Patient #1, #3, #5, and #6) records did not document the receipt of patient rights including the complaint process.

Findings included

Patient #1's, #3's, #5's, and #6's records did not document the receipt of patient rights including the complaint process.

During an interview on 1/22/18 at 9:59, Personnel #1 was informed there was no Patient Rights notice for Patient #1. Personnel #1 reviewed the record and confirmed.

Paper discharge records were reviewed on 1/23/18 ending at 4:29 PM and findings confirmed at the exit conference.

The June 2017, last revised "Patient Rights and Responsibilities" policy required, "Upon admission every patient and/or family member will receive a copy..."

Based on record review and interview, the hospital failed to ensure telephone or verbal orders were dated, timed, and authenticated within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent with the written orders for 2 of 2 patients (Patient #1 and #2).

Findings included

Patient #1's record had unsigned telephone orders > 48 hours old.

Patient #2's record had unsigned telephone orders > 48 hours old.

During an interview on 1/23/16 at 2:21 PM, Personnel #2 and #6 were asked to confirm both patients had current unsigned orders >48 hours old although their physician had recently rounded. Personnel #2 and #6 reviewed and confirmed.

The June 2017, last revised "Standards for Completion of Medical Records" required, "timely completion of all medical records...Verbal and telephone orders shall be co-signed, dated and timed by the ordering physician or another member of the medical staff within forty eight (48) hours..."

Based on record review and interview, the hospital failed to ensure completion of medical records within 30 days following the day of discharge for 3 of 4 patients (Patient #4, #5, and #6).

Findings included

Patient #4's, #5's, and #6's record was incomplete > 30 days following their discharge date, missing physician signatures.

During an interview on 1/23/16 at 4:29 PM, Personnel #1 was informed 3 records were incomplete greater than (>) 30 days past the discharge date and physician signatures were missing. Personnel #1 confirmed the finding.

The June 2017, last revised "Standards for Completion of Medical Records" required, "timely completion of all medical records...All medical records shall be complete within thirty (30) days of the discharge date...This shall include all dictated reports, written forms, and required signatures. Physicians will be notified by HIM if there are any physicians related components of the medical record not complete...suspension will occur..."

Based on observation, record review, and interview, the hospital failed to ensure there was a full-time, qualified, Dietary Director responsible for daily management from 12/12/17 through 1/23/18.

Findings included

During a dietary tour and interview on 1/23/18 ending at 12:59 PM with Personnel #1, #2, and #4 (dietary employee), Personnel #4 was asked for menus and substitution process. Personnel #4 provided the menus. Personnel #4 was asked who she talks to about substitutions in the menu. Personnel #4 stated, "I tell the nurse or charge nurse and they say if it is okay." Personnel #4 was asked if she had notified a dietician since returning to her role on 1/09/18. Personnel #4 stated, "No."

The 12/12/17 RIF (Reduction in Force) meeting with staff sign-in sheet was reviewed. Thirty-Five employees were laid off including the dietary department.

The hospital's organizational chart reflected no Director for Food and Dietary Services.

The 1/09/18 "Personnel Action Form" reflected Personnel #4 was rehired after the RIF (Reduction in Force) for the position of "Catering Associate."

The 1/12/18 "Personnel Action Form" reflected Personnel #4 was changed to the position of "Dietary Supervisor."

As of 1/16/18, the "Deleted positions" page included: Director of Food Service. The other deleted employee positions included: Food Handlers.

The 1/22/18 "Personnel Action Form" reflected Personnel #4 was changed to the position of "Dietary Manager."

During an interview on 1/22/18 ending at 10:40 AM, Personnel #1 was asked who the Directors were including Dietary Director. Personnel #1 stated,"We don't not have one. The employees were laid off 12/12/17. I had been told we had a food vendor contract in place and later realized there was not. The employees of the departments which have no director are now reporting to me (CNO). At the time of the RIF, there were no diets needing food preparation, only tube feedings or TPN (total parental nutrition). We had stopped our food vendor contract in August and had hired employees to run the kitchen with food delivery, then had to RIF them. At some point, (12/13/17 to 12/19/17) we needed food for one patient's clear to Full liquid diet. Once aware, we looked in the food supply and only found red jello and did not find broth. I sent someone to the store for pre-packaged jello and broth. We later found broth. The hospital did not have any patients from 12/27/17 until 1/09/18. On 1/09/18, we hired a full time employee (Personnel #4) with food handlers certificate and supervisory experience from our previous food contractor. She worked here before and we brought her back (to prepare food for admitting patients). She covers 7 days right now. Prepares and serves breakfast/lunch and prepares dinner for the nurses to serve."

During an interview on 1/23/18 ending at 9:39 AM, Personnel #1 was asked if Personnel #4 met the requirements of the Director of Dietary.Personnel #1 stated, "She said in her interview that she had supervisor experience." Personnel #1 was asked if she verified the experience. Personnel #1 stated, "I can." We reviewed the resume and it was unclear as to when she would have had "supervisory" experience.

Based on record review and interview, the hospital failed to ensure a (RD/Registered Dietician) dietician evaluated and documented in the record for 2 of 2 current inpatients, in that, Patient #1 and #2 did not have a documented evaluation by a dietician.

Findings included

Patient #1 had a 1/17/18 order for the Registered Dietician Consult and the evaluation was not completed. (Admit 1/17/18, documented BMI 14.56, low intake documented: less than 50%, Sepsis, Diabetes, and 1/18/18 Pre-Albumin 11.48).

Patient #2 had a 1/09/18 order for the Registered Dietician Consult and the evaluation was not completed. (Admit 1/09/18, 1/09/18 RD Consult order, Post operative infections, ESRD/End Stage Renal Disease, Disruption of Surgical wound, Diabetes, MRSA/Methicillin Resistant Staphylococcus Aureus Infection, Renal Dialysis, Pressure ulcer left heel, Stage I, Pressure Ulcer of other side, Stage II, absence of right leg below knee, and 1/15/18 Pre-Albumin 15.08).

During an interview on 1/23/18 ending at 9:39 AM, Personnel #1 was told that both inpatients had orders for a Registered Dietician Consult and neither had been evaluated. Personnel #1 stated, "Yes." Personnel #1 was asked to review the printed patient diet reports to verify poor consumption by both patients during their stay with no dietician intervention. Personnel #1 reviewed and confirmed.

The June 2017, last revised "Initial Nutrition screening, Assessment and Priority Assignment" policy required, "Nutrition Assessment and Intervention...Dietician...Evaluates available information within 48 hours of admission to determine if patient is at nutrition risk...Albumin/Prealbumin...diet orders...TPN/PPN...assess patient identified at potential nutrition risk and documents the initial nutrition assessment in the medical record...criteria and clinical judgement...Nutritional Classification Guide: High Risk (includes) Limited PO (by mouth) intake 0-25%...TPN/PPN...Diagnosis...Sepsis...Pressure Ulcer Stage III-IV...ESRD...Prealbumin < 10...BMI <15 or > 40...Reassessment: Follow up will occur a minimum of 2 times per week...Moderate Risk (includes) Limited PO (by mouth) intake 25-50%...Fluid Restriction...Diagnosis...Pressure Ulcer Stage II...ESRD stable...Prealbumin 10-13...BMI 15 - 16.9 or 35 - 39...Reassessment: Follow up will occur a minimum of 2 times per week...Low Risk...Limited PO intake 50-75%, Amputation...Pressure Ulcer Stage I...Cellulitis...Pre-Albumin 14 - 16...Follow up...1 time per week..."

Based on record review and interview, the hospital failed to ensure that Physical therapy, occupational therapy, or speech therapy was provided by qualified therapist., in that, 3 of 3 therapy employees (Personnel #14, #18, and #26) personnel file did not include current credentials to qualify them for the job.

Findings included

Personnel #14's employee file reflected an expired (exp 12/31/17) state licensure, no signed job description or evaluation since 2015.

Personnel #18's employee file reflected no signed job description or evaluation since 2016.

Personnel #26's employee file reflected an expired CPR (exp 12/31/17, cardiopulmonary resuscitation certificate), no signed job description or evaluation since 2016.

The June 2017, last revised "Job Descriptions" policy required, "reviewed and revised annually...All employees will review, and sign, their job descriptions annually at the time of the performance evaluation and upon any revisions made..."

The current job descriptions for Physical therapy, occupational therapy, and speech therapy required licensure and CPR.

The June 2017, last revised "Orientation Period / Annual Performance Evaluations" policy required, "Evaluations are conducted...annually on or before the employees anniversary date...department specific competencies are completed...the competencies/checklists become a permanent part of the employee's personnel file...employee should sign the evaluation form and a current copy of the job description..."

Based on Record Review and interview, the hospital failed to ensure there was a director of respiratory care services with the knowledge, experience and capabilities to supervise and administer the service properly since 1/09/18.

Findings included

As of 1/16/18, the hospital's "Deleted Positions" included: Directors of Respiratory.

The hospital's organizational chart reflected no Director of Respiratory Services.

During an interview on 1/22/18 ending at 10:40 AM, Personnel #1 was asked if there was a Director of Respiratory. Personnel #1 stated, "No. We had a Pulmonologist until the vent (ventilator) patient discharged in December. We had a vent patient (discharged 12/27/17) but, at no time were we without coverage for respiratory (therapist) support. Once discharge, we didn't have a patient until the 9th. We don't plan on taking vent patients. The employees of the departments which have no director are now reporting to me."

Based on record review and interview, the hospital failed to ensure that Respiratory therapy was provided by a qualified therapist, in that, 1 of 1 therapy employee (Personnel #17) personnel file did not include current credentials to qualify them for the job.

Findings included

Personnel #17's employee file reflected no signed job description or evaluation since 2015.

The June 2017, last revised "Job Descriptions" policy required, "reviewed and revised annually...All employees will review, and sign, their job descriptions annually at the time of the performance evaluation and upon any revisions made..."

The June 2017, last revised "Orientation Period / Annual Performance Evaluations" policy required, "Evaluations are conducted...annually on or before the employees anniversary date...department specific competencies are completed...the competencies/checklists become a permanent part of the employee's personnel file...employee should sign the evaluation form and a current copy of the job description..."