HospitalInspections.org

Based on interviews and record review, the hospital failed to ensure that the medical staff enforced the Medical Staff Rules and Regulations as approved by the Governing Body, as evidenced by physician's being allowed to give verbal/electronic orders for patient care to non licensed clinical staff of the hospital. The hospital had a total census of 23 patients.

Findings:
Review of the Medical Staff Rules and Regulations revealed in part: verbal/electronic orders may be accepted by the following licensed clinical staff within the scope of their licensure: Registered Nurse, Licensed Practical Nurse, Registered Respiratory Technician, Certified Respiratory Therapy Technician, Physical Therapist, Speech Therapist, Occupational Therapist, Registered Dietician, Advanced Practice Registered Nurse, Registered Radiology Technician, Physician Assistant, and Pharmacist.

In an interview on 11/19/13 at 11:30 a.m. with S6 Food Service Coordinator she indicated that she was responsible for the management of the hospital's kitchen and the kitchen staff to include in part: planning and coordinating all kitchen activities to ensure patient meals were prepared appropriately and supervised and coordinated all kitchen functions and activities. S6 Food Service Coordinator further indicated that she also accepted verbal/electronic physician orders for patient's nutritional supplements.

Review of S6 Food Service Coordinator's employee file revealed she was hired as the Food Service Coordinator. A further review of S6 Food Service Coordinator's employee file revealed she was a Dietetic Technician, had an Associate Degree from a Community College and was a Dietetic Technician, registered in good standing with the Commission on Dietetic Registration. A review of S6 Food Service Coordinator's employee file revealed no evidence of any specialized clinical dietary training or any licenses or certifications designating that she had any specialized clinical dietary training.

In an interview on 11/19/13 at 3:00 p.m. with S1Vice President she indicated that she was not aware that S6 Food Service Coordinator was accepting physician orders. S1 Vice President further indicated that this practice did not adhere to the Medical Staff Rules and Regulations and that S6 Food Service Coordinator had no specialized clinical dietary training and should not be accepting verbal / electronic physician dietary orders.

In an interview on 11/19/13 at 3:30 p.m. with S4MD, Medical Director she indicated that she often gave verbal orders to S6 Food Service Coordinator. S4MD further indicated she was not aware she could not give verbal orders to the Dietetic Technician.

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient by failing to ensure a psychiatry consult was conducted as ordered by the physician for 1 (Patient #3) out of 7 (Patient #1-#7)sampled patients.
Findings:

Review of the hospital's policy on Consultations revealed in part, "...Consulted practitioners shall respond to consultation requests within 24 hours of request unless otherwise indicated by the attending physician, not to exceed 72 hours..."

Review of the medical record for Patient #3 revealed she was a 80 year old female with the history of having a hemilaminectomy performed on 10/14/13 at Hospital A. She was admitted to Hospital B on 10/24/13 for rehabilitation services. She had a history of poor appetite, flat affect, and noncompliance with physical, occupational, and speech therapy during her hospitalization.

Review of her medical record revealed S15MD ordered a psychiatry consult on 10/28/13 for Patient #3 due to her depression and confusion.

An interview was conducted with S3DON on 11/20/13 at 11 a.m. She reported with review of the medical record the psychiatrist office was notified of the consult, but the consult was not performed by S12 NP(Nurse Practitioner) as ordered. S3DON went on to report the nurses should had continued to make sure the consult was conducted after notifying the psychiatrist's office.

Based on interview and record review the hospital failed to ensure that a patient's nursing care plan was based on assessing all the patient's nursing care needs and not solely on those needs related to the admitting diagnosis. This failed practiced was evidenced by the nursing care plan not kept current by an ongoing assessment for 1 patient (#1) out of 7 patients (#1-#7) sampled out of a total patient census of 23, for failing to care plan the patient for a cardiac problem on a patient admitted as a post surgical laminectomy.

Findings:
Patient #1 was admitted to the hospital on 10/30/13 for rehabilitation following a surgical laminectomy on 10/15/13 at another hospital. Patient #1's diagnoses included in part: hypertension, chronic kidney disease, diabetes, hyperlipidemia, shortness of breath, neuropathy, coronary artery disease, and history of chest pain. A review of Patient #1's medical record revealed the patient had experienced chest pains post operatively on 10/15/13 and had an angioplasty with a cardiac stent on 10/17/13 and also had a cardioversion for atrial fibrillation on 10/18/13 and 10/20/13, all prior to his admit to the rehabilitation hospital on 10/30/13. A further review of Patient #1's medical record revealed the patient was admitted to another hospital's emergency room on 11/01/13 for evaluation of chest pains and returned to the rehabilitation hospital on 11/02/13. Patient #1 was again sent to another hospital's emergency room on 11/03/13 for hypotension and dizziness and returned to the rehabilitation hospital again on 11/07/13.

Review of Patient #1's medical record and nursing care plan on 11/18/13 with S3RN, Director of Nursing revealed no evidence of any plans of care or educational teachings on Patient #1's cardiac problems when he was admitted on 10/30/13, his re-admit on 11/02/13, or his next re-admit on 11/07/13.

In an interview on 11/18/13 at 3:00 p.m. with S3RN she indicated that there should have been a care plan initiated for Patient #1's cardiac problems.

Based on interviews and record review the hospital failed to ensure that technical personnel were competent in their duties. This failed practice was evidenced by the Dietetic Technician performing patient's nutritional assessments and consults and having no documented evidence of any credentials, education, or specialized training or any demonstrated competency in the clinical nutritional assessments of patients. The hospital had a total census of 23 patients.

Findings:
In an interview on 11/19/13 at 11:30 a.m. with S6 Food Service Coordinator she indicated that she was responsible for the management of the hospital's kitchen and the kitchen staff to include in part: planning and coordinating all kitchen activities to ensure patient meals were prepared appropriately and supervised and coordinated all kitchen functions and activities. S6 Food Service Coordinator further indicated that she performed the nutritional assessments on all patients admitted to the hospital. S6 Food Service Coordinator indicated that she also did nutritional consults on patients who triggered during the nurse's admission assessments when the patient required a further nutritional needs assessment.

In an interview on 11/19/13 at 11:45 a.m. with S10RD, Registered Dietician she indicated that S6 Food Service Coordinator did most of the patient nutritional assessments and consults. S10RD indicated she assisted with the assessments and consults when S6 Food Service Coordinator was not available. S10RD further indicated that she would co-sign S6 Food Service Coordinator's assessments and consults by means of the hospital's electronic patient medical record system and would not physically assess the patient herself. S10RD indicated that a Registered Dietician was on site at the rehabilitation hospital only about twice a month. S10RD further indicated that she acted more in the capacity of a support system for the dietary department for the hospital's system (which included the main hospital, the rehabilitation hospital and the clinic) and that this was the practice throughout the hospital's system.

Review of S6 Food Service Coordinator's employee file revealed she was hired as the Food Service Coordinator. A further review of S6 Food Service Coordinator's employee file revealed she was a Dietetic Technician, had an Associate Degree from a Community College and was a Dietetic Technician, registered in good standing with the Commission on Dietetic Registration. A review of S6 Food Service Coordinator's employee file revealed no evidence of any specialized clinical dietary training or any licenses or certifications designating that she had any specialized clinical dietary training.

In a review of S6 Food Service Coordinator's employee file on 11/20/13 in the presence of S1 Vice President she was made aware that S6 Food Service Coordinator had no documented evidence of any credentials, education, or specialized training or any demonstrated competency in the clinical nutritional assessments of patients.

In an interview on 11/20/13 at 10:00 a.m. with S1Vice President she indicated that she was not aware that S6 Food Service Coordinator was performing nutritional assessments and nutritional consults without appropriate overseeing by the Registered Dietician and without documented evidence of competency in patient nutritional assessments. In the interview, S1 Vice President was made aware that this dietary department's practice involved the entire hospital's system (which included the main hospital, the rehabilitation hospital and the clinic) and that this was the practice throughout the hospital's system.

Based on interviews and record reviews the hospital failed to ensure that the nutritional needs of the patients were met in accordance with orders of the practitioner responsible for the care of the patient. This failed practice was evidenced by nutritional supplements being ordered by the Dietetic Technician. The hospital had a total census of 23 patients.

Findings:
In an interview on 11/19/13 at 11:30 a.m. with S6 Food Service Coordinator she indicated that she was responsible for the management of the hospital's kitchen and the kitchen staff to include in part: planning and coordinating all kitchen activities to ensure patient meals were prepared appropriately and supervised and coordinated all kitchen functions and activities. S6 Food Service Coordinator further indicated that she also ordered the patient's nutritional supplements. S6 Food Service Coordinator indicated that after her nutritional assessment of the patient upon admit, she would order any needed nutritional supplements for the patient. S6 Food Service Coordinator indicated the nutritional supplements ordered included in part: Protinex, Glucerna, and Ensure. S6 Food Service Coordinator further indicated that she could order nutritional supplements for patients without a physician order.

In an interview on 11/19/13 at 3:30 p.m. with S4MD, Medical Director she indicated that she did not always order all the nutritional supplements for her patients. S4MD indicated that if a patient was on a particular nutritional supplement upon admit, then she would order the nutritional supplement for the patient on the patient's admit order sheet. S4MD indicated that she was able to view all patient orders on her patient summary screen and would notice that patients were also on nutritional supplements ordered by dietary. S4MD further indicated that she was not aware that she had to authorize all nutritional supplement orders or that all patient nutritional supplement orders had to be ordered by the patient's physician.

In an interview on 11/19/13 at 3:00 p.m. with S1Vice President she indicated that she was not aware that S6 Food Service Coordinator was ordering patient nutritional supplements without a physician order.