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Based on observation, interview, and document review, it was determined for 5 of 5 (Pt #1, Pt #4, Pt #5, Pt #8, and Pt #9) patients, the Hospital failed to ensure effective, ongoing process for Registered Nurse (RN) supervision and communication of patient nutritional and hydration needs to ensure these needs are met. This has the potential to affect all patients who receive care on the second floor Cardiac, Medical/Surgical (2 CMS) unit, with a current census of 29 patients. Therefore, the Condition of Participation, 42 CFR 482.23, Nursing Services is out of compliance, as evidenced by:

Findings include:

1. The Hospital failed to ensure nursing staff, both nursing and those whom are delegated tasks by nursing, were knowledgeable of patient nutritional care needs. See A-395A.

2. The Hospital failed to ensure the RN supervised and evaluated the delegated nutritional interventions for completion and/or changes. See A-395B.

3. The Hospital failed to ensure the nursing care plan accurately reflected the patient nutritional needs and interventions.
See A-396.

A. Based on observation, interview, and document review, it was determined the Hospital failed to ensure nursing staff and those whom are delegated tasks by nursing, were knowledgeable of patient nutritional care needs. This has the potential to affect all patients who received care on the second floor Cardiac, Medical/Surgical (2 CMS) unit, with a current census of 29 patients.

Findings include:

1. An observational tour, with concurrent interviews, of the 2 CMS unit was conducted on
7/7/2020 between approximately 11:45 AM and 12:15 PM with the Food and Nutrition Manager (E#8). E#8 stated, "Patients should be fed minimally within an hour of receiving their tray. The dining hosts do not know who requires feeding assistance or not. We (dietary staff) don't feed patients."

2. An interview was conducted with the 2 CMS Nurse Manager (E#10) on 7/7/2020 at approximately 12:00 PM. E#10 stated, "The Dietician, Case Manager, Lead nurse, and physician meet (interdisciplinary team meetings) each day, Monday through Friday and discuss each patient on the unit... No, the bedside RN (Registered Nurse) does not participate... Trays (meal trays) are usually passed around 7:00 AM, noon, and 5:00 PM... We have no patients on the unit who are feeds (require feeding assistance at this time)... The CNAs (Certified Nursing Assistants) generally feed (the patients) but RN's will do it if needed..."

3. During the entrance conference on 7/7/2020 at approximately 10:00 AM, a list of patients who required feeding assistance was requested. At approximately 3:00 PM, the Manager of Accreditation (E#1) presented a list with two patients on 2 CMS (Room 240 - Pt #5 and Room 214 - Pt #8) that required feeding assistance. Neither patient had been reported as needing assistance during the tour of the unit.

4. A follow-up observational tour, with concurrent interviews, of the 2 CMS unit was conducted on 7/8/2020 between approximately 8:45 AM and 9:15 AM, with the Nursing Professional Development Specialist (E#4). The following were noted:
a. Room 240 (Pt #5) was observed to not have a tray at the bedside. A nurse at the nurses' station stated, "240 (Pt #5) feeds (himself/herself)." Pt #5 had been reported by E#1 and Hospital documentation on 7/7/2020, as needing feeding assistance.
b. Room 214 (Pt #8) was observed to have a breakfast tray on the bedside table which had not been opened. At approximately 9:00 AM, E#11 (2 CMS Registered Nurse) stated, "I haven't had time yet (to feed Pt #8). I'm heading in there soon." This was approximately 2 hours after the meal tray had been delivered to Pt #8.
c. The CNA Communication Board (a dry erase board with each patient's activity level, diet, precautions, etc.), located at nurses' station #2 was observed to note that "241 (Pt #6) mech (mechanical soft diet) feed 1:1". A nurse at nurses station #2 stated, "241 transferred to ICU (intensive care unit) yesterday sometime." The CNA Communication Board had not been updated to reflect the change.
d. The CNA Communication Board at the nurses station #1 lacked documentation of any patient information, including feeding status for rooms 212, 214, 215, 216, 218, and 219, all of which were occupied with patients.

5. Pt #5 Admission date: 7/6/2020.
Diagnoses: Shortness of breath, elevated potassium, and insulin dependent diabetes. The record was reviewed on 7/8/2020 at approximately 11:00 AM. The record noted Pt #5 had diet orders although lacked documentation as to whether or not feeding assistance was required.

6. Pt #6 Admission date: 7/6/2020.
Diagnoses: Fractures forearm, fractured femur, and severe protein malnutrition. The record was reviewed on 7/8/2020 at approximately 10:30 AM. The record noted Pt #6 required feeding assistance and was transferred to ICU on 7/7/2020 at 4:19 PM. Pt #6 remained on the CNA Communication Board, as of the time of the observational tour on 7/8/2020.

7. Pt #8 Admission date: 6/23/2020.
Diagnosis: Cerebrovascular accident. The record was reviewed on 7/7/2020 at approximately 2:00 PM. The record noted Pt #8 required feeding assistance. (See 4 a, above).

8. The observational tour and interviews during the tour on 7/8/2020 at approximately 8:45 AM through 9:15 AM were conducted with E#4. E#4 verbally agreed there were two patients (Pt 6 and Pt #8) that required feeding assistance; Pt #5 did not require feeding assistance; the CNA Communication Boards were not updated and lacked patient information for nutritional care needs; patients that require feeding assistance should be fed minimally within an hour of receiving their meal tray; and Pt #8 did require feeding assistance and had not been fed in a timely manner, as of the observational tour time.

9. During an interview on 7/8/2020 at approximately 9:30 AM, E#1 verbally agreed the Nurse Manager should have known which patients required feeding assistance and stated, "That (patients that required feeding assistance) should be discussed in the IDT (interdisciplinary team) meetings."

B. Based on document review and interview, it was determined for 5 of 5 (Pt #1, Pt #4, Pt #5, Pt #8, and Pt #9) patients, the Hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the delegated nutritional interventions for completion and/or changes. The has the potential to affect all patients who receive care on the second floor Cardiac, Medical/Surgical Unit (2 CMS), with a current census of 29 patients.

Findings include:

1. Pt #1 Admission date: 6/3/2020.
Diagnoses: Weakness and falls. The record was reviewed 7/7 through 7/8/2020. On 6/4/2020, the Nutritional Assessment, conducted by the Registered Dietician (E#5), indicated a dietary goal of consuming at least 50% of meals/oral nutritional supplements on average; an Ensure Enlive supplement with dinner and a Magic Cup supplement with lunch; to monitor meal/oral supplement intakes; and a fluid need of approximately 1335 (milliliters per day).

-Nutritional documents for Pt #1 dated 6/3/2020 and 6/19/2020 were reviewed - food consumption %:
a. 15 out 42 meals lacked any documentation of the % of food consumed.
b. 9 out of the 27 documented intakes were 0%.
c. 3 out of the 27 documented intakes were 5%.
d. 6 out of the 27 documented intakes were 20 to 27%.
e. The record lacked documentation of nursing oversight of the amount of meals/supplements consumed to assure Pt #1's nutritional needs were being met.

-The hydration documents for Pt #1 dated 6/3/2020 and 6/19/2020 were reviewed- oral fluid intake:
a. Pt #1 had an intravenous infusion from 6/16 at approximately 4:30 PM to 6/17/2020 at approximately 10:08 AM.
b. The oral intake range per day was 0 to 850 milliliters (ml), with the exception of 6/11/2020, oral intake was 1170.
c. The record lacked documentation of nursing oversight of the amount of fluid intake to assure Pt #1's fluid intake needs were met.

2. Pt #4 Admission date: 6/8/2020.
Diagnoses: Paroxysmal atrial fibrillation and acute cerebrovascular accident. The record was reviewed on 7/7 through 7/8/2020. On 6/9/2020, the Nutritional Assessment, conducted by the Registered Dietician (E#5), indicated a dietary goal of consuming at least 50% of meals/oral nutritional supplements on average; to send vanilla Magic Cup at dinner and a Mighty shake three times a day; and a fluid need of approximately 1 milliliter per kcal. Pt #4's kcal were 2057 to 2228 per day, which would also be the amount of fluid intake needed.

-The Nutritional documents for Pt #4 dated 6/8/2020 and 6/17/2020 were reviewed - food consumption %:
a. 12 out of 24 meals lacked documentation of the % of food consumed.
b. 3 out of the 12 documented meal intakes were less than 50%.
c. The record lacked documentation of nursing oversight of the amount of meals/supplements consumed to assure Pt #4's nutritional needs were being met.

-The hydration documents dated 6/8/2020 and 6/17/2020 were reviewed - oral fluid intake:
a. Pt #4 was nothing by mouth on 6/8/2020.
b. 3 out of 9 days, the record lacked documentation of oral intake amounts.
c. The oral intake range, per day, was 200 to 840 milliliters per day.
d. The record lacked documentation of nursing oversight of the amount of fluid intake to assure Pt #4's fluid intake needs were met.

3. Pt #5 Admission date: 7/6/2020.
Diagnoses: Shortness of breath, elevated potassium, and insulin dependent diabetes. The record was reviewed on 7/8/2020 at approximately 11:00 AM. As of 7/8/2020, the record lacked documentation of the % food consumed for 6 out of 6 meals.

4. Pt #8 Admission date: 6/23/2020.
Diagnosis: Cerebrovascular accident. The record was reviewed on 7/7/2020 at approximately 2:00 PM. On 7/3/2020, there was a physician order for a pureed, low carbohydrate, nectar thick liquid diet. As of 7/7/2020, the record lacked documentation of the % food consumed for 11 out of 15 meals.

5. Pt #9 Admission date: 6/24/2020.
Diagnoses: Hip fracture and dysphagia. The record was reviewed on 7/7/2020 at approximately 1:00 PM. On 6/26/2020, there was a physician's order for nectar thick liquids and a Nutrition Assessment note for Ensure three times a day. As of 7/7/2020, the record lacked documentation of the % food consumed for 12 out of 30 meals and no documentation of the amount of Ensure consumed.

6. During an interview on 7/8/2020 at approximately 9:00 AM, a Registered Nurse (E#11) stated, "If a patient refuses a meal, we (nurses) document refused or 0%... it (% of meal consumed) gets documented on the white board in the room, if we don't get it into the computer right away. Sometimes, if the dining hosts picks up a tray, they will circle what was eaten on the meal ticket and leave it for us (nurses) to document a %."

7. During an interview on 7/8/2020 at approximately 2:00 PM, E#4 reviewed the records of Pt #1, Pt #4, Pt #5, Pt #6, and Pt #9. E#4 verbally agreed the % of meals consumed and the % supplements consumed were not documented and should have been for all 5 patients. E#4 verbally agreed the oral fluid intake was not met and/or followed up on for Pt #1 and Pt #4 and they should have been.

C. Based on document review and interview, it was determined for 3 of 6 (Pt #5, Pt #6, and Pt #9) patients, the Hospital failed to ensure the nursing dysphagia screening was conducted, as triggered by the admission assessment. This has the potential to affect all patients who receive care on the second floor Cardiac, Medical/Surgical Unit (2 CMS), with a current census of 29 patients.

Findings include:

1. The policy titled,"Assessment and Reassessment of Patients" (dated 10/10/19) was reviewed on 7/7/2020. The policy noted, "The RN (Registered Nurse) workflow Admission documentation... includes questions... will trigger a more in-depth, thorough assessment by the interdisciplinary team member... 2. Dysphagia Screen..."

2. Pt #5 Admission date: 7/6/2020.
Diagnoses: Shortness of breath, elevated potassium, and insulin dependent diabetes. The record was reviewed on 7/8/2020 at approximately 11:00 AM. The record lacked documentation of a completed nursing dysphagia screen.

3. Pt #6 Admission date: 7/6/2020.
Diagnoses: Fractured forearm, fractured femur, and severe protein malnutrition. The record was reviewed on 7/8/2020 at approximately 10:30 AM. The record lacked documentation of a completed nursing dysphagia screen.

4. Pt #9 Admission date: 6/24/2020.
Diagnoses: Hip fracture and dysphagia. The record was reviewed on 7/7/2020 at approximately 1:00 PM. The record lacked documentation of a completed nursing dysphagia screen.

5. During an interview on 7/8/2020 at approximately 2:00 PM, the Nursing Professional Development Specialist (E#4) reviewed Pt #5, Pt #6, and Pt #9's records and verbally agreed the nursing dysphagia screens were not conducted by the RN and should have been.

Based on document review and interview, it was determined for 5 of 5 (Pt #1, Pt #4, #5, Pt #8, Pt #9) patients, the Hospital failed to ensure the nursing care plan accurately reflected the patient nutritional needs and interventions. This has the potential to affect all patients who receive care on the second floor Cardiac Medical Surgical (2 CMS) unit, with a current census of 29 patients.

Findings include:

1. Pt #1 Admission date: 6/3/2020.
Diagnoses: Weakness and falls. The record was reviewed on 7/7 to 7/8/2020. The nursing Plan of Care noted patient problems "inadequate oral intake" and "hydration". 38 out of 42 meals lacked documentation as to whether or not Pt #1 was fed. The other 4 meals meals noted "total assist". See A-395 B. The care plan lacked nursing interventions to assist Pt #1 with feeding to meet Pt #1's nutritional and hydration needs.

2. Pt #4 Admission date: 6/8/2020.
Diagnoses: Paroxysmal atrial fibrillation and acute cerebrovascular accident. The record was reviewed 7/7 to 7/8 2020. See A-395 B. The nursing Plan of Care lacked documentation of any nutritional or hydration nursing interventions to meet Pt #4's needs.

3. Pt #5 Admission Date: 7/6/2020
Diagnoses: Shortness of breath, elevated potassium and insulin dependent diabetes. The record was reviewed on 7/8/2020 at approximately 11:00 AM. A Physician's order dated 7/6/2020 noted Pt #5 to have a mechanical soft, low carbohydrate, potassium restricted diet due to difficulty chewing, diabetes management and elevated potassium. A Nutrition Assessment conducted by E#5 (Registered Dietician) noted "Patient identified at (as) potential nutritional risk from nursing admission nutritional screening due to possible unintended weight loss... weight fluctuation likely fluid related... Patient has upper/lower dentures..." The nursing Plan of Care lacked documentation of any nutritional or hydration nursing interventions.

4. Pt #8 Admission Date: 6/23/2020
Diagnosis: Cerebrovascular accident. The record was reviewed on 7/8/2020 at approximately 1:00 PM. The record noted Pt #8 had a pureed, low carbohydrate, nectar thick liquid diet due to difficulty swallowing and diabetes management and required feeding assistance on 7/3/2020. A Nutrition Note dated 7/6/2020 noted "Patient no longer on NG (Nasogastric) tube feeding... high risk for aspiration." The nursing Plan of Care noted "Nutrition Deficit... Interventions... Enteral (NG tube feeding) tube feeding management... Nutrition Therapy... Tolerance of enteral feeding... Intervention... Enteral nutrition administration..." The nursing Plan of Care had not been updated to reflect the discontinuation of the feeding tube, interventions to prevent aspiration, and the feeding assistance requirement.

5. Pt #9 Admission Date: 6/24/2020
Diagnoses: Hip fracture and dysphagia. The record was reviewed on 7/7/2020 at approximately 1:00 PM. A Case Management Continued Stay Review note, dated 6/26/2020, noted "...son... states that patient has a high risk for aspiration. He/She states the patient needs to sit straight up when eating. He/she states Pt #9 often swallows 3-4 times to get one bite down..." The nursing Plan of Care noted Pt #9 had swallowing difficulty and interventions included "Meals and snacks... Medical food supplement". The Plan of Care lacked documentation that Pt #9 required thickened liquids to prevent aspiration due to the swallowing difficulty. The daily nursing Plan of Care progress toward goals and outcomes for each identified problem, lacked documentation of Pt #9's Nutritional deficit, goals and progress toward outcomes 13 of 13 days.

6. During an interview on 7/8/2020 at approximately 1:15 PM, E#4 (Nursing Professional Development Specialist) reviewed Pt #1, Pt #4, Pt #5, Pt #8 and Pt #9's records and verbally agreed the nursing Plans of Care did not accurately reflect the patients nutritional needs and interventions to meet those needs and should have.

Based on document review and interview, it was determined for 5 of 5 (Pt #1, Pt #4, Pt #5, Pt #8, Pt #9) patients, the Hospital failed to establish, implement, and maintain an effective, ongoing, collaborative process for the evaluation/re-evaluation, communication,and documentation of specialized patient nutritional needs, to assure these nutritional needs are being met. This has the potential to affect all patients who receive care on the second floor Cardiac, Medical/Surgical unit (2 CMS), with a current census of 29 patients. Therefore, the Condition of Participation, 42 CFR 482.28, Food and Dietary Services is out of compliance, as evidenced by:

Findings include:

1. See A-395 B.

2. The Hospital failed to establish, implement, and maintain an effective, ongoing, collaborative process for the evaluation/re-evaluation, communication, and documentation of specialized patient nutritional needs to ensure nutritional needs are met. See A-629.

Based on document review and interview, it was determined for 5 of 5 (Pt #1, Pt #4, Pt #5, Pt #8, Pt #9) patients, the Hospital failed to establish, implement, and maintain an effective, ongoing, collaborative process for the evaluation/re-evaluation, communication, and documentation of specialized patient nutritional needs to ensure nutritional needs are met. This has the potential to affect all patients who receive care on the second floor Cardiac Medical Surgical (2 CMS) unit, with a current census of 29 patients.

Findings include:

1. Pt #1 Admission date: 6/3/2020.
Diagnoses: Weakness and falls. The record was reviewed 7/7 to 7/8/2020. On 6/4/2020, a Nutritional Assessment, conducted by the Registered Dietician (E#5), indicated, "Patient identified at potential nutritional risk from nursing admission nutritional screening due to possible unintended weight loss and poor intake... Patient may benefit from oral nutritional supplements to ensure adequate calorie/protein intake..." The Assessment further indicated nutritional supplement and fluid needs. (See A-395B).
a. On 6/8/2020, a Follow-up Nutrition Note indicated, "Evaluation: Per record, patient consumed 90% breakfast & (and) 60 % lunch today." and that Pt #1 likes the Magic Cup and Ensure.
(1) Between 6/4/2020, the record lacked the % nutritional intake for 6 out of 9 meals.
(2) The daily oral fluid intake indicated 200 milliliters (mls), 0 ml, 240 ml, 850 ml, and 450 ml, respectively since the last nutritional assessment.
(3) The records lacked documentation as to the amount of nutritional supplements consumed.
(4) The record lacked documentation of follow-up or collaboration by dietary with nursing related to the lack of documentation of meal and/or fluid intake to assure Pt #1's nutritional needs were met.

b. On 6/12/2020, a Follow-up Nutrition Note indicated, "Evaluation: Note meal intakes variable, ranging 0 - 90%. Patient may benefit from smaller size nutritional supplement."
(1) Between 6/8/2020 and 6/12/2020, 2 out of 12 meals lacked the % consumed.
(2) 3 out of the 10 documented meals indicated 0% consumed.
(3) 3 out of the 10 documented meals indicated 5% consumed.
(4) The daily oral fluid intake indicated 560 ml, 90 ml, 1170 ml, and 180 ml respectively.
(5) The record lacked documentation as to the amount of nutritional supplement consumed, the amount of meals consumed, and the amount of fluid intake to assure Pt #1's nutritional needs were met.
(6) The record lacked documentation of follow-up or collaboration by dietary with nursing to assure Pt #1's nutritional needs were met.


c. On 6/15/2020, a Nutrition Consult/Assessment Note indicated a nutritional consult had been ordered by the physician. The Note indicated, "Limited meal intake record to evaluate...Nursing communication (an order) to assist patient with meals, record meal/supplement intake..."
(1) The daily oral fluid intake indicated no oral intake, 33 ml, 100 ml, and 0 ml, respectively.
(2) The record lacked documentation related to the lack of oral fluid intake.
(3) The record lacked documentation of follow-up or collaboration by dietary with nursing to assure Pt #1's hydration needs were met.

d. On 6/18/2020, a Follow-up Nutrition Note indicated, "Note palliative care consult; order for comfort care. Per family, pt unable to eat/drink."

2. Pt #4 Admission date:6/8/2020.
Diagnoses: Paroxysmal atrial fibrillation and acute cerebrovascular accident. The record was reviewed 7/7 to 7/8/2020.
a. On 6/9/2020, the Nutritional Assessment, conducted by E#5, indicated, "Patient identified at potential nutritional risk from nursing admission nutritional screening due to unintended weight loss of > (greater than) 33 lb. (pounds) and poor intake & (and) stroke consult." The consult further indicated the nutritional supplements and daily fluid needs for Pt #4 (See A-395B).

b. On 6/10/2020, a Follow-up Nutrition Note indicated, "Evaluation: Per (name of RN) pt consumed 50% breakfast & 40% lunch today..." Fluid intake was not addressed. The record lacked documentation of meal consumption and fluid intake for 6/9/2020.

c. Between 6/12/2020 to 6/17/2020, 11 out of 16 meals lacked the % consumed. There was no documentation of supplement intake and the daily oral fluid range was 0 ml to 750 ml. The record lacked documentation of follow-up or collaboration between dietary and nursing of these interventions to assure Pt #4's nutritional and hydration needs were met.

3. During an interview with E#4 on 7/8/2020 at approximately 1:00 PM, E#4 reviewed the records of Pt #1 and Pt #4 and verbally agreed there did not appear to be a consistent process in place between nursing and dietary to ensure a coordinated, effective process to ensure patient nutritional and hydration needs are met. "We have some definite opportunities for improvement here."

4. Pt #5 Admission Date: 7/6/2020
Diagnoses: Shortness of breath, elevated potassium and insulin dependent diabetes. The record was reviewed on 7/8/2020 at approximately 11:00 AM. The record noted Pt #5 was ordered a mechanical soft, low carbohydrate and potassium restricted diet. A Nutrition Note dated 7/7/2020 authored by E#5 (Registered Dietician) noted Pt #5 had weight fluctuations likely fluid related and lower extremity edema although lacked a goal or intervention related to the fluid retention; note lacked documentation as to why Pt #5 was on a mechanical soft, low carbohydrate, potassium restricted diet; noted "Per available meal intake records, patient has been consuming 75-100% of meals" although the record lacked documentation of the percentage of meals eaten (see A- 0395); the note lacked documentation the dyphagia screen was assessed (see A-0395); noted the nutrition goal as to consume 50% of meals and intervention was to continue the current diet although lacked patient specific nutritional goals and interventions. The Plan of Care lacked documentation of any nutritional or hydration interventions (see A-0396). The record lacked documentation of follow-up or collaboration between dietary and nursing of these interventions to assure Pt #5's nutritional and hydration needs were met.

5. Pt #8 Admission Date: 6/23/2020
Diagnosis: Cerebrovascular accident. The record was reviewed on 7/7/2020 at approximately 2:00 PM. The record noted Pt #8 required feeding assistance. The Nutrition Note dated 7/6/2020 lacked documentation Pt #8 required feeding assistance and the percentages of meals eaten were accurately documented for each meal (A- 0395).

6. Pt #9 Admission Date: 6/24/2020
Diagnoses: Hip fracture and dysphagia. The record was reviewed on 7/7/2020 at approximately 1:00 PM. A Case Management Continued Stay Review note, dated 6/26/2020, noted "...son... states that patient has a high risk for aspiration. He/She states the patient needs to sit straight up when eating. He/she states Pt #9 often swallows 3-4 times to get one bite down..." The Nutrition Note dated 6/26/2020 authored by E#5 noted "Regular diet with nectar-thick liquids had been recommended during previous hospitalization... Patient appears to have mild to moderate skeletal muscle depletion... moderate to severe subcutaneous fat depletion..." and recommended ensure (nutritional supplement) three times daily, thickened milk and thickened ice cream twice daily. The note lacked documentation of an assessment related to the difficulty swallowing; lacked a referral to a speech and language pathologist; lacked interventions to prevent choking; lacked documentation the dysphagia screen was assessed (A- 0395); lacked documentation the percentages of meals were accurately documented for each meal (A-0395) lacked documentation of nutritional goals, and lacked documentation of follow-up or collaboration between dietary and nursing of these interventions to assure Pt #9's nutritional and hydration needs were met. .

7. During an interview on 7/8/2020 at approximately 1:00 PM, E#4 (Nursing Professional Development Specialist) reviewed Pt #5, Pt #8 and Pt #9's records and verbally agreed the nutritional screens were not complete and not accurate and the findings were communicated with the interdisciplinary team members and should have been.