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Based on interviews and document review, the facility failed to ensure nursing staff monitored patient hydration and intake according to physician orders and facility policy in one of two patient medical records reviewed (Patient #1).

Findings include:

Facility policies:

The Physician Orders policy read, an order of a physician for patient care which is conveyed by someone other than a licensed physician may be accepted by nurses providing the individual conveying the order is acting as a direct intermediary of the physician. The duly authorized persons includes registered dietitians for diet orders.

The Patient Assessment and Reassessment policy read, the needs of each patient are assessed and reassessed by the appropriate discipline. The information generated through the analysis of patient specific data is integrated to identify, modify and prioritize the patient's needs for care. Patients received care based on documented assessment of the patient care needs and problem identification. A patient's need for care is assessed by a registered nurse. Patient needs, response to treatments and interventions, and change in condition are reassessed as necessary and at minimum of every shift. Physician orders and consults serve as a mechanism for the medical staff to communicate the patient's care, treatment needs, response to treatment and continued care requirements.

The Intake and Output policy read, intake is the amount of liquid a person takes in by mouth or by IV fluid. This also includes fluids that are put into a patient through the use of a feeding tube. All liquid intake and output is to be measured in milliliters. I and O's (intake and output) are totaled at the end of 12 hours, 6 a.m. and 6 p.m., and documented in the EMR (Electronic Medical Record). Patients and families should be instructed to report any intake or output that is not observed by caregiver staff.

1. The facility failed to ensure nursing staff monitored and accurately documented patient fluid intake according to physician orders and facility policy.

a. On 3/3/22 at 10:30 a.m., Patient #1 was interviewed. Patient #1 stated he had been at the facility for several months. He stated he drank water throughout the day and staff consistently refilled his water. He stated he did not remember any days that he did not drink water or that staff did not provide him with water, and he stated to his knowledge he had no issues with dehydration or poor fluid intake.

b. Patient #1's medical record was reviewed for an admission beginning on 10/23/21 and ending on 1/17/22.

i. On 10/23/21 a physician order was entered which read, Intake/Output to be performed every shift.

ii. On 10/26/21 at 3:44 p.m., the Clinical Dietitian (Dietitian) #1 entered a Nutrition Assessment. Dietitian #1 documented Patient #1 was receiving enteral nutrition (nutrition provided via a feeding tube) and was allowed to have PO (per orem; oral) fluid intake of thin liquids via straw.

iii. According to subsequent Nutrition Notes entered by Dietitian #1, Patient #1 had consistent oral fluid intake. For example, on 11/22/21 Dietitian #1 entered a Nutrition Note which read, Patient #1 was taking one to three liters of PO water per day and had three to eight liters of urine output documented each day. On 11/29/21 Dietitian #1 documented Patient #1 took PO sips of water and the free water flushes (fluid provided to a patient via a feeding tube) were decreased by the physician to account for Patient #1's PO fluid intake.

iii. The Intake/Output flowsheets were reviewed. Between 10/23/21 and 12/23/21 there were 18 days in which no oral fluid intake was recorded. Examples included:

On 10/29/21 and 10/30/21 no oral fluid intake was documented.

On 11/15/21, 11/16/21, 11/17/21 and 11/18/21 no oral fluid intake was documented.

On 12/20/21 and 12/21/21 no oral fluid intake was documented.

iv. On 12/23/21 an order was entered by Dietitian #1 and was authorized by Provider #1. The order read, please chart all PO intakes of water/ ice to ensure hydration needs are being met.

iv. Review of the Intake/Output flowsheets between 12/23/21 when the order was placed and 1/17/21 when Patient #1 discharged revealed additional dates in which no oral fluid intake was recorded. Examples included:

On 12/28/21 no oral fluid intake was documented.

On 1/1/22 no oral fluid intake was documented.

On 1/3/22 no oral fluid intake was documented.

There was no evidence of oral fluid intake for a total of 17 dates during Patient #1's admission. This was in contrast to the nutrition notes which documented Patient #1 had consistent oral intake of water and ice accounting for up to three liters of daily oral fluid intake.

c. Patient #1's current medical record beginning on date of admission 1/31/22 was reviewed. The medical record revealed multiple additional dates for which there was no documented oral fluid intake for Patient #1. Examples included:

On 2/19/22 and 2/20/22 no oral fluid intake was documented.

On 2/25/22 and 2/26/22 no oral fluid intake was documented.

On 3/1/22, two days prior to the interview with Patient #1, no oral fluid intake was documented.

Review of Patient #1's medical record was in contrast to interview with Patient #1, as Patient #1 stated he drank water throughout the day and he did not remember any days in which he did not drink water or the staff did not provide water to him.

d. On 3/3/22 at 8:01 a.m., Dietitian #1 was interviewed. Dietitian #1 stated her role was to assess patients and develop the treatment plan for the patient's nutrition needs. She stated when a patient received enteral nutrition the patient's hydration needs were met through free water flushes through the feeding tube and oral fluid intake if the patient was allowed to drink fluids. Dietitian #1 stated if a patient received a lot of fluid via oral intake, she would adjust the free water flushes to ensure the patient did not take in too much fluid; similarly if the patient was unable to take PO fluids she would need to adjust the free water flushes to ensure the patient met their hydration needs.

Dietitian #1 reviewed Patient #1's medical record. She stated Patient #1 was allowed to drink water and consistently took one to two liters of water orally each day. She stated because he was drinking so much she had to decrease the amount of free water flushes he received to ensure his sodium levels did not become low.

Dietitian #1 reviewed the intake and output flowsheet for Patient #1 for 11/19/21. She stated there was no oral fluid intake documented for that day. She stated based on what she knew of Patient #1 she did not believe the documented intake and output for that day was correct as she had observed the patient had consistent oral fluid intake.

Dietitian #1 reviewed the intake and output flowsheets for 12/20/21 and 12/21/21. She stated again the staff did not document any oral fluid intake for Patient #1 on these days. She stated from what she knew of the patient he was still consistently drinking water during this time, and it was unfortunate the oral fluid intake was not documented. Dietitian #1 stated it was important for nursing staff to accurately document patient intake to ensure patients' hydration needs were met and because other members of the care team needed to review patients' intake and output to accurately monitor their progress.

Dietitian #1 stated staff did not always accurately document patients' oral fluid intake. She stated when fluid intake was not accurately documented it was challenging for her to plan the patient's care. Dietitian #1 stated she had approached the facility's nursing leadership in the past to request staff be reminded to document intake and output.

e. On 3/3/22 at 9:37 a.m., RN #3 was interviewed. RN #3 stated nursing staff were to document a patient's oral fluid intake any time staff gave water or ice to a patient. She stated it was important to monitor exactly how much fluid a patient consumed to ensure the patient was adequately hydrated and because fluid intake could affect the patient's sodium levels.

RN #3 stated Patient #1 consistently drank water and because he often asked for water she ensured there was always water available to him.

RN #3 stated all staff, including nurses and Certified Nursing Assistants (CNA) were to monitor and document the amount of fluids patients drank. She stated if a CNA provided water to a patient or saw the patient drink fluids, the CNA should either document the amount or tell the nurse how much the patient consumed. RN #3 stated this was important so the dietitian and other staff knew if a patient was receiving adequate hydration and nutrition.

RN #3 stated staff often did not report patients' oral intake accurately. She stated staff sometimes forgot to alert the nurse when a patient drank fluids. RN #3 stated the nurse had the ultimate responsibility to ensure patients' fluid intake was monitored. She stated the topic had been recently discussed in staff huddles however she had not observed improvement in accurate documentation for patients' oral fluid intake.

f. On 3/3/22 at 11:12 a.m., Provider #2 was interviewed. Provider #2 stated fluid intake was important because all patients needed to stay hydrated. He stated if a patient was not adequately hydrated their sodium levels could become elevated or their kidney function could become impaired.

Provider #2 stated he always reviewed a patient's intake and output to ensure the patient received adequate hydration. Provider #2 stated nursing staff did not always accurately document patients' fluid intake, and he stated the intake he saw in the patient's medical record was often not reliable.

g. On 3/3/22 at 1:22 p.m., the Director of Nursing (DON) #4 was interviewed. DON #4 stated nurses and CNAs were both responsible to ensure patient intake was monitored and accurately recorded. She stated staff should document a patient's intake when it was observed. She stated providers, dietitians and other nursing staff needed to review the intake and output in a patient's medical records in order to plan a patient's care.

DON #4 stated nursing leadership often needed to remind staff to monitor and record patient intake and output. She stated the facility dietitians had notified her on more than one occasion of their concerns with inaccurate documentation of intake and output. DON #4 stated this had been discussed in recent staff huddles.

i. DON #4 provided documentation of topics discussed at staff huddles which were held in January 2022. The huddles included a reminder for staff to monitor and chart patient intake. However, review of Patient #1's current admission revealed continued lack of documentation for the patient's oral fluid intake in February 2022. This was in contrast to interviews with Patient #1 and facility staff who reported Patient #1 had consistent oral intake of fluids.