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Based on clinical record review and interview, it was determined the Facility failed to evaluate and re-assess the weight for one (#6) of two (#6 and #7) patient clinical records reviewed with reported weight loss and at risk for skin breakdown as identified by Dietary and included on the patient's plan of care. Failure to re-assess the weight did not allow the Facility to determine if care plan interventions were effective for preventing weight loss and improving nutritional status. The failed practice affected patient #6 and #7 and is likely to affect all patients with weight loss. The findings were:

A. Clinical record review on 09/29/16 and 09/30/16 revealed Patient #6 was admitted to the Facility (Oncology Unit) on 08/31/16. Diagnosis included: chronic lymphocytic leukemia; HCAP (healthcare associated pneumonia); neutropenic fever; malignant tumor of the lung; acute myloblastic leukemia and anemia.

1) A Nutritional Screen was completed on admission 08/31/16 by a Registered Nurse. The Nutrition Screen Risk stated "unintentional loss of 10 lbs. (pounds) or more in the past 2 months; reduced oral intake over the last month."

2) A Care Plan by Registered Dietitian #1 dated 9/01/16 revealed "...unintentional weight loss and reduced oral intake." Percentage of weight loss from baseline was listed as greater than 2% in one week (severe). "Patient weighed 166 #(pounds) a month ago. Patient weighs 132 #. This is 34 # (18%) in 1 month. Pt. stated she has fair p.o. (by mouth) intake. Patient likes Chocolate Ensure; will order TID (three times per day)." Last documented height was 5'4" and current weight (08/31/16 at 1131): 132# per Dr. (Named) clinic note." Edema: none noted. Additional assessment factors: There is no weight on file to calculate BMI. BMI of 22.65 is within normal range. Braden Score: 18 (09/01/16 at 0416)." The Recommendation/Plan listed "BMI is within normal range. Patient has had 34 # (18%) weight loss in the past month. Patient is at risk for malnutrition. Patient agreeable to Ensure Enlive TID (three times daily). Will monitor."

3) The care plan on 09/06/16 at 0829 by Registered Dietitian #1 revealed "Weight 09/01/16 128#. Recommend obtaining new weight."

4) The care plan on 09/09/16 at 0953 by Registered Dietitian #1 revealed "Weight: 09/01/16 of 128#."

5) The care plan on 09/15/16 at 0815 by Registered Dietitian #1 revealed "Weight: 09/01/16 of 128#. Recommend obtaining new weight."

6) The care plan on 09/21/16 at 1348 by Registered Dietitian #1 revealed "Weight: 09/01/16 of 128# recommend obtaining new weight. Intake: 33% average of 7 meals. Patient's intake has dropped. Patient is still drinking about two Ensure Enlives per day. Encouraged p.o. intake. Patient has menu."

7) A Progress Note by Registered Dietitian #2 on 09/27/16 at 1506 revealed "Patient weight at 128 recorded on 09/01/16. Current diet order: Cardiac with Ensure BID eating 52% average for 7 meals recorded."

B. The findings in "A" were confirmed at the time of clinical record review by Business Solution Analyst #1.

C. Registered Dietitian #1 and #2 were interviewed on 09/29/16 at 1545 and stated if they need a weight on a patient they will tell the nurse and "the nurse will usually get it." They stated they just keep asking if they need a weight and don't have it."



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Based on clinical record review and interview, it was determined that a Registered Nurse (RN) failed to supervise and evaluate the nursing care for six (#10-#15) of 15 (#1-#15) patients in that nurses failed to follow physician's orders for the following: failed to perform neurological checks on two (#12 and #14) of two (#12 and #14) patients; failed to perform Point of Care Glucose testing every four hours on two (#13 and #15) of two (#13 and #15) patients; failed to turn every two hours three (#12, #13 and #15) of three (#12, #13 and#15) patients; failed to obtain vital signs every four hours for one (#12) of one (#12) patient; did not document intravenous fluids given as ordered for one (#12) of one (#12) patient; and failed to obtain/record intake and output for six
(#10 - #15) of six (#10 - #15) patients. Failure to follow physician's orders did not ensure the patient's physicians had the necessary patient results to make informed decisions regarding patient care and facilitate the patient's discharge . The failed practice affected patients #10 - #15 on 09/30/16. Findings follow:

A. Review of Patient #10's clinical record revealed a physician's order authored by Physician #9 at 0326 on 09/28/26 for hourly intake and output measurement and call physician if urine output < (less than) 30 mls (milliliters) per hour. A second order for intake and output measurement authored by Physician #10 at 1650 on 09/29/16 revealed the intake and output measurement was to continue at transfer to floor. Review of the clinical record revealed the output was not collected every one hour from 09/28/16 0400 until 0800 on 09/30/16. The above was verified by Business Solution Analyst at 0934 on 09/30/16.
B. Review of Patient #11's clinical record revealed a physician's order authored by Physician #10 at 2036 on 09/21/16 for intake and output measurement every four hours for 72 hours. Review of the clinical record revealed output was not documented every four hours for 72 hours. The above was verified by the ICU (Intensive Care Unit) Supervisor at 1608 on 09/29/16.
C. Review of Patient #12's clinical record revealed the following:
1. A physician's order authored by Physician #5 at 0051 on 03/16/16 for neurological checks every two hours until specified. Review of the clinical record revealed neurological checks were not performed every two hours from 03/16/16 midnight until 2000 on 03/19/16.
2. A physician's order authored by Physician #5 at 2354 on 03/15/16 for vital signs to be performed every four hours. Review of the clinical records from 0733 on 03/16/16 to 1645 on 03/19/16 revealed vital signs were not performed every four hours.
3. A physician's order authored by Physician #5 at 2354 on 03/15/16 for intake and output measurement and call physician if urine output <120 mls in four hours. Review of the clinical record revealed intake and output were not documented every four hours from 0300 on 03/16/16 through 1700 on 03/19/16.
4. During an interview with the Clinical Manager of Critical Care at 1500 on 09/28/16 she stated the Skin Care Prevention Pathway was generated by a patient's Braden Score of less than 14. Patient #12's initial Braden score on 03/16/16 was 9. Review of the clinical records revealed Patient #12's Braden Score was never above a 12 during the hospital stay. Per above interview, review of the Skin Care Prevention: Pressure Ulcer Injury pathway and the Braden Risk Assessment Algorithm received from the Chief Nursing Officer (CNO) at 1040 on 09/30/16, Patient #12 should have been turned every two hours. Review of the clinical records from 03/16/16 at midnight until 1700 on 03/19/16 revealed Patient #12 was not turned every two hours. The above findings were verified by the Clinical Manager of Critical Care at 1030 on 09/29/16.
5. A physician's order authored by Physician #5 at 2354 on 03/15/16 revealed an order for continuous Normal Saline 125 mls per hour. Review of the medication administration record revealed a Normal Saline bag of 1000 mls was started at 0156 and 1648 on 03/16/16, at 1930 on 03/17/16, at 0357 and 2100 on 03/18/15, and at 1437 on 03/19/16. The above findings were verified in a telephone interview with the Clinical Manager of Critical Care at 1442 on 10/05/16.
D. Review of Patient #13's clinical record revealed the following:
1. A physician's order authored by Physician #11 at 0323 on 09/25/16 for hourly intake and output measurement and call physician if output < 30 ml/hour for the first 24 hours. Review of the clinical record revealed hourly intake and output were not documented every four hours from 0323 on 09/25/16 through 0323 on 09/26/16. The above findings were verified by the ICU Supervisor at 1118 on 09/29/16.
2. A physician's order authored by Physician #11 at 1406 on 09/25/16 for POC (point of care) glucose testing every four hours until the order was discontinued at 1316 on 09/29/16. Review of the clinical record revealed the POC Glucose testing was not documented every four hours during that time frame.
3. Review Patient #13's clinical records revealed Patient #13's initial Braden score was12. Review of the clinical records revealed Patient #13's Braden score had not been above 13 during the course of the hospital stay. Per review of the Skin Care Prevention: Pressure Ulcer Injury Pathway, Patient #13 should have been turned every two hours. The findings in #2 and #3 were verified by the Clinical Manager of Critical Care at 1050 on 09/29/16.
E. Review of Patient #14's clinical record revealed the following:
1. A physician's order authored by Physician #4 at 0156 on 09/26/16 for intake and output measurement every four hours and call physician if output was < 120 mls. Review of the clinical record revealed every four hour intake and output were not documented for the duration of the hospital stay.
2. A physician's order authored by Physician #4 at 0156 on 09/26/16 for neurological checks every four hours. Review of the clinical record revealed no documentation of neurological checks performed every four hours. The above findings in #1 and #2 were verified by the ICU Supervisor at 1347 on 09/29/16.
F. Review of Patient #15's clinical record revealed the following:
1. Review of physician's orders authored by Physician #10 at 0924 on 09/26/16 POC Glucose testing to be performed every four hours from 0930 09/26/16 through 0930 09/28/16. Review of the clinical record revealed the POC Glucose testing was not performed every four hours as ordered.
2. Review of Patient #15's clinical record revealed a Braden score was 13 on 09/25/16. Patient #15's Braden score dropped to 11 on 09/28/16. Per review of the Skin Care Prevention: Pressure Ulcer Injury Pathway, Patient #15 should have been turned every two hours. Review of the clinical record revealed Patient #15 was not turned every two hours during the hospital stay. The findings in #1 and #2 were verified by ICU Supervisor at 1455 on 09/29/16.





Based on clinical record review, policy and procedure review and interview, it was determined a nursing assessment for one (#12) of fifteen (#1-#15) patients was not performed by a Registered Nurse. Failure of the Registered Nurse to perform an assessment did not allow for professional assessment, planning and supervision to be provided for the patient. The failed practice affected Patient #12. Findings follow:

A. Review of Patient #12's clinical record revealed the shift assessment was performed by Licensed Practical Nurse #2 when Patient #12 arrived to the floor at 2347 on 03/15/16.

B. Review of the policy and procedure titled "Nursing Documentation Guidelines" received from the Chief Nursing Officer at 1300 on 09/27/16 revealed the following: Policy: ...Responsibilities of the RN include patient assessment, planning, delivery, teaching and supervising care and reporting and recording the patient's responses to that care. ... and the following:

Type of Documentation WHO WHERE WHAT Time Frame
Ongoing assessment, RN EHR Progress of patient Every Intervention and evaluation ... shift and as needed

C. During an interview with the Clinical Manager of Critical Care at 1020 on 09/28/16 she verified the above findings.