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Based on record reviews, interviews, and observations the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure to ensure the condition of patients' skin was accurately assessed, on admit , every shift, and upon discharge, as per policy, for 3 (#1, #2, #5) of 3 (#1, #2, #5) sampled patients reviewed for skin assessments out of a total patient sample of 5 (#1-#5);
2) failure of the RN to ensure sliding scale insulin had been administered as ordered for 1 (#2) of 2 (#2, #4) sampled Diabetic patient records reviewed from a total patient sample of 5 (#1-#5); and
3) failure of the RN to ensure patient weights were obtained and recorded, as ordered, for 2 (#1,#2) of 5 (#1-#5) total sampled patient records reviewed.

Findings:

1) Failure to ensure the condition of patients' skin was accurately assessed, on admit, every shift, and upon discharge, as per policy.

Review of the hospital policy titled," Wound Prevention, Care, and Documentation", policy number: 3.180, revealed in part: Policy: All patients admitted to this hospital will be screened for risk of skin breakdown and alteration in skin integrity by a liccensed nurse, utilizing interdisciplinary assessment/nursing assessment. If any skin breakdown observed skin breakdown protocols will be initiated. IV. Procedure: 1. Assessment, Documentation, and Establish a Plan of Care: A. Assess and document the patient's skin for alteration in skin integrity and risk for breakdown on admission using the interdisciplinary assessment. B. Initiate a customized plan of care if the patient has an alteration in skin integrity and/or if patient is at risk for skin breakdown as determined by the RN. C. If the patient has a Stage II or greater document your initial and weekly findings on the wound addendum/weekly update. 1. at aminimum, photo documentation must be completed using the following guidelines: a. obtain photo consent from patient on admission paperwork. b. take a photograph of all Stage II or greater and/or partial or full thickness. 2. Number thewound and document location and onset date. 3. State type of wound. 4. Stage or Tissue involved: i. Stage I: Non-blanchable erythema of intact skin. In individuals with darker skin discoloration of the skin, warmth, edema, induration, or hardness may also be indicators. ii. Stage II: partial thickness skin loss involving epidermis, dermis, or both. The ulcer is supeficial and presents clinically as an abrasion, blister, or shallow crater. iii. Stage III: full thickness skin loss involving damage to or necrosis of subcutaneous tissue which may extend down to , but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacenst tissue. iv. Stage IV: full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle bone or supporting structures. Undermining and sinus tracts may be associated with Stage IV pressure ulcers. v. Do not stage ulcers covered with avascular tissue (eschar or slough). 5. Size: measure the wound ( open surface area and depth) weekly and record in cm. 6. Exudate (drainage) amount, moist, moderate or large, characteristics, serous, serosanguinous, bloody, purulent, thin, thick, clear, yellow, tan, green, foul odor. 7. wound base: state color, and type of tissue located in wound base (%). 8. Undermining and tunneling 9. Wound edges: assess and document presence of new tissue epithelium edges rolled and thickened, etcetera. 10. Condition of surrounding skin: assess at least 4 cm extending from wound edge for discoloration, swelling/edema, skin tears or maceration. Palpate for induration ( firmness) or fluctuance (spongy, soft). 11. Signs and Symptoms of Infection: Local and Systemic. 12. Current treatment. i. Assess and document all areas of the skin daily using the patient reassessment and progress notes- nursing. ii. Reassess and dcoument the patient's risk for skin breakdown weekly. iii. Assess the wound base, edges, exudate, surrounding skin, signs/symptoms of infection with each dressing change and document any changes.


Patient #1
Review of Patient #1's electronic medical record revealed an admission date of 7/23/18 and a discharge date of 8/10/18. Further review revealed the patient had been acting out by scratching and gouging his lower extremities and he had an unstageable left heel wound covered with eschar.

Review of Patient #1's Initial Nursing Assessment, dated 7/23/18, revealed the following skin assessment documentation: marks on knees, upper legs, and left heel. Further review revealed no description of the marks on the knees and upper legs such as number, size, color, and shape. Additional review revealed no documentation of a description of the wound on the patient's left heel such as size, color, drainage, and presence of or lack of odor.

Further review of Patient #1's nurses notes revealed the following entry on 8/1/18 9:18 p.m.: skin breakdown on buttocks. Further review of Patient #1's nurses' notes from 7/23/18 - 8/10/18 revealed the only mention of skin breakdown in the buttocks area was the 8/1/18 entry at 9:18 p.m. Additional review revealed no documented evidence of a description of the skin breakdown on the patient's buttocks such as size, color, drainage, and presence of or lack of odor.

Review of Patient #1's entire electronic medical record from 7/23/18 - 8/10/18 revealed no documented evidence of a description of the patient's unstageable wound on his left heel and the skin breakdown on the patient's buttocks in order to record the color, size, presence or absence of drainage, and presence of or lack of odor of the wounds, stage of healing. Further review revealed no photos had been taken of either wound as per hospital policy.

In an interview on 8/27/18 at 3:30 p.m. with S2ADON, she confirmed skin assessments should have been completed on admit, every shift, with any skin changes, and on discharge. S2ADON further reported the hospital's policy was to take a photo and measurement of the wound. S2ADON stated wound measurements were to be done weekly. S2ADON confirmed, after review of the patient's entire electronic medical record and paper record from 7/23/18 - 8/10/18, that there had been no photos, measurements, or descriptive assessments (color, size, odor, drainage, and stage of healing) of the patient's unstageable left heel wound and the skin breakdown on the patient's buttocks.

In an interview on 8/28/18 at 2:38 p.m. with S5NP, she reported Patient #1 had to have his legs covered because he dug in the skin of his legs and when he first came in his legs were weeping, almost like burns. She further reported the patient had an unstageable wound with eschar to his left heel on admit. S5NP further reported an aide had told her there was an odor in Patient #1's buttock area. S5NP said the patient had a tunneled wound inside his buttock cheek and it was draining and had a foul odor. S5NP reported she had written the order for wound treatments for the buttock wound and for the left heel wound.

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of 7/31/18 and a discharge date of 8/14/18. Review of Patient #2's pre-admission screening assessment revealed the patient had no wounds on admission.

Review of Patient #2's electronic medical record revealed the following nurses' note entries:
8/1/18 at 6:36 a.m.: Braden Skin Risk Assessment: High risk with score of 13.

8/1/18 7:53 a.m.: No skin assessment documented.

8/2/18 7:56 a.m.: No skin assessment documented.

8/3/18 8:49 p.m.: Skin assessment: Bruises. Further review revealed no description of the size, color, number or location of the bruises.

8/5/18 11:42 p.m.: Skin assessment: Intact with poor turgor, no documentation related to bruises.

8/6/18 8:51 p.m.: Skin assessment: dry skin and bruises. Further review revealed no description of the size, color, number or location of the bruises.

8/6/18 10:33 p.m.: Skin assessment: Bruises. Further review revealed no description of the size, color, number or location of the bruises.

8/7/18 8:30 a.m.: Skin assessment: Dry skin and bruises. Further review revealed no description of the size, color, number or location of the bruises.

8/7/18 8:00 p.m.: Skin assessment: No rash, lumps itching or other skin changes. Further review revealed no documentation regarding the patient's bruises.

8/8/18 7:20 p.m.: Skin Assessment: Dry skin otherwise no symptoms referable to skin are present. Further review revealed no documentation regarding the patient's bruises.

8/9/18 9:08 a.m.: Skin assessment: Skin warm, dry and intact. Further review revealed no documentation regarding the patient's bruises.

8/9/18 7:07 p.m.: No skin assessment documented.

8/10/18 6:00 a.m.: Skin assessment: Scattered bruises and abrasions to legs and arms. Performed Braden: Scored High Risk for skin breakdown- Score: 11. Further review revealed no documented evidence of a description of the size, color, exact location and number of bruises.

8/10/18 10:37 a.m.: Skin assessment: Scattered bruises and abrasions to legs and arms. Further review revealed no documented evidence of a description of the size, color, exact location and number of bruises.

8/10/18 8:35 p.m.: No skin assessment documented.

8/11/18 8:08 a.m.: Skin assessment: Abrasions, bruises, skin changes, breakdown on buttocks. Further review revealed no documented evidence of a description of the size, color, exact location and number of bruises. Additional review revealed no documented evidence of a description (color, size, presence or absence of drainage, presence of or lack of odor, and stage of healing) of the skin breakdown on the patient's buttocks.

8/11/18 8:30 p.m. Skin assessment: Bruises and Stage III pressure ulcer to coccyx. Further review revealed no documented evidence of a description of the size, color, exact location and number of bruises. Additional review revealed no documented evidence of a description (color, size, presence or absence of drainage, presence of or lack of odor, and stage of healing) of the skin breakdown.

8/12/18 8:34 a.m.: No skin assessment documented.

8/12/18 8:50 p.m.: Skin assessment: Wound on coccyx- Stage III. Further review revealed no documentation of the patient's bruises and no description of the wound on the patient's coccyx.

8/13/18 at 11:12 a.m.: Skin assessment: Wound to buttocks. Further review revealed no documentation of the patient's bruises and no description of the wound on the patient's buttocks.

8/14/18 at 3:51 a.m.: Skin assessment: Severe risk for skin breakdown per Braden scale, Pressure Ulcer to inner right buttocks. Further review revealed no documentation of the patient's bruises and no description of the wound on the patient's buttocks.

8/14/18 at 9:56 a.m.: Skin assessment: Abrasions bilaterally on lower extremities, healing within normal limits. Further review revealed no documentation of the patient's bruises and no mention of the patient's sacral pressure ulcer or buttocks ulcer.

Review of the photo of Patient #2's sacrum and right buttock, dated 8/11/18, revealed the patient had a Stage II pressure ulcer on his right buttock and on his sacrum. S2ADON reviewed the photo, with the surveyor, on 8/28/18 at 12:02 p.m., and confirmed the patient had a Stage II pressure ulcer on his right buttock and on his sacrum.

Review of S5NP's progress note, dated 8/11/18 at 6:30 p.m., revealed the following: Stage II to buttock. Instructions: clean wound to buttock with dermal wound cleanser, cover with duoderm, and change every 3 days and as needed with soilage.

In an interview on 8/28/18 at 3:30 p.m. with S2ADON, she confirmed Patient #2's skin should have been assessed on admission, every shift, with any changes, and on discharge. She also confirmed the patient's bruises should have been described to include the size, color, exact location and number of bruises. S2ADON further confirmed documentation of Patient #2's buttock and sacral skin breakdown should have included a description of the color, size, presence or absence of drainage, presence or lack of odor, and stage of healing of the wounds.

Patient #5
Review of Patient #5's electronic medical record revealed an admission date of 8/10/18 with admission diagnosis of Bipolar Disorder and Late Onset Dementia.

Review of Patient #5's medication orders revealed the patient was receiving 81 milligrams of Aspirin (anti-coagulant) by mouth once daily.

Review of Patient #5's Initial Skin Assessment, completed on admission, revealed the following, in part: Skin: bruises-bilateral upper extremities. Braden Skin Risk Assessment: Moderate risk for skin breakdown with a score of 11. Further review revealed no documented description of the size, color, exact location and number of bruises.

Review of Patient #5's Skin assessment for the night shift of 8/28/18 revealed the following, in part: Braden Skin Risk Assessment: Moderate risk- score of 14. Skin abnormality- bruising upper extremities. Further review revealed no documented description of the size, color, exact location and number of bruises.

Review of Patient #5's entire electronic medical record from 8/10/18 - 8/28/18 revealed no documented evidence that a photo had been taken of Patient #5's bruising.

On 8/29/18 at 8:40 a.m. S2ADON verified, after review of Patient #5's entire electronic medical record, that there had been no photos taken of Patient #5's bruises and she also verified there had been no documented description of the size, color, exact location and number of the patient's bruises. S2ADON confirmed any skin breakdown, bruising, and/or redness should have been photographed and measured per hospital policy. S2ADON also reported, per hospital policy, that a repeat photo should have been taken every week.

An observation was made of performance of Patient #5's skin assessment on 8/29/18 at 9:35 a.m. The patient had the following observed bruised areas/skin abnormalities in varying stages of healing:
#4: 4.5 cm laceration/healing skin tear scabbed- left forearm;
#5: 5cm x 6 cm reddish purple bruise on left elbow;
#6: 4cm x 5 cm reddish purple bruise left upper arm above elbow;
#7: 2.5 cm circular red spot on left upper arm;
#8: 1.5 cm circular red spot on left upper arm;
#9: 5 cm reddish purple bruise on anterior left upper arm;
#10: 1 cm bluish green bruise left armpit;
#11: 2 cm reddish purple bruise;
#12: 2 cm reddish purple bruise right lateral elbow;
#13: 1 cm reddish purple bruise to right lateral elbow;
#14: 14.5 cm circumference purplish red bruise around right lower forearm/wrist;
#15: 3 cm greenish purple bruise on right shoulder;
#16: 2 cm greenish purple bruise on right posterior shoulder;
#17: 3 cm purplish red bruise on right inner forearm;
#18: 2 cm purplish red bruise on right antecubital;
#19: 2 cm reddish purple bruise on left upper later thigh;
#20: 2.5 cm reddish purple bruise on right lateral upper thigh; #20 2.5 cm purplish red bruise on right upper thigh;
#21: 1 cm purplish green bruise left lateral mid-thigh;
#22: 3 cm purple bruise inside large edematous area on right lateral lower leg;
#23: 3 cm purple bruise anterior right lower leg; #24: 5 cm purplish bruise left lateral lower ankle; #25: 1 cm purplish bruise left lateral foot;
#26: 13cm x 6.5 cm purplish red bruise on left posterior thigh;
#27: 4 cm purplish red bruise on left posterior thigh;
#28: 10 cm reddened area on left buttock; and
#29: 6 cm edematous purplish red bruise on right posterior thigh.

S2ADON was present during the assessment and verified the skin assessment from the night shift of 8/28/18 (the night before the observed patient skin assessment referenced above) had lacked a documented description of the size, color, exact location and number of Patient #5's bruises based upon the observed findings referenced above.


2) Failure of the RN to ensure sliding scale insulin had been administered as ordered.

Review of Patient #2's electronic medical record revealed he had been admitted on 7/31/18 with a comorbid diagnosis of Diabetes Mellitus Type II.

Review of Patient #2's electronic medical record revealed an order, dated 7/31/18 at 5:59 p.m., for capillary blood glucose checks before meals and at hour of sleep with sliding scale insulin for coverage of blood glucose levels.

Further review revealed the following sliding scale parameters for insulin administration:
Blood glucose less than 80: give pt. orange juice;
81-200: no coverage;
201-250: 2 units Humalog SQ (subcutaneous);
251-300: 4 units Humalog SQ;
301-350: 6 units Humalog SQ;
351-400: 8 units Humalog SQ;
Greater than 401 - Give 10 units Humalog SQ and notify MD.

Review of Patient #2's Sliding Scale Insulin Medication Administration Record revealed the following entries:

8/6/18 11:00 a.m.: Capillary blood glucose - 369. According to the patient's sliding scale insulin order coverage of 8 units of Humalog Insulin SQ should have been administered. Further review revealed no documented evidence that sliding scale insulin had been administered and no documentation of any reason for the dose to have been held.

8/6/18 4:00 p.m.: Capillary blood glucose - 393. According to the patient's sliding scale insulin order coverage of 8 units of Humalog Insulin SQ should have been administered. Further review revealed no documented evidence that sliding scale insulin had been administered and no documentation of any reason for the dose to have been held.

8/7/18 11:00 a.m.: Capillary blood glucose - 398. According to the patient's sliding scale insulin order coverage of 8 units of Humalog Insulin SQ should have been administered. Further review revealed no documented evidence that sliding scale insulin had been administered and no documentation of any reason for the dose to have been held.

8/7/18 4:00 p.m.: Capillary blood glucose - 381. According to the patient's sliding scale insulin order coverage of 8 units of Humalog Insulin SQ should have been administered. Further review revealed no documented evidence that sliding scale insulin had been administered and no documentation of any reason for the dose to have been held.

8/7/18 7:11 p.m.: Capillary blood glucose - 363. According to the patient's sliding scale insulin order coverage of 8 units of Humalog Insulin SQ should have been administered. Further review revealed no documented evidence that sliding scale insulin had been administered and no documentation of any reason for the dose to have been held.

In an interview on 8/28/18 at 12:19 p.m. with S2ADON, she verified, during the patient's electronic medical record review, the above mentioned insulin dosages should have been administered as per ordered sliding scale. S2ADON further verified, after review of the patient's entire electronic medical record, that there was no documentation of administration of the ordered sliding scale insulin coverage and no documentation of an order to hold the sliding scale insulin coverage.

In an interview on 8/29/18 at 8:40 a.m. with S6RN, he reported the sliding scale insulin was documented on the patients MAR (medication administration record). He further reported insulin coverage related to capillary blood glucose level results and any actions taken, including physician notification, were also documented in the drop box on the MAR.


3) Failure of the RN to ensure patient weights were obtained and recorded, as ordered.

Patient #1
Review of Patient #1's electronic medical record revealed an admission date of 7/23/18 and a discharge date of 8/10/18 with admission diagnoses including Major Depressive Disorder, Bipolar Disorder, and Paraplegia (the patient was wheelchair bound).

Review of Patient #1's admit orders, dated 7/23/18 at 3:50 p.m., revealed an order for weight on admit and then every Monday and record.

Review of Patient #1's Initial Nursing Assessment, dated 7/23/18, revealed no weight had been documented. Additional review revealed the section labeled weight had a notation indicating the patient was unable to stand.

Further review of Patient #1's medical record revealed a nurses' note with a recorded weight of 99.2 lbs. on 7/25/18.
Additional review revealed the patient should have been weighed on Monday 7/30/18 and Monday 8/6/18 and no weights were documented on those dates. The patient was discharged on 8/10/18 and no discharge weight was recorded.

In an interview on 8/28/18 at 3:30 p.m. with S2ADON she confirmed, after review of Patient #1's entire medical record, that there were no weights documented on admission and on the above referenced dates. S2ADON also confirmed the hospital had a scale that enabled staff to weigh wheelchair bound patients.

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of 7/31/18 and a discharge date of 8/14/18. Further review revealed the patient had diagnoses including Parkinson's Disease, Alzheimer's Disease, and insulin dependent Diabetes Mellitus. Patient #2 was wheelchair bound.

Review of Patient #2's admit orders, dated 7/31/18, revealed an order for weight on admit and then every Monday and record.

Review of Patient #2's vital sign flowsheets revealed an admission weight of 159 lbs. on 7/31/18. Further review revealed on 8/2/18 the patient's weight was 153 lbs. Additional review revealed no other recorded weights. According to Patient #2's orders the patient should have been weighed on Monday 8/6/18 and Monday 8/13/18 and no weights were documented on those dates. The patient was discharged on 8/14/18 and no discharge weight was recorded.

In an interview on 8/28/18 at 1:30 p.m. with S2ADON she confirmed, after review of Patient #2's entire electronic medical record, that there were no weights documented on admission and on the above referenced dates.

Based on record review and interview, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. The deficient practice was evidenced by failure of the hospital to ensure all patients, including patients with a documented decline in meal intake and documented weight loss, had been referred for a nutritional assessment/re-assessment due to being at risk for nutritional deficiencies associated with a decline in nutritional intake and weight loss for 2 (#2, #3) of 5 (#1-#5) total sampled patients reviewed.

Findings:

Patient #2
Review of Patient #2's medical record revealed an admission date of 7/31/18 and a discharge date of 8/14/18. Further review revealed the patient had diagnoses including Parkinson's Disease, Alzheimer's Disease, Chronic Kidney Disease Stage III, and insulin dependent Diabetes Mellitus. Additional review revealed the patient had required staff assistance for meal and fluid intake and was dependent on staff for activities of daily living.

Review of Patient #2's vital sign flowsheets revealed an admission weight of 159 lbs. on 7/31/18. Further review revealed on 8/2/18 the patient's weight was 153 lbs. (a weight loss of 6 lbs. in 3 days). Additional review revealed no other documented weights for Patient #2.

Review of the hospital vital sign flowsheet record, used to document meal intake of all inpatients, revealed the following meal intake information for Patient #2:

8/2/18: Breakfast: 25%, Lunch: 25%, and Dinner: 100%;
8/4/18: Breakfast: 50%, Lunch: 50%, and Dinner: 50%;
8/5/18: Breakfast: 25%, Lunch: 25%, and Dinner: 25%.

Review of Patient #2's medical record revealed the following nurses' note entries, in part:
8/1/18 6:36 a.m.: Patient is rigid and requires total care, has Parkinsons'; chewing problem and swallowing problems are present.
8/1/18 7:53 a.m.: Patient has diminished food and fluid intake and needs to be coaxed to eat and drink.
8/2/18 7:56 a.m.: Patient has diminished food and fluid intake, encouraged to engage and attend meals.
8/11/18 8:08 a.m.: Diminished food and fluid intake.
8/12/18 8:34 a.m.: Diminished food and fluid intake.
8/13/18 11:12 a.m.: Diminished food and fluid intake, cannot perform ADLs without assistance.

Review of Patient #2's Physician Progress notes revealed the following entries, in part:

8/4/18 12:31 p.m.: Patient inadequately improved, in wheelchair, barely able to feed self, holding a piece of chicken. Staff reported he consumed 50% of his lunch. Male staff assisting, not resisting or fighting. Appetite has decreased further. Has diminished food and fluid intake. A slight weight loss is noted.

8/6/18 8:00 p.m.: Patient sleepy, body slumped forward. Self- care impaired, needs cues, especially earlier this p.m. Diminished food and fluid intake.

Review of Patient #2's entire electronic medical record revealed no documented evidence that an initial nutritional assessment had been conducted. Further review revealed the only documented nutritional assessment for Patient #2 was dated 8/14/18 at 2:14 p.m. (date of discharge), completed by S4CDM. This finding was verified by S2ADON, chart navigator, at the time of the medical record review on 8/28/18 at 2:30 p.m. S2ADON further verified there was no ongoing documentation of assessment of Patient #2's nutritional status by S4CDM or by a consultant dietician. S2ADON agreed Patient #2 should have had ongoing assessments of his nutritional status due to the patient's diminished meal intake and weight loss.

In an interview on 8/27/18 at 1:00 p.m. with S4CDM (Certified Dietary Manager), she reported she performed patient nutrition assessments on all patients. S4CDM further reported she had up to 72 hours after admission to perform an initial nutritional assessment. S4CDM indicated when she performed nutritional assessments she reviewed patient intake information, observed the patient consuming one or two meals to observe intake, observed the patient's ability to chew and swallow, and evaluated the patient's dental condition. S4CDM also indicated she received reports from nurses regarding patients' decline in intake and/or weight loss. S4CDM said after performing her assessment she made dietary recommendations for modified consistency diets, thickened/thinned liquids, and supplemental oral nutritional items. S4CDM reported at times the ordering practitioner may have requested an evaluation of a patient, such as a patient who may have been a brittle Diabetic, by a consulting dietician supplied through contract with the hospital's food service provider.

In an interview on 8/28/18 at 2:14 p.m. with S5NP, she reported she remembered Patient #2. S5NP reported she had been a part of management of Patient #2's care at the transferring facility and during his stay at the inpatient psychiatric hospital. S5NP reported Patient #2 had diagnoses including Parkinson's Disease and Dementia and been thin and frail. She further reported the patient had not eaten well during his stay at the inpatient psychiatric hospital.

Patient #3
Review of Patient #3's electronic medical record revealed an admission date of 7/16/18 with admission diagnoses including Paranoid Schizophrenia and Dementia with worsening symptoms.

Review of Patient #3's weight documentation revealed the following entries:
7/16/18 (admit): 157.2 lbs.;
7/23/18: 157.2 lbs.;
7/30/18: refused weight;
8/6/18: refused weight;
8/13/18: 144.5 lbs.;
8/20/18: refused weight;
8/27/18 140.1 lbs. (a total documented weight loss of 17.1 lbs. in 12 days). S2ADON verified the referenced weights.

Review of Patient #3's meal intake documentation revealed the following entries:
7/17/18: Breakfast: 50%, Lunch: 0%, Dinner: 25%;
7/26/18: Breakfast: 0%, Lunch: 0%, Dinner: 10%;
7/27/18: Breakfast: 0%, Lunch: 0%, Dinner: 10%;
7/28/18: Breakfast: 25%, Lunch: 25%, Dinner: 25%;
7/30/18: Breakfast: 50%, Lunch: 0%, Dinner: 0%;
8/6/18: Breakfast: 0%, Lunch: 0%, Dinner: 0%;
8/26/18 Breakfast: 0%, Lunch: 25%, Dinner: blank.

Review of Patient #3's Master Treatment Review Team Conference form, dated 8/8/18, revealed the following entry: Nursing Assessment/Recommendation: not eating well, eating part of one meal.

Review of Patient #3's electronic medical record revealed the patient had an initial nutritional screen performed by S4CDM on 7/19/18 (3 days after admission). Further review revealed no documented evidence of a referral/order for re-assessment of Patient #3's nutritional status per S4CDM or by a consultant registered dietician to address the patient's decreased intake and documented weight loss.

On 8/28/18 at 4:46 p.m. S2ADON confirmed, during review of Patient #3's electronic medical record, that there was no re-assessment of Patient #3's nutritional status by S4CDM or a referral for an assessment by a consultant dietician as of 8/28/18 (date of review).

Based on record review and interview, the hospital failed to ensure the psychiatric evaluation included supportive information utilized to determine judgment, insight, and memory functioning for 3 (#1, #3, #5) of 5 ( #1- #5) total sampled patient records reviewed for psychiatric evaluations.

Findings:

Patient #1
Review of Patient #1's electronic medical record revealed an admission date of 7/23/18 with admission diagnoses including Major Depressive Disorder and Bipolar Disorder.

Review of Patient #1's Psychiatric Evaluation, dated 7/24/18 at 10:30 a.m., revealed the patient's judgement and insight were documented as fair with no methodology for assessment documented. Further review revealed the patient's recent and remote memory was documented as intact with no methodology for assessment documented.


Patient #3
Review of Patient #3's electronic medical record revealed an admission date of 7/16/18 with admission diagnoses including Paranoid Schizophrenia and Dementia with worsening symptoms.

Review of Patient #3's Psychiatric Evaluation, dated 7/17/18 at 11:30 a.m. , revealed the patient's judgement and insight were documented as poor with no methodology for assessment documented. Further review revealed the patient's recent and remote memory was documented as impaired with no methodology for assessment documented.


Patient #5
Review of Patient #5's electronic medical record revealed an admission date of 8/10/18 with admission diagnoses including Bipolar Disorder and Late Onset Dementia. .

Review of Patient #5's Psychiatric Evaluation, dated 8/10/18 at 8:00 p.m. , revealed the patient's judgement and insight were documented as impaired with no methodology for assessment documented. Further review revealed the patient's recent and remote memory was documented as impaired with no methodology for assessment documented.

In an interview on 8/28/18 at 4:46 p.m. with S2ADON she confirmed assessment of patient judgement, insight and memory should have included the method used for assessment.

Based on record review and interview, the hospital failed to ensure each patient had a comprehensive treatment plan that included all medical and psychiatric diagnoses for 3(#1,#3,#5) of 5 (#1-#5) sampled patient records reviewed.

Findings:

Review of the hospital policy titled, "Treatment Plan Overview", Policy number: 208.1, revealed in part: Policy: Each patient admitted to the hospital shall have an individualized written treatment plan based on interdisciplinary clinical assessments. The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Goals and Objectives are established and discharge and continuing care plan is determined. Procedure: Master treatment Plan: 2. Both medical and psychiatric needs should be addressed. 3. Nursing shall be responsible for addressing issues related to medical conditions, medication regimes, signs and symptoms and compliance. 7. All diagnoses should be listed on the treatment plan and treatment status indicated.

Patient #1
Review of Patient #1's electronic medical record revealed an admission date of 7/23/18 and a discharge date of 8/10/18. Further review revealed the patient had been acting out by scratching and gouging his lower extremities and he had an unstageable left heel wound covered with eschar.

Review of Patient #1's Initial Nursing Assessment, dated 7/23/18, revealed the following skin assessment documentation: marks on knees, upper legs, and left heel. Further review revealed the following entry on 8/1/18 9:18 p.m.: skin breakdown on buttocks.

Review of Patient #1's master treatment plan revealed the impaired skin integrity had not been addressed as an identified problem on the patient's plan of care upon admission and the plan had not been updated to include the skin breakdown on the patient's heel and the skin breakdown on the patient's buttocks.

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of 7/31/18 and a discharge date of 8/14/18.

Further review of Patient #2's medical record revealed the following nurses' note skin assessment documentation:
8/11/18 8:08 a.m. Skin assessment: Abrasions, bruises, skin changes, breakdown on buttocks.

Review of Patient #2's vital sign flowsheets revealed an admission weight of 159 lbs. on 7/31/18. Further review revealed on 8/2/18 the patient's weight was 153 lbs. (a weight loss of 6 lbs. in 3 days).

Review of Patient #2's medical record revealed the following nurses' note entries, in part:
8/1/18 6:36 a.m.: Patient is rigid and requires total care, has Parkinsons'; chewing problem and swallowing problems are present.
8/1/18 7:53 a.m.: Patient has diminished food and fluid intake and needs to be coaxed to eat and drink.
8/2/18 7:56 a.m.: Patient has diminished food and fluid intake, encouraged to engage and attend meals.
8/11/18 8:08 a.m.: Diminished food and fluid intake.
8/12/18 8:34 a.m.: Diminished food and fluid intake.
8/13/18 11:12 a.m.: Diminished food and fluid intake, cannot perform ADLs without assistance.

Review of Patient #2's master treatment plan revealed the plan had not been updated to include impaired skin integrity as an identified problem related to the above referenced skin abrasions, bruises, and breakdown on buttocks. Further review revealed impaired nutrition and weight loss had also not been addressed as an identified problem on the patient's treatment plan.

Patient #5
Review of Patient #5's electronic medical record revealed an admission date of 8/10/18 with admission diagnosis of Bipolar Disorder and Late Onset Dementia.

Review of Patient #5's medication orders revealed the patient was receiving 81 milligrams of Aspirin (anti-coagulant) by mouth once daily.

Review of Patient #5's Initial Skin Assessment, completed on admission, revealed the following, in part: Skin: bruises-bilateral upper extremities. Braden Skin Risk Assessment: Moderate risk for skin breakdown with a score of 11.

On 8/29/18 at 9:35 a.m. an observation was made of performance of Patient #5's skin assessment. The patient was noted to have multiple bruised areas, areas of redness, and skin tears in various stages of healing.

Review of Patient #5's master treatment plan revealed the plan had not been updated to include impaired skin integrity as an identified problem related to the above referenced bruises, and skin tears. Further review revealed the patient's potential for bleeding and bruising related to treatment with an anticoagulant was also not addressed on the patient's treatment plan.

In an interview on 8/29/18 at 10:00 a.m. with S2ADON, she confirmed the above referenced patients' skin impairment, potential for bruising and bleeding due to use of an anticoagulant, and decreased oral intake and weight loss should have been addressed on the patients' treatment plans.


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