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Based on record review and interview the RN (Registered Nurse) failed to reassess a patient's care needs regarding a patient's weight for 1 of 1 (#3) patient after a recorded weight loss as evidenced by failing to reassess the patient's care on an on-going basis when the patient's admit weight was documented as 190# (pounds) on 05/22/17 and with a documented weight of 164# on 05/30/17 indicating a 26# weight loss in 7 days.

Findings:
A review of the policy titled "Nursing Admission Assessment, Reassessment, and Plan of Care", provided by S1VP/QA as the most current, revealed in part: The plan of care is updated at least once a shift and target dates and goals are established and re-assessed based on a patient's current condition. A change in condition warrants a re-assessment.

Patient #3
A review of the patient's medical record at the hospital's Rehab (Rehabilitation) Unit revealed the patient was admitted to the Rehab Unit on 5/22/17 for rehabilitation services. A review of the patient's care plan revealed a care plan for nutritional needs and weekly weights. A review of the Dietary and Meal Intake notes revealed documentation that the patient required assistance with all meals by staff. A further review of the medical record revealed the patient's admit weight was documented as 190# (pounds) on 05/22/17 and with a documented weight of 164# on 05/30/17 indicating a 26# weight loss in 7 days.


In an interview on 0 8/16/17 at 5:30 p.m. with S7RN/Rehab, Clinical Rehab Specialist, he indicated that he conducted the pre-screening evaluation for the patient to ensure the patient met rehab criteria prior to admit to the Rehab Unit. He indicated the patient's weight of 190# was a weight reported to him by the discharging hospital's staff and he did not know how the staff had measured the patient's weight that was reported to him. S7RN/Rehab indicated that he usually tried to get accurate weights from staff on patients being admitted to the Rehab Unit and he did not ask the staff how they measured the patient's weight. S7RN/Rehab indicated the patient's weight was a reported weight.

In an interview on 08/16/17 at 5:40 p.m. with S5MgrRehab she indicated that she attended the patient's ID (Interdisciplinary ) team conferences on 05/23/17 and 05/30/17. She was asked if the patient's weight loss was addressed by the ID team. S5MgrRehab reviewed the ID team's documented notes and she indicated that the patient's weight loss was not addressed by the ID team during those conferences. S5MgrRehab indicated that since the patient's lab values were within normal range and the RD's (Registered Dietician) nutritional assessments on the patient on 05/23/17 and 05/30/17 were assessed at low risk for malnutrition that the weight loss was probably not viewed as a negative outcome.

Based on record review and interview the RD (Registered Dietitian) failed to reassess a patient's nutritional status regarding a patient's weight for 1 of 1 (#3) patient after a recorded weight loss as evidenced by failing to re-address the patient's nutritional status on an on-going basis when the patient's admit weight was documented as 190# (pounds) on 05/22/17 and with a documented weight of 164# on 05/30/17 indicating a 26# weight loss in 7 days.

Findings:
A review of the Dietary policy titled "Continuous Nutrition Monitoring", as provided by S8DirDietary as the most current, revealed in part: Clinicians will continue to monitor patients for nutritional risks by predetermined criteria based on feeding modality, nutrition care order, condition, and diagnosis - to identify patients at potential nutritional risk not identified during the initial nutrition screening completed by nursing upon admission.

A review of the Dietary policy titled "Re-assessment and Follow up", as provided by S8DirDietary as the most current, revealed in part: The purpose of the policy is to monitor the effectiveness of multidisciplinary nutrition care plan and to reassess the patient's nutritional status, as changes occur during the course of hospitalization to include: changes in weight status.

Patient #3
A review of the patient's medical record at the hospital's Rehab (Rehabilitation) Unit revealed the patient was admitted to the Rehab Unit on 5/22/17 for rehabilitation services. A review of the patient's care plan revealed a care plan for nutritional needs and weekly weights. A review of the Dietary and Meal Intake notes revealed documentation that the patient required assistance with all meals by staff. A further review of the medical record revealed the patient's admit weight was documented as 190# (pounds) on 05/23/17 and with a documented weight of 164# on 05/30/17, indicating a 26# weight loss. A further review of the patient's medical record upon the patient's discharge from the Rehab Unit on 06/05/17 had a documented weight of 150#, which was a total weight loss of 40# in 2 weeks.

A review of S3RD nutrition assessment notes dated 05/23/17, the day after the patient was admitted to the Rehab Unit, revealed in part: The patient's weight was recorded at 190# and indicated that the weight of 190# was a reported weight. The patient was on a heart healthy pureed diet. The patient's nutritional risk appears to be normal. The patient did not meet clinical indicators for malnutrition. Goal: Maintain adequate nutrition and hydration. Patient will be able to meet nutritional needs with current diet. Continue current diet, advancing consistency per Speech Therapist evaluations. If oral intake declines, provide Ensure with meals.

A review of S4RD nutrition assessment notes dated 05/30/17, revealed in part: Diet - heart healthy mechanical soft. Eating 50-75% of meals per nursing documentation. New weight: 164# (bed scale weight). S4RD documented a possible measurement error from the reported weight on 05/23/17 of 190#. Patient's nutritional risk appears to be normal. Patient did not meet clinical indicators for malnutrition. Goal: Maintain adequate nutrition and hydration. Patient will be able to meet nutritional needs with current diet. Continue current diet, advancing consistency per Speech Therapist evaluation. If oral intake declines, provide Ensure with meals.

In an interview on 08/16/17 at 6:00 p.m. with S3RD she was asked about the patient's weight loss of 26# from 05/23/17 to 05/30/17 (7 days). She indicated that she conducted the initial RD nutritional assessment upon the patient's admit to the Rehab Unit on 05/23/17. She indicated that the weight she documented on 05/23/17 was a "reported" weight from S7RN/Rehab's clinical notes. She was asked about the documented patient weight of 164# on 05/30/17 from S4RD, which indicated a weight loss 26# in 7 days. S3RD indicated that she could not speak for S4RD, but that S4RD indicated in her notes that the weight discrepancy was probably a measurement error. S3RD indicated that the patient's weight loss was probably not addressed by the ID team since he had a reported good appetite and he had no clinical indicators for malnutrition and since the patient had hypertension and congestive heart failure issues that losing weight was probably a benefit for him since he was in the obese range. A further review of the patient's medical record with S3RD revealed a discharge weight of 150# on 06/05/17 which was a total weight loss of 40# in 2 weeks. She indicated that a rapid weight loss in a patient would normally trigger a nutritional concern that would need to be evaluated and addressed and indicated that the patient's nutritional status should have been reassessed.

Based on record review and interview, the hospital failed to ensure a Discharge Planning Evaluation was completed within 48 hours according to hospital policy as evidenced by failing to conduct a Discharge Planning Evaluation for 2 (#4, #5) of 5 (#1- #5) sampled patient medical records reviewed for Discharge Planning Evaluations.

Findings:
A review of the policy titled "Interdisciplinary Discharge Planning", as provided by S1VP/QA as the most current, revealed in part: The discharge planning interdisciplinary process begins on admission and involves the patient, the patient family, and all team members and identifies all patients who are likely to suffer adverse outcomes when there is inadequate discharge planning. Each patient is screened within 24-48 hours of admission or next business day. SW (Social Workers) and CM (Case Managers) utilize the risk assessment, by completing the patient Psychosocial Assessment tool.

Patient #4
The patient was admitted through the ED (Emergency Department) to a hospital inpatient room on 07/24/17 and was discharged to home on 07/29/17. The patient was a 34 year old male with deafness, chronic right lower extremity ulcer who presented to the Emergency Room with leg pain of his extremity. Patient was admitted for further evaluation for hypoxia due to de-saturation on room air while in the ED.

A review of the patient's medical record revealed that no psychosocial initial assessment was conducted by a discharge planner staff member that documented a Discharge Planning Evaluation. There was no documented evidence of a Discharge Planning Evaluation that was completed within 48 hours by a discharge planner on the patient's medical record.

Patient #5
The patient was a 38 year old male admitted as an inpatient on 04/11/17 and was discharged on 04/14/17 to home. The patient had a history of end stage renal disease, chronic cirrhosis, and had a history of endocarditis that required a prior heart valve repair. He was admitted to the Intensive Care Unit from the Operating Room after a hypotension episode on induction during an elective hernia repair.

A review of the patient's medical record revealed that no psychosocial initial assessment was conducted by a discharge planner staff member that documented a Discharge Planning Evaluation. There was no documented evidence of a Discharge Planning Evaluation that was completed within 48 hours by a discharge planner on the patient's medical record.
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In an interview on 08/16/17 at 11:00 a.m. with S2DirCM/SW she indicated that a psychosocial assessment was not conducted by a discharge planner on Patient #4 and Patient #5 and therefore a discharge plan was not formulated upon admit and present in the patient's medical record within 48 hours, as per discharge planning policy. She indicated that a Discharge Planning Evaluation should be formulated for all inpatients and placed in the medical record within 48 hours. S2DirCM/SW further indicated that a Discharge Planning Evaluation helped prevent discharge oversights from occurring. She indicated that the discharge planners are supposed to do their own psychosocial assessments upon a patient's admit within 48 hours, separate from the nurse's admit psychosocial assessment.

Based on record review and interview, the hospital failed to ensure a Discharge Planning Evaluation was completed within 48 hours according to hospital policy and placed on the patient's medical record for 2 (#4, #5) of 5 (#1- #5) sampled patient medical records reviewed for Discharge Planning Evaluations.

Findings:
A review of the policy titled "Interdisciplinary Discharge Planning", as provided by S1VP/QA as the most current, revealed in part: The discharge planning interdisciplinary process begins on admission and involves the patient, the patient family, and all team members and identifies all patients who are likely to suffer adverse outcomes when there is inadequate discharge planning. Each patient is screened within 24-48 hours of admission or next business day. SW (Social Workers) and CM (Case Managers) utilize the risk assessment, by completing the patient Psychosocial Assessment tool.

Patient #4
The patient was admitted through the ED (Emergency Department) to a hospital inpatient room on 07/24/17 and was discharged to home on 07/29/17. The patient was a 34 year old male with deafness, chronic right lower extremity ulcer who presented to the Emergency Room with leg pain of his extremity. Patient was admitted for further evaluation for hypoxia due to de-saturation on room air while in the ED.

A review of the patient's medical record revealed no documented evidence of a Discharge Planning Evaluation on the patient's medical record.

Patient #5
The patient was a 38 year old male admitted as an inpatient on 04/11/17 and was discharged on 04/14/17 to home. The patient had a history of end stage renal disease, chronic cirrhosis, and had a history of endocarditis that required a prior heart valve repair. He was admitted to the Intensive Care Unit from the Operating Room after an hypotension episode on induction during an elective hernia repair.

A review of the patient's medical record revealed no documented evidence of a Discharge Planning Evaluation on the patient's medical record.

In an interview on 08/16/17 at 11:00 a.m. with S2DirCM/SW she indicated that a psychosocial assessment was not conducted by a discharge planner on Patient #4 and Patient #5 and therefore a discharge plan was not formulated upon admit and present in the patient's medical record within 48 hours, as per discharge planning policy. She indicated that a Discharge Planning Evaluation should be formulated for all inpatients and placed in the medical record within 48 hours.