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Based on record review and interview, the hospital failed to ensure nutrition could be received for one (Patient #6) of ten patients.

This failed practice has the likelihood to put patients at risk of delayed healing and a prolonged hospital stay.

Patient #6

Review of the medical record showed no documentation the patient was assisted to eat breakfast, lunch, or dinner from 07/12/21 through 07/18/21 (seven days). Medical record showed that the patient having limited use of his or her upper extremities.

Review of a document titled "Admit Assess-Adult" dated 06/30/21 read in part, " ...left sided weakness ...arm is unable to overcome gravity."

Review of documents titled "Restraint Documentation" showed both of the patient's arms were in restraints from 07/12/21 8:08 AM through 07/18/21 10:00 PM.

Review of a dietitian note dated 07/15/21 read in part, "Assist [with] meal set up/feeds [as necessary].

On 07/23/21 at 9:51 AM, Staff J reviewed the medical record for Patient #6 and stated the following:

1. There was no documentation to show the patient was assisted to eat meals on 07/12/21 through 07/18/21.

2. The patient's left-sided weakness would likely have required the patient to need assistance to eat.

Based on record review and interview, the hospital failed to ensure:

1. interventions were completed as ordered for one (Patient #6) of ten patients,

2. care was provided in accordance with the hospital's written instruction for one (Patient #7) of ten patients.

This failed practice has the likelihood to result in delayed recognition of change in patient condition and increased risk for decline in patient condition. (See Tag 395)

Based on record review and interview, the hospital failed to ensure:

1. interventions were completed as ordered for one (Patient #6) of ten patients,

2. care was provided in accordance with the hospital's written instruction for one (Patient #7) of ten patients.

This failed practice has the likelihood to result in delayed recognition of change in patient condition and increased risk for decline in patient condition.

Review of a policy titled "Intake and Output" read in part, "Routine intake and output will be monitored on every patient, unless ordered otherwise by physician ...Intake and output will be documented by Registered Nurse and at a minimum of every 4 hours, or as ordered by the provider."

Review of a policy titled "Documentation of Inpatient Nursing Care" read in part, "To provide guidelines for the documentation of assessment, planning, delivery and evaluation of nursing care provided ...Routine care activities include: ...Hygiene Care/Meals/Ambulation (Repositioning) ...Registered Nurse collects data through observation and interview. Records data on patient medical record.

Review of a policy titled "Skin and Wound Care" read in part, "Applies to all staff members working in clinical areas who perform physical assessments ...Wounds are assessed ...with shift assessments ...The following parameters are assessed on all wounds: Anatomical location of the wound ...Presence/absence of drainage ...Condition of dressing if not removed at time of assessment and reason wound not visualized."

Intake/Output

Patient #6

Review of the medical record showed orders dated 06/29/21 and 06/30/21 for routine intake monitoring and a regular diet, respectively. Further review of the medical record showed no documentation the patient ate or refused breakfast, lunch, or dinner from 07/12/21 through 07/18/21 (seven days).

On 07/23/21 at 9:45 AM, Staff J reviewed the medical record for Patient #6 and stated the following:

1. They did not see where the patient ate or refused breakfast, lunch, or dinner from 07/12/21 - 07/18/21 and it should have been documented.

2. Not eating put the patient's wound at risk of not healing and put the patient at risk of infection.


Weight

Patient #6

Review of the medical record showed an order for daily weight dated 06/29/21.There was no documentation of the patient's weight for 15 of 23 days. The following dates had missed weight entries:

July: 1, 2, 4, 6, 7, 8, 9, 10, 11, 15, 16, 17, 18, 19, and 21.

On 07/22/21 at 2:36 PM, Staff H reviewed the medical record for Patient #6 and stated there was an order for daily weights and weights were not entered daily.

On 07/22/21 at 2:53 PM, Staff I reviewed the medical record for Patient #6 and stated weighing patients as ordered helped to assess fluid balance and affected weight-based medication.


Turns

Patient #6

Review of the medical record showed an order dated 07/13/21 to turn the patient every two hours and showed the patient was turned two times on 07/19/21 (10 missed turns).

On 07/23/21 at 10:15 AM, Staff J reviewed the medical record for Patient #6 and stated the following:

1. The patient should have been turned every two hours per the order.

2. The patient was admitted on 06/29/21 and on 07/12/21, a new deep tissue injury was documented.


Wound assessment

Patient #7

Review of nursing shift assessments showed no documentation of an assessment of a right malleolus wound for six of six assessments:

06/09/21: AM shift PM shift
06/10/21: AM shift PM shift
06/11/21: AM shift PM shift

Review of physical therapy notes dated 06/09/21, 06/10/21, and 06/11/21 documented a right malleolus wound with purulent drainage and a dressing.

On 07/23/21 at 11:11 AM, Staff J reviewed the medical record for Patient #7 and stated the following:

1. Nurses should have documented the existence of wounds, dressing status and drainage to monitor for infection even if the patient was being seen by physical therapy.