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Based on interviews and record reviews, the facility failed to provide nursing services in an organized manner in that nursing staff failed to accurately assess Patient #4's meal intakes nor notify physician of Patient #4's declining meal intakes, placing Patient #4 at risk for malnutrition.

Findings included:

Review of Patient #4's face sheet revealed an 85-year-old male admitted to the facility on 1/22/19 from a nursing home. There was no information recorded under "Admitting Diagnosis."

Review of Patient #4's H&P (History and Physical) with an encounter date of 1/21/19 revealed in part " ...brought in for visit due to his recent placement in nursing home ... has become more agitated, uncooperative, aggression towards other members ... the biggest problem that he has had not only at home but in the facility is adequately taking fluids and nutrition ..."

In an interview on 2/6/19 at 4:30 p.m. with Staff #7, MD (Medical Doctor), he stated he noticed Patient #4's meal intake was declining and ordered additional supplements. He stated he found the decline himself and no one had notified him.

Review of Patient #4's Physician Note dated 1/26/19 revealed " ...patient has poor intake."

Review of Patient #4's Physician Order dated 1/26/19 revealed an addition of Ensure TID (three times a day), Gatorade TID, and change to a Pureed Diet.

Review of Patient #4's Observation Check Sheet revealed the following meal consumption (expressed in % and in order of breakfast, lunch, and dinner):
-1/23/19: 50, 50, 30
-1/24/19: 25, 50, 0
-1/25/19: 0, 50, 25
-1/26/19: not documented for any meals
-1/27/19: 0, 30, 30

Review of Patient #4's Daily Nurse Note revealed the following remarks under "Nutrition/Fluid":
-1/23/19: "adequate"
-1/24/19: "prompting"
-1/25/19: "adequate"
-1/26/19: "adequate"
-1/27/19: "adequate" and "supplement"

In an interview on 2/6/19 at 4:08 p.m. with Staff #22, RN (Registered Nurse), she was asked about staff communication related to meal intake issues. She stated MHTs (Mental Health Technicians) were expected to report to nurses if second consecutive meals were missed or inadequate.

In an interview on 2/6/19 at 5:00 p.m. with Staff #22, RN, she stated based on Patient #4's Observation Check Sheet from 1/23/19 to 1/27/19 the physician should have been notified about meal intake issues around 1/26/19. When asked about facility policy on physician notification, she stated she did not know exactly when to notify physician of meal intake issues.

In an interview on 2/6/19 at 5:40 p.m. with Staff #2, ADON (Assistant Director of Nursing), she was asked about what was considered adequate or inadequate regarding meal intakes. She stated 50% or less was inadequate, and after 48 hours of consecutive meal intake issues, she expected staff nurses to notify the physician. After communicating over the phone with Staff #3, DON (Director of Nursing), Staff #2 stated staff nurses were expected to document on Multi-Disciplinary Note of any physician notification and notify daily of nutrition/meal intake issues. Staff #2 was asked to provide a policy on physician notification.

Review of Patient #4's Multi-Disciplinary Notes from 1/23/19 to 1/27/19 revealed no evidence of physician notification regarding declined meal intakes.

In an interview on 2/6/19 at 6:10 p.m. with Staff #4, Patient Advocate, she stated facility did not have a policy on physician notification.

Based on interviews and record reviews, the facility failed to effectively maintain clinical records in that facility was unable to timely retrieve Patient #1's clinical records as needed.

Findings included:

During an entrance conference on the morning of 2/6/19, the facility was asked to provide clinical records (closed record) of Patient #1.

In an interview on 2/6/19 at 10:15 a.m. with Staff #5, Director of Medical Records, she stated that medical records of Patient #1 were not physically available onsite. She stated facility outsourced storage of older medical records to a company in Abilene, but was transferred to another company (VRC- Vital Records Control) in Dallas back around October 2018. She further stated she contacted VRC company for records retrieval but was given response that "it would take a while since the file is somewhere among the pile of pallets and company would have to go through each pallets."

Review of contracted service agreement between the facility and VRC revealed contract was signed on 9/6/17 by facility personnel and on 8/31/17 by VRC personnel.

In an interview on 2/6/19 at 11:50 a.m. with Staff #1, Administrator, she stated there was a system of storing medical records by reference number in each file box. She stated facility was told by VRC company that the file box storing Patient #1's medical records was missing and VRC company was currently going through each boxes in an attempt to locate Patient #1's medical records. She further stated Corporate was responsible for maintaining medical records and Corporate communicated with Staff #5.

Review of facility policy titled "Retention & Destruction, Section: Management of Information" revealed the following:
-purpose: "This policy is intended to establish a process for the efficient, systematic and consistent control of company records from creation through processing, distribution, retrieval, and destruction."
-responsibilities: 1. "Managers ... responsible for assisting with the records retention policy and ensuring compliance ... requesting retrieval of records from offsite storage facilities when required by respective functions ... ensuring stored records are retained, protected, retrieved ..." 2. "All Company personnel (employees, managers, contractor, etc.) are responsible for ensuring ... records are identified, stored, protected ..."

In an interview on 2/6/19 at 6:05 p.m. with Staff #5, she stated VRC company was still looking for Patient #1's medical records and was unable to provide a timeframe for retrieval.