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Based on policy and procedure review, medical record review, and staff interview, the hospital nursing staff failed to maintain nutrition and hydration for 1 of 2 geriatric patients reviewed (Patient #2).

The findings included:

Review on 07/30/2019 of the "Intake Support Policy #11", revised 01/2019, revealed " ... IV. The dietician will provide direction and recommendation regarding the appropriate type of intake support, food items on trays, and nourishments/supplements. Nourishments/supplements will be ordered in the EMR [electronic medical record] by the dietician as "per protocol" ... The nurse records the patient's intake in the EMR ... Food Service provides food/nourishments/supplements acceptable to the patient within the confines of the diet order. Acceptable nourishments/supplements are: Mighty Shakes, Magic Cup ..."

Review on 07/30/2019 of the "Intake and output assessment" Lippincott Procedure, revised June 14, 2019, revealed "... Many patients require fluid intake and output monitoring ... those receiving IV therapy or parenteral or enteral feedings ... Intake and output assessment aids in monitoring a patient's response to treatment, particularly when treating dehydration ... Fluid intake includes oral intake of fluids; IV fluids, medications, and flushes; tube feedings and flushes ... Intake and output measurement should be recorded ... on a 24-hour intake and output record ... A calculation of total intake and output should occur at the end of 24 hours and be recorded, as required by the facility ... Accurate measurement and documentation are essential to guide treatment and achieve optimal fluid balance ... Special Considerations Assess and record indicators of the patient's hydration status such as ... daily weight, thirst ... Notify the practitioner of abnormal findings ..."

Medical record review for Patient #2, on 07/30/2019, revealed a 76-year-old male presented to the Emergency Department (ED) with multiple falls throughout the week, on 03/14/2019 at 1815, and concerns for a urinary tract infection (UTI). Review of the triage nursing assessment by Registered Nurse (RN) #1, on 03/14/2019 at 1903, revealed Patient #2 was 5 foot, 7 inches and 121 pounds. Review revealed Patient #2 was admitted to the medical unit on 03/15/2019 at 2308. Review of the History and Physical (H&P) by Medical Doctor (MD) #1, on 03/15/2019 at 2359, revealed Patient #2's history included dementia and that he had "recurrent falls in the past week." MD #1's assessment of Patient #2's Neurological status revealed, "Alert ....patient does not follow specific commands, does not move legs voluntarily, Not oriented ...Dementia with behavioral disturbance - patient has been having worsening symptoms recently, possibly secondary to his UTI ..." Review of the electronic orders revealed an order by MD #1, on 03/15/2019 at 1144, for "NPO" (nothing by mouth). Continued review revealed an order for a bedside swallow study 03/16/2019 at 0343 by MD #2 and performed on 03/16/2019 at 0721 by the Speech-Language Pathologist (SLP). The SLP noted, " ... Assessment/Findings ... dysphagia Severity: Moderate Severity - Pharyngeal Phase (passage of food or liquid through the vocal cords): Severe Pt is having overt s/s (signs/symptoms) of asp (aspiration) ..." Continued review of the electronic orders revealed a Modified Barium Swallow (MBS) study was ordered by MD #2, on 03/18/2019 at 0915. Review of the MBS report performed 03/18/2019 at 0948, by the SLP revealed "...No Penetration/Aspiration: Contrast does not enter the airway ... Feel he will continue to fluctuate with sw [swallow] function given his cognition and has been requiring sedating meds [medications]. Will thus recommended diet above [Regular, Low Fat/2 gm, Nectar thick, Dysphagia diet] ..." Review of physician progress notes, nursing notes, and the Intake and Output flowsheet, revealed Patient #2 remained NPO until 03/18/2019 at 1008 (approximately 3 days, 15 hours and 5 minutes [87 hours, 5 minutes] prior to MD #2's order for a Regular, Low Fat/2 gm, Nectar thick, Dysphagia diet. Review of the registered dietician (RD) "Nutrition Note", on 03/22/2019 at 1516, revealed " ... Not all PO (by mouth) intake is documented well in the Electronic Medical Record (EMR) ..." Review of the electronic orders revealed on 03/22/2019 at 1517, the RD ordered two (2), Mighty Shake Nectar thick dietary supplements with each meal tray three (3) times per day (t.i.d.) and "Magic Cup", (an oral dietary supplement), t.i.d. on 04/01/2019 at 1104. Review of the documented oral intake for Patient #2 revealed dietary supplements were not documented on the "Oral Nutritional Information" flowsheet or in nursing progress notes. Continued review of the flowsheet revealed the "Feeding Method" was not documented consistently and did not align with the dates and times of the noted percentage of meals eaten. On 04/05/2019 at 1010, the RD placed an order for Patient #2 to be NPO, to begin NG tube feedings, and to flush the NGT with 180 ml water every 4 hours. Continued review of the electronic orders, on 04/06/2019 at 1241, revealed MD #5 ordered to increase flushes to 250 ml water every 4 hours via NGT. " Review of MD #3's consultative note, on 03/25/2019 at 1429, revealed " ... He is eating but very little." Review revealed no documented percentage of meals noted on the "Oral Nutritional information" flowsheet. On 03/30/2019 at 1341, MD #4 noted, "... Not eating much per dgtr. (daughter)." Review of MD #4's progress note, on 04/03/2019 at 1120, revealed " ...currently not responding well enough for po [oral intake by mouth]. cont (continue) npo [nothing by mouth] for now ... appears to be severely dehydrated ... IVF (IV fluids) were stopped overnight ..." Review of the "Nephrology Consult" by MD #7, on 04/05/2019 at 1553, revealed " ... Serum creatinine (test used to measure kidney function) 0.76 [Reference Range: 0.9 - 1.3] on 3/18. On recheck on 4/2 was notable for significant acute kidney injury with creatinine of 5.5 sodium [test used to measure nerve and muscle function] 157 [Reference Range: 135-145]. Patient was started on saline infusion with improvement in renal function. However, serum sodium has increased over the last 5-6 days, now at 176 ... Intake and Output (I&O): 04/04/2019 ... Enteral Tube Flush ... 24Hr: 0 ml ... Oral Intake 24Hr: 0 ml ... Plan: 1. Profound free water deficit noted, currently approaching 6 L (liters) ... poor oral intake/access to free water, and interruption in IV (intravenous) fluid administration ... 3. Increase free water flushes to 250 cc every 4 hours ..." Continued review of provider progress notes revealed, on 04/06/2019 at 0944, MD #7 noted Patient #2's I&O for 04/05/2019 as follows: " ... Enteral Tube Flush: 24Hr 20 ml ... Oral Intake 24Hr 0 ml ... Plan: Renal function continues to improve in the setting of appropriate volume resuscitation ... Hyponatremia (low sodium) improving appropriately on D5W (IV fluid mixture) infusion plus free water flushes ..." On 04/07/2019 at 1142, MD #7 noted that on 04/06/2019 there was no enteral tube flush or oral intake noted. "... Plan: Discussed need to continue D5W and free water flushes to appropriately address the hypernatremia (high sodium), and consistent evaluation of serum sodium level ... If no significant improvement despite normalization of serum sodium levels, resolution of acute kidney failure, transition to comfort care is appropriate. Continued review of progress notes revealed on 04/08/2019 at 1028, MD #7 noted, " ... Continues to be unresponsive ... Plan: Serum sodium continues to improve in the setting of D5W plus free water flushes. Will change flushes to 100 cc every hour, continue D5W ..." Review revealed MD #7 noted on 04/07/2019 there was no enteral tube flush or oral intake noted. Review of physician orders revealed on 04/05/2019 at 1009, MD #4 ordered an NGT, that was placed by RN #2 on 04/05/2019 at 1241. Review of the "Feeding/Diet Information", used to document the "Feeding Method - Ordered Diet Type," nursing flowsheet revealed nursing staff documented the "Feeding Method" as "Oral" from 03/18/2019 at 2000 to 03/31/2019 at 0800; "NPO" from 04/02/2019 at 1204 to 04/05/2019; and Nasogastric tube (NGT), NPO 04/05/2019 at 1600 to 04/08/2019 at 1952. Review of the "Oral Nutritional Information", used to document the percentage of meals eaten, nursing flowsheet revealed nursing staff documented on 03/18/2019 at 1300, Patient #2 ate 50% of lunch and 50% of dinner at 1700. On 03/20/2019 at 0728, Patient #2 ate 50% of breakfast. Review revealed there were no documented additional percentage of meals eaten on the flowsheet until 03/26/2019 (6 days later) at 0900. On 03/26/2019 at 0900, nursing staff noted that Patient #2 ate 75% of breakfast and 50% of lunch at 1300. Review revealed no documented percentage of meals eaten until 03/28/2019 (2 days later) at 1654, when it was noted that Patient #2 ate 25% of dinner. Continued review of the "Oral Nutritional Information" revealed, on 03/29/2019 a 1134, nursing staff noted Patient #2 ate 50% of lunch. On 03/30/2019 at 0945 it was noted that Patient #2 ate 5% of breakfast; 0% of lunch at 1315 and 25% of dinner at 1755 and on 03/31/2019 at 0930, it was noted Patient #2 ate 20% of breakfast and 100% of dinner. On 04/01/2019 at 0930, nursing staff noted Patient #2 ate 0% of breakfast and 0% of lunch at 1130. Review revealed there were no other percentages of meal documented after 04/01/2019 at 1130. Review of the flowsheet revealed the dietary supplements were not documented and Patient #2's percentage of meals eaten were not documented consistently. Review of the Intake and Output documentation from 03/16/2019 at 0700 to 04/09/2019 at 0700 revealed Patient #2's oral fluid intake and the ordered NGT flushes were not documented per policy.

In summary, review of the documented I&O revealed no dietary supplements or additional NGT flushes per physician orders were documented. Review of the documentation revealed the "Feeding Method" was not consistently indicated and did not align with the dates and times of the noted percentage of meals eaten.

Interview on 07/31/2019 at 1025 with RN #3 revealed all nursing staff were taught to document the I&O in the EMR. Upon review of the "Oral Nutritional Information" flowsheet, RN #3 shared that the percentage of meals eaten, dietary supplements and NG tube flushes "were not documented" according to policy and that it was the nurse's responsibility to provide oversight of patient care.

Telephone interview on 07/31/2019 at approximately 1330 with RN #4 revealed the registered nurse is responsible for ensuring nursing care is documented. Interview revealed all intake should be documented in the medical record, including NG tube flushes and dietary supplements. Interview revealed that if NG tube flushes and dietary supplements were not documented in Patient #2's medical record, he (RN #4) could not verify they were done.

Interview with the Chief Nurse Executive on 07/31/2019 at 1430, during record review revealed, nursing staff were trained and expected to document percentage of meals eaten, all known oral intake, NG tube flushes and other ordered treatments. "This is not acceptable practice and it will certainly be addressed."

Interview on 07/31/2019 at 1555 with the Clinical Nutrition Manager (CNM) revealed that when dietary supplements are ordered, the kitchen staff included the supplement on the patient's meal tray. Interview revealed the RD periodically checks meal trays to ensure dietary supplements are provided but there were no formal audits performed. During the interview the CNM shared 100% of the Dysphagia trays are audited for the correct consistency and ordered supplements and are signed off by the kitchen supervisor. In review of the I&O flowsheet for Patient #2 and of the "Nutrition Note", on 03/22/2019 at 1516 by the RD, the CNM indicated that nursing staff failed to document dietary supplements, fluid intake, and percentage of meals eaten per policy.

Interview on 08/01/2019 at approximately 1330 with MD #7 revealed he was consulted on 04/05/2019 and provided consultative services for Patient #2 until 04/07/2019. Interview revealed he recalled that Patient #2 had poor oral intake, had difficulty swallowing and was limited to the access of free water. Interview revealed when initially consulted, on 04/05/2019, IV fluids for Patient #2 had been stopped and he that he was dehydrated. Interview revealed the frequency of NG tube flushes were increased, IV fluids were changed to D5W, potassium repletion per protocol was initiated and "there was improvement in his hydration status noted with appropriate volume resuscitation (replacement)" the next day (04/06/2019).

NC00152900