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Based on the review of 8 open records and 2 closed records it was determined that 2 open records out of 8 total records did not have a Medicare Important Message upon admission for a Medicare recipient as required by the regulation. Specifically 2 patients did not received the Medicare Important Message within 2 days of admission.
Patient #4 was admitted to an inpatient medical/surgical unit on 11/6/2015. There was no evidence in the record that the patient received the Important Message form within 2 days of admission. Per the hospital policy the Medicare Important Message should be given through a registration area or at the patient ' s bedside.
Patient # 3 was admitted and being held in the ED waiting for a bed on 11/08/15. There was no evidence in the record that the patient received the Important Message form within 2 days of admission. Per the policy Emergency Room patients will be presented the form after the medical screening exam and upon stabilization.

Patient #7 was admitted 09/24/2015. On 09/25/2015 patient was assessed as not having capacity for decision making by the physician and patient #7's sister stated she was health care decision maker. There was no capacity assessment by a physician on 09/24/2015 or 09/25/2015. On 09/26/2015 patient #7 was assessed by the physician along with a witness to have capacity to make their own decisions. Mini mental exams and physician assessments were done during the stay to assess for capacity. On 10/10/15 patient #7 had difficulty with the mini mental exam and was confused. On 10/12/2015 patient #7 was assessed and was not able to perform a mini mental. The RNs were also able to assess during the stay the patient ' s capacity level, which is not an assessment capability of a nurse. Multiple RN ' s assessed patient #7 as not capable for decision making form 10/12/15 to 10/19/2015. A capacity statement was signed by two physicians on 10/15/2015 to certify the patient to lack capacity. There was no rationale as to why the physicians certified for lacking capacity on the form. On 09/24/2015 a form for consent for a G/J tube evaluation was completed and stated that the legal guardian approved the procedure. Per the record there is no evidence of a legal guardian or health care decision maker for the patient. The sister presented a letter from a lawyer stating she was the guardian, but it was not an official court appointment. On 10/05/2015 a form for consent for oral contrast was completed and stated that the sister approved the procedure. At this point patient #7 was deemed to have competency and make their own informed decisions. On 10/12/2015 a form for consent of a blood transfusion was completed and the mother signed approving of the procedure. Patient #7 was starting to get confused and unable to be aroused and make decisions. At this time no capacity for patient #7 was made to determine if patient #7 was capable of making their own decisions.

Based on a review of 8 open records and 2 closed records it was determined that 3 open records and 2 closed out of 10 records did not have a signed informed consent. The form included the patient's facesheet at the top, with an area for informed consent at the bottom, in 4 out of 10 records reviewed the bottom portion of the sheet was not filled out with a signature or a date.
Patient #4 was admitted 11/06/2015 to an inpatient unit, upon reviewing the medical record, the consent at the bottom of facesheet was not signed, dated, or timed by the patient.
Patient #5 was admitted 10/23/2015 to an inpatient unit, upon reviewing the medical record, the consent at the bottom of facesheet was not signed, dated, or timed by the patient.
Patient #6 was admitted 11/04/2015 to an inpatient unit, upon reviewing the medical record, the consent at the bottom of facesheet was not signed, dated, or timed by the patient.
In 2 out of 10 records there was a consent signed by a witness/registrar, but not acknowledged by the patient and did not include a date or time that it was given to the patient.
Patient #7 was admitted to an inpatient unit 09/24/2015, upon reviewing the medical record, the consent at the bottom of facesheet was not signed, dated, or timed by the patient, but was signed by the registrar/witness.
Patient #10 was admitted to an inpatient unit, upon reviewing the medical record, the consent at the bottom of facesheet was not signed, dated, or timed by the patient, but was signed by the registrar/witness.
With this information being included in the record, but not signed it is unknown if the consent was reviewed with the patient upon admission.

Based on a review of 8 open and 2 closed records reviewed, it was determined that 4 out of 10 records did not include a nursing care plan based on dietary needs.

Patient #4 was admitted on 11/6/2015 and was receiving tube feeding through a g-tube during their stay. The care plan for the patient did not include any dietary needs that a patient with tube feeding should have.

Patient #5 was admitted on 10/28/2015 and was receiving total parenteral nutrition( TPN). The care plan for the patient did not include any dietary needs that a patient with total parenteral nutrition should have.

Patient #6 was admitted on 11/04/2015 and was receiving total parenteral nutrition. The care plan for the patient did not include any dietary needs that a patient with total parenteral nutrition should have.

Patient #7 was admitted 09/24/2015 and was receiving tube feeding, along with TPN later in the patient ' s stay/ The care plan for the patient did not included any dietary needs that a patient with tube feeding and TPN should have.

Based on medical record review and staff interviews, it was determined that the nursing and nutrition departments failed to assess and document a plan of care to address significant weight fluctuations for 4 out of 11 medical records reviewed. On 11/9/15, during an interview with Nurse #1 and Registered Dietitian (RD) #1, it was determined that the facility staff failed to have a system or policy In place for identifying significant changes in weight, notifying the physician regarding this significant change in condition and implementing a plan of care to address it. Lastly, it was determined that the nutrition department failed to follow the facility policy and procedure for triaging nutrition risk and potential malnutrition and subsequently determined nutrition assessment and follow up based on this procedure. The findings include the following:
On 11/9/15, during an interview with RD #1 and RD #2, both employees confirmed that the dietitian's do not use the nutrition risk determined levels of care according to the Standards of Nutrition Care Policy to determine when a patient receives an initial nutrition assessment and reassessment. The dietitian's talk amongst themselves to determine which patients to track, assess and reassess nutritionally. The timeframe that nutrition assessments and reassessments will be completed is not documented in the medical record. As a result, the nursing and medical staff cannot identify which patients are assessed to be Nutrition Risk Level of Care III, II or I, high to low risk, respectively, as determined by the dietitians.
Further investigation and interviews of, Nurse #1 and Nurse #2 on the same day revealed that the facility does not have a policy and procedure for monitoring and assessing significant changes in patient 's weight. As a result, there is not a policy to ensure that the physician is notified when a patient experiences a significant weight gain or loss. Without a system for monitoring weights, timely assessment and implementation of interventions to address possible dehydration, fluid overload or malnutrition will not occur. Without a policy and procedure for significant weight change, there is a potential for progressive decline in medical condition due to lack of timely response to weight loss and/or gain.
On 11/9/15, when Nurse #2 was asked who is responsible for monitoring patient weights for significant changes, she replied, "nurses do not track weights that is the dietitian's job " . Respectively, when RD# 1 and RD#2 were asked who is responsible for monitoring weight variances, both stated the nurses follow patient weights daily because we cannot be here 24 hours a day to track weights. Medical record review and interviews revealed there is not any nutrition care plans in the medical records.
Examples of the failure to monitor weights include:
1. Patient #7 has multiple diagnoses including but not limited to brainstem stroke, dysphasia, aspiration pneumonia and sepsis with dependence on a PEG tube, a tube inserted into stomach for nutrition, hydration and medications. Medical record review revealed a confirmed admission weight on 9/24/15 of 116#. Medical record review did not reveal a nutritional assessment including caloric, energy and fluid needs or a targeted weight range despite physician orders for a nutrition consult on 9/25/15, 9/27/15 and 10/9/15.

On 9/27/15, patient #7 ' s weight was 122.76 pound (lb.) indicating a 6.76 lb/5.8% significant total body weight gain in 3 days. There is no documentation in the medical record addressing this weight gain. On 9/29/15, patient #7's weight was 121.4 lb. On 9/30/15, patient #7's weight was 141.2 lb indicating a 19.8 lb/16% total body weight gain in 1 day. Again, there is no documentation addressing the significant weight increase.

On 10/1/15, the weight was 131.1 lb indicating a 10 lb/7.1% total body weight loss in 1 day. Again, there is no assessment of these weight fluctuations. The weight was confirmed on 10/2/15 at 131.3 lb and 10/3/15 at 133.7 lb.

On 10/5/15, the Patient #7's weight was 143.2 lb indicating a 9.5 lb/7.1% significant total body weight gain in 2 days. No documentation was found in the nutrition notes indicating that the weight fluctuations were addressed. The next day, the weight was 138.6 lb, with a 4.6 lb/3.2% weight loss in a day. Nothing in the medical record was found to indicate this weight change was evaluated.

On 10/11 and 10/12/15, patient #7's weights were 137.5 lb and 138.2 lb respectively. On 10/14/15, patient #7 ' s weight was 146.7 lb showing an 8.5 lb/6.2% weight gain in 2 days. An assessment of the weight gain was not documented in the medical record. The next day, the weight was 141.46 lb indicating a 5.2 lb/3.6% weight loss in a day. On 10/17/15, patient #7 weighed 129.36 lb with a 12.1 lb/8.5% significant total body weight loss in 2 days. No nutritional assessment was located in the record regarding this severe weight loss. On 10/19/15, the weight loss was confirmed at 129.8 lb. Again, a nutritional assessment regarding this patient #7's significant weight fluctuations was not done. There is also no evidence to show that the physician was notified regarding the patient #7's significant weight fluctuations.

2) Patient #10 is a 93 year old male with diagnoses including new onset Congestive Heart Failure and recent treatment of pneumonia. According to the Daily Weight Log, on 9/22/15, and the nutrition assessment note dated 9/23/15, the patient #10 admission weight was 156.2 lb, which is 88% of ideal body weight of 178 lb. On 9/24/15, the Daily Weight Log indicated the patient #10 weight was 145.2 lb which is an 11 lb/7% total body weight loss in 2 days. On 9/25/15, the weight was confirmed at 143.6 lb. The RD note on this day, failed to mention the significant weight loss and instead incorrectly stated that patient #10 weighed 156 lb. On 9/26/15, the patient #10 ' s weight was 136.6 lb, which is a 7 lb/4.9% total body weight loss in 1 day. On 9/27/15, weight was confirmed at 132.4 lb. All 3 nutrition progress notes on 9/28, 9/29 and 9/30/15 failed to assess or mention the patient #10 ' s progressive significant weight loss. On 10/1/15, the patient #10 ' s weight was documented at 144.1 lb indicating an 11.7 lb/8.8% weight gain in 4 days. Again, there is no nutrition assessment of this CHF patient experiencing a significant weight increase.

3) Patient #9 is a 94 year old female with diagnoses including pneumonia, sepsis with a tracheotomy and tube feeding dependent for nutrition, hydration and medications. On 11/4 and 11/5/15, patient #9's weight was recorded at 159.2 lb.. The nutrition assessment included a weight the same day of 160 lb. which is 160% of ideal body weight. On 11/6/15, the patient #9 ' s weight increased to 169.4 lb. indicating a 10.2 lb/6.4% significant total body weight gain in a day. On 11/8/15, patient #9's weight was stable at 171.8 lb. On 11/9/15, patient #9 ' s weight was 179.5 lb, which is a 7.7 lb/4.5% significant total body weight gain in a day. The nutrition progress notes failed to assess or mention the progressive significant weight gain in the dietitian progress notes on 11/6, 11/7 or 11/10/15.

4) Patient #8 is a 60 year old female with diagnoses including dehydration, chronic kidney disease and Type II Diabetes. According to the Paragon Flow Sheet, at 9 PM on 10/17/15, the admission weight was 153.78 lb. The " Patient Profile " also indicates on 10/17/15, patient #8 admission weight was 145 lb. The documentation indicates an 8.78 lb/5.7% weight decrease during the same day, which may indicate fluid loss. There is no nutrition assessment in the medical record on 10/17 or 10/18/15.
The physician ordered a renal diabetic diet with Boost Glucose Control three times per day with meals for additional 750 calories, 42 grams protein and 604 ml free water.
On 10/22/15, the weight increased to 155 lb indicating a 10 lb/7% significant total body weight gain in 5 days.
A nutrition assessment was not done until 10/28/15. The dietitian inaccurately states that patient #8 ' s weight is 145 lb on this day. The #8 ' s most recent weight is 155 lb on 10/22/15. The nutrition assessment fails to include an assessment of the significant weight gain on 10/22/15. Instead, the dietitian recommends to initiate a protein modular one packet three times per day with med pass to provide additional 180 calories and 45 grams of protein due to "poor meal intake " .
On 10/29/15, patient #8's weight increased further to 173.8 lb which shows an 18.8 lb/12% total body weight gain in 1 week. There is not a nutrition assessment in the medical record to assess and/or implement interventions regarding this significant weight gain. There is no documentation to show that the physician was notified regarding the weight increase either.
On 11/2/15 and 11/6/15, the physician ordered daily weights be obtained. On 11/2/15, the weight decreased to 158 lb indicating a 15.8 lb/9% significant total body weight loss in 4 days. On 11/3/15, the patient's weight was confirmed at 157.3 lb. Despite a physician order for daily weights, no weight was obtained on 11/4/15 and 11/6 through 11/8/15. Again, there is no nutrition assessments in the medical record after 10/28/15 regarding the confirmed weight loss in November.