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Based on observation, interview and document review the hospital failed to:
1. Correctly implement the physician's fluid restriction order for patient 5
2. Clarify Resident 8's tube feeding order to include a total volume rate and did not follow the physicians's present order as written.
3. Clarify Resident 11's tube feeding for the rate and/or frequency of advancement of the feeding.

Findings:

Patient 5 was admitted with diagnoses including congestive heart failure and had physician's diet order including 1200 ml fluid restriction. On 8/17/10 at 1:00 p.m. during observations of lunch tray delivery, it was observed Patient 5 had spaghetti noodles with meat sauce, diet pudding, an 8 ounce can of diet cola, and a sealed clear plastic cup of canned mandarin oranges in liquid.
Concurrent observation of the meal tray card revealed the order for the 1200 ml total daily total fluid restriction and information that the current tray provided 8 ounces of liquid. When asked by the surveyor about the fluid in the mandarin oranges, Dietary Supervisor Staff D stated the tray came up right and no fluid would ever be drained "on the floors."

At 1:10 p.m. during an interview in the diet office, Dietary Staff E provided the 9/10/02 hospital "Fluid Restriction Procedure." The procedure did not identify canned fruits in liquid as a source of fluids. Additionally, DS E stated "We only count fluids when the patient asks for them. That patient didn't select them meal. The "system" (menu system) knows how much the patient gets." At 1:15 p.m. DSS D drained the fluid from a plastic cup of mandarin oranges identical to the one the patient received and determined that there was approximately two ounces of fluid provided.

At 1:20 p.m. during an interview, Registered Dietitian F observed the liquid drained from the mandarin oranges and stated "that could really add up." Upon review of the Fluid Restriction Procedure, RD 4 stated the lunch tray should have provided only 240 mls and that for the entire day dietary was allowed 720 mls total from all meals and nursing was allowed the remaining fluids to give to the patient so that the entire day was only 1200 mls. At 1:30 p.m. HDMS C acknowledged the fluid restriction procedure had failed to ensure the physician's fluid restriction orders would be complied with by the dietary department.

2. Patient 8 was admitted with diagnoses that included pneumonia. Medical record review was conducted on 8/17/10 beginning at 11:40 am. A physicians' order dated 8/16/10 noted an order for Crucial (a nutritional supplement) via tube feeding at a rate of 10 cc's/hour; increase by 10 cc's every 6 hours if tolerated. There was no final goal rate established. It was also noted that nursing staff failed to clarify the order.

Observation of Patient 8 on 8/17/10 at 12:15 pm, revealed that the patients' pump was set at a rate of 40 cc's/hour. Concurrent review of the daily flow sheet dated 8/17/10 revealed that on 8/17/10 at midnight nursing staff initiated the tube feeding at 20 cc's hour. The feeding was advanced to 30 cc's/hour on 8/17 at 4 am and to 40 cc's/hour at 8 am. In addition to the lack of final goal rate it was also noted that nursing staff advanced the feeding every 4 hours rather than following the physicians' orders of advancing every 6 hours.

In a concurrent interview with RN 2 the surveyor asked her to describe how nursing staff would ensure that physicians' orders were both complete and were followed. She stated that it was the responsibility of the nurse ending her shift to report to the nurse assuming the care of the patient to review all physicians' orders.

Hospital policy titled Enteral Feeding Management, dated 8/28/08 guided nursing staff to "verify physicians' orders for formula, rate, route and frequency."

3. Patient 11 was admitted with acute respiratory failure and severe hypoxia due to pneumonia. The physician diet order dated 8/15/10 revealed an order for tube feeding of Peptamin starting at 15 cc's/hour with a final rate of 90 cc's/hour. There was no guidance for nursing staff for the rate and/or frequency of advancement of the feeding.

Medical record review was conducted on 8/17/10 beginning at 2 pm. Review of nursing flow sheet noted that the feeding was implemented on 8/15/10 at 12 pm at a rate of 15 cc's. The feeding was advanced to 30 cc's at 6 pm; to 45 cc's at 11 pm; to 55 cc's on 8/16/10 at 2 am; to 70 cc's at 4 am and to 75 cc's at 5:15 am. There was no documentation that nursing staff clarified the diet order.

Hospital policy titled Enteral Feeding Management, dated 8/28/08 guided nursing staff to "verify physicians' orders for formula, rate, route and frequency."