HospitalInspections.org

Based on review and interview Nursing failed to:

1. document Activities of Daily Living (bathing, oral care, shaving, general hygiene care) performed on the patients daily and prn on 2 (1and 4) out of 5 (1-5) charts reviewed.

2. monitor the patients diet, by failing to document the patients intake in 2(1 and 4) of 5 (1-5) charts reviewed.

Review of patient # 1's chart revealed he was admitted to the facility on 11-23-20 in the evening hours. He had complained of passing out for two to three days. His O2 Saturation in the ER was at 69%. Patient #1 was admitted to the telemetry floor and placed on Bipap. The patient respiratory status started to decline, and he was placed in ICU on a ventilator. The patient had a diagnosis of Respiratory Failure, Hypertension, and Extreme Obesity.
Patient #1 experienced Multisystem Organ Failure while in ICU and was placed on dialysis. The patient developed decubiti to the buttocks and became septic. Patient #1 had multiple surgical interventions for debridement of the decubitus to the buttocks and wore a wound vac. The patient was extubated from the ventilator and was moved to a surgical floor in the facility on 12-30-20.

1. Patient #1 was documented in the nurses notes as bed bound and in need of assistance for all Activities of Daily Living (ADL's include: bathing, oral care, shaving, general hygiene care) and with meals. The patient had weakness to left arm and had difficulty with eating and drinking without assistance. The patient had a Foley catheter but was incontinent of his bowels.

An interview was conducted with Patient #1 on 1-25-21. He was still a patient in the facility and was awake and alert. Patient #1 stated he had not had a bath that he could remember from the staff. Patient #1 stated his family had come in at times and helped him bathe. Patient #1 stated he was not given a tooth brush and assisted with brushing his teeth. The patient had a lot of residue and build up on his teeth. The patient's hair was matted and unclean. The patient was unshaven and had a beard. Patient #1 stated that sometimes they turn me and sometimes they don't. Patient #1 stated that they are "rough" with him when turning so there had been times he asked not to be turned. Patient #1 stated he had a bowel movement in his bed after lunch one day and it took 1 hour for anybody to come down to help him get cleaned up. Patient #1 stated sometimes he's afraid to eat because he will have a BM and no one will come to help him. Patient #1 stated he has told staff members about the lack of care he had received but could not give dates or names.

Review of Patient #1's chart revealed the Nursing Care Plan had goals documented under Integumentary System. The goals stated, "Assess skin q shift and prn, monitor skin q shift and prn, reposition q 2hrs and prn, apply barrier cream as needed, utilize pillows to offload bony areas, maintain clean and dry skin." There was no documentation noted that the patient was turned, bathed, given routine hygiene care or who performed that care.

An interview with Staff #7 was conducted on 1-26-21. Staff #7 assisted the surveyor with the chart review. Staff #7 confirmed there was no place to document ADL's and the goals in the care plan were to be followed. Staff #7 stated if the patient received a bath it would be in the free text of the nurse's notes. Staff #7 was asked how you would know if the task were carried out and who did the ADL's, turning and feeding if it was not documented and Staff #7 stated, "I'm not sure unless they documented it in the free text section". Staff #6 also confirmed there was no specific place for the documentation. The facility was unable to provide a policy and procedure for ADL's or incontinent care.

Review of Patient #1's Nurses Notes dated 01-15-21 thru 01-24-21 revealed there was no documentation that the patient received a bath or any other ADL's.

2. Review of Patient #1's chart revealed a physician order to monitor and document the patient's intake and output. Review of the chart revealed inconsistent documentation of the patient's meal consumption as follows:
1-15-21 No documentation that patient ate or was given supplements
1-16-21 No documentation that patient ate or was given supplements
1-17-21 Breakfast 0% Lunch 0% and no documentation of Dinner. No documentation was given supplements.
1-18-21 Breakfast 5% Lunch 10% and no documentation of Dinner.
1-19-21 No documentation that patient ate or was given supplements
1-20-21 Breakfast -R Lunch-R and no documentation of Dinner.
1-21-21 No documentation that patient ate or was given supplements
1-22-21 Breakfast 60% Lunch 60% and no documentation of Dinner.
1-23-21 No documentation that patient ate or was given supplements
1-24-21 No documentation that patient ate or was given supplements Staff #7 confirmed the chart findings.

An interview was conducted with Patient #1 on 1-25-21. Patient #1 stated they bring in his tray and leave it without being set up. Patient #1 had some paralysis to his left side and stated it was difficult to reach for things and needs assistance with meals. Patient #1 stated, "they will come in to get my tray and its still sitting on the table because I couldn't get to it. I tell them not to take my tray because I'm hungry. They just said, 'you won't eat it anyway and leave with it.' I do want my food." Review of Patient's weight revealed he weighed 198kg (435.6lbs) on 11-25-20 and on 1-25-21 he weighed 138.4kg (304.5) a 131.1 lb. weight loss in 60 days.

An interview was conducted with the nursing staff of 4S on 1-25-21. The staff was asked how the patient received trays and who picked them up. Staff #10 stated the trays are delivered and picked up by nursing staff most of the time but can be by dietary. Staff #10 and Staff #9 both confirmed there was a possibility that the trays were not set up and picked up before the patient was done.

Review of Patient #4's chart revealed he was admitted on 9-17-20 with a CVA. The patient had deficits and required assistance with meals. Review of the chart revealed his meals documented as follows:
1-22-21 Breakfast 95% Lunch 95% and Dinner 100%.
1-23-21 No documentation of meals or snacks.
1-24-21 no documentation on meals and 100% for a snack. There was no documentation on why the patient had no meals.

Review of Patients # 2, 3, and 5 revealed there was missing documentation of meals and snacks with no narrative reasons documented. Staff #7 confirmed the chart findings.

An interview with Staff #8 was conducted on 1-26-21. Staff #8 was asked how the Dietician monitored the patient's intake if there was no documentation for multiple days. Staff #8 stated she went by other means to find out which may be by patient interview, talking to the nurse, looking for weight loss, or changes in the patient. Staff #8 confirmed the dietary intake was an important tool in managing a patient's diet. Staff #8 could give no reason on why the patients' diet was not being recorded or why the dieticians had not made that known to administration.