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Based on record review and interviews, the facility failed to meet the needs for 3 (P (Patient) 1, P6 and P8) of 10 (P1 - P10) patients reviewed for neglect.

1. Failed to ensure patients were able to eat and meet nutritional and hydration needs for P1.

2. Failed to provide recommended treatment for P6

3. Failed to reposition P8.

These deficient practices has the potential of harm and death to all patients admitted.

The findings are:

Failed to ensure adequate nutritional and hydration needs for P1:

A. Record review of P1's medical records revealed P1 was admitted on 09/15/2023. Diet ordered on 9/15/2023, at 6:13 pm, was IDDS (Diabetic Diet) minced and moist (texture) with thin liquids. On 9/16/2023 at 12:31 pm diet order changed to ADA (diabetic) dysphagia Pureed (food for patients unable to swallow whole food).

1. Occupational Therapist evaluation dated 09/19/2023, at 10:01 am, stated P1 needs assistance with ADL's (activities of daily living which include, personal hygiene, dressing, toileting, transferring, and eating.)

2. On 09/20/2023, Normal Saline (0.9% salt in water) was ordered by provider to run continuously intravenously, (a catheter inserted in the vein to administer medications and fluids).

3. Nutrition note dated 09/21/2023, stated P1 needs a staff member to assist with meal intake also high protein shakes were ordered.

4. Review of the flowsheets titled, "Activities of Daily Living," revealed the patient only had three (3) meals over the course of seven days.

5. Provider order dated 09/22/2023, naso-gastric (NG tube, a feeding tube placed down the nose into the stomach) tube to be placed for nutrition and hydration.

B. During an interview on 02/12/2024, at 9:30 am, with Staff (S)2, Executive Director of Clinical Services, confirmed that meal intake was not evident in the chart and meal intake should have been documented to monitor for nutritional needs.

Failed to provide recommended treatment for P6:

C. Record review of P6's medical records on a physical therapy note dated 02/1/2024, at 4:32 pm, Occupational Therapist notified Physical Therapist that patient was experiencing drop foot (foot that can no longer stand up and falls forward) on the right foot. Physical therapy assessed and wrote " PF [plantar fascitis] night splint and splint wearing schedule [in form of turn clock that outlines splint to be on for 2 hours and off for 2 hours] provided to patient, RN [Registered Nurse] notified."

1. Review of flowsheet titled, "Musculoskeletal," revealed the splint was not applied to the right foot from 02/01/2024 to 02/10/2024.

D. During an interview on 02/08/2024, at 12:04 pm, with P6 and patient's child, they both stated that the nurses were supposed to be applying a boot to the patient's right foot, on and off every two (2) hours and they have not been doing this.

Failed to reposition P8:

E. Refer to tag A-0398 for findings for P8.

Based on record review and interview the facility failed to ensure that staff were following policy regarding skin care for 1(P [Patient]8) of 10 (P1-P10) patients reviewed for skin care. This deficient practice could lead to patients developing pressure injuries (local damage to the skin and underlying tissue from prolonged pressure).

The findings are:

A. Record review of facility's policy titled, "Pressure Injury Prevention" dated 11/28/2023 on page 3 under "Repositioning" it stated, "Nurses are responsible for turning patients at risk for skin breakdown and documenting the change in position." Additionally, on page 4 it stated, "Care for patients at increased risk per Braden [Structured risk assessment tools used to identify adult individuals at risk for pressure injury and to quantify that risk to support decision-making] or Braden Q Subscale [scale for children ages 3 weeks to 8 years] scores. In addition to the standard prevention measures, incorporate the following:. . . 1.9.3 Reposition every 2 hours and post a turn clock [clock created by therapy to define which direction a patient should be positioned in their bed or in equipment] at the bedside."

B. Record review of P8's medical record for admission date 10/09/2023 revealed the following:

1. Orders revealed an order dated 10/10/2023 at 9:46 PM, ordered generated automatically based on protocols in system, to turn patient every two (2) hours.

2. Document titled, "RN [Registered Nurse] Wound Svcs [Services] Progress Note Form" dated 10/12/2023, at 1:15 PM, revealed a Braden Score of 10 indicating patient was at high risk for developing pressure injuries. Under, "Plan of Care" it stated, ". . . RN wound care received system consult due low Braden score being charted. . . No pressure injuries noted. Recommend preventative mepilex [absorbent type of dressing] foam dressings and [every 2] hour turns, and support surface ASAP [as soon as possible]. Patient currently in stretcher, and at high risk for breakdown."

3. Review of flowsheets titled, "Activities of Daily Living" from 10/09/2023-10/14/2023 revealed that patient was only turned four (4) times on 10/14/2023. The record did not contain any evidence that patient was turned at all from 10/09/2023-10/13/2023.

C. During an interview on 02/12/2024, at 2:40 PM, with Staff (S)4, Executive Director of Clinical Services it was confirmed that there was no evidence of turns in P8's chart.

D. During an interview on 02/13/2024, at 11:24 AM, with S7, Registered Nurse (RN) it was confirmed that patients are turned every two hours if they are at risk for pressure injury and when patients are turned it is charted in the flowsheets.