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Based on document review, staffing plan review, and staff interview it was determined the facility failed to maintain an adequate number of nursing staff on the 5 South Nursing Unit.

Findings included:

The review of the Staffing Plan revealed a matrix consisting of the number of FTEs (Full Time Equivalent) nursing staff required for the 5 South nursing unit depending on the patient census at the start of the shift. The staffing assignment sheets for 10/6/17 through 11/12/17 on the 5 South nursing unit was reviewed in conjunction with the staffing plan on 1/9/17.

The review of the staffing plan and the review of the staff assignment sheets revealed 9 shifts had 1 FTE RN (full time equivalent registered nurse) on duty less than was required by the staffing plan. On 4 shifts there were 2 FTE RNs on duty less than was required by the staffing plan.

The Risk Manager confirmed the finding in an interview conducted on 1/9/18 at 2:45 p.m.

Based on record review, policy review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care to ensure the patient's needs were met for two (#7, #8) of 10 sampled patients.

Findings included:

1. The History and Physical dated 9/30/17 at 12:18 p.m. and signed by the attending physician included documentation Patient #7 was treated with hemodialysis and had a venous shunt for dialysis access in the right arm. The Interdisciplinary Plan of Care included documentation blood pressure readings were not to be performed in the right arm. The review of the Vital Signs documentation for Patient #7 revealed blood pressure readings were documented to have been taken in the right arm on 10/6/17 at 12:06 p.m., 10/8/17 at 3:55 p.m., 10/13/17 at 3:19 a.m., 10/24/17 at 5:28 p.m., 10/24/17 at 8:28 p.m., 11/17/17 at 7:01 a.m. and 3:26 p.m., 11/18/17 at 3:28 p.m., 11/24/17 at 5:28 p.m. and 11/27/17 at 12:12 a.m., a total of 10 documented occasions. In addition, there were 80 occasions where the location of the blood pressure reading was not documented making it impossible to determine whether or not the blood pressure readings avoided the use of the right arm on these 80 occasions.

The review of the Clinical Progress Notes dated 10/1/17 at 7:00 p.m. indicated Patient #7 was status post a colostomy and ileostomy that afternoon. The review of the Assessments and the Narrative Notes revealed evidence the ostomy appliances were changed on 10/1/17 at 11:00 p.m., 10/9/17 at 12:28 p.m., 10/11/17 at 11:40 a.m., 10/21/17 at 1:30 p.m., 10/30/17 at 4:35 p.m., and 11/24/17 at 17:10 a.m. There was no evidence the ostomy appliances were changed again before Patient #7's discharge on 11/29/17.

The review of the Assessments failed to reveal any evidence of the assessment of the ostomies on 10/10/17 through 10/12/17, 10/17/17 through 10/20/17 and 10/22/17 through 10/26/17. There was no evidence of weekly measurements of the stomas.

The review of the Interdisciplinary Plan of Care failed to reveal any identification of patient needs or nursing interventions related to the care of the patient's ostomies.

A request to provide the facility's policy and procedure related to the care of colostomies resulted in receiving a document titled "Ostomy Pouching: Colostomy or Ileostomy". The document indicated to minimize skin irritation, the nurse should change the skin barrier wafer every 3 to 7 days for a colostomy and every 3 to 5 days for an ileostomy. The document indicated a new stoma was often swollen for the first 2 to 3 post-operative weeks, but it should decrease in size over time. The stoma should be measured at least weekly for the first 8 weeks.

An interview was conducted with the Certified Wound and Ostomy Nurse on 1/9/18 at 10:45 a.m. She indicated new post-operative ostomy patients generally require appliance changes daily to every few days initially. Once the stoma matures and an appliance was properly applied, the appliance will usually need to be changed on an average of five to seven days and very rarely may remain functional up to ten days. The primary reason an appliance required changing was the seal between the appliance and the skin breaks and the contents of the ostomy bag begin leaking. The Ostomy Nurse confirmed the finding the record failed to include evidence Patient #7's ostomy sites and appliances were assessed and changed at expected intervals. She confirmed the finding Patient #7 did not receive ostomy care per policy.

Patient #7, the subject patient, had intestinal surgery on 10/1/17 and received parenteral nutrition advanced to tube feedings and eventually pureed solids.

The Patient Nutrition Assessment dated 10/28/17 at 8:51 a.m. and signed by the RN, indicated Patient #7 required maximum assistance with feeding. The Nutrition Interventions were documented by the RN to be aspiration precautions, offer fluids, offer small frequent meals, offer supplemental snack, oral intake supervision and sitting position for meals.

The review of the Patient Nutrition documentation for Patient #7 from 10/28/17 through discharge on 11/29/17 revealed Patient #7 was provided 3 meals, breakfast, lunch and dinner daily. The documented intake for each meal ranged from 0% to 100%. The meal intake assessments were incomplete for 14 of the 33 days reviewed. There was no evidence Patient #7 was fed or what manner of feeding assistance was provided for 30 of the 33 days reviewed. There was no evidence of the assessment of Patient #7's meal intake for 20 of the 99 meals provided. There was no evidence Patient #7 was offered small frequent meals.

2. Patient #8 was observed to be sitting on the edge of the bed in room 448 with the meal tray in front at 12:50 p.m. on 1/9/18. The tray contained an open milk carton, an opened bottle of ensure with the contents in a plastic cup, and an opened plastic container of juice with the foil seal peeled back. In response to questions, Patient #8 indicated the staff who delivered her tray opened the containers. The meal tray was observed to be black in color.

An interview was conducted with the Director of Dietary Services on 1/9/18 at 11:00 a.m. The Director indicated the facility had implemented a procedure whereby patients who were identified as requiring assistance with opening containers and preparation prior to being able to feed themselves were served meals on a red tray as a flag to the staff. She indicated there was no written policy regarding this practice. She indicated the RN was responsible for identifying patients with assistance needs and notifying the dietary department.

The Risk Manager confirmed the finding there was no evidence Patient #8 was being served meals on a red tray or being assisted with opening containers in an interview conducted on 1/9/18 at 2:45 p.m.. She confirmed the finding the nursing staff failed to appropriately assess and reassess Patient #7's nutritional status. The Risk Manager confirmed the finding there was no evidence the nursing staff ensured Patient #7 was provided small frequent meals. She confirmed the finding there was no evidence the nursing staff provided appropriate assistance with meals to ensure optimal dietary intake for patient #7.