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Based on record review, interview, and policy review, the provider failed to ensure one of one sampled patient (1) who had died, had been re-assessed and provided nutrition during his hospitalization. Findings include:

1. Review of patient 1's electronic medical record revealed he had:
*Fallen at home and was transferred by ambulance to the hospital emergency department.
*A right hip fracture.
*Been admitted on 8/21/23.
*An open reduction and internal fixation surgery of his right hip fracture had been completed on 8/22/23.
*Sustained a large skin tear to his right elbow which was repaired in surgery.
*Diagnoses included: alcohol abuse, macular degeneration, hepatitis C, and hypertension.

Review of patient 1's 8/21/23 history and physical revealed he:
*Was alert and oriented upon arrival to the emergency department.
*Was pleasant and cooperative.
*Reported he drank at least six or more beers each night.
-In the past when he was hospitalized he was placed in the intensive care unit and did have significant hallucinations and alcohol withdrawal symptoms.
-He had been sedated for those.

Review of his physician progress notes from 8/21/23 through 8/27/23 included severe protein calorie malnutrition.
*Documentation supporting the malnutrition included:
-He was to have a protein calorie supplement post-operative.
-His albumin (a type of protein that is found in your blood. It is produced by your liver and serves several important functions in the body. One of its main roles is to help maintain the right amount of water in your blood and tissues).was low at 3.0.
*He had body wide muscle mass loss.
-Most likely was secondary to his alcohol use.
*Physician progress notes from 8/28/23 through 8/31/23 revealed:
-"Currently too weak to eat, however restart calorie protein supplement when more awake."
-"He has not had nutrition since 8/4. Would consider PPN [peripheral parenterall nutrition] versus tube feeds after 7 days."
*Physician progress note on 9/1/23 revealed:-"Appreciate nutrition consult. Recommend Tube feeds as opposed to PPN to use the gut."
-"Nutrition to put tube feed orders in."
-"If patient pulls feeding tube, at that point would consider PPN."

His initial nursing nutrition screen was completed:
*On 8/21/23 at 5:26 a.m.
-The screening scores indicated he was not a nutritional risk.
*He had no unplanned weight loss, no non-healing wounds, his oral health was good, he had no chewing or swallowing problems, and he had no issues in obtaining food.
*No further nutrition screening had been completed.

Review of patient 1's care plan initiated on 8/21/23 and classified as continuing care revealed:
*A problem for potential for compromised skin integrity.
*One of the goals was his nutritional status would improve.
*Interventions included:
-Monitor and assess patient for malnutrition.
-Monitor patient's weight and dietary intake as ordered or per policy.
-Determine patient's food preferences and provide high-protein, high-caloric foods as appropriate.
-Assist patient with eating.
-Allow adequate time for meals.
-Encourage patient to take dietary supplement as ordered.
-Collaborate with dietitian.
-Include patient/family/caregiver in decisions related to nutrition.
*This care plan area had been documented by nursing that he was progressing towards his goal during his entire hospitalization.

Review of nursing progress notes received from 8/27/23 at 6:22 a.m. through 9/2/23 at 2:08 p.m. did not contain any documentation in regard to patient 1's nutrition.

Review of patient 1's diet orders and intake records from 8/21/23 thrugh 9/2/23 revealed:
*No documentation he had received any protein calorie supplements.
*Nothing by mouth (NPO) on 8/21/23.
*Advance diet as tolerated on 8/22/23 after his hip surgery.
*His intake record for 8/23/23 was requested but was not received.
*He ate 20% of his breakfast, 30% of his lunch, and no amount recorded for his dinner on 8/24/23.
*He refused any food on 8/25/23, 8/26/23, and his 8/27/23 for all his meals.
*The dietitian had not been consulted until 9/1/23.
*He was NPO starting on 8/27/23 at 6:00 p.m.
*A naso-gastric feeding tube was inserted on 9/1/23.
-On 9/2/23 he received Fiber Source HN formula 130 cubic centimeters (cc) at 6:00 a.m., 150 cc at 8:20 a.m., and 48 cc at 8:39 a.m.
*He died on 9/2/23 at 11:20 a.m.

Review of patient 1's 9/2/23 inpatient death summary revealed:*Causes of death were listed as alcohol withdrawal delirium due to his hip fracture.
*Other significant conditions that contributed to his death were listed as severe malnutrition, elevated international normalized ratio (the time it takes blood to clot), severe alcohol use disorder, and possible Wernicke encephalopathy (type of brain injury caused by a lack of thiamine).
*After the surgical repair of his right hip fracture he developed severe alcohol withdrawal symptoms.
-Those symptoms had been treated with Librium and Ativan [used to treat anxiety].
-His severe hospital delirium persisted.
-He was treated with high dose thiamine for possible Wernicke's encephalopathy.
*He had no nutrition for seven plus days.
-A naso-gastric feeding tube was placed on 9/1/23 with initiation of slow tube feedings.
*It was suspected he had terminal delirium secondary to complex hospital stay.

Interview on 10/25/23 at 1:00 p.m. with registered nurse (RN) C revealed:
*She had provided care to patient 1.
*At the time she cared for him he was sedated due to his alcohol withdrawal symptoms.
*He would not have been able to eat or drink anything due to his sedation.
*She had not reassessed his nutritional needs when she had cared for him.

Interview on 10/25/23 at 2:30 p.m. with RN A revealed:*She had cared for patient 1 on several shifts.
*He was either too sedated to swallow or was agitated.
*He had not been offered any food or fluids, including a protein supplement when she cared for him.
*She had not reassessed his nutritional needs when she had cared for him.
*Medical doctor (MD) E was aware he was not eating or drinking.

Interview on 10/26/23 at 8:00 a.m. with MD E revealed:
*She had been aware he had not been eating.
*The 8/4/23 date in her notes was an error, it should have been 8/24/23.
*Patient 1 was not safe to eat or drink during his alcohol withdrawal.
*She stated she was watching his intake for seven days after the last time he had eaten to address his nutrition.
*When she had ordered the nutritional consult the registered dietitian had recommended starting with tube feeding instead of total parentaral nutrition (TPN).
*She agreed with the:
-Surgical repair of his hip fracture.
-Wound to his right arm from his fall.
-Increased calorie needs during his alcohol withdrawal.
-Nutritional interventions should have been put in place earlier.

Interview on 10/26/23 at 9:30 a.m. with quality, safety, and risk manager B revealed:*An initial nutrition assessment was completed upon admission.
*A follow-up assessment should be completed at least every seven days.
*She agreed patient 1's condition had changed during his hospitalization.
*Another nutritional screening should have been conducted.
*A new nutritional assessment should have been completed again based on the professional judgement of the nurse.

Review of the provider's revised November 2022 Nutrition Screening & Nutrition Assessment policy revealed:*"A nutrition screen will be completed by the nursing staff on each patient within 24 hours of admission and documented on the nursing nutrition screen flowsheet in Epic [electronic medical record]."
*"Those patients determined to be at nutritional risk based on screening results, consult order, or diet order will receive an initial nutrition assessment by the Registered Dietitian within 48 hours of the nutrition screening."
*"Follow up and reassessment will be determined by the Registered Dietitian using professional judgment and nutrition risk indicators. Patients determined to be high risk will be reassessed every 3 days, moderate risk every 4 days and low risk every 7 days. A completed nutrition reassessment form will be placed in an interdisciplinary progress note in the patient's electronic health record by the Registered Dietitian."