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Based upon policy and procedure review, observation during tours, patient, staff, and physician interviews, and open and closed medical record review the nursing staff failed to monitor the patient's weight and nutrition intake for 4 of 10 sampled patients (#1, 3, 6, & 9).

The findings include:

Review of the hospital's policy and procedure "Interdisciplinary Patient Assessment/Reassessment" effective date of 04/2010 revealed "...This process involves collection and analysis of data to provide for appropriate care decisions by an interdisciplinary team...G. The medical record will serve as a mechanism for communication of assessment and reassessment data among the interdisciplinary team for the purpose of coordinating and prioritizing care. H. Health care providers consider the following in the design of a disciplne specific assessment: ..13. Nutritional status...I. Reassessment is done: 3. To evaluate effect of treatment/intervention..."

Review of the hospital's policy and procedure "Nursing Documentation in BHH (Behavioral Health Hospital) revision date of 01/2012 revealed "to provide a systematic interdisciplinary approach in the medical record for the documentation of actual and potential health care needs...IV.A.2. ...documentation is required to support ongoing reassessment...D. 2. Patient Assessment a...when appropriate, the psychiatric nurse will assess and evaluate a patient using the Minimal Data Set comprised of the following: 6) Nurtrition: Diet/Feeding, Type, Tolerance..."

1. Open medical record review of patient #6 on 08/22/2013 revealed a 42 year old female admitted on 08/16/2013 with diagnosis of Altered Mental Status (AMS). Further review revealed a nutritional consult was requested and completed on 08/17/2013 at 1223 for "poor po (oral) intake" Review of the Nutrition Assessment revealed "consult due to poor po intake: Pt admitted with mental confusion and weakness. Swallow evaluation indicated safe for clear liquids at this time with plan to re-evaluate in a few days ...Stage 1 pressure wound on sacrum noted. Hypercalcemia (elevated calcium levels) possible cause for confusion and poor po intake. Pt weighed 116 lb on March 2013 admission ...Ht: 5' 1"; Wt: 85 lb ...Nutrition Diagnosis: Malnutrition related to mental confusion with hypercalcemia and end-stage cirrhosis as evidence by BMT (body mass index) less than 19.0 severe weight loss of 27% over 5 to 6 months and current weight is 81% of IBW (idea body weight). Nutrition Intervention: 1. Advance diet from clear liquids per SLP (speech/language therapist) evaluation. 2. Will include Boost Breeze supplements with meals while on clear liquids to increase po intake 3. Encourage intake. Nutrition Monitoring and Evaluation: 1. Patient will tolerate advancement of diet and be able to eat greater than 60% of meals and supplements with good tolerance. 2. Monitor patient's po intake and weight status. 3. Follow patient for advancement of diet, tolerance of meals, supplements and clinical course."

Continued medical record review revealed a Nutrition Follow-Up Assessment on 08/21/2013 at 1349 revealed "...Bedside swallow eval (evaluation) on 08/19 with ST (speech therapist) recommends regular texture and thin liquids; diet advanced ...Stage II noted to sacrum per RN flow sheet.. Pt very preoccupied during visit, unsure if she was drinking supplements. Spoke with RN, reports very low intake of food, a few bites of toast at breakfast and hasn't seen much intake of supplements ... Wt.: 85 lb ...Nutrition Intervention: 1. continue regular diet, changing meal service to needs assistance ... 3. consider appetite stimulant d/t (due to) pt with inadequate intake. Nutrition Monitoring and Evaluation: 1 ...meet estimated needs via oral diet and use of supplements 2. Monitor tolerance to and adequacy of diet, goal > (greater than) 50% intake of meals and 100% intake of supplements 3. Continue to follow pt status, clinical course and plan of care."

Continued medical record review revealed documentation of patient #6's weights on 08/16/2013 at 1801 of 85 lb. Review of the medical record revealed no other weights documented.

Continued medical record review of meal intake revealed on 08/17/2013 and 08/18/2013 no documentation of meal intake. Continued review revealed on 08/19/2013 at 1048 - 50% meal intake; 08/19/2013 at 1633 - 10% meal intake (no documentation of lunch meal intake); 08/21/2013 at 1118 - 5% meal intake; 08/21/2013 at 1403 - 0% meal intake (no documentation of dinner intake).

Interview on 08/21/2013 at 1415 with the NA #1 (nursing assistant) revealed "...the NA documents meal intake three times a day for each meal ...if the patient does not eat we enter a 0% or if they are NPO (nothing by mouth) we write in NPO. If the patient is not eating well we inform the RN (registered nurse) who will inform the physician ...we weigh every patient upon admission and then if the doctor orders more or if the RN tells us to then we weigh the patient based upon that."

Interview on 08/21/2013 at 1500 with the RN Clinical Manager revealed "we document the percent of meal intake for every meal ...if a patient is not eating well the nurse can enter a nutritional consult to the dietician ...definitely I would expect the nurses to weigh patients that are not eating even if the doctor has not ordered it to be done."

Interview on 08/22/2013 at 0830 with the Registered Dietician revealed "once we are consulted the dieticians will monitor and evaluate the patient's weight gain or loss and food intake ...if we can't get sufficient information from the chart then we speak with the nursing staff, the patient, or the family to try to determine what the oral intake is ...weight measurements is determined by the nutritional risk level, if a patient is high risk I would expect the weights to be no more than every 7 days but preferably every 3-4 days ..."

Interview on 08/22/2013 at 1300 with administrative staff revealed "per protocol the percent of meal intake is to be documented for each meal ...I see that it is not done for this patient ...yes our documentation could be better, there is subjectivity to the RN's documentation ...I would expect a nurse to use their critical thinking skills to determine when a patient should be weighed and not wait on a physician order ...nutritionally compromised patient's should be weighed regularly and have their meal consumption documented for each meal." The interview confirmed the facility staff failed to document and monitor the patient's weight and nutrition intake.

2. Open medical record review of patient #9 on 08/22/2013 revealed a 78 year old male admitted on 08/16/2013 with diagnosis of Pleural Effusion (fluid in the lungs), Fractured ribs, poor po intake, and weight loss (reported 15 lb weight loss), metastatic cancer, and prostate cancer. Further review revealed a nutritional consult was requested and completed on 08/18/2013 at 1348 for "poor po intake and weight loss". Review of the Nutrition Assessment revealed " nutrition risk triggered by poor po intake and weight loss: reports 15 lb wt loss over the past month w (with)/decreased appetite and loss of interest in eating ...Ht: 5' 11"; Wt. 189 lb ...Nutrition Diagnosis: Inadequate oral intake related to catabolic illness and recent fall as evidenced by observed poor po intake and severe weight loss of 7% over 1 month. Nutrition Intervention: 1. Continue consistent CHO (carbohydate) diet and encourage intake at meals 2. Include Boost Glucose Control supplements with meals to increase po intake. Nutrition Monitoring and Evaluation: 1. Pt will increase po intake to eat greater than 60% of meals and supplements with good tolerance. 2. monitor patient po intake and weight status 3. Follow patient for tolerance of meals, supplements and clinical course."

Continued medical record review revealed documentation of patient #9's weight on "08/16/2013 at 1422 of 189 lbs." Review of the medical record revealed no other weights documented.

Continued medical record review of meal intake revealed on 08/17/2013 at 0845 - 50% meal intake (no documentation of lunch or dinner meal intake). Continued review revealed no documentation of meal intake on 08/18/2013. Continued review revealed on 08/19/2013 at 0920 - 50% meal intake; 08/19/2013 at 1735 - 75% meal intake (no documentation of lunch meal intake). Continued review revealed no documentation of percent of meal intakes for 08/21/2013.

Interview on 08/21/2013 at 1415 with the NA #1 (nursing assistant) revealed " ...the NA documents meal intake three times a day for each meal ...if the patient does not eat we enter a 0% or if they are NPO (nothing by mouth) we write in NPO. If the patient is not eating well we inform the RN (registered nurse) who will inform the physician ...we weigh every patient upon admission and then if the doctor orders more or if the RN tells us to then we weigh the patient based upon that ... "

Interview on 08/21/2013 at 1500 with the RN Clinical Manager revealed "we document the percent of meal intake for every meal ...if a patient is not eating well the nurse can enter a nutritional consult to the dietician ...definitely I would expect the nurses to weigh patients that are not eating even if the doctor has not ordered it to be done."

Interview on 08/22/2013 at 0830 with the Registered Dietician revealed "once we are consulted the dieticians will monitor and evaluate the patient's weight gain or loss and food intake ...if we can't get sufficient information from the chart then we speak with the nursing staff, the patient, or the family to try to determine what the po intake is ...weight measurements is determined by the nutritional risk level, if a patient is high risk I would expect the weights to be no more than every 7 days but preferably every 3-4 days."

Interview on 08/22/2013 at 1300 with administrative staff revealed "per protocol the percent of meal intake is to be documented for each meal ...I see that it is not done for this patient ...yes our documentation could be better, there is subjectivity to the RN's documentation ...I would expect a nurse to use their critical thinking skills to determine when a patient should be weighed and not wait on a physician order ...nutritionally compromised patients should be weighed regularly and have their meal consumption documented for each meal." The interview confirmed the facility staff failed to document and monitor the patient's weight and nutrition intake.

3. Open medical record review of patient #1 on 08/21/2013 revealed an 80 year old male admitted on 08/08/2013 with diagnosis of UTI (urinary tract infection) Further review revealed a nutritional consult was requested and completed on 08/09/2013 at 1243 for "weight loss and poor po (by mouth) intake." Review of the Nutrition Assessment revealed "ate approx (approximately) 1/3 of meal. Visitor present in room reports intake better at lunch than it was at breakfast this am. Pt (patient) had not been eating well at home. Admitted with increased confusion, diarrhea, UTI (Urinary Tract Infection) and elevated creatinine....Ht (height) 5' 6"; Wt. (weight) 165 lb (pounds) ...Nutrition Diagnosis: Inadequate oral intake related to mental confusion and urological obstruction as evidenced by report and observed po intake. Nutrition Intervention: 1. continue consistent CHO (carbohydrate) diet. 2. Encourage intake at meals. Nutrition Monitoring and Evaluation: 1. Patient will increase po intake to eat greater than 60% of meals with good tolerance. 2. Monitor patient's po intake; if po intake continued to be less than optimal, will add nutrition supplements. 3. Follow patient for tolerance of meals and clinical course. "

Continued medical record review revealed a Nutrition Follow-Up Assessment on 08/14/2013 at 1510 revealed " ...spoke with pt and SO (significant other). SO reports pt ate approximately 1/3 of breakfast and lunch today. Says he ate better yesterday with approximately ? of each meal tray consumed. Says pt is having some trouble chewing and is trying to order him soft food. ..agrees to trying chopped meats with gravy ...Wt: 157 lb 3.2 oz (ounces) ...Nutrition Monitoring and Evaluation: 1. Patient will increase po intake to eat greater than 60% of meals consistently with good tolerance. 2. Monitor patient's po intake; if po intake continues to be less than optimal, will add nutrition supplements. 3. Follow patient for tolerance of meals, chewing/swallow status and clinical course. "

Continued medical record review revealed documentation of patient #1 weights on 08/08/2013 at 1531 - 165 lb (admission weight); 08/11/2013 0517 at 174 lb 6.4 oz; 08/12/2013 at 0304 - 168 lb 8 oz.; 08/14/2013 at 0321 157 lb 3.2 oz.; 08/15/2013 at 0011 - 164 lb (last date a weight is documented - 6 days since last weight).

Continued medical record review of Patient #1's meal intake revealed 08/09/2013 at 0934 - 15% intake (no documentation of lunch or dinner); 08/10/2013 (no documentation of meal intake); 08/11/2013 at 1234 - 50% (no documentation of breakfast or dinner intake); 08/12/2013 no documentation of intake; 08/13/2013 no documentation of meal intake; 08/15/2013 at 0320 - 0% intake (no documentation of breakfast, lunch, or dinner); 08/17/2013 at 2041 - 0% (no documentation of breakfast or lunch); 08/20/2013 at 1412 - 20% (no documentation of breakfast or dinner).

Interview on 08/21/2013 at 1415 with the NA #1 revealed "...the NA documents meal intake three times a day for each meal ...if the patient does not eat we enter a 0% or if they are NPO (nothing by mouth) we write in NPO. If the patient is not eating well we inform the RN (registered nurse) who will inform the physician ...we weigh every patient upon admission and then if the doctor orders more or if the RN tells us to then we weigh the patient based upon that ... "

Interview on 08/21/2013 at 1500 with the RN Clinical Manager revealed "we document the percent of meal intake for every meal ...if a patient is not eating well the nurse can enter a nutritional consult to the dietician ...definitely I would expect the nurses to weigh patients that are not eating even if the doctor has not ordered it to be done."

Interview on 08/22/2013 at 0830 with the Registered Dietician revealed "once we are consulted the dieticians will monitor and evaluate the patient's weight gain or loss and food intake ...if we can't get sufficient information from the chart then we speak with the nursing staff, the patient, or the family to try to determine what the oral intake is ...weight measurements is determined by the nutritional risk level, if a patient is high risk I would expect the weights to be no more than every 7 days but preferably every 3-4 days."

Interview on 08/22/2013 at 1300 with administrative staff revealed "per protocol the percent of meal intake is to be documented for each meal ...I see that it is not done for this patient ...yes our documentation could be better, there is subjectivity to the RN's documentation ...I would expect a nurse to use their critical thinking skills and determine when a patient should be weighed and not wait on a physician order ...nutritionally compromised patient's should be weighed regularly and have their meal consumption documented for each meal ..." The interview confirmed the facility staff failed to document and monitor the patient's weight and nutrition intake.

4. Closed medical record review of patient #3 on 08/21/2013 revealed a 59 year old male admitted on 06/15/2013 to the BH (Behavioral Health) unit with diagnosis of Paranoid Schizophrenia and MR (mental retardation). Continued review of the medical record revealed on 06/22/2013 the patient began having uncontrolled seizures and was admitted to the Acute Care Medical floor with admission diagnosis of Seizures and Aspiration Pneumonia. Continued review revealed the patient was discharged to home on 06/28/2013. Continued review revealed the patient was readmitted to the medical floor on 07/18/2013 with a diagnosis of "Anorexia ... UTI (urinary tract infection) ..." Continued review revealed the patient was discharged on 08/02/2013 to a long term care facility.

Review of the Nutrition Assessment on 06/24/2013 at 1334 revealed "Nutritional Assessment: Consulted for tube feeding recommendations: Nutritional Risk Identified on initial admission assessment due to decreased po intake > 7 days prior to admission. Intubated/sedated (breathing tube). Problem list includes status epilepticus (seizures), aspiration pneumonia, hypernatremia, UTI, ...Ht: 6' 0". Wt: 186 lb 4.6 oz. Nutrition Diagnosis: Inadequate oral intake related to Respiratory failure as evidenced by ETT (endotracheal tube) in place. Nutrition Intervention: Recommend Nutren Replete (tube feeding) ...Nutrition Monitoring and Evaluation: Goal: Meet 100% EEN (expected energy needs) via Enteral Nutrition (Tube feeding) if not extubated in next 24 - 48 hours.."

Review of the Nutrition Assessment: Follow-up note on 06/27/2013 at 1829 revealed "pt is incomprehensible. He has not had any nutrition since prior to admission. Dx: extubated (ETT removed), failed swallow eval (evaluation)."

Continued medical record review revealed a Nutrition Follow-Up Assessment on 08/14/2013 at 1510 revealed "...spoke with pt and SO (significant other). SO reports pt ate approximately 1/3 of breakfast and lunch today. Says he ate better yesterday with approximately ? of each meal tray consumed. Says pt is having some trouble chewing and is trying to order him soft food. ..agrees to trying chopped meats with gravy ...Wt: 157 lb 3.2 oz (ounces) ...Nutrition Monitoring and Evaluation: 1. Patient will increase po intake to eat greater than 60% of meals consistently with good tolerance. 2. Monitor patient's po intake; if po intake continues to be less than optimal, will add nutrition supplements. 3. Follow patient for tolerance of meals, chewing/swallow status and clinical course."

Continued medical record review revealed documentation of patient #3's weights on "06/15/2013 at 2028 - 185 lb; 06/16/2013 at 0308 - 185 lb.; 06/22/2013 at 1300 - 186 lb 4.6 oz (6 days before discharge date of 08/28/2013).

Continued medical record review of meal intake revealed 08/09/2013 at 0934 - 15% intake (no documentation of lunch or dinner); 08/10/2013 (no documentation of meal intake); 08/11/2013 at 1234 - 50% (no documentation of breakfast or dinner intake); 08/12/2013 (no documentation of intake; 08/13/2013 no documentation of meal intake; 08/15/2013 at 0320 - 0% intake (no documentation of breakfast, lunch, or dinner); 08/17/2013 at 2041 - 0% (no documentation of breakfast or lunch); 08/20/2013 at 1412 - 20% (no documentation of breakfast or dinner).

Interview on 08/21/2013 at 1415 with the NA #1 revealed "...the NA documents meal intake three times a day for each meal ...if the patient does not eat we enter a 0% or if they are NPO (nothing by mouth) we write in NPO. If the patient is not eating well we inform the RN (registered nurse) who will inform the physician ...we weigh every patient upon admission and then if the doctor orders more or if the RN tells us to then we weigh the patient based upon that ..."

Interview on 08/21/2013 at 1500 with the RN Clinical Manager revealed "we document the percent of meal intake for every meal ...if a patient is not eating well the nurse can enter a nutritional consult to the dietician ...definitely I would expect the nurses to weigh patients that are not eating even if the doctor has not ordered it to be done."

Interview on 08/22/2013 at 0830 with the Registered Dietician revealed "once we are consulted the dieticians will monitor and evaluate the patient's weight gain or loss and food intake ...if we can't get sufficient information from the chart then we speak with the nursing staff, the patient, or the family to try to determine what the po intake is ...weight measurements is determined by the nutritional risk level, if a patient is high risk I would expect the weights to be no more than every 7 days but preferably every 3-4 days ..."

Interview on 08/22/2013 at 1300 with administrative staff revealed "per protocol the percent of meal intake is to be documented for each meal ...I see that it is not done for this patient ...yes our documentation could be better, there is subjectivity to the RN's documentation ...I would expect a nurse to use their critical thinking skills and determine when a patient should be weighed and not wait on a physician order ...nutritionally compromised patient's should be weighed regularly and have their meal consumption documented for each meal ..." The interview confirmed the facility staff failed to document and monitor the patient's weight and nutrition intake.

Based upon policy and procedure review, observation during tours, and staff interviews the facility failed to secure patient medical records for 1of 2 units toured (medical/pulmonary/oncology unit).

The findings include:

Review of the hospital's policy and procedure "Security of the Medical Record" effective date 03/2012 revealed "...hospital leadership, will strive to ensure that medical records and other information will be maintained in secure and restricted areas with access limited to those staff members who have need for access based on either patient care needs and/or position responsibilities...D. The medical record will be under the surveillance of the Director of Health Information Management, other department managers and staff 24 hours a day...G. Medical Records required in patient care areas are maintained in a controlled setting and within the secured confines of the nursing unit..."

Observation during tour on 08/20/2013 at 1045 revealed a 44 bed medical pulmonay/oncology unit with a current census of 40 patients. Observation revealed the unit had one centralized nursing station and 6 pods (desks) that were strategically located throughout the hallways of the nursing unit. Observation revealed the pods were recessed alcoves that contained a desk with 2 computers. Observation revealed on the wall over the desk was a chart rack that held medical records for current patients. Observation of the contents in the chart revealed signed consents for surgery, EKG (electrocardiogram) strips, and PAS (preadmission screening documents for mental health placement). Continued tour and observation of the POD's revealed 3 stations were unattended and medical records were in the racks above the POD's with no staff monitoring the access of the records. Observation revealed housekeepers and visitors in the hallways.

Interview during the tour with administrative staff revealed "at times there is no one in attendance at the pods and the station (pod) is left unattended. I can see that the charts are not secured and this may be a problem." Inteview confirmed the patient's medical records are not maintained in a controlled and secure setting.

NC00090646