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Based on interview, record review, and policy review, the facility did not ensure care was appropriately provided for 3 of 10 sampled patients (Patients #1, #6, & #9). Specifically, a significant weight loss was not identified in a timely manner and the loss was not reported to the physician according to facility policy. Patients were not weighed according to policy.

Findings include:

The facility's "Patient Weight Process Policy", dated 07/28/2010, stated in part, "Weight gain or loss of five (5) percent or more will be reported to the charge nurse. The charge nurse will notify the attending physician of the weight change. The patient will be weighted again within 24 to 36-hours...". The policy stated, "Patients with an admitting diagnosis of Heart Failure (HF/CHF) will be weighed daily".

The facility's "Hemodialysis Order Sheet Policy", dated 03/2012, stated in part, "Obtain daily weight".

The facility's "Standard Order for all Tube Feedings" policy, dated 2011, stated in part, "document the amount of formula and water provided (every 8 hours). Total intake (every 24 hours)".

Patient #1:

Patient #1 was admitted to the facility on 07/16/2012, with diagnoses that included septicemia, systemic inflammatory response syndrome, gastrostomy, cancer, and debility. The patient was discharged to home with home health care on 08/13/2012. The discharge plan included "Home care nurse visiting is arranged for home safety evaluation and for home PEG tube feeding with rate of 70 mL per hour with free water flushing at 200 mL" every six hours. "The patient's wife received PEG tube feeding teaching prior to the patient's discharge". A review of Patient #1's clinical record from the acute facility he entered on 08/14/2012, indicated his "chief complaint" was "vomiting since last night".

Patient #1's admission weight was 177 pounds on 07/16/2012.

Patient #1 was evaluated by the facility's Registered Dietician on 07/17/2012. She documented that no skin breakdown was noted, "moderately depressed visceral protein stores. BMI (body mass index) WFL (within functional limits) at 24.7. Suggest Fibersource HN via PEG continuous (with) goal rate of 70 mL/hour to provide 1680 mL volume 2016 Kcal (25 Kcal/Kg), 89 gm protein (1.1 gm/Kg), 1368 mL free fluids/day..."

Patient #1 was again evaluated by the facility's RD on 07/31/2012. She documented Patient #1's albumin level indicated "moderately depressed visceral protein stores", and that no new weights were available "to assess, weekly checks suggested".

Patient #1 was evaluated again by the facility's RD on 08/10/2012. She outlined a possible bolus schedule, versus continuous feeding "if desired". She documented, "Tolerating (tube feeding). No new (weight) noted... Suggest check (weight) now & then weekly". The RD filled out a "Diet Order and Communication" that stated "Suggest check weight now & then weekly". It was dated 08/10/2012, and cosigned by Patient #1's physician". Patient #1's Medication Administration Record (MAR), indicated that on 08/10/2012, Patient #1's weight was 144 pounds. The patient's clinical record was reviewed. There was no documentation the patient's physician was informed of the weight loss. The patient was discharged home on 08/13/2012.

The facility's RD was interviewed on 09/06/2012. She stated that she expected Patient #1 to maintain his weight because she had taken his cancer and chemotherapy treatment into consideration when she calculated his needs. She stated Patient #1 had experienced a significant weight loss, and her expectation was that a Registered Nurse would be able to identify a significant weight loss and should know a significant weight loss should be reported. She further stated she did not know the facility policy in regard circumstances that an RD should be notified of a weight loss.

Patient #1's care plan identified the problem, "Actual Potential Alteration in Nutrition". One intervention to meet the goal of "maintain/improve nutritional status", included, "Monitor (intake & output)". Patient #1's Intake and Output sheets were reviewed with the RD on 09/06/2012. She acknowledged the sheets were incomplete and had many blanks where an amount of feeding should be documented. A review of the documents indicated there were blanks on 07/17/2012, 07/19/2012, 07/20/2012, 07/22/2012, 07/23/2012, 07/24/2012, 07/25/2012, 07/29/2012, 07/30/2012, 07/31/2012, 08/02/2012, 08/08/2012, and 08/12/2012.


Patient #6:

Patient #6 was admitted to the facility on 08/16/2012, with diagnoses that included acute respiratory failure, congestive heart failure, and neoplasm of the esophagus.

The facility's "Patient Weight Process Policy", dated 07/28/2010, stated in part, "Patients with an admitting diagnosis of Heart Failure (HF/CHF) will be weighed daily". A review of Patient #6's clinical record indicated he had not been weighed daily in accordance with facility policy.

Patient #6's Adult Flow Sheets were reviewed. Patient #6 was not weighed on the following dates:
08/29/2012, 09/03/2012, 09/04/2012, 09/05/2012, 09/06/2012, 09/08/2012, 09/09/2012, 09/10/2012, 09/11/2012, 09/12/2012, 09/13/2012, 09/14/2012, 09/15/2012, 09/16/2012, and 09/18/2012.

Patient #9:

Patient #9 was admitted to the facility on 08/20/2012, with diagnoses that included end stage renal disease, and gastrostomy. The facility's "Hemodialysis Order Sheet Policy", dated 03/2012, stated in part, "Obtain daily weight".

Documentation that Patient #9 was weighed on 09/01/2012 and 09/07/2012, could not be located.


Based on the findings of the investigation, Complaint #NV00032861 was substantiated.