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Based on review of facility policies and interviews it was determined the facility failed to review nursing policies periodically or have a policy in place for when policies should be reviewed.

Findings included:

A review of facility nursing policies and procedures revealed the following policies were not reviewed to ensure current practice.

On 12/27/2016 at 2:00 p.m. a review of the nursing policies revealed the following:
1. RE: Physician Order Management, #PC 307.600, Last Reviewed 03/2014 signed by Chief Nursing Officer
2. Electronic Medication Administration Record System (eMAR), #IM.912.600, Last Reviewed 11/2013 signed by Chief Nursing Officer
3. Patient Care Acuity Levels, #ED-07, Last Reviewed 11/2013, signed by Chief Nursing Officer
4. Admission and Discharge Criteria for Critical Care Unit, #NA, Last Reviewed 03/2015, signed by Chief Nursing Officer
5. Telemetry Standards of Care, #ADM-010, Last Reviewed 08/2012, Department Nursing.

On 12/28/2016 at 12:00 p.m. an interview with the Vice President of Quality Management confirmed the findings. The Vice President of Quality Management revealed there was no policy outlining when nursing policies should be reviewed. The Vice President of Quality Management was unable to determine if the policies were in compliance with the national standards of nursing practice and quality of care initiatives with process improvement.

Based on record review, facility policy review and interviews it was determined the registered nurse failed to supervise and evaluate nursing care related to notifying the physician of changes in condition and meeting the patient's needs for nutrition and personal care for one (#1) of ten sampled records.

Findings included:



On 12/27/2016 at 2:00 p.m. a review of Patient #1's record revealed the patient was admitted on 03/09/2016. The nursing documentation dated 03/15/2016 stated "subject alert and oriented to person, place and time. Wife states poor appetite and patient hardly ever eats, but he appears obese. Patient has refused breakfast and lunch because he didn ' t like what was on the tray, family requested we feed him, certified nursing assistant notified of request". A review of the nursing notes and flow sheets documentation did not show evidence of the patient being fed. The review failed to show evidence of substitution meals being offered to the patient. Documentation failed to show daily personal care needs being met.

A detailed review of the medical record with the Vice President of Quality Management did not reveal any documentation of nursing assisting with meals as request by the family or documentation activities of daily living.

On 12/28/2016 at 11:00 a.m. the Vice President of Quality Management confirmed the above findings.

Review of facility policy titled "assessment/Reassessment", # PC 004.600 stated: Reassessments are performed a minimum of every 4 hours or more frequently as patient's condition indicates; any changes in the patient's status are to be documented. Policy titled "Telemetry Standards of Care", # ADM-010, stated: to document the notification.

A review of patient #1's physician orders revealed an order dated 03/12/2016 for BiPAP [Bilevel Positive Airway Pressure] and to keep the oxygen saturation greater than or equal to 92 percent.

On 12/27/2016 at 2:00 p.m. a review of patient #1's medical record revealed the patient was admitted on 03/09/2016 at 4:31 p.m. A review of the documentation of vital signs and oxygen saturation showed on 03/12/2016 the Oxygen Saturation was documented as 90 percent.
On 03/13/2016 the Oxygen Saturation was documented as 89 percent.
On 03/14/2016 the Oxygen Saturation was documented as 86 percent.
On 03/15/2016 the Oxygen Saturation was documented as 90 percent and 88 percent.
On 0316/2016 the Oxygen Saturation was documented as 89 percent and 85 percent.
On 03/17/2016 at 6:33 a.m. nursing documented "patient did not sleep much throughout the night as he was struggling to keep his BiPAP mask on all night. Patient was getting very frustrated .... Respiratory Therapy... increased his oxygen level . . . also attempted to place patient on non-re-breather however his oxygen saturation would only reach 78 percent...".

A detailed review of the medical record with the Vice President of Quality Management did not reveal documentation the physician was notified of the patient's change in condition.

On 12/28/2016 at 11:00 a.m. the Vice President of Quality Management confirmed the above findings.

Based on review of hospital policy and medical records and staff interview, the facility failed to update the Plan of Care for one (#7) of ten sampled records for nutritional needs.

Findings include:

Review of the facility policy titled "Documentation of Patient Care: Patient's Plan of Care" #IM904.600, indicated "The Plan of Care is initiated and approved by the RN ...the RN will then be responsible for reviewing and prioritizing all problems identified for the patient ...the RN must update the care plan's problem list, goals and interventions a minimum of every twenty-four hours (24) hours".

On 12/28/16 at 8:55 a.m. a review of patient #7's medical record revealed the patient was admitted on 12/26/16. Review of patient #7's Plan of Care (POC) revealed it was initiated on 12/26/16 by an RN. It indicated on the priority list the patient had Impaired Neurological Function with dysphagia (difficulty swallowing) and at risk protocol screen should be performed as soon as possible and before eating. Swallow tool will be added to the chart and nursing interventions should include 1. Nothing by Mouth 2. Head of Bed up.

Review of physician orders revealed a Heart Healthy Diet was ordered on 12/26/16 by the attending Physician. There were no restrictions on oral intake ordered by the physician.

Review of the patient's daily intake revealed the patient was eating 70 percent of meals on 12/27/16 and 12/28/16. Review of the patient's oral intake revealed 500 milliliters (ml) of oral fluids were taken on 12/27/16 and 800 ml of oral fluids were taken on 12/28/16.

Review of Patient #7's POC revealed the following nursing documentation:
On 12/25/16 at 10:26 p.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC.
On 12/26/16 at 8:15 a.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC.
On 12/26/16 at 8:00 p.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC.
On 12/27/16 at 8:00 p.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC.

On 12/28/16 at approximately 12:30 p.m. an interview conducted with Vice President of Quality Management confirmed Patient #7's POC was not updated as required by hospital policy.