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Based on interview and record review, RN staff failed to supervise and evaluate the care of Patient ID # 1 per facility policies and professional Standards of Nursing Practice. Nursing staff failed to consistently provide and / or document :

a. strict measurement of intake & output and daily weight per physician orders.

b. percentage of each meal intake;

c. bathing and /or perineal care.

Findings included:

TX00412055

Record review of facility policy titled "Intake and Output ( I & O) Monitoring and Documentation," dated 10/1/2020, showed: The nurse will ensure I & O are documented accurately. I & O is monitored every 4 hours in acute care ( hourly in critical care); and tallied and recorded at change of each shift. I & O will be documented in the electronic health record (EHR) .
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Record review of facility policy titled "Patient Bathing," dated 01/29/2020, showed:

-Bathing for inpatients should occur at least daily, and as needed to maintain clean skin.
-Peri-care should be performed at least once per shift; some patients may require additional care if incontinent.
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Record review of Texas Administrative Code (TAC) Title 22; PART 11 Texas Board of Nursing ; CHAPTER 217 ; RULE §217.11 "Standards of Nursing Practice" showed:

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(B) Implement measures to promote a safe environment for clients and others;
(D) Accurately and completely report and document:
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;
(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;
(U) Supervise nursing care provided by others for whom the nurse is professionally responsible;

Record review of the electronic health record of Patient ID #1, with Staff- L, RN, showed the following:

-MD-History & Physical exam, dated 3/3/2022, showed Patient ID # 1 was a 98 year old female brought to the ER for diarrhea and a poor appetite. Patient was found to have have atrial fibrillation; a urinary tract infection; low potassium, and positive for for C difficile and norovirus colitis. Admission orders included "strict I & O and daily weights." Patient # 1 was admitted to the hospital on 3/3/2022 and discharged home on 03/15/2022.

Review EHR documentation of I & O; daily weights; percentage of meal intake, and bathing/peri-care [from 3/4/2022 to 3/14/2022] showed the following:

- I & O: six ( 6) days were incomplete

- Daily weights: five (5) days- no weights documented.

- Percentage of meal intake : five (5) days: no meal percentage recorded; five (5) days: one meal percentage recorded; two(2) days: two meal percentages recorded.

- Bathing : seven(7) days no bath or refusal by patient was documented.

- Pericare/ adult brief change: four (4) days- no peri-care or adult brief change documented on either shift.

The above information was acknowledged and verified by Staff-L, RN during the record review. During an interview on 12/14/2022 at 4:10 PM with Staff D- RN, Senior Accreditation Specialist , she stated the above information should have been documented by nursing staff. The interventions could not be verified if not documented.