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Based on observation, interview, and record review, the hospital failed to ensure the nursing staff had evaluated the nursing care for one of three sampled patients (Patient 3) as evidenced by:

1. Patient 3's fingernails and toenails were not trimmed properly.

2. The nursing staff did not consistently weigh Patient 3 weekly as per the hospital's P&P.

3. The nursing staff did not consistently document the meal intakes for Patient 3.

These failures had the potential for unsafe care to the patient.

Findings:

On 8/22/24, Patient 3's medical record was reviewed with the Clinical Nursing Director and Licensing Coordinator. Patient 3's medical record showed Patient 3 was admitted to the hospital on 1/26/24.

1. On 8/22/24 at 1035 hours, an observation of Patient 3's fingernails and toenails was conducted with RN 1. The patient's nails were thick and yellowish. The patient's left hand was contracted, and the fingernails were curved to the palm. RN 1 was asked to measure the patient's fingernails and toenails. The patient's left 3rd fingernail measured 12 mm from the tip of the finger to the edge of the nail. The patient's right and left big toenails measured 5 mm from the tip of the finger to the edge of the nail.

On 8/22/24 at 1116 hours, RN 1 was interviewed. When asked, RN 1 stated if a patient's nails were long, the RN would notify the provider, and many times, it was the NP who would cut the patient's nails. When asked, RN 1 stated she was not aware if anyone had notified the provider of the patient's long nails.

Further review of Patient 3's medical record failed to show the documentation on the nail care.

On 8/22/24 at 1440 hours, during interview with Nurse Manager 1, Nurse Manager 1 stated Patient 3 was in the Medical Surgical Unit, and the physician should cut the patient nails. However, when the patient was transferred to the Behavior Unit on 6/6/24, the information that the physician would cut the patient's nails was not communicated to the Behavior Unit.

2. Review of the hospital's Nursing Clinical Standard titled Physiologic Monitoring/Hygiene/Comfort- Adult Acute Care Units dated December 2021 showed to weight the patient upon admission and weekly (i.e. every Tuesday).

Patient 3's weight records from 6/1 to 8/22/24 were requested.

Review of the weight records showed the following:

* On 6/4/24 at 0600 hours, Patient 3's weight was 64.2 kg.
* On 8/20/24 at 0536 hours, Patient 3's weight was 69 kg.

Further review of Patient 3's medical record failed to show Patient 3's weights were recorded weekly from 6/24 to 8/20/24, as per the hospital's Nursing Clinical Standard.

3. Review of the hospital's Nursing Clinical Standard titled Physiologic Monitoring/Hygiene/Comfort- Adult Acute Care Units dated December 2021 showed to assess the intake and output totals at a minimum of every eight hours.

The random dates were selected to review Patient 3's meal intakes. Review of the meal intakes showed the following:

* On 6/1/24, there was no documentation of the meal intakes for breakfast, lunch, and dinner.
* On 6/2/24, there was no documentation of the meal intakes for lunch and dinner.
* On 6/3/24, there was no documentation of the meal intake for dinner.
* On 7/21/24, there was no documentation of the meal intake for dinner.
* On 7/22/24, there was no documentation of the meal intakes for breakfast and lunch.
* On 8/2/24, there was no documentation of the meal intake for dinner.
* On 8/3/24, there was no documentation of the meal intakes for lunch and dinner.

On 8/22/24 at 1427 hours, the Clinical Nursing Director verified the above findings.