HospitalInspections.org

Based on a review of facility policy and procedures, a medical record review, and interviews with facility staff, it was determined that the facility failed to promote and protect the rights of five out of five sampled patients (P#1, P#2, P#3, P#4, and P#5). Specifically, the facility failed to protect a patients' rights to be free from neglect and lack of personal comforts due to infrequent monitoring of dietary intakes and infrequency of hygienic care. As a result, P#1 lost 19 pounds while under the facility's care and developed a moisture-related rash on the buttocks and groin.

Cross-reference A0145 as it relates to the right of patients to be free from all forms of abuse.

Based on a review of policy and procedures, a medical record review, and interviews with staff, it was determined that the facility failed to protect patient right to be free from neglect for five out of five sampled patients (P#1, P#2, P#3, P#4, and P#5) when the frequency of hygiene and dietary intake was not monitored to ensure adequate nutrition and hygiene.

Findings:

A review of the facility's policy titled "Patient Rights and Responsibilities" policy #G-53, revised 5/19, revealed that patients had the right to be free from all forms of abuse or harassment.

A review of the facility's policy titled "Nursing Plan of Care Guidelines for Use," policy #6010-042, revised 12/20, revealed the nursing plan of care would be developed by the Registered Nurse (RN) and remained the responsibility of the RN. The RN would initiate the plan of care within 12 hours of admission. Each patient would be screened for problems as part of the nursing assessment. The nurse would individualize interventions if the assessment revealed that a patient was experiencing a problem. Additional problems would be addressed through Care Paths or other appropriate care plans. Interdisciplinary Teams would develop Care Paths. The care plan would be reviewed daily by the RN or Licensed Practical Nurse (LPN) under the supervision of an RN. If the plan remained appropriate, the nurse would document that the care plan had been reviewed. The RN would adjust the care plan as required for the addition or removal of problems.

A review of the facility's policy titled "Nursing Documentation" policy #6010-092, revised 2/22, revealed that continuity of care was assured through the accurate and complete documentation of assessment, planning for care, nursing interventions, and evaluation of patient progress and outcomes. Persons providing care were responsible for documenting the care provided. At a minimum, there would be evidence that the nursing process was used in documenting assessments, history, screening, and interventions via the flowsheets. In addition, the patient problem list and appropriate interventions would be documented in the care plans. Nursing narrative notes would also be used to document the effectiveness of nursing interventions, including the patient's responses to nursing interventions. Other disciplines would also document via the flow sheets available for all other disciplines to view.

A medical record review for Patient (P) #1 revealed that P#1 was admitted to the facility from the Emergency Department (ED) on 10/11/22 at 7:30 p.m. with pneumonia, COVID-19, Urinary Tract Infection (UTI), difficulty walking, left-side paralysis, fever, and muscle weakness. An ED History and Physical on 10/11/22 at 12:42 p.m. revealed no rashes on P#1's skin at the time of admission to the hospital.

A review of an Initial Nutrition Note on 10/13/22 at 8:46 a.m. by Registered Dietician (RD) AA revealed the nutrition diagnosis was inadequate oral intake related to decreased appetite. Zero percent of meals had been consumed for the past two days. The goals were for P#1 to consume at least 25 percent of meals and oral nutritional supplements, maintain a stable weight, and meet established needs. Encouraging oral intake was added to the plan of care. P#1's weight, oral intake, laboratory tests, and intake/output were to be monitored.

A review of a note by the Registered Dietician (RD) AA on 10/18/22 revealed that P#1 was on a regular diet with nutritional supplements twice daily. P#1 had a poor to fair appetite, with 35 percent of meals consumed. P#1 weighed 68.6 kilograms (kg.) (151 pounds) (lbs.). P#1's weight had decreased by 1.58 kg. (3.48 lbs.) Recommendations were to encourage good oral and nutritional supplement intake.

A review of a note by the RD BB on 10/21/22 at 3:01 p.m. revealed that P#1's weight had decreased to 62.8 kg (139 lbs.). P#1 was on a regular diet with liquid supplements twice daily. P#1's appetite was fair to poor, with an average of 25 to 60 percent meal consumption per the flowsheets.

A review of flowsheets for P#1 revealed the following weights, rounded to the nearest whole number:

10/13/22 - 154 lbs.
10/14/22 - 154 lbs.
10/19/22 - 140 lbs.
10/20/22 - 134 lbs.
10/22/22 - 138 lbs.
10/23/22 - 137 lbs.
10/24/22 - 135 lbs.

A review of the flowsheets revealed documentation of the following dietary input:

10/12/22 - Breakfast, 9:00 a.m. - 0 percent
10/13/22 - Breakfast, 9:00 a.m. - 10 percent
10/13/22 - Lunch, 1:00 p.m. - 5 percent

A continued review of the flowsheets revealed that RN GG documented on 10/13/22 at 12:00 p.m. the following: breakfast 20 percent, lunch 50 percent, and dinner 50 percent (dinner would not have been served by noon). RN GG further documented that P#1 needed meals set up.

In addition, a review of the flowsheets revealed that RN GG documented on 10/15/22 at 12:00 p.m. the following: breakfast 50 percent, lunch 50 percent, dinner 50 percent, and snack 50 percent (again, dinner would not have been served by noon).

10/16/22 - Lunch, 1:00 p.m. - 5 percent
10/17/22 - Lunch, 2:00 p.m. - 100 percent
10/18/22 - Breakfast - 8:00 a.m. - 60 percent and 5 percent dietary supplement, 50 percent Juven (therapeutic nutrition to provide nutritional support)
10/19/22 - 9:34 a.m. - 0 percent Juven

Further medical record review for P#1 revealed that a plan of care was initiated on 10/12/22 at 12:46 p.m. for potentially compromised skin integrity. Skin Breakdown/Pressure Injury Prevention included turning the patient every two hours, pressure relief boots and surfaces, and monitoring hygiene, including bath temperature, type of soap, and frequency.

A review of the plan of care by Occupational Therapist (OT) SS on 10/16/22 at 12:34 p.m. revealed that P#1 required maximum assistance bathing and had a bathing deficit of the legs and buttocks.

A review of the hygiene section of the flowsheets revealed that P#1 was bathed, and the perineal area was cleansed on the following dates and times:

10/12/22 at 3:00 p.m., complete bath, peri care (cleansing of the genitals and buttocks)
10/14/22 at 8:00 a.m., complete bath, peri care
10/17/22 at 8:00 a.m., complete bath, peri care
10/20/22 at 6:41 p.m., bath cloth, peri care

A review of the flowsheets revealed that redness to the buttocks and scrotum was first assessed and cleansed on 10/19/22. The site was moist, red, and open to air. Medicated cream was applied twice daily from 10/20/22 until discharge.

A continued review of the flowsheets revealed that P#1 had urine and bowel incontinence.

A review of a consult with the Wound-ostomy Care (WOC) RN TT on 10/21/22 at 3:32 p.m. revealed the skin was red, suspected due to moisture, and P#1 complained of burning and itching. Moisture barrier cream was in place with a plan to apply a medicated cream twice daily. The skin was to be monitored, and WOC consulted if P#1's skin condition deteriorated.

P#1 was discharged to a skilled nursing facility on 10/24/22.

An interview was conducted with Clinical Nutrition Manager (RD) CC on 11/15/22 at 11:39 a.m. in the Conference Room. RD CC said nurses would normally document percentages of meals consumed because dieticians used the percentages to track what patients were eating, including any food a family brought in.

An interview was conducted with the Patient Service Manager (PS) DD on 11/15/22 at 11:57 p.m. in the Conference Room. PS DD said that the dietary staff was not allowed to elevate or move patients, but the dietary staff could open or put items closer to the patient. The nurse would be notified if a patient needed to be elevated or needed assistance with feeding. If a patient's food was not eaten, dietary would try to get things the patient would like according to the prescribed diet.

An interview was conducted with RD AA on 11/15/22 at 2:31 p.m. in the Conference Room. RD AA said that dieticians would speak to patients directly or look at the documentation from the nurse or doctor to determine meal consumption. RD AA said documentation of meal consumption was not consistent.

An interview was conducted with RD BB on 11/15/22 at 2:58 p.m. in the Conference Room. RD BB said there was inconsistency with documenting meals, and RD BB preferred talking to people to determine the percentages of meals consumed instead of looking at the medical record.

An interview was conducted with the department manager for the 7NS unit, RN PP, on 11/16/22 at 1:08 p.m. in the Conference Room. RN PP said the percentage of meals consumed should have been documented with each meal. RN PP further said medicated cream was used for P#1 twice daily. P#1 had an external urinary catheter and was having small incontinent bowel movements, which may have been the cause of redness to the buttocks. RN PP said patients were typically bathed daily and should have a bath at least every other day, more often if a bath was requested or the patient was soiled. Baths would be documented on the safety care flowsheet.

An interview was conducted with Chief Nursing Officer (CNO) NN on 11/16/22 at 12:39 p.m. in the Conference Room. CNO NN said meal consumption should have been documented with each meal, and documentation was required for all patients. CNO NN further said that typically baths were done daily on both day and night shifts, and patients would be split between the shifts. Some baths would take priority over others. Whoever did the bath would document the bath in the computer, and if the patient refused the bath, the refusal would be documented.

A telephone interview was conducted with the complainant on 11/18/22 at 10:45 a.m. The complainant said P#1 did not like the taste of the food at the facility and would not eat the food. P#1 was paralyzed on the left side. P#1 could feed himself but could not cut up his food without assistance. The complainant said pieces of meat given to P#1 by the facility were too big for P#1 to swallow without choking. The complainant brought homemade soup and other food to P#1, but the nurses quit giving P#1 the food from home. The complainant further said that P#1 was dirty and soiled with feces when the complainant visited, and the toothpaste had not been opened.

A review of four additional medical records (P#2, P#3, P#4, and P#5) was conducted. The nursing 'Flowsheets' revealed that dietary intake was not recorded consistently for all four patients. In addition, a review of nursing 'Flowsheets' revealed that four out of four patients did not have baths documented daily or every other day.

Based on a review of policy and procedures, a medical record review, and interviews with staff, it was determined that the facility failed to protect patient right to be free from neglect for five out of five sampled patients. Specifically, P#1 lost 19 pounds while under care of the facility and developed a moisture related rash on the buttocks and groin. Additionally, percentages of dietary intake and frequency of baths and perineal care were not consistently documented for five out of five patients reviewed.

Based on facility policy, medical record review, and staff interviews, it was determined that the facility failed to ensure that nursing services monitored patients' dietary intake and hygiene according to the plan of care for five out of five sampled patients (P) (P#1, P#2, P#3, P#5, and P#5). As a result, P#1 lost 19 pounds while under the facility's care. In addition, P#1 developed a moisture-related rash on the buttocks and groin. Furthermore, percentages of dietary intake and frequency of baths and perineal care were not consistently documented for five out of five patients reviewed.

Cross-reference A0396 as it relates to the facility's failure to ensure that nursing staff followed patients' plan of care to ensure that patients' needs were met.

Based on facility policy, medical record review, and staff interviews, it was determined that nursing services failed to monitor patients' dietary intake and hygiene according to the plan of care for five out of five sampled patients (P#1, P#2, P#3, P#5, and P#5). Furthermore, percentages of dietary intake and frequency of baths and perineal care were not consistently documented for five out of five patients reviewed.

Findings:

A review of the facility's policy titled "Patient Rights and Responsibilities" policy #G-53 revised 5/19 revealed that all patients had the right to personal privacy. Inherent in this right was the right to respect, dignity, and comfort. Patients had the right to receive care in a safe setting and the right to be free from all forms of abuse or harassment. Neglect was a form of abuse.

A review of the facility's policy titled "Nursing Plan of Care Guidelines for Use," policy #6010-042, revised 12/20, revealed the nursing plan of care would be developed by the Registered Nurse (RN) and remained the responsibility of the RN. The RN would initiate the plan of care within 12 hours of admission. Each patient would be screened for problems as part of the nursing assessment. The nurse would individualize interventions if the assessment revealed that a patient was experiencing a problem. Additional problems would be addressed through Care Paths or other appropriate care plans. Interdisciplinary Teams would develop Care Paths. The care plan would be reviewed daily by the RN or Licensed Practical Nurse (LPN) under the supervision of an RN. If the plan remained appropriate, the nurse would document that the care plan had been reviewed. The RN would adjust the care plan as required for the addition or removal of problems.

A review of the facility's policy titled "Nursing Documentation" policy #6010-092, revised 2/22, revealed that continuity of care was assured through the accurate and complete documentation of assessment, planning for care, nursing interventions, and evaluation of patient progress and outcomes. Persons providing care were responsible for documenting the care provided. At a minimum, there would be evidence that the nursing process was used in documenting assessments, history, screening, and interventions via the flowsheets. In addition, the patient problem list and appropriate interventions would be documented in the care plans. Nursing narrative notes would also be used to document the effectiveness of nursing interventions, including the patient's responses to nursing interventions. Other disciplines would also document via the flow sheets available for all other disciplines to view.

A medical record review for P#1 revealed that P#1 was admitted to the facility from the Emergency Department (ED) on 10/11/22 at 7:30 p.m. with pneumonia, COVID-19, Urinary Tract Infection (UTI), difficulty walking, left-side paralysis, fever, and muscle weakness. An ED History and Physical on 10/11/22 at 12:42 p.m. revealed no rashes on P#1's skin at the time of admission to the hospital.

A review of a plan of care initiated on 10/12/22 at 12:46 p.m. revealed a potential for compromised skin integrity. Skin Breakdown/Pressure Injury Prevention included turning the patient every two hours, pressure relief boots and surfaces, and monitoring hygiene, including bath temperature, type of soap, and frequency.

A review of the plan of care by Occupational Therapist (OT) SS on 10/16/22 at 12:34 p.m. revealed that P#1 required maximum assistance bathing and had a bathing deficit of the legs and buttocks.

A review of the hygiene section of the flowsheets revealed that P#1 was bathed, and the perineal area was cleansed on the following dates and times:

10/12/22 at 3:00 p.m., complete bath, peri care (cleansing of the genitals and buttocks)
10/14/22 at 8:00 a.m., complete bath, peri care
10/17/22 at 8:00 a.m., complete bath, peri care
10/20/22 at 6:41 p.m., bath cloth, peri care


A review of the flowsheets revealed that redness to the buttocks and scrotum was first assessed and cleansed on 10/19/22. The site was moist, red, and open to air. Medicated cream was applied twice daily from 10/20/22 until discharge.

A continued review of the flowsheets revealed that P#1 had urine and bowel incontinence.

A review of a consult with the Wound-ostomy Care (WOC) RN TT on 10/21/22 at 3:32 p.m. revealed the skin was red, suspected due to moisture, and P#1 complained of burning and itching. Sensicare (barrier cream) was in place with a plan to apply Calmoseptine (medicated cream used to treat skin irritations) twice daily. The skin was to be monitored, and WOC consulted if P#1's skin condition deteriorated.

P#1 was discharged to a skilled nursing facility on 10/24/22.

An interview was conducted with the Chief Nursing Officer (CNO) NN on 11/16/22 at 12:39 p.m. in the Conference Room. CNO said that typically baths were done daily on both day and night shifts, and patients would be split between the shifts. Some baths would take priority over others. Whoever did the bath would document the bath in the computer, and if the patient refused the bath, the refusal would be documented. CNO NN said meal consumption should be documented with each meal and was required for all patients.

An interview was conducted with the department manager for the 7NS unit, RN PP, on 11/16/22 at 1:08 p.m. in the Conference Room. RN PP said the percentage of meals consumed should have been documented with each meal. RN PP further said medicated cream was used for P#1 twice daily. P#1 had an external urinary catheter and was having small incontinent bowel movements, which may have been the cause of redness to the buttocks. RN PP said patients were typically bathed daily and should have a bath at least every other day, more often if a bath was requested or the patient was soiled. Baths would be documented on the safety care flowsheet.

A review of four additional medical records (P#2, P#3, P#4, P#5) was conducted. A review of the nursing 'Flowsheets" revealed that dietary intake was not recorded consistently. In addition, a medical record review of nursing 'Flowsheets' revealed that all four patients did not have baths documented daily or every other day.

Based on facility policy, medical record review, and staff interviews, it was determined that nursing services failed to monitor patients' dietary intake and hygiene according to the plan of care for P#1, P#2, P#3, P#4, and P#5. P#1 lost 19 pounds while under the facility's care. In addition, P#1 developed a moisture-related rash on the buttocks and groin. Furthermore, percentages of dietary intake and frequency of baths and perineal care were not consistently documented for P#1, P#2, P#3, P#4, and P#5.