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Based on interviews and record review (RR), the facility failed to ensure a family member's (FM) verbal concern brought to the attention of hospital staff regarding patient care was addressed as a grievance for the purposes of these requirements. FM's concerns of P1's low body temperature, 86.1 degrees Fahrenheit (F), lack of hydration, and lack of nutrition were brought to the attention of Registered Nurse (RN)2, Charge Nurse (RNC), Director of Hospital Operations (DIR), and Manager Clinical Services (MGR)2. FM's concerns were not able to be resolved at the time and required further investigation for resolution. A complaint is considered resolved when the patient is satisfied with the actions taken of their behalf. As a result of this deficiency, patient's rights are not protected or promoted. The facility's process fails to identify an informal verbal complaint related to patient care as a grievance.

Findings include:

1. P1 was a 83 year old with ALS (Lou Gehrig's disease) and chronic respiratory failure admitted to the telemetry unit on 05/24/20 for bilateral pneumonia. P1 is nonverbal and unresponsive at baseline. Her history and physical (H&P) documented pertinent medical history of Diabetes on insulin, tracheostomy/ventilator dependent, chronic Foley catheter, Gastrostomy tube feeding dependent, and abnormal albumin with possible malnutrition. A RR of P1's electronic medical record (EMR) documented a decline of P1's temperature (lowest temperature was 86.1 degrees F) and blood pressure. A Rapid Response was called on 05/25/20 at 06:20 PM due to P1's systolic blood pressure below 90 mm Hg and failure to respond to treatment.

2. RR of the facility's Complaint and Grievance Management Policy and Procedure (P&P) revealed the P&P defines a grievance as, a written or verbal complaint (when the verbal complaint about patient care is not addressed at the time of the complaint by the staff present) made to the hospital by a patient or the patient's representative regarding the patient's care, abuse or neglect, patient harm, issues. Furthermore, complaints and grievances are entered into the patient relations database for tracking and trending purposes.

3. RR of the grievances for the 2020 calendar year received from the Patient Relations Coordinator (PRC) on 06/03/2020 at 11:00 AM did not include documentation of P1's FM's verbal complaint regarding P1's temperature and hydration/nutrition.

4. On 06/03/20 at 10:30 AM, an interview was conducted with P1's FM. FM stated on 05/25/20, had expressed concerns to RN2 regarding staff not identifying P1's low body temperature (86.1 degrees F at 11:50 AM); not receiving any fluids or nutrition (P1 last received 300 ml of tube feeding on 05/24/20 between 6:00 AM- 8:00 AM at home prior to going to the emergency department and subsequent admission); hospital lack of communication to FM regarding health status and patient care; expressed concern of a different enteral nutrition formula (Jevity) hanging for P1 which was not ordered. P1's order for enteral nutrition formula was Glucerna; and P1's overall change in baseline presentation (P1 is unable to track and is not coherent).

5. FM stated on 5/25/20 the concerns were discussed with RN2. RN2 referred FM to physician (MD)3 regarding P1's hydration and enteral nutrition. FM stated hospital staff had not provided warm blankets for P1 prior to leaving. FM made RNC aware that P1 was awaiting blankets and low body temperature. FM later called the hospital to ask when the blankets were provided. The following day FM was contacted by Director of Hospital Operations (DIR) and Manager Clinical Services (MGR)2 to discuss patient care concern. FM did not feel adequate information and updates were received from the hospital about P1's medical condition. FM stated called and left a message for the Patient Relations Coordinator (PRC). As of 06/03/20 at 10:30 AM, FM had not been contacted by the PRC and was awaiting follow up from DIR and MGR2.

6. On 06/02/20 at 01:30 PM, conducted an interview with RNC. RNC stated he/she first became aware of P1's low temperature when approached by FM on 05/25/20 at approximately 04:00 PM. Prior to speaking with FM, RNC was not made aware of P1's temperature or enteral feeding status by RN2. RNC made DIR and MGR2 aware of FM concerns on 05/26/20 during rounds.

7. On 06/03/20 at 09:31 AM, conducted an interview with DIR and MGR2, who stated they had spoken to P1's FM and were investigating the complaints. MGR2 summarized the complaints as to be P1's cold room, delay in staff applying the Bair Hugger (warming system), nutritional concerns including fluid management, and the wrong tube-feed formula hanging at the bedside. FM was referred to Physician (MD)3 regarding P1's fluid management. DIR and MGR2 shared information pertaining to the on-going investigation and stated after reviewing P1's Electronic Medical Record (EMR), there were concerns about the untimely manner in which staff implemented interventions to address P1's low temperature, staff not communicating the seriousness of P1's medical condition to RNC, lack of documentation, and the lack of addressing P1's fluid management.

8. On 06/03/20 at 11:01 AM, interviewed with PRC regarding FM's verbal complaints to staff regarding P1. Inquired with PR what is considered a grievance. PRC stated, " A grievance is when patients or family members call, file a complaint letter or submit anything in writing including online. PRC explained if concerns reach me, they are considered a grievance. Staff are encouraged to follow the chain of command." PRC stated he/she is not always made aware of patient concerns. PRC was first made aware of P1's FM concerns during a safety huddle telephone call on 05/26/20. During a discussion with DIR and MGR2, PR was informed they were investigating FM's concerns. Inquired if PRC had any communication or contact with FM after hearing about the situation in the safety huddle. PRC responded he/she. " did not contact or communicate with FM but did recall receiving a phone message. On the phone message, PRC stated he/she heard FM's name, but the message was not clear, and I could not make out the telephone number, so I did not pursue the matter." PRC stated he/she does not get involved unless asked. Inquired with PRC if patient care concerns similar to P1's FM's are not identified as grievances, if there a process to track and trend. PRC was unable to verbalize there was a process in place to address this issue.

The facility failed to ensure hospital staff and contracted staff adhered to policy procedures for documentation of clinical interventions, care/activities performed in response to one Patients (P)1 condition. The staff also did not verbally report critical information of P1's condition in a timely manner to appropriate individuals, including the Physician, Registered Nurse (RN), and Charge Nurse (RNC) to ensure P1 was reassessed, interventions implemented timely with ongoing monitoring to prevent decline. As a result of this deficient practice, on 05/25/20 when P1's temperature (temp) was noted to be 96 degrees Fahrenheit (F) at 08:09 AM, the Nurses Aide (NA) did not report it to the RN. At 11:50 AM, P1's temp was 86.1F. P1 had a subsequent decline in blood pressure and pulse which resulted in the initiation of a Rapid Response (a medical team trained in early interventions of resuscitation).

A-395 RN Supervision of Nursing Care
The hospital staff failed to identify the early signs that one (P)1 was developing hypothermia (occurs when the body temperature (temp) falls below 95 F. During hypothermia and rewarming process the patient's temp, pulse (P), Respirations, and Blood pressure (BP) must be checked frequently. Left untreated, hypothermia can potentially lead to complete failure of the heart and respiratory system and eventually to death. P1 had an abnormal temperature (temp) of 96 degrees Fahrenheit (F) at 08:09 AM on 05/25/20 at 08:09. The RN was not notified of the abnormal temp. The next time P1's temp was taken at 11:50 AM it had dropped to 86.1 degrees F. P1's blood pressure subsequently declined and a Rapid Response (team of healthcare providers trained in early resuscitation interventions that respond to patients with signs of deterioration) to stabilize P1's condition. P1 received multiple medications and treatments to stabilize her condition.

A-396 Nursing Care Plan
The facility failed to ensure the nursing staff developed and kept current a nursing care plan that reflected individualized needs, goals and interventions for five of six patients (P1, P2, P3, P4, P5) sampled.

A-398 Supervision of Contract Staff
Hospital staff and contract staff failed to adhere to policy/procedures for documentation of assessments, monitoring, interventions, response to interventions, and notification of appropriate individuals in response to one patients (P)1's medical condition.

Based on interview, observations and record review (RR), the hospital failed to identify the early signs that one (P)1 was developing hypothermia (occurs when the body temperature falls below 95 Fahrenheit.) During hypothermia and rewarming process, the patient's temperature (temp), pulse (P), respirations (R) , and blood pressure (BP) must be checked frequently. Hypothermia is a special concern for the elderly and for those who are at risk of malnutrition. Hypothermia can cause dehydration and if left untreated, can potentially lead to complete failure of the heart, respiratory system, and eventually death. P1 had an abnormal temperature (temp) of 96 degrees Fahrenheit (F) at 08:09 AM on 05/25/20. The Registered Nurse (RN) was not notified of the abnormal temp. The next time P1's temp was taken was 11:50 AM when a FM requested it to be taken. The temp at that time was 86.1F. P1's BP subsequently declined and a Rapid Response (team of healthcare providers trained in early resuscitation interventions that respond to patients with signs of deterioration) was called at 06:20 PM. P1 received multiple medications and treatments to stabilize his/her condition.

Findings Include

1. P1 was a 83-year-old with ALS (Lou Gehrig's disease) and chronic respiratory failure admitted to the telemetry unit on 05/24/20 for bilateral pneumonia. P1's documented pertinent medical history included insulin dependent diabetes, tracheostomy/ventilator dependent, chronic Foley catheter, gastrostomy tube feeding dependent, multiple pressure injuries (PU), and abnormal albumin with possible malnutrition. P1's baseline was documented as nonverbal and unresponsive.

2. RR revealed lack of reassessments and monitoring of P1's condition. Abnormal vital signs are flagged in the computer with red print and an exclamation mark. All temps are temporal (forehead scanned) with the exception noted. Entries for vital signs, notes and pertinent findings include:
"05/24/20 12:06... temp 98.3 F"
"05/24/20 18:10... temp 98.6 F"
"05/24/20 19:39... temp 97.8 F"
"05/24/20 23:17... temp 97 F"
"05/25/20 03:31... temp 97.6 F"
"05/25/20 08:09 BP 116/59, P60, temp 96 F (!)"
"05/25/20 11:40 BP 96/51, P58," no temp
"05/25/20 11:50 BP 106/56, P54 (!) temp 86.1(!) F, Comment: RN notified"
"05/25/20 13:10 temp 89 F (!)" No BP, or P (repeat temp was one hour and 20 minutes after temp of 86.1F)
"05/25/20 01:22 order time" for Bair Hugger
"05/25/20 15:04 BP 95/46 (!), P56, temp 96.3 F (!)" (repeat BP and P over three hours after 86.1F temp)
"05/25/20 16:00 BP 77/41 (!), P58," no temp
"05/25/20 16:11 BP 88/46 (!), P60," no temp
"05/20/20 16:15 BP 87/50 (!), P64," no temp
"05/25/20 16:30 BP 98/49 (!), P66," no temp
"05/25/20 16:45 BP 92/50, P66," no temp
"05/25/20 17:00 BP 99/51, P66," no temp
"05/25/20 17:15 BP 98/50, P70," no temp
"05/25/20 17:45 BP 88/52 (!), P74," no temp
"05/25/20 18:00 BP 67/30 (!), P72," no temp (Rapid Response called)
"05/25/20 18:15 BP 66/32 (!), P74," no temp
"05/25/20 18:24 BP 85/38 (!), P72," no temp
"05/25/20 18:30 BP 86/42 (!), P72," no temp
"05/25/20 18:45 BP 102/50, P66," no temp
The next temp documented was 96.9 F axillary at 19:45 on 05/25/20

3. On 06/02/20 at 12:00 PM, interviewed RN2, who said he/she was a contracted traveler hired for ICU (Intensive Care Unit), but floats to the other floors. RN2 was assigned to P1 on day shift 05/25/20 07:00 AM to 07:00 PM. He/She said the Nurse Aide (NA) takes vitals, and "things are a little different on telemetry. They are supposed to report abnormal vitals to the RN." When asked what was considered abnormal at the hospital, RN2 replied, "I'm not sure." Reviewed P1's vital signs and asked RN2 if he/she had been made aware of the low temperature recorded at 08:09 AM, and RN2 said, "No, the first I knew, was when NA1 told me face to face around 11:30 AM ... I recall retaking the temperature afterward, but it does not appear I recorded it. We put warm blankets on at that time. I noticed the thermostat was lower and raised it and opened the blinds." Asked RN2 if there was documentation of notification of MD, and he/she replied, "I notified the MD at 11:53 AM via messaging. Some physicians prefer to be notified like that rather than a phone call." RN2 explained the messaging is not part of the medical record and can only be seen by the two individuals messaging. RN2 added, "I should have documented in the record." When asked what time the Bair Hugger (warming system) was put on, RN2 said, "I don't have information when it was ordered. We get it from another department." RN2 said the "Bair Hugger was put on at about 02:30 PM." Discussed RN2's assignment for the day and workload. RN2 said he/she had three patients to start and gave away two, when received an ICU (intensive care) transfer. RN2 said the Charge Nurse (RNC) discussed the assignment and, " I told her it was OK...Telemetry's (nursing unit) not my home base, but RN5 helped. I asked RN5 what to do when P1's BP was going down and the doctor wasn't answering. RN5 was the one who called the rapid response. "

4. On 06/03/20 at 10:30 AM, during an interview with P1's FM, he/she stated, "When I went to see P1 on Monday (05/25/20), about 11:00 AM, P1 was pale, and very cold to touch. I requested the RN to take P1's temperature and was 89.9 F. I noted the thermostat was turned down all the way and thought it read 55 degrees. P1 had pneumonia and was in a room that was blowing cold air on him/her. I requested to please warm P1 up and was told they would get warm blankets. I had to leave, but called later to ask what time the warm blankets were put on. I was told noon, but told them that couldn't have been correct because I was there until noon, and nothing had been done before I left. I was then told it was about 02:00 PM. Now I'm thinking they were talking about the Bair Hugger, but at the time I didn't know that's what they were doing." Inquired what covers P1 had on the bed, and FM replied, "A sheet and a blanket." FM stated, " I was also upset about P1's lack of hydration, fluids and nourishment. I found out that P1 did not receive the scheduled TF's and the last time had any nourishment was the TF bolus I gave of 300 ml (milliliters) on 05/24/20 between 6:00 AM- 8:00 AM at home prior to going to the Emergency Department. I was told P1 didn't get the TFs because they were concerned about aspiration because the Respiratory Therapist (RT) had suctioned tan secretions that may have been TF. I told them I didn't believe it was TF that was suctioned. I felt P1 needed to have the feedings as it is the only source of nourishment. P1 was not getting intravenous fluids (IV's). I asked RN2 how long a person could live without food, and just flushing TF with water. I asked to see the doctor. When I left, I told the RNC, because I wanted to let her know what was going on."

5. On 05/25/20 at 09:37 AM Registered Dietician (RD) progress note documented: Nutritional Diagnosis: Patient with inadequate oral intake related to swallowing difficulty as evidenced by NPO (nothing by mouth), tube feeding dependent. Goal: Resume TF safely...Recommend discontinue current tube feeding regimen, when able to safely resume tube feeds, recommend initiate full strength Promote (high protein formula) at a rate of 10 ml. hr, increase as tolerate until a goal of 55 ml/hr is reached (total volume = 1320 ml), Water flush 30 ml every 4 hours. This provides 1320 kcals (kilocalorie, same as calorie), 83 grams of protein, 1287 free water."
On 06/03/20 at 11:30 AM, during an interview with RD stated the TF was stopped the evening before because of possible aspiration. The respiratory note documented suctioned tan color secretions." Inquired if P1 was receiving any other nutrition, and RD replied, "At that point, she wouldn't be getting any calories. I don't believe P1 did have nutrition. I wanted her to resume TF's when able. I don't recommend IV fluids, that has to be the doctor. It's also up to the physician regarding any flushes. I assessed the intake based on her pressure injury needs...." Inquired who was responsible to monitor fluid management, intake and output to determine needs, and RD said, "As a dietician, we do an initial screening, and then reassessments in two to three days unless notified or asked to consult. The clinical team does the monitoring of intake and output.

6. On 06/02/20 at 08:47 AM, conducted an interview and reviewed P1's medical record with RN1. Asked RN1 to detail care provided to P1 during the shift. RN1 stated she had started P1's TF. Then shortly after, RT informed RN1 tan secretions were suctioned that may have been TF formula. RN1 stated she contacted MD2, who said to stop the tube feeding for now, at which time there were no new orders addressing hydration/nutritional maintenance. The only progress note RN1's entered was dated 5/25/20 at 02:33 AM, which documented Care Planning (CP) for blood glucose, spontaneous ventilation impairment, risk for infection, and airway clearing impairment. Nutritional needs had not been identified as a problem. RN1 stated, "It should have been included," and confirmed the order to hold the TF was not in the record.

7. P1's admission orders by MD1 on 05/24/20 at 07:54 PM included: Glucerna full strength formula tube feeding 15 ml/hr. Advance to 35 ml/hr as tolerated. P1 did not have any maintenance fluid (therapy to preserve blood volume and electrolyte balance to provide some calories) orders for IV (Intravenous therapy) fluids or additional water flushes. RR documented P1 received 5 ml of Glucerna from the time she presented to the ER until the Rapid Response was called on 05/25/20 at 06:20 PM because the TF had been held. In addition to the Glucerna, P1 received minimal intake of IV fluids with antibiotics and received albumin.
RR of MD3's progress noted dated 05/25/20 at 8:02 AM, revealed the entry, " Hold tube feeds for now, but consider restarting later today if respiratory status stable."

8. On 06/02/20 at 01:30 PM interviewed the RNC on 05/25/20 day shift. RNC said they have several travelers, and the travelers are the first to float if there are staffing needs on the units. She explained the traveler orientation included a one day corporate training and one 12 hour shift on their assigned unit. The supervisors monitor to see if they need more time. RNC said the daily routine is to have a "safety huddle at 07:00 AM. The night shift discuss what occurred on their shift and pertinent information the day shift needs to know to plan the day. The report includes expected discharges, information on new admits, drips (IV medications), ventilators, PU's, and Foleys...I recall hearing P1 was admitted the evening before with possible aspiration pneumonia and was on contact precaution..." RNC said he/she was first made aware of the low temperature by RN2 about 04:00 PM. I remember the time because I was breaking for the monitor tech. A few seconds later, P1's FM greeted me and told me she wanted to let me know what was going on and that she was concerned about P1's temperature...I called RN2 to the station and we discussed it. RN2 asked me what the Bair Hugger looked like and where to get it." RN2 went on to say, " We did round with MD3 at 09:30 AM that day. MD3 was not familiar with P1 because P1 was a new admit. I don't recall discussing TF or nutrition." Reviewed with RNC that a TF was held due to possible aspiration. RNC said, "This is the first time I am hearing this." RNC said, " I would expect it to be brought up in the huddle if a TF was held due to possible aspiration, and to be told if it the only source of nutrition. I would have made sure there was a follow up chest x-ray, because it is the only source of nutrition, and would have looked into maintenance fluid... we can ask for new orders during the huddle." The timeline of identification of abnormal temperature and action taken was reviewed with RNC. RNC said, "I would have gotten the Bair Hugger up, and called the doctor. All of this would have been pushed up sooner." RNC was asked if this would be considered to meet the standard of care, and RNC replied, "No, it does not meet standards of care."

9. On 06/02/20 at 02:28, conducted an interview with the MGR1, who stated it to be the first day back to work from vacation, and that MGN2 had been covering. MGR1 was aware of the concerns regarding P1's care and that MGR2 and the DIR were investigating. MGR1 stated, " They said there were missing pieces, temps that didn't show. Said there was a gap rechecking temp." Asked MGR1 what response she would expect if a temp was found to be 86.1F. MGR1 responded, " MD notification, do some kind of immediate intervention, repeat temp, blankets, open blinds, hot water in hands. I agree there was an issue with rechecking temps and delay in getting the Bair Hugger on." Inquired how long usually takes to get a Bair Hugger, and RNC said, " I've gone to SPD (where Bair Hugger is kept) a lot. They give it to you right away."

10. Cross reference 0396: Nursing care plan:
P1's initial CP that was developed on 05/25/20 did not include Nutrition as an "active" problem.

11. Cross reference 0398: Supervision of contract Staff
Hospital staff and contract staff failed to adhere to policy/procedures for documentation of assessments, monitoring, interventions, response to interventions, and notification of appropriate individuals in response to (P)1's medical condition.

Based on interviews, observation and record review (RR), the facility failed ensure the nursing staff developed and kept current a nursing care plan that reflected their individualized needs, goals and interventions for five of six patients (P1, P2, P3, P4, P5) sampled. As a result of this deficient practice, there is the potential that the needs of other newly admitted patients and those who need care plan (CP) revision/updates may not be identified and may result in a negative outcome.

Findings Include:


1. Review of the facility policy titled, "Interdisciplinary Assessment and Plan of Care" dated 09/2018, defined Care Plan, as "A documented plan based on data gathered during assessment that identifies care needs and treatment goals, describes the strategy for meeting those needs and goals..." The procedure for Plan of Care and Care Decisions states "Based upon the initial/ongoing assessment and analytics of assessment data, the interdisciplinary plan of care is developed and prioritized collaboratively by the clinical disciplines based upon patient care needs..., and through assessment and reassessment qualified members of the patient's treatment team will identify treatment priorities to be addressed in the active plan of care." The policy further states, "The patients plan of care will be individualized and based on identified goals and outcomes..."

2. P1 was a 83 year old with ALS (Lou Gehrig's disease) and chronic respiratory failure admitted to the facility on 05/24/20 for bilateral pneumonia. Her history and physical (H&P) documented pertinent past medical history of tracheostomy/ventilator dependent, chronic Foley catheter, tube feeding dependant, and abnormal albumin with possible malnutrition. P1 had multiple pressure ulcers on admission.
At 05/29/20 on initial tour, observed a "Contact Precaution" sign placed by P1's door.
RR of P1's initial nutritional assessment completed on 5/25/20 revealed the following entry: Nutrition Diagnosis: Patient with inadequate oral intake related to swallowing difficulty as evidenced by NPO, tube feeding dependent."
RR of P1's initial CP was developed on 05/25/20 and did not address or identify P1's indwelling Foley Catheter, nutrition or risk of transmission of infection addressing the contact precautions. In addition, the CP identified the "Problem: Prevention of PU (Pressure Ulcer)," but did not address the current pressure ulcers P1 had on admission. In addition the CP did not include P1's needs related to the chronic Foley catheter or her risk for infection transmission.
It was not until a week later on 06/01/20, that the CP was revised to include the Problems: Actual Pressure Ulcer, Nutrition Imbalance, Risk for Infection Transmission with Contact Precautions, and Urinary Elimination Impaired.

3. P2 was a 83 year old admitted to a telemetry unit on 02/22/20 with a principal diagnosis of bilateral pneumonia. RR of P2's history and physical (H&P) revealed she complained of "weakness, confusion, fevers. Not eating well." P2 was subsequently intubated (tube inserted through the trachea to allow air to pass freely to and from the lungs) and placed on a ventilator.
P2's initial nutritional screen was by completed on 02/23/20 and included the following entries:
"Nutritional Diagnosis:Patient with inadequate oral intake related to intubation as evidenced by NPO (nothing by mouth), need for tube feeding (TF).
RR of P2's CP revealed the following:
On 02/22/20, the initial CP was developed and did not include nutrition.
On 3/17/20, the CP was revised to include the "Problem: Nutrition Imbalance" with goals and interventions. P2's nutritional needs were identified when the Nutritional Assessment was completed on 02/23/20.
On 04/01/20, the CP was revised to include the "Problem: Immobility," and "Risk of Infection." P2 was immobile and at risk for infection at the time of admission.

4. P3 is a 79 year old admitted to the facility on 05/24/20. She had a history of myasthenia gravis, coronary artery disease, Parkinson, hypertension and hyperlipidemia. RR of the H&P documented P3 had "gradual worsening SOB (shortness of breath) and generalized weakness." She was intubated in the ER (Emergency Room) and admitted to the ICU (intensive care unit).
P3's initial nutritional screen was completed on 05/24/20 and revealed the following entries:
"Admit weight:... 82 lb (pounds) 14.3 oz (ounces)...Usual Body Weight: 103 lb. 5 months ago per wt (weight) hx (history)... Meets criteria for: underweight ...Per rounds, plan to start TF today."
"Nutrition Diagnosis: Patient with inadequate oral intake related to intubation as evidenced by current NPO order."
RR of P3's CP revealed the following:
On 05/24/20 the initial CP was developed. Although P3 was to receive tube feedings, it was not identified as a problem in the CP.

5. P4 was a 50 year old admitted to the facility on 05/29/20 after being found unresponsive at home. She was intubated at the scene, transported to the hospital and admitted to ICU. Her admission diagnosis included Sepsis with shock, Left Cerebral Vascular Accident (Stroke/CVA), hypotension, Urinary Tract Infection (UTI), Type 2 Diabetes and Hyperkalemia (elevated potassium in the blood). P4 was NPO and the plan was for a TF to meet nutritional needs.
P4's initial nutritional screen was completed on 05/30/20 and revealed the following entries:
"Appetite PTA (prior to arrival): Poor for several weeks..."
"Per rounds, pt (patient) w (with)/wounds all over body...has been bed bound the past 1 week, not eating/drinking..."
"Nutritional Diagnosis: Patient has severe protein caloric malnutrition related to acute illness (acute CVA, UTI) as evidenced by patient consuming <50% of estimated nutritional needs x1 week PTA, ...moderate muscle wasting, wounds..."
The assessment documented wounds and one pressure injury with some were being treated with different types of dressings (Mepitel and Foam),.and others left open to air.
RR of P4's CP revealed the following:
On 05/29/20, the initial CP was developed. The CP had the active "Problem: Prevention of Pressure Ulcers", but did not include the treatment of the multiple wounds identified in her assessments she had on admission.
On 05/30/20, the "Problem: Nutritional Imbalance" was entered with interventions that included: "document appetite and amount of meal consumed,... moisten dry food with melted butter, broth, soup, or gravy," and "place food within unaffected visual field." This section of the CP was not individualized for P4, who was intubated and NPO.
On 06/03/20 the "Goal: Maximized nutritional intake" was added to "Nutritional Imbalance" Problem which addressed the TF with appropriate individualized interventions.
.
6. P5 was a 92 year old admitted to the facility on 05/19/20 for shortness of breath and pneumonia. P5's H&P identified active problems that included, "Acute respiratory failure, Acute congestive heart failure and Acute renal failure..." He was subsequently intubated and had a dietary consult for Tube feeding recommendations.
The initial nutrition assessment was completed on 05/20/20 and revealed the following entries:
"Per MD, plan to start trickle tube feeds today."
"Nutritional Diagnosis: Patient with inadequate oral intake related to intubation as evidenced by NPO x 2 days, need for tube feeding."
RR of P5's CP revealed the following:
On 05/19/20, the initial CP was developed, and did not include Nutrition as a Problem.


7. On 06/03/29 at 11:00 AM RR of P1, P2, P3, P4, and P5 was conducted with the Nurse Manager (NM). When P1's CP was reviewed, the NM stated, it was not personalized and the interventions did not apply to her." At that time during an interview, the NM agreed the CP's of these patients were not complete, and failed to identify nutritional needs.

During RR of a sample size of six patients (P's), it was identified that the hospital staff and contract staff failed to adhere to policy/procedures for documentation of assessments, monitoring, interventions, response to interventions, and notification of appropriate individuals in response to one patients (P)1's medical condition. On 05/25/20 at 08:09 AM, when P1's temperature (temp)was 96 degrees Fahrenheit (F), the Nurse Aide (NA) did not report it to the Registered Nurse (RN)2. At 11:50 AM, P1's temp went down to 86.1F. There was a subsequent decline in blood pressure (BP) which resulted in the initiation of a Rapid Response (team of healthcare providers trained in early resuscitation interventions that respond to patients with signs of deterioration). There was lack of documentation of timely repeat temperatures, assessments, as well as interventions to address the critically low temp. As a result of this deficient practice, there is the potential that other patients with a change of condition may not be recognized, reported timely, and interventions implemented to prevent decline that may result in harm or death.

Findings include:

1. P1 was a 83 year old with ALS (Lou Gehrig's disease) and chronic respiratory failure admitted to the telemetry unit on 05/24/20 for bilateral pneumonia. Her history and physical (H&P) documented pertinent past medical history of tracheostomy/ventilator dependent, chronic Foley catheter, tube feeding dependant, and abnormal albumin with possible malnutrition. P1 had admitting orders for Glucerna tube feedings which were to start that evening.

1. Review of Policy Procedure titled " Documentation of Nursing Care" review date 07/20/18 directs staff to "document patient foci, patient concerns or abnormal findings ... in the DAR (Data Action Response) format."
"D (Data) - ... objective information gathered through assessment and observation to a patient focus or patient concern."
"A (Action) - Plan and actions/interventions taken to resolve the problem ..."
"R (Response) - Patient's response to the plan or action ...."
The policy further states, "Assessments of the patients progress toward meeting goals are documented in the DAR format once each shift by the RN, and more frequent DAR notes are indicated if the assessment changes from normal to abnormal."
The policy directs " Nursing Assistant reports any abnormal findings to the primary nurse caring for the patients and/or the team leader."

2. On 06/02/20 at 08:47 AM, during an interview with RN1, discussed expectations of nursing documentation. RN1 said, "On telemetry, we take vitals every four hours along with assessment. We do an initial assessment at the beginning of the shift and then a focused assessment every four hours. We also check IV (intravenous line/site) and intake (I) and output (O) ...Normally we do temporal temperatures ...Notification to MD would show up in event ,or progress note ...Don't want to say it should be one place or the other. The DAR documentation is what happens during the shift. A short note should be used if something important happens. Asked RN2 what the NA's are taught to report to the nurse, and what was considered an abnormal vital sign, and she replied, "I'm not sure." When asked if she had ever had a situation when a NA did not report an abnormal vital sign, she said, "It's possible."

3. RR of P1's record revealed the following entries/timeline:
On 05/25/20 at 08:09 AM, P1's temp was 96 F. The electronic medical record is set up to flag abnormal values with red print and an exclamation mark. The Temp and the P were flagged by the system, as abnormal, but NA1 did not report it to RN2.
On 05/25/20 at 11:50 AM, vitals were documented as "Temp 30.1C (86.1 F)! Pulse 54!, BP 106/56."

4. On 06/01/20 at 02:30 PM conducted an interview with NA1, who was assigned to P1 day shift (7 AM- 7 PM). NA1 said, " I took her vitals at the beginning of the shift, I recall her temperature was so low, because the AC (air conditioner) was low. I noticed it was, I cannot recall the temperature. The thermostat can be adjusted. I adjusted the AC, but it takes hours for her to adjust her temperature ...we put about five warm blankets on her." When asked NA1 if she documented notifying RN2 and the application of the warm blankets, she replied, "I'm not sure." The Family Member (FM) was there and asked what her temperature was, she asked me if I knew what I was doing or if I was new ...RN2 asked me to take P1's temp again, then she called the doctor right away. RN2 charted in the computer in the room, so it was right in the morning." When asked NA1 if she knew what time the Bair Hugger went on, she replied, " It know it was on at the end of my shift."
There is no documentation that NA1 notified RN2 after the 08:09 AM abnormal temp, no documentation of a repeat temp either at 08:09 AM or 11:50 AM, and no documentation of placing warm blankets on P1.

5. RR of Nursing Progress notes revealed the following entries:
On 05/25/20 at 04:56 PM, RN2 documented:
"D: ...Pt hypothermic, temp as low as 86.1 F. MD3 made aware. Bair hugger applied. Temp improved to 96.3 F ...BP was low as 77/44 (recorded as 77/41 at 04:00 PM). MD3 made aware ..."
On 05/25/20 at 05:59 PM, RN2 documented:
" pts (P1) BP (Blood pressure) 71/31, rapid response called MD2 at bedside. Order received for dopamine (for blood pressure control) at 5 mcg/k/min (micrograms per weight per minute). Started at 18:28. Additional PIV's (peripheral intravenous lines) placed. 250 cc NS (Normal Saline) bolus initiated. Pt placed in Trendelenburg (bed adjusted with head down and feet elevated)... Temp: (!) 35.7-degree C (96.3 F) ...BP: (!) 85/38.
P1's temp was documented low at 08:09 AM and at 11:50 AM. There is no documentation the time the Bair Hugger was applied and no documentation of any other interventions. In addition,
there were no nursing notes that indicate P1 was monitored and reassessed frequently after RN2 became aware of the critically low temperature.

6. On 06/02/20 at 12:00 PM, during an interview with RN2, she stated she was a contracted traveler hired for ICU (Intensive Care Unit), but floats to the other floors. She was assigned to P1 on day shift 05/25/20 07:00 AM to 07:00 PM. RN2 said the NA takes vitals, and "things are a little different on telemetry. They are supposed to report abnormal vitals to the RN." When asked what is considered abnormal at the hospital, RN2 replied, "I'm not sure." Reviewed P1's vital signs and asked RN2 if she was aware of the low temperature recorded at 08:09 AM, or that NA had applied warm blankets to P1, and she said, "No, the first I knew, was when NA1 told me face to face around 11:30 AM ... I recall retaking the temperature afterward, but it does not appear I recorded it. We put warm blankets on at that time. I noticed the thermostat was lower and raised it and opened the blinds to get some sun in." The next documented temp was 89 F at 01:10 PM. Asked RN2 if there was documentation, she notified the MD, and she replied, "I notified the MD at 11:53 AM via messaging. Some physicians prefer to be notified like that rather than a phone call." RN2 explained the messaging is not part of the medical record and can only be seen by the two individuals messaging. RN2 added, " I should have documented in the record." When asked if she knew what time the Bair Hugger went on, she said, "I don't have information when it was ordered. We get if from another department." RN2 said she put the "Bair Hugger on at about 02:30 PM.
Review of the orders revealed the Bair Hugger order was entered at 01:30 PM
RN2 shared her text messages between her and MD3, which included the following content:
11:53 AM, RN2: Pt temp 85.9; gave warm blanket, adjusted room temp ...
01:21 PM, RN2 Requested an order for Bair Hugger ...

7. On 06/03/20 at 01:00 PM, during an interview with MD3, she said " I only took care of P1 that one day (05/25/20)." She stated rounds were done at 09:30 that morning, and the Charge Nurse (RNC) and RN2 were present and discussed P1's condition and pertinent details because P1 was a new admit. MD3 said, " RN2 did not use the computer to look at but had notes on paper. I recall P1 had a tracheostomy and a G-tube for tube feedings (TF)." MD3 was asked if she was made aware of the abnormal low temperature taken at 08:09 AM during rounds, and she replied, "No." Reviewed P1's vital signs with MD3 and that P1's temp went down to 86.1 F at 11:50 AM. Inquired if MD3 was made aware of this critical temp, and she replied, " I can't recall that. I don't believe so." There is no documentation when and if MD3 was notified in the medical record.

8. On 06/02/20 at 01:30 PM during an interview with the RNC on duty 05/25/20, asked when she was made aware of P1's low temperature, she replied, "I would say about 04:00 PM. Shortly after that P1's family member approached me and expressed concern that P1 was very cold and asked for warm blankets and wanted me to be aware that this was going on.

9. P1's TF order was for Glucerna. MD3 said when she saw P1 on 05/25/20, she noticed the TF bag hanging at the bedside was "Jevity," which was the wrong type of TF. The TF was not being administered at the time. There is a text message between MD3 and RN2 that revealed a message MD2 sent to RN2 about finding the Jevity TF at P1's bedside. There is no documentation of Jevity in P1's record. During an interview, with the UM, she stated she was not aware of the incident and was unable to explain what happened.

10. MRG2 and the Director Hospital Operations (DIR) had been notified by the RNC that P1's FM had expressed concerns about P1's lack of nourishment and how cold P1 was. During an interview with MRG2 and DIR, they said they were still doing an investigation and had asked the weekend Supervisor (RNS) to follow up with staff.
The email below was sent by RNS to MRG2 and revealed investigation findings.
Q. When was the Bair Hugger applied?
A. 14:30.
Q. How often was she (NA) monitoring the temperature for improvements.
A. Possibly every 1 hour. But she is not sure.
Q. What is your usual process?
A. For checking after an intervention, it would be 30 minutes.
Q. Were other interventions initiated (room temp adjustment)
A. Yes, Increased the room temperature & applied warm blankets.
Q. I do not see a temperature taken after 1504 or during the RRT (Rapid Response Team)
A. R2 reviewed the chart. Said she was probably checking the temperature but did not enter it.
She is certain that after the NA told her the temp (86.1), she went in to do a re-check.
From 12:00 - 13:00, she possibly took it 2 times.
From 13:00 - 14:00, she took it again.
She KNOWS she rechecked with oral and axillary.
She checked the temp before the Bair Hugger was applied, but she did not chart it.
She said both she and the NA were taking temps.
Q. Were there any barriers that you experienced? What was your day like?
A. When she was told about the low temp, she did a recheck.
She notified the MD and got the order for the Bair Hugger.
She applied warm blankets and turned up the room temp while waiting for the Bair Hugger.
It took some time for the Bair Hugger to come and she did not know exactly WHEN it came
Up.
The FM had been in the room. Unsure of when the FM left.
There was some confusion in regards to the "parts" of the Bair Hugger (tubing).
R2 found the Bair Hugger at the nurses' station and took it to the pt.'s room and applied it.
Q. Did she (RN2) ask the NA to apply it?
A. She did not. In retrospect, thinks she should have delegated it. In the ICU, they have 1 Bair
Hugger. If they order another one, their unit is small so it's easy to see it.
Q. How was your assignment?
A. Had 3 patients to start. Gave up 2 pts to take a new pt., downgrade from ICU. During the time
she was getting report from ICU, was when the low Temperature was reported to her.