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Based on observation, interview and record review the facility failed to ensure nursing staff prepared thickened liquids as directed by a physician in 1 of 1 patients (#2) and failed to ensure there were complete assessments on skin and edema in 2 of 7 patients (#s' 3 and 4).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

During an observation on 04/08/2014 at 10:45 a.m., Patient #2 was noted to have a sign over her bed indicating she was on nectar consistency fluids.

Review of an "Order Report" revealed Patient #2 was an 87 year old female admitted on 04/01/2014 with diagnoses of pneumonia, hypoxia and dehydration. Review of the "Order Report" dated 04/01/2014 revealed Patient #2 was placed on a Cardiac diet, Aspiration precautions and required a nutritional consult for difficulty swallowing.

Review of a physician "Progress Note" dated 04/04/2014 revealed Patient #2 had bilateral aspiration pneumonia, severe anemia/source unknown, dysphagia with poor airway protection, and chronic kidney failure. Two of the interventions documented on the physician's progress notes were for thickened fluids and nutrition consults.

Review of the dietary "Assessment Report" dated 04/04/2014 revealed "MD requesting thickened liquids per progress notes. RN reports she is tolerating her solids. CNA reports unable to eat much lunch due to excessive coughing." "To assess textures is out of professional training. RD will send oral supplements and thickener on tray."

Review of physician orders dated 04/07/2014 revealed an order for a Cardiac pureed diet and thickener on each tray for fluids. There was no consistency written in the order.

Review of the "Dietary Report" dated 04/08/2014 revealed Patient #2 was to have the supplement Ensure Plus, 1 can with meals and thickener. There was no consistency on the "Dietary Report" for nursing staff or dietary to follow.

During an interview on 04/08/2014 the following statements were made about the thickened liquids:
At 9:42 a.m. Staff #9 reported receiving hand outs on thickened liquids, but she still did not know the difference between the consistencies of the liquids.
At 10:40 a.m. Staff #13 reported receiving hand outs on thickened liquids, but still not really knowing how to mix them up. Staff #13 reported she had not received a demonstration.
Review of the facility's "Aspiration Precautions" protocol revealed "Physician or Dietitian should specify the desired consistency."

Review of an "Assessment Report" dated 04/06/2014 at 6:40 a.m., revealed Patient #3 was an 84 year old female admitted with "one small healing bruise on the right buttock." Another skin assessment at the same time revealed the patient's skin was within normal limits and there were no bruises.
Review of skin assessments from 04/07/2014 and 04/08/2014 revealed the same discrepancies documented.
There was no documented assessment of the size or color of the bruise.


Review of an "Assessment Report" revealed Patient #4 was a 77 year old female admitted on 04/06/2014 with diagnoses which included sepsis, pneumonia and hypoxia.

Review of an "Assessment Report" dated 04/06/2014 at 8:35 p.m. revealed Patient #4 was on oxygen at 3 liters, respirations unlabored and her breath sounds were diminished with coarse rhonchi (low pitched, snore-like sounds caused by airway secretions and airway narrowing). There was no assessment of edema underneath the section where it was supposed to be documented.
On 04/07/2014 at 1:00 p.m. there was no documented assessment of the edema. The first noted documentation addressing edema was on 04/07/2014 at 8:20 p.m...
On 04/08/2014 at 9:49 a.m., there was documentation of Patient #4 having edema, but there was no documentation of how much edema was present.
During an interview on 04/08/2014 after 2:00 p.m. Staff #4 confirmed the missing order and missing assessments for skin and edema.
Review of a facility policy named "Organization Wide Assessment of Patients" dated 03/2014 revealed the following:


"K. Patient Care Plan
1. Upon completion of a comprehensive assessment, an individualized plan of care will be developed in consultation with the patient/family member/significant other. A RN will base each patient's care on the analysis of the assessment of data and patient care standards. Anticipated length will be considered when evaluating the patient' s care needs.
2. The RN will be responsible for prioritizing the patient's care needs and developing a plan of care utilizing information gathered from the patient, family members/significant others, physician, licensed staff, non-licensed staff and other disciplines as appropriate.
3. Nursing care needs are evaluated at least daily by an RN and reassessed as the condition of the patient warrants with the plan of care updated accordingly."

Based on observation, interview and record review the facility failed to have documented physician orders for the type of thickened liquids 1 of 1 patients (#2) and failed to ensure there were complete documented assessments on skin and edema in 2 of 7 patients (#s' 3 and 4).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

During an observation on 04/08/2014 at 10:45 a.m., Patient #2 was noted to have a sign over her bed indicating she was on nectar consistency fluids.

Review of an "Order Report" revealed Patient #2 was an 87 year old female admitted on 04/01/2014 with diagnoses of pneumonia, hypoxia and dehydration. Review of the "Order Report" dated 04/01/2014 revealed Patient #2 was placed on a Cardiac diet, Aspiration precautions and required a nutritional consult for difficulty swallowing.

Review of a physician "Progress Note" dated 04/04/2014 revealed Patient #2 had bilateral aspiration pneumonia, severe anemia/source unknown, dysphagia with poor airway protection, and chronic kidney failure. Two of the interventions documented on the physician's progress notes were for thickened fluids and nutrition consults.

Review of the dietary "Assessment Report" dated 04/04/2014 revealed "MD requesting thickened liquids per progress notes. RN reports she is tolerating her solids. CNA reports unable to eat much lunch due to excessive coughing." "To assess textures is out of professional training. RD will send oral supplements and thickener on tray."


Review of physician orders dated 04/07/2014 revealed an order for a Cardiac pureed diet and thickener on each tray for fluids.

Review of the "Dietary Report" dated 04/08/2014 revealed Patient #2 was to have the supplement Ensure Plus, 1 can with meals and thickener. There was no consistency on the "Dietary Report" for nursing staff or dietary to follow.

There was no mentions of the consistency of fluids on the physician progress notes, dietary consultant report or physician orders.

Review of the facility's "Aspiration Precautions" protocol revealed "Physician or Dietitian should specify the desired consistency."


Review of an "Assessment Report" dated 04/06/2014 at 6:40 a.m., revealed Patient #3 was an 84 year old female admitted with "one small healing bruise on the right buttock." Another skin assessment at the same time revealed the patient's skin was within normal limits and there were no bruises.
Review of skin assessments from 04/07/2014 and 04/08/2014 revealed the same discrepancies documented.
There was no documented assessment of the size or color of the bruise.


Review of an "Assessment Report" revealed Patient #4 was a 77 year old female admitted on 04/06/2014 with diagnoses which included sepsis, pneumonia and hypoxia.
Review of an "Assessment Report" dated 04/06/2014 at 8:35 p.m. revealed Patient #4 was on oxygen at 3 liters, respirations unlabored and her breath sounds were diminished with coarse rhonchi (low pitched, snore-like sounds caused by airway secretions and airway narrowing). There was no assessment of edema underneath the section where it was supposed to be documented.
On 04/07/2014 at 1:00 p.m. there was no documented assessment of the edema. The first noted documentation addressing edema was on 04/07/2014 at 8:20 p.m...
On 04/08/2014 at 9:49 a.m., there was documentation of Patient #4 having edema, but there was no documentation of how much edema was present.
During an interview on 04/08/2014 after 2:00 p.m. Staff #4 confirmed the missing order and missing assessments for skin and edema.
Review of a facility policy named "Organization Wide Assessment of Patients" dated 03/2014 revealed the following:


"K. Patient Care Plan
1. Upon completion of a comprehensive assessment, an individualized plan of care will be developed in consultation with the patient/family member/significant other. A RN will base each patient's care on the analysis of the assessment of data and patient care standards. Anticipated length will be considered when evaluating the patient' s care needs.
2. The RN will be responsible for prioritizing the patient's care needs and developing a plan of care utilizing information gathered from the patient, family members/significant others, physician, licensed staff, non-licensed staff and other disciplines as appropriate.
3. Nursing care needs are evaluated at least daily by an RN and reassessed as the condition of the patient warrants with the plan of care updated accordingly."