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Based on record review, policy review, and staff interview it was determined the facility failed to ensure the nursing staff provided care and services to meet the needs of 1 (#2) of 10 sampled patients.

Findings included:

Patient #2 was admitted to the facility via ambulance on 8/21/16 at 7:00 a.m., with uncontrolled high blood pressure, severe nausea and vomiting, and abdominal pain.

The Physician Orders for Patient #2 dated 8/21/16 at 9:35 a.m., and signed by the attending physician included orders for Catapres 0.1 mg (milligram) tablet every 4 hours as needed for systolic blood pressure greater than 160 or diastolic blood pressure greater than 90. On 8/21/16 at 1:41 p.m., the same physician signed an order to administer Apresoline 10 mg IV (intravenously) every 4 hours as needed to Patient #2 for systolic blood pressure greater than 160 or diastolic blood pressure greater than 90.

The record for Patient #2 revealed the following blood pressure readings on 8/21/16: 177/88 at 10:44 a.m. and 201/92 at 12:16 p.m. The review of the Medication Administration Record (MAR) failed to reveal evidence of the administration of Catapres 0.1 mg tablet or any documentation of reasons the medication was not administered as ordered. The MAR did show documentation of the administration of Apresoline 10 mg IV at 2:08 p.m. on 8/21/16. Patient #2's blood pressure readings following the dose of blood pressure medicine were: 177/88 at 3:20 p.m.; 161/74 at 4:10 p.m.; 148/96 at 7:55 p.m.; and at 162/79 at 11:19 p.m. The review of the MAR failed to reveal evidence of the administration of a repeat dose of Apresoline or documentation of reasons the medication was not administered as ordered. On 8/22/16 at 8:12 p.m. Patient #2's blood pressure was 135/99. The MAR failed to reveal evidence of the administration of either Catapres or Apresoline, or documentation of the reasons why the medication was not administered as ordered. On 8/25/16 blood pressure readings for Patient #2 included 169/81 at 7:30 p.m.; 168/80 at 7:45 p.m.; 164/73 at 8:00 p.m.; 164/75 at 8:25 p.m.; and 187/84 at 9:47 p.m. The MAR failed to reveal evidence of the administration of either Catapres or Apresoline, or documentation of the reasons why the medication was not administered as ordered.

The History and Physical examination dated 8/21/16 at 1:50 p.m., and signed by the attending physician included documentation Patient #2 underwent a CT scan of the abdomen and pelvis while in the ED that showed Patient #2 had a rectal fecal impaction. The review of the record failed to reveal any evidence of medical or nursing intervention for the rectal impaction between 8/21/16 at 10:09 a.m., the time of her arrival on the nursing unit, until 8/24/16 at 11:03 when she was administered a rectal suppository.

The History and Physical examination dated 8/21/16 at 1:50 p.m., included documentation Patient #2 was admitted with severe nausea and vomiting secondary to encephalopathy caused by her accelerated hypertension. The Admission [Nursing] Assessment dated 8/21/16 at 3:20 p.m., and signed by the RN included documentation Patient #2's neurological status and GI/Nutrition status were Within Defined Parameters (WDP) indicating the nurse had assessed both organ systems and found no abnormalities.

The Admission Assessment included documentation Patient #2 was 4 feet 11 inches tall and weighed 110 pounds, 8 ounces on 8/21/16 at 3:20 p.m. Her Body Mass Index was computed at 22.2 indicating her height and weight were within normal proportions. On 9/2/16 at 10:12 a.m. Patient #2 was discovered to be 5 feet 4 inches tall, not 4 feet 11 inches tall.

A Swallow Test was performed on 8/23/16 at 1:10 p.m. The documentation included Patient #2 had a history of bulimia since age 12. The dysphagia evaluation was limited to liquids only due to the patient's refusal to accept anything other than liquids.

The Consultation Note dated 8/25/16 at 10:22 a.m., and signed by the consulting surgeon included documentation Patient #2's general appearance was cachectic and emaciated, indicating Patient #2 appeared to have a wasted, malnourished, chronically ill appearance. A review of the entire record for Patient #2 failed to reveal any evidence her dietary intake was being monitored.

The Adult Nutrition Assessment dated 8/27/16 at 10:58 a.m. and signed by the Registered Dietician indicated Patient #2 was seen and evaluated by a Registered Dietician for the first time because she had been unable to take anything by mouth for three consecutive days. The documentation included the patient's height was 4 feet 11 inches and her weight was 125 pounds. Her BMI was calculated at 25.2 indicating Patient #2 was overweight. The Registered Dietician recommended Patient #2 start liquid tube feedings due to being at high risk of malnutrition.

The review of the facility policy Assessment/Reassessment, policy #2.600.048, revised 8/2/16 was reviewed on 10/12/16. Page 3 included documentation indicating each discipline is responsible for the appropriate assessment and reassessment of patients under their care. Page 6 indicated nutritional screening is part of the patient admission assessment completed by the RN to determine if the patient's nutritional and hydration status are appropriate. The nutritional screening included determining if the patient had been eating poorly due to poor appetite for 5 days or more. Based on the result of the nutrition screen, the RN can order a dietician consult.

An interview and record review was conducted with the RN Quality Management Coordinator and the RN Clinical Applications Director on 10/12/16 at 2:00 p.m. They confirmed the following findings:
1. The nursing staff failed to ensure Patient #2 received blood pressure medication in compliance with the physician ordered plan of treatment.
2. The nursing staff failed to appropriately assess the neurologic and GI/nutritional status of Patient #2 in light of her documented diagnoses of encephalopathy, severe nausea and vomiting, and rectal fecal impaction.
3. The nursing staff failed to intervene appropriately to initiate treatment for the rectal fecal impaction on a timely basis.
4. The nursing staff failed to ensure accurate measurements were used to compute the patient's body mass index, an indicator of nutritional status. Patient #2's BMI calculated as 18.9, indicating Patient #2 was less than half a pound away from being classified underweight (18.5 pounds) when her BMI was calculated using her accurate height of 5 feet 4 inches 1. instead of the height of 4 feet 11 inches documented by the RN performing the admission assessment on 8/21/16, and the Registered Dietician on 8/27/16.
5. As a result of the inaccurate nutritional assessment at the time of her admission, the nursing staff failed to order a consultation with the dietician on a timely basis.