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Based on record reviews and interview, the hospital failed to ensure its grievance process was implemented as evidenced by failure to identify a complaint as a grievance and to conduct a thorough investigation in accordance with hospital policy for 1 (#1) of 4 patient complaints/grievances received in November 2017.
Findings:

Review of the policy titled "Grievance Procedure Patient And family Louisiana", presented as a current policy by S1ADM, revealed that a complaint was defined as an expression of dissatisfaction about the standard of service, actions or lack of action by staff or regarding the facility, and is resolved by staff at the time the complaint is made requiring no further resolution. A grievance was defined as an allegation of a violation of a patient's rights, quality of care, premature discharge, and/or a complaint that is not resolved at the time the complaint is made and requires further action for resolution. If no resolution is made at the time of the complaint, the Administrator is notified, and the grievance process is initiated. The Administrator logs the grievance allegation onto the "Complaint/Grievance Log" and contacts the patient and/or family and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. The Administrator completes the investigation and the "Grievance Report" within 10 days of the date of notification or receipt of the allegation. The Administrator issues a written determination. A copy of the "Grievance Report" containing the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance allegation, the results of the grievance process, the resolution of the grievance, and the date of completion is sent to the complainant on the 10th day following notification or receipt of the grievance allegation.

Review of the "Complaint And Grievance Log" revealed Patient #1's daughter complained on 11/13/17 that Patient #1 returned to the nursing home without her dentures. Further review revealed the copy of patient #1's inventory sheet with her daughter's phone number was given to the Patient Advocate. Further review revealed S9LCSW, the Patient Advocate/Clinical Director, spoke with Patient #1's daughter on 11/14/17 to discuss her report that Patient #1's lower dentures were missing. Documentation revealed that S9LCSW discussed the inventory sheet that showed that Patient #1 arrived with upper dentures only. Patient #1's daughter reported that she had spoken with S2DON who told her (daughter) that she (S2DON) would follow-up with the nursing home "to determine." A note was written on 11/20/17 (no signature on the log to indicate who wrote the notes on the log) that S2DON reported that she spoke with the nursing home, and they stated Patient #1 arrived to Oceans Behavioral Hospital of Lake Charles with her lower dentures the week of 11/20/17 to 11/24/17. Further review revealed documentation of "attempted to contact daughter related to inability to locate dentures" with no documented evidence of a signature of the person who wrote the entry. Review of all documentation presented revealed no documented evidence of an investigation that included interviews with staff who conducted and documented the inventory search at admission, the staff who transferred Patient #1 to a higher level of care, and the discussion held with the nursing home staff.

In an interview on 12/11/17 at 3:10 p.m., S9LCSW indicated she was the Patient Advocate and Clinical Director. When asked by the surveyor why the complaint wasn't handled as a grievance, S9LCSW indicated she didn't consider it a grievance, because Patient #1's daughter was satisfied with the response given by the hospital. She further indicated the documentation didn't show that Patient #1 was admitted with the dentures that her daughter said were missing. S9LCSW indicated a complaint is when the hospital is able to make a resolution to what was complained about, and a grievance is "when they have to do an investigation like a self-report, patient care, or rights." When asked by the surveyor if the complaint was able to be handled without further investigation, such as checking the record and calling the nursing home, S9LCSW indicated some follow-up was needed and confirmed that the complaint should have risen to the level of a grievance. S9LCSW confirmed she had no documented evidence of any investigation that was conducted.

Based on record reviews and interview, the hospital failed to ensure a patient was provided with written notice of the hospital's decision in its resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in accordance with hospital policy for 1 (#1) of 4 patient complaints/grievances received in November 2017.
Findings:

Review of the policy titled "Grievance Procedure Patient And family Louisiana", presented as a current policy by S1ADM, revealed that the Administrator would send a copy of the "Grievance Report" containing the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance allegation, the results of the grievance process, the resolution of the grievance, and the date of completion to the complainant on the 10th day following notification or receipt of the grievance allegation.

Review of the "Complaint And Grievance Log" revealed Patient #1's daughter complained on 11/13/17 that Patient #1 returned to the nursing home without her dentures. Further review revealed the copy of patient #1's inventory sheet with her daughter's phone number was given to the Patient Advocate. Further review revealed S9LCSW, the Patient Advocate/Clinical Director, spoke with Patient #1's daughter on 11/14/17 to discuss her report that Patient #1's lower dentures were missing. Documentation revealed that S9LCSW discussed the inventory sheet that showed that Patient #1 arrived with upper dentures only. Patient #1's daughter reported that she had spoken with S2DON who told her (daughter) that she (S2DON) would follow-up with the nursing home "to determine." A note was written on 11/20/17 (no signature on the log to indicate who wrote the notes on the log) that S2DON reported that she spoke with the nursing home, and they stated Patient #1 arrived to Oceans Behavioral Hospital of Lake Charles with her lower dentures the week of 11/20/17 to 11/24/17. Further review revealed documentation of "attempted to contact daughter related to inability to locate dentures" with no documented evidence of a signature of the person who wrote the entry. There was no documented evidence that a resolution letter had been sent to Patient #1's daughter that included the above-listed information.

In an interview on 12/11/17 at 3:10 p.m., S9LCSW indicated she was the Patient Advocate and Clinical Director. When asked by the surveyor why the complaint wasn't handled as a grievance, S9LCSW indicated she didn't consider it a grievance, because Patient #1's daughter was satisfied with the response given by the hospital. She further indicated the documentation didn't show that Patient #1 was admitted with the dentures that her daughter said were missing. S9LCSW confirmed she had no documented evidence of any investigation that was conducted, and a resolution letter had not been sent to Patient #1's daughter.

Based on observations, record review, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having beds in Rooms "a", "b", "c", and "d" with ligature points with Patient R1, who was on suicide precautions, admitted to Room "b"; having gowns (Room "b", "f"), pants (Room "e), and a hooded jacket (Room "b") in patient rooms with ties approximately 8 to 14 inches long that presented a ligature risk for psychiatric patients; having exposed plumbing with access to pipes that present a ligature risk in Rooms "g" and "h"; having a plastic liner in the large garbage can located in the hall used by psychiatric patients to walk from their rooms to Room "i" that presented a risk for suffocation; having multiple items stored in plastic bags that presented a risk for suffocation in unlocked cabinets and unlocked drawers in Room "i", and having personal toiletry items in patient rooms that were not stored in accordance with hospital policy.
Findings:

Observations of the psychiatric unit on 12/04/17 at 1:20 p.m. with S1ADM and S4QD present revealed the following safety risks:
1) Two patient beds each in Rooms "a", "b", "c", and "d" had a metal frame with an approximate 2 inch opening between the outer frame and the section holding the mattress at the head, foot, and both sides that presented a ligature risk. Further observation revealed that Patient R1, who was admitted on 11/12/17 with a diagnosis of Major Depressive Disorder with Suicidal Ideations and placed on suicide precautions, was assigned to a bed in Room "b."
2) Patient gowns with an approximate 8 inch tie at the neck and sides that presented a ligature risk were found in Rooms "b" (1 gown) and "f" (3 gowns. Further observation revealed hooded jacket with an approximate 14 inch tie was on the shelf in Room "b", and a pair of pants with an approximate 14 inch tie was found in Room "e."
3) The material used to contain the sink plumbing in Rooms "g" and "h" had openings large enough that provided access to the pipes that could present a ligature risk for psychiatric patients.
4) A large garbage can located in an alcove in the public hall used by patients to walk from their room to Room "i" had a plastic liner that presented a risk for suffocation.
5) The unlocked drawer under the counter in Room "i" had plastic utensils that contained forks with pointed edges that presented a risk for injury for psychiatric patients. The unlocked pantry in Room "i" had a box of plastic forks with sharp edges that were contained in a plastic liner that presented a risk for injury by stabbing and a risk for suffocation (plastic liner). An unlocked cabinet in Room "i" had plastic bags with 8 oz. Styrofoam cups, a blanket, puzzle pieces, bingo chips, and bingo balls, a cup filled with approximately 30 sharpened pencils (stabbing risk), 5 pot holder-making frames that had sharp, pointed edges (stabbing risk), and several long, sharp-tipped pipe cleaners, all which presented risk for injury and suffocation.
6) A hairbrush, a bottle of shampoo and body wash, and an unlabeled plastic medicine cup with a type of cream was on the shelf in Room "b". A hairbrush was on the shelf in Room "j."

Review of the "Program Handbook", presented as the patient handbook given to patients at the time of admit by S1ADM, revealed that guidelines for clothing and personal property included the following: 3 complete changes of clothing without drawstrings; patients must sleep in pajamas, shorts, and T-shirts or sweats; and toiletries including 1 comb and brush set, one toothbrush and tube of toothpaste, one squeeze bottle of body lotion, and one plastic bottle of shampoo/conditioner must be kept in patient belonging bins. Items kept in patient bins may be checked out from wake-up until breakfast and 30 minutes prior to bedtime. All items are to be returned to the nurses' station.

In an interview on 12/04/17 at 1:20 p.m. during the above observations, S1ADM confirmed the above findings and confirmed they presented potential risks for injury by stabbing, suffocation, and strangulation. She indicated that the MHT is supposed to remove patient clothing that has ties or cords. She offered no explanation for the hospital gowns with ties and the toiletry items found in patient rooms.

Based on record reviews and interviews, the hospital failed to use data collected through its QAPI program to identify opportunities for improvement and make changes that will lead to improvement. The hospital failed to develop and implement a plan to address the identified increase in the fall rate and wound prevention that scored below the facility goal.
Findings:

Review of the monitoring indicators presented by S4QD and S22DCC for the period from January 2017 through 12/13/17 revealed the fall rate for the 1st quarter of 2017 was 5.93%, 7.46% for the 2nd quarter, and 15.04% for the 3rd quarter.

Review of the QAPI meeting minutes revealed the following:
02/20/17 - 1 fall;
03/24/17 - 8 falls;
04/25/17 - 9 falls;
05/12/17 - 8 falls;
06/08/17 - 10 falls;
no documented evidence of the number falls in the QAPI meeting minutes of 07/20/17, 08/17/17, 09/15/17, 10/18/17, and 11/13/17.

Review of the monitoring indicator for wound prevention protocol the following indicators with facility goal and the year-to-date average of compliance:
1) Wound care protocol implemented and documented in treatment plan upon identification of a wound - goal 90%; compliance 48.10%;
2) Photos of wound obtained upon identification and at least every 3 days thereafter - goal 90%; compliance 43.33%;
3) Each photo contains date taken and a description of the wound - goal 90%; compliance 65.21%;
4) Wound care provided as ordered - goal 90%; compliance 89.17%;
5) Treatment plan is updated as needed regarding the progress of the wound and care provided - goal 90%; compliance 39.86%.

In an interview on 12/13/17 at 9:50 a.m. with S4QD and S22DCC present, S22DCC indicated they opened the main campus in July which affected the increased number of falls for the 3rd quarter. S4QD indicated they didn't discuss falls at the last QAPI meeting on 10/18/17. S22DCC indicated they have 17 falls documented thus far for November 2017. S2DON entered the interview and indicated they did training on 08/24/17 and 08/25/17 related to falls, but to her knowledge no action plan had been developed related to the increase in falls.

In an interview on 12/13/17 at 11:00 a.m. with S3RDCO, S4QD, and S22DCC present, S3RDCO confirmed no action plan was developed and incorporated through QAPI related to wounds.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of participation of Nursing Services as evidenced by failing to ensure the RN supervised and evaluated the nursing care of each patient.

1) The RN failed to assess, measure, and document the measurement and description of the wound and surrounding skin for 3 (#2, #4, #5) of 5 patient records reviewed with wounds from a total sample of 5 patients. Observation on 12/11/17 at 4:15 p.m. revealed Patient #4 had a 1 cm wide by 4 cm long shearing-type wound to the left buttock that had not been identified by the nursing staff.

2) The RN failed to ensure MHTs observed patients every 15 minutes as ordered by S5Psych for 2 (#4, R5) of 2 patients observed on a hospital-provided video. Observation of the video for 12/11/17 at 11:00 p.m. through 12:51 a.m. on 12/12/17 revealed Patient #4 and Patient R5 were not observed every 15 minutes by the MHT or nurse for 1 hour 3 minutes.

3) The RN failed implement droplet precautions for a patient diagnosed with the Flu for 1 (#2) of 1 observed with a diagnosis of Flu from a sample of 5 patients. Patient #2 was observed on 12/11/17 at 11:15 a.m. in Room "i" without a face mask with other patients and staff present. Observation on 12/12/17 at 2:23 p.m. revealed S13RN entered Patient #2's room without wearing a face mask. (see findings in tag A0395)

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to assess, measure, and document the measurement and description of the wound and surrounding skin for 3 (#2, #4, #5) of 5 patient records reviewed with wounds from a total sample of 5 patients. Observation on 12/11/17 at 4:15 p.m. revealed Patient #4 had a 1 cm wide by 4 cm long shearing-type wound to the left buttock that had not been identified by the nursing staff.
2) The RN failed to ensure MHTs observed patients every 15 minutes as ordered by S5Psych for 2 (#4, R5) of 2 patients observed on a hospital-provided video. Observation of the video for 12/11/17 at 11:00 p.m. through 12:51 a.m. on 12/12/17 revealed Patient #4 and Patient R5 were not observed every 15 minutes by the MHT or nurse for 1 hour 3 minutes.
3) The RN failed implement droplet precautions for a patient diagnosed with the Flu for 1 (#2) of 1 observed with a diagnosis of Flu from a sample of 5 patients. Patient #2 was observed on 12/11/17 at 11:15 a.m. in Room "i" without a face mask with other patients and staff present. Observation on 12/12/17 at 2:23 p.m. revealed S13RN entered Patient #2's room without wearing a face mask.
4) The RN failed to assess a patient prior to the LPN administering Ativan for anxiety when the patient was yelling and crying out to determine if alternative measures had been attempted and failed for 1 (#1) of 1 patient record reviewed with administration of Ativan for behaviors from a sample of 5 patients.
Findings:

1) The RN failed to assess, measure, and document the measurement and description of the wound and surrounding skin:
Patient #4
Observation on 12/11/17 at 11:20 a.m. revealed Patient #4 was seated in a wheelchair at a table in Room "i". Continuous observation from 11:20 a.m. through 12:25 p.m. revealed Patient #4 remained in the wheelchair in Room "i."

Observation on 12/11/17 at 4:15 p.m. revealed Patient #4 was seated in her wheelchair at the same table as observed at 12:25 p.m. Observation of the MHT's "Close Observation Check Sheet" revealed no documented evidence that observations were made since 3:15 p.m. when the surveyor observed the record at 4:20 p.m.

Observation in Room "d" on 12/11/17 at 4:25 p.m. with S2DON present revealed Patient #4's diaper was saturated with urine from the front of the diaper to the back of the diaper. Further observation revealed she had a shearing-type wound measuring 1 cm wide by 4 cm long and a shearing-type wound measuring 1 cm wide by 6.5 cm long on the left buttock that was measured by S2DON in the presence of the surveyor.

Observation of a hospital-provided video on 12/12/17 at 7:50 a.m. with S1ADM and S3RDCO present revealed from 11:05 a.m. through 4:24 p.m. on 12/11/17 no observation of Patient #4 being taken to the bathroom or to her room for 5 hours 4 minutes.

Review of the policy titled "Skin/Wound Care Protocol", presented as a current policy by S1ADM, revealed that if the Braden score is less than 18, the wound care prevention/protocol will be implemented. Pictures of wounds should be placed on each patient's wound assessment form that includes a description and documentation of the wound. If a patient is identified to have a wound, a picture is taken and documentation of the wound is completed. Pictures will be retaken at a minimum of every 3 days. The nurse will use the wound assessment form guidelines to describe and document the wound in a consistent and accurate manner that may include the location, type, where acquired, stage, length, and width. Wound assessment includes staging of pressure injuries, wound measurement, wound drainage, and wound bed description. Further review revealed the most important prevention protocol is pressure relief. Immobility is the most significant risk factor for pressure ulcer development. Chair-bound patients should be repositioned at least every hour, patient should shift weight every 30 minutes if able, and a foam, gel, or air cushion should be used to relieve pressure.

Review of the policy titled "Treatment Planning: Integrated/Multidisciplinary", presented as a current policy by S1ADM, revealed that the admitting nurse is responsible to formulate the initial treatment plan. The primary RN is responsible to re-evaluate goals and objectives and revise the plan as needed.

Review of S14RN's wound assessment documented on 12/08/17 at 6:00 p.m. revealed a wound from shearing on the left buttock measuring 1.6 cm wide by 6.5 cm long with a beefy red wound bed, no drainage, and no odor. Review of S21RN's assessment on 12/10/17 at 6:15 a.m. revealed a wound to the left buttock that measured 1 cm wide by 6 cm long. There was no documented evidence of the type of wound, the description of the wound bed, the color, and the presence or absence of drainage and odor.

Review of Patient #4's medical record revealed no documented evidence that the physician was notified of the wound identified on 12/08/17 and 12/10/17.

Review of Patient #4's "Daily Nurse Note" documented on 12/11/17 at 10:00 a.m. by S13RN revealed skin was assessed as intact, and toilet every 2 hours while awake was checked.

Review of Patient #4's nursing care plan revealed a plan was developed on 12/08/17 for impaired skin integrity that included the following nursing interventions: document skin assessment per protocol; document wound measurements per orders and protocol; inspect skin every shift, inspect bony prominences and feet; cleanse skin at time of soiling; reposition in bed every 2 hours; place pillow/foam wedges to keep bony prominences from direct contact; elevate heels or ankles off bed; notify physician of change in condition; relieve pressure from prolong sitting; lift patient using sheet or lifting device; reduce exposure to moisture, offer toileting every 2 hours and PRN; apply absorbent underpad. The short-term nursing goals included comply 100% with wound prevention/ wound treatment measures within 7 days and patient will comply with Risamine application with every diaper change until wound is healed.

In an interview on 12/11/17 at 4:15 p.m., S18MHT indicated she and S15MHT didn't take Patient #4 to the bathroom on 12/11/17 from 11:05 a.m. through the time of this interview. She further indicated if she was taken to the bathroom, it would have been S16MHT who took her. (S16MHT was unable to be interviewed because she left ill.)

In an interview on 12/11/17 at 4:25 p.m., S2DON confirmed the wound measuring 1 cm wide by 4 cm long had not been identified by the nursing staff prior to the surveyor's observation.

In an interview on 12/12/17 at 1:05 p.m. with S13RN and S3RDCO present, S13RN indicated when she checks "toilet every 2 hours" on her nurse's note, she knows that the MHTs were taking the patient to toilet. When S13RN was informed by the surveyor of the observations made by video review of 12/11/17 from 11:05 a.m. through 4:24 p.m. that showed Patient #4 wasn't toileted for 5 hours 4 minutes, S13RN indicated "I don't know." She further indicated her nursing note was written at 10:00 a.m. S3RDCO indicated that documentation on the nurse's note is supposed to account for the entire shift.

Patient #2
Review of Patient #2's wound assessment documented by S13RN on 12/03/17 at 4:00 p.m. revealed he had an abrasion to the left elbow that measured 1 cm wide by 3 cm long with a reddened wound bed and no drainage or odor.

Review of Patient #2's wound assessment documented by S26LPN on 12/10/17 at 1:00 p.m. revealed a pressure wound to the distal PEG site at the 6 o'clock position that was 2 cm wide by 1.5 cm long with a pink wound bed and no odor or drainage. Further review revealed S26LPN documented an abrasion to the left elbow that measured 2 cm wide by 2 cm long with a scabbed wound bed, no odor or drainage, and erythema surrounding the wound that measured 7 cm by 7 cm. S26LPN documented that a dry gauze dressing was placed under the PEG button to alleviate rubbing on the skin, and the left elbow wound was cleaned with Normal Saline, Triple Antibiotic Ointment was applied, and it was covered with Xerofoam. There was no documented evidence of an assessment by the RN of these 2 wounds.

Review of Patient #2's nursing care plan revealed a plan was developed on 12/08/17 for potential impaired skin integrity related to limited immobility. There was no documented evidence that the plan was revised and interventions developed when the above wounds were identified on 12/03/17 and 12/10/17.

In an interview on 12/11/17 at 11:50 a.m., S13RN indicated Patient #2 didn't have wounds when she assessed him. When informed of the abrasion documented by her on 12/03/17, S13RN had no comment. After review of the record, she confirmed there was no documented evidence that a RN assessed Patient #2's wounds that were identified by S26LPN on 12/10/17.

Patient #5
Review of patient #5's Braden Scale assessment conducted on 12/01/17 revealed he scored a 16 (score of less than 18 equals at risk for development of a pressure injury). A nursing care plan for potential impaired skin integrity was not developed in accordance with hospital policy until 12/09/17.

Review of S26LPN's wound assessment on 12/10/17 at 5:30 p.m. revealed Patient #5 had a pressure wound to the left buttock that measured 1/2 cm wide by 1/2 cm long, and 3 areas to the right buttock that measured 1/2 cm wide by 1/2 cm long with wound bed pink with no drainage or odor. S26LPN documented that the wounds were cleansed with normal Saline and covered with Xerofoam. There was no documented evidence of an assessment of the pressure wounds that included staging by the RN.

In an interview on 12/12/17 at 1:30 p.m. with S2DON and S3RDCO present, both confirmed the medical record of Patient #5 did not have an assessment of his wounds by a RN, and his impaired skin integrity care plan wasn't initiated when his Braden Scale score indicated the need.

2) The RN failed to ensure MHTs observed patients every 15 minutes as ordered by S5Psych:
Observation on 12/11/17 at 4:15 p.m. in Room "i" revealed Patient #4 was seated in a wheelchair. Further observation revealed her MHT observation record did not include every 15 minutes observations as ordered by the physician since 3:15 p.m.

Observation of a hospital-provided video with S1ADM and S3RDCO present for the hours of 11:00 p.m. on 12/11/17 through 12:51 a.m. on 12/12/17 revealed no observation of a MHT or nurse making a physician-ordered observation every 15 minutes for Patient #4 and Patient R5 from 11:00 p.m. to 11:34 p.m. (34 minutes) and from 11:48 p.m. to 12:51 a.m. (1 hour 3 minutes).

Patient #4
Review of patient #4's medical record revealed she was admitted on 12/08/17 and ordered to be on close observation every 15 minutes.

Patient R5
Review of patient R5's medical record revealed she was admitted on 12/08/17 and ordered to be on close observation every 15 minutes.

Review of the "Close Observation Sheet" for the above-listed times revealed S25MHT documented every 15 minutes observations for Patient #4, and S24MHT documented every 15 minutes observations for Patient R5.

Review of the policy titled "Level Of Observations", presented as a current policy by S1ADM, revealed that observation levels included every 15 minutes and one-to-one observation. Every 15 minutes was defined as a staff member visually observing the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. The staff member utilizes the close observation form to document the location of the patient. The form is initialed with the observing staff's initials to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The RN must perform observations in addition to the other assigned staff and will initial their rounds in the column indicating the RN rounds.

In an interview on 12/12/12/17 at 7:50 a.m., S1ADM confirmed the every 15 minutes observations were not made as ordered for Patients #4 and R5.

3) The RN failed implement droplet precautions for a patient diagnosed with the Flu:
Observation on 12/11/17 at 11:15 a.m. revealed a note was posted outside Room "a" noting "droplet precautions." Further observation revealed Patient #2 was assigned to Room "a" but was not present in the room. Continuous observation revealed Patient #2 was seated in Room "i" with no face mask on with other patients and staff in the room.

Review of Patient #2's medical record revealed a lab report dated 12/10/17 indicating he was positive for the presence of Flu A antigen and negative for the presence of Flu B antigen. There was a physician's order from S6MD on 12/10/17 at 5:35 p.m. for Tamiflu 75 mg po BID for 5 days. There was no documented evidence of an order for droplet precautions.

Review of the policy titled "Isolation Precautions", presented as a current policy by S1ADM, revealed that in addition to standard precautions, droplet precautions should be used for a patient known or suspected to be infected with microorganisms transmitted by large particle droplets that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures. Place the patient in a private room. A mask and eye protection should be worn when working within 3 feet of the patient. Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplets by placing a surgical mask on the patient if possible.

In an interview on 12/11/17 at 11:50 a.m., S13RN indicated there should be a physician's order obtained for droplet precautions. She further indicated he was placed on droplet precautions the morning of 12/11/17 but should have been placed on precautions when the staff was notified of positive Flu diagnosis.

In an interview on 12/11/17 at 1:32 p.m., S14RN indicated S6MD didn't give orders for droplet precautions. She further indicated she took it upon herself to move the other patient who had been assigned to Room "a" with Patient #2. She indicated she didn't initiate droplet precautions, because another nurse present told her he wasn't contagious anymore. S14RN confirmed that Patient #2 was allowed out his room on 12/10/17 without a mask after they were aware of the positive Flu diagnosis.

4) The RN failed to assess a patient prior to the LPN administering Ativan for anxiety when the patient was yelling and crying out to determine if alternative measures had been attempted and failed:
Review of Patient #1's medical record revealed an order on 10/20/17 at 12:00 p.m. for Ativan 2 mg po BID PRN agitation.

Review of patient #1's multidisciplinary notes revealed Ativan was administered on 10/20/17 at 3:15 p.m. and on 10/21/17 at 6:45 p.m. by S20LPN, on 10/22/17 at 1:15 a.m. by S17LPN, and on 10/24/17 at 8:00 p.m. by an LPN with no documented evidence of alternative interventions attempted with failure and an assessment by a RN prior to administration of the PRN medication.

In an interview on 12/11/17 at 2:05 p.m., S17LPN indicated Ativan was ordered for anxiety and combativeness. She further indicated she administers it if she can't redirect the patient verbally. When asked by the surveyor to review the medical record and show where she documented that alternative interventions were Attempted and failed, S17LPN indicated the LPNs don't document in the nurse's notes. She further indicated the RN documents the nurse's notes. She confirmed that she doesn't document in the multidisciplinary notes the alternative attempts she makes prior to administering a PRN medication. She indicated the RN doesn't assess the patient before she administers PRN medication.

In an interview on 12/11/17 at 2:35 p.m., S8HS indicated the RN is supposed to assess a patient before PRN Ativan is given by the LPN. She further indicated there should be an assessment documented by the RN before any PRN medication is administered.

Based on observation, record reviews, and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the competence of the available nursing staff as evidenced by:
1) Failing to ensure nurses demonstrated competence in the use of the Braden Scale, implemented wound protocol and prevention, and initiated treatment plan documentation. Competency evaluation was conducted verbally without documented evidence of demonstration of skills for 7 (S8HS, S10RN, S12RN, S14RN, S17LPN, S20LPN, S21RN) of 7 RN and LPN personnel files reviewed for competency related to wound protocol, prevention, and treatment from a total of 12 employed/contracted direct care nurses at the off-site campus. Observation by the surveyor on 12/11/17 at 4:15 p.m. revealed Patient #4 had 2 areas of broken skin (a shearing-type wound) to the left buttock, one measuring 1 cm by 4 cm and one measuring 1 cm by 6 cm. The nursing staff had not identified one of the wounds until it was identified by the surveyor. Review of medical records of Patients #1, #2, #3, and #5 revealed each patient had a wound that had no documented evidence of measurements and description of the wound and surrounding skin by a RN.
2) Failing to ensure MHTs demonstrated competency in obtaining patient weights as evidenced by having competency in obtaining werights of patients evaluated by interview and oral evaluation for 6 (S15MHT, S16MHT, S18MHT, S19MHT, S24MHT, S25MHT) of 6 MHTs' personnel files reviewed for competency in obtaining weights from a total of 12 employed MHTs at the off-site campus. Review of the medical records of Patients #1 and #3 revealed no documented evidence that weights had been assessed and documented in accordance with physician orders.
Findings:

1) Failing to ensure nurses demonstrated competence in the use of the Braden Scale, implemented wound protocol and prevention, and initiated treatment plan documentation:
Observation on 12/11/17 at 4:15 p.m. revealed S2DON and a MHT brought Patient #4 from Room "i" to her room in a wheelchair. Further observation revealed a diaper saturated with urine from the front to the back of the diaper was removed, and S2DON measured 2 shearing-type wounds to the left buttock. One wound was observed to be 1 cm wide by 4 cm long and one was 1 cm wide by 6 cm long. Review of Patient #4's medical record revealed only one wound measuring 1 cm wide by 6 cm long had been documented on 12/10/17 at 6:15 a.m.

Review of the medical records of Patients #1, #2, #3, and #5 revealed each patient had a wound that had no documented evidence of an assessment by a RN.

Review of the policy titled "Job Descriptions And Competencies", presented as a current policy by S1ADM, revealed that all staff, contractors, volunteers, and students must demonstrate competency. Each supervisor will be responsible for ensuring that the competence of his/her employees is continuously assessed, demonstrated, maintained, and improved. Acceptable methods of assessing competency include a written test, direct observation by a supervisor or designated evaluator while the employee demonstrates the skill, interview and oral evaluation, and return demonstration by the employee during an in-service. It is not sufficient to merely demonstrate a skill. Competence can only be assessed by performance.

Review of the personnel files of S8HS, S10RN, S12RN, S14RN, S17LPN, and S20LPN revealed their competency in the use of the Braden Scale, implementation of wound protocol and prevention, and initiation of treatment plan documentation had been done verbally and not by demonstration of performance in accordance with hospital policy. Review of S21RN's personnel file, a contracted RN from Company A, revealed no documented evidence that he had been evaluated for competency by a hospital-employed, competent RN.

In an interview on 12/13/17 at 9:30 a.m., S1ADM and S3RDCO confirmed the above findings.

2) Failing to ensure MHTs demonstrated competency in obtaining patient weights:
Review of the medical records of Patient #1 and #3 revealed the weights were not obtained in accordance with physician orders.

See review of the policy titled "Job Descriptions And Competencies" as written above.

Review of the personnel files of S15MHT, S16MHT, S18MHT, S19MHT, S24MHT, and S25MHT revealed each evaluation of competence for obtaining patient weights was evaluated by interview and oral evaluation and not by demonstration in accordance with hospital policy.

In an interview on 12/13/17 at 9:30 a.m., S1ADM and S3RDCO confirmed the above findings.

Based on record reviews and interview, the hospital failed to ensure the DON provided adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing services as evidenced by the DON assigning charge nurse duties on the night shift (7:00 p.m. to 7:00 a.m.) of 12/10/17 to S21RN who was a contract nurse of Company A and the only RN in the hospital for this 12 hour period.
Findings:

Review of the assignment sheet for the night shift of 12/10/17, presented as the assignment sheet for the night shift of 12/10/17 by S2DON, revealed S21RN was the charge nurse and the only RN in the hospital during the 12 hour period from 7:00 p.m. on 12/10/17 to 7:00 a.m. on 12/11/17. There was no documented evidence that a competent, hospital-employed RN was present to supervise the clinical activities of S21RN.

Review of S21RN's personnel file revealed he was a contract RN from Company A. Further review revealed he received "short orientation" on 12/09/17 which included information on safety, medical equipment, fire safety, security, emergency preparedness, utilities failure, social environment, and confidentiality. Further review revealed in case of a medical emergency (such as a person falls and appears unconscious) or a crisis situation (such as a person becomes verbally or physically aggressive), employees respond as appropriate to training and position. Non-employees are not to physically respond. The non-employee must contact the nearest employee or locate the nearest phone and page "Code Blue" for a medical problem or "Code green" for a psuchiatric problem. The non-employee must identify the area he/she is in and get assistance from staff trained in CPI or CPR immediately. Further review revealed no documented evidence that S21RN had been evaluated for competence by a competent, hospital-employed RN.

In an interview on 12/12/17 at 1:15 p.m., S1ADM and S3RDCO confirmed that S21RN was a contract RN from Company A and had been assigned as charge nurse on the night shift of 12/10/17. They indicated that they didn't know that the federal acute care hospital regulations required a non-employee nurse to be supervised by a hospital-employed RN.

Based on record reviews and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with physician orders as evidenced by having physician-ordered medications not administered as ordered and having no documented evidence of the reason for not administering the medication for 3 (#1, #2, #3) of 5 patient records reviewed for medication administration from a total sample of 5 patients.
Findings:

Review of the policy titled "Medications", presented as a current policy by S1ADM, revealed that the physician must include the medication indication for each medication ordered. Medication orders written as PRN must include the indication for use of the PRN medication. Further review revealed all medications shall be documented on the patient's MAR immediately after administration. If a dose of scheduled medication is withheld or not given, the nurse is to circle the hour of administration for the medication dose in question and initial next to the circled time. The nurse is to record a full explanation in the integrated progress notes and/or MAR. The physician must be notified with documentation of physician notification in the pink progress notes. A medication variance must be completed and placed in the bin to be processed.

Patient #1
Review of Patient #1's physician orders revealed an order at admit on 10/19/17 at 7:45 p.m. for Megace 20 mg po TID, Omnicef 300 mg po BID, and Deplin 314 mg po daily. Further review revealed a recommendation on 10/20/17 at 8:37 a.m. by S7RD for Med Pass (nutritional supplement) 2 oz. po BID and follow with water.

Review of Patient #1's MARs revealed Megace, Deplin, Omnicef, and Med Pass were not administered on 10/26/17 at 9:00 a.m. as evidenced by the nurse's initials being circled. Further review revealed Med Pass was not administered at 9:00 p.m. on 10/27/17, 10/28/17, and 10/29/17 as evidenced by the nurse's initials being circled for each day.

Review of Patient #1's "Multi-Disciplinary Note" for 10/26/17 at 6:30 p.m. revealed an entry by S20LPN that the morning medications were held due to sedation. There was no documented evidence that the physician was notified and an incident report documented in accordance with policy. Further review revealed no documented evidence of the reason the Med Pass was not administered at 9:00 p.m. on 10/27/17, 10/28/17, and 10/29/17, and there was no documented evidence the physician was notified and an incident report documented.

In an interview on 12/11/17 at 2:35 p.m., S8HS confirmed the above findings after reviewing Patient #1's MARs and medical record.

Patient #2
Review of Patient #2's physician orders revealed an order at admit on 12/03/17 at 1:30 p.m. for Vitamin D3 1000 units daily per PEG and Jevity 1.5, 2 cans, TID bolus per PEG. Further review revealed a telephone order received on 12/10/17 at 5:35 p.m. from S6MD for Tamiflu 75 mg po BID for 5 days. Further review revealed a telephone order received on 12/10/17 at 7:00 p.m. from S5Psych of "OK to start Tamiflu" in the a.m.

Review of Patient #2's MARs revealed no documented evidence that Vitamin D3 was administered at 9:00 a.m. on 12/08/17 and Jevity was administered at 9:00 a.m. and 3:00 p.m. on 12/08/17 as ordered as evidenced by no initials were documented in the space on the MAR for these medications and times. Further review revealed Tamiflu 75 mg was administered per PEG (ordered po) on 12/11/17 at 9:00 a.m.

In an interview on 12/11/17 at 11:30 a.m., S27LPN indicated Tamiflu wasn't available to be administered when ordered on 12/10/17.

In an interview on 12/11/17 at 11:32 a.m., S23RPh indicated a pharmacist is at the pharmacy 24 hours a day 7 days a week. She further indicated the pharmacy usually has a driver to make deliveries to the hospital until 2:00 a.m., but the pharmacy could call someone if a delivery is needed outside these hours. She further indicated the pharmacy also has an agreement with a local retail drug store for 1st dose medications. After checking with the pharmacy personnel at the pharmacy, S23RPh indicated the pharmacy received the order for Tamiflu on 12/10/17 at 5:35 p.m., and S28LPN said it could be started in the morning of 12/11/17. She confirmed that she brought the first dose to the hospital the morning of this interview.

In an interview on 12/11/17 at 12:10 p.m., S27LPN indicated she gave Vitamin D3 and Jevity at 9:00 a.m. on 12/08 and Jevity also at 3:00 p.m. on 12/08/17, but she failed to document the administration on the MAR.

In an interview on 12/11/17 at 4:00 p.m., S5Psych indicated he was told when he received a phone call that the pharmacy didn't have Tamiflu. When he was informed by the surveyor that S23RPh indicated the nurse told the pharmacist that the Tamiflu could be started the morning of 12/11/17, S5Psych indicated he was told the pharmacy didn't have it, so he gave the order to wait to start it in the morning.

In an interview on 12/12/17 at 2:42 p.m., S6MD indicated the medical doctor typically handled medical problems such as the flu, and he should have been notified of the order to hold the Tamiflu, since he gave the order.

Patient #3
Review of Patient #3's physician orders revealed an order at admit on 09/30/17 at 11:15 a.m. for Lantus 100 units per ml, 15 units subcutaneously at bedtime and Metoprolol 50 mg via PEG BID. Further review revealed an order on 10/17/17 at 5:30 p.m. to flush the PEG with 200 ml water TID. An order documented on 10/03/17 at 3:30 p.m. for Risamine to buttocks BID and PRN had no documented evidence of the indication for use PRN. Further review revealed a recommendation on 10/03/17 at 4:00 p.m. by S7RD to increase the flush to 300 ml of water 5 times a day per PEG. An order written on 10/08/17 at 12:30 a.m. for Omnicef 300 mg po BID had no indication for use as well as an order for Z-Pack received on 10/09/17 at 8:15 a.m.

Review of Patient #3's MARs revealed no documented evidence that his PEG was flushed with 300 ml water 5 times a day on 10/07/17, 10/08/17, 10/10/17, and 10/11/17. Further review revealed no documented evidence Lopressor was administered at 9:00 p.m. on 10/07/17, and his pulse was 103 (MAR revealed Lopressor was to be held if the apical pulse was less than or equal to 60, and the physician was to be notified) and on 10/04/17 at 9:00 p.m. with his pulse documented as 66. Further review revealed Glucerna was not administered on 10/06/17 and 10/07/17 at 1:00 p.m. as evidenced by the nurse's initials being circled. There was no documented evidence that the physician was notified of the medications and water flushes that were not administered, and there was no incident report documented. There was no documented evidence of a clarification order obtained by the nurse for the medications that were ordered without an indication for use.

In an interview on 12/11/17 at 2:55 p.m., S8HS reviewed Patient #3's medical record and confirmed the above findings.

Based on record reviews and interviews, the hospital failed to ensure individual patient nutritional needs were met as evidenced by failure of staff to offer substitutes that are of equal nutritional value in order to meet the patient's basic nutritional needs when food served is refused, ensuring the patient's care plan included monitoring of the patient's weight and intake and output for patients identified as having specialized nutritional needs, and failure to notify the physician and RD when the patient was assessed as having inadequate nutrition for several days for 2 (#1, #3) of 2 patient records reviewed of patients with specialized nutritional needs from a total sample of 5 patients.
Findings:

Review of the policy titled "Assessment Process", presented as a current policy by S1ADM, revealed that the admitting RN will assess weight and the nutritional screen. If the screen identifies high risk factors, the physician will be notified.

Review of the policy titled "Nutritional Screening", presented as a current policy by S1ADM, revealed that patients are screened for the need of nutritional intervention as a component of the Individual Nursing assessment process performed by the admitting nurse. The physician orders a dietary consult based on the nutritional screen and other patient needs. The nursing staff continually assesses patients' nutritional risk by monitoring the patient's food intake at every meal and ensuring that staff documents intake on the graphic sheet in the medical record, weighing patients as per policy to monitor for significant changes, identifying patients requiring adaptive feeding devices, and monitoring for eating difficulties such as choking on food, lack of compliance to prescribed diet, or if the patient has any other special nutritional needs. The RD completes the nutrition assessment when ordered, documents the assessment in the medical record, communicates the findings of the assessment with the nursing staff, and makes recommendations to the medical staff when needed.

Review of the policy titled "Nutritional Consults Assessment/Reassessment", presented as a current policy by S1ADM, revealed that nutritional consults are to be ordered for patients at nutritional risk by the attending physician, so that the RD can conduct a nutritional assessment to evaluate the needs of the individual and provide recommendations, counseling, and instruction. The assessment is to be completed within 3 days of the physician's order for consult. Reassessments and follow-ups are conducted as ordered by the physician or initiated by the RD and may include addressing and documenting changes in nutritional status and progress of nutritional intervention. High risk conditions listed for the nurse to consider included a patient refusing to eat for 3 days and tube feeding or artificial nutrition. Patients will be reassessed by the RD if ordered by the physician, when significant change occurs in condition or diagnosis, if nutritional goals are not being met or previous intervention isn't tolerated or complied with, upon identifying a patient with a 5% weight loss since admit (nurse notified physician and RD within 24 hours), and intake less than 25% consistently will be addressed through the treatment team and may include follow up by the RD. Nutritional issues will be incorporated into the treatment plan as relevant.

Review of the policy titled "Snacks/Nourishments/Nutritional Supplements", presented as a current policy by S1ADM, revealed that patients eating less than 25% of meals may be offered an alternative meal or house supplement that is appropriate for the diet.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 10/19/17 with a diagnosis of Severe Neurocognitive Disorder. Further review revealed a routine dietary consult was ordered by S5Psych and to weigh on admit then 3 times weekly.

Review of S29RN's admit nursing assessment of Patient #1 revealed she scored the nutritional screen at 13, with a score of 10 or above requiring a RD consult. Further review revealed the question of "RD Consult Needed?" was not answered as evidenced by no check mark in then yes, no, or NA (not applicable) box.

Review of S7RD's "Nutrition Assessment" performed on 10/20/17 (no time documented) revealed the following: appetite/intake good; past intake good; skin breakdown to coccyx; weight 117.8 #; moderate nutritional risk; Megace ordered as appetite stimulant; recommended Med Pass 2 oz. po BID to follow with water; RD follow up PRN; goals - patient will consume 75-100 % of meals daily and will achieve weight maintenance by discharge.

Review of Patient #1's "Daily Nurse Note" revealed documentation of inadequate nutrition or no documented evidence of whether nutrition was adequate or inadequate on 10/20/17, 10/21/17, 10/23/17, 10/24/17, 10/26/17, 10/27/17, 10/28/17, and 10/29/17.

Review of Patient #1's MARs revealed Med Pass was not administered on 10/26/17 at 9:00 a.m. as evidenced by the nurse's initials being circled. Further review revealed Med Pass was not administered at 9:00 p.m. on 10/27/17, 10/28/17, and 10/29/17 as evidenced by the nurse's initials being circled for each day.

Review of Patient #1's "Vital Signs and I&O" record revealed her weight was 117.8# on admit. Further review revealed a note of "unable" in the weight space on the record on 10/21/17 and 10/26/17. Her weight was documented as 110# on 10/28/17, which was more than 5% weight loss since admit (9 days). Further review revealed documentation of her meal intake was as follows:
10/20/17 - 25% breakfast; 50% lunch; refused supper;
10/21/17 - refused breakfast; 25% lunch and supper;
10/22/17 - 100% breakfast; 50% lunch; 25% supper;
10/23/17 - 0% breakfast; 50% lunch; 75% supper;
10/24/17 - 50% breakfast and lunch; refused supper;
10/25/17 - 25% breakfast, 50% lunch, 100% supper;
10/26/17 - refused breakfast and supper, 25% lunch;
10/27/17 - 25% breakfast and lunch; refused supper;
10/28/17 - 25% breakfast; refused lunch and supper;
10/29/17 - 25% breakfast; refused lunch and supper;
10/30/17 - refused breakfast and lunch, was transferred to acute hospital.
There was no documented evidence that an alternative meal was offered at any time that she refused her meal. There was no documented evidence that S5Psych was notified of the decrease in food intake, assessment of inadequate nutrition by the nurses, that Patient #1's weight was not assessed as ordered, and that she had a more than 5% weight loss in 9 days. There was no documented evidence that S7RD was notified of the significant change in Patient #1's nutritional status and the need for reassessment.

Review of S5Psych's "Physician Progress Note" revealed documentation that Patient #1 was not eating well on 10/27/17, refusing to eat on 10/28/17, and not eating food anymore on 10/29/18. Patient #1 was transferred to a higher level of care on 10/31/17 at 8:30 a.m.

Review of Patient #1's nursing care plan revealed no documented evidence that a care plan had been developed for nutritional risk.

In an interview on 12/11/17 at 1:00 p.m., S14RN indicated when she documented inadequate intake, she meant that Patient #1's intake was lower than her caloric needs. She further indicated she verbally updated S5Psych during the treatment team meeting, but she didn't document when she did inform him. She further indicated she didn't know what the hospital's process was for notifying the RD of the need for a reassessment. S14RN confirmed Patient #1's nursing care plan did not include a plan developed to address nutritional risk.

In an interview on 12/11/17 at 1:50 p.m., S7RD indicated she does a reassessment when the nurse, physician, or nurse practitioner writes an order if the weight or intake changes. She further indicated she doesn't automatically do a reassessment, because the length of stay "doesn't lend itself to that." S7RD indicated since Patient #1 had a history of calorie malnutrition (on Megace for nutrition), redness to the coccyx, and documentation by multiple nurses of inadequate nutrition, she should have been contacted for a reassessment and a revised intervention.

In an interview on 12/11/17 at 2:35 p.m., S8HS indicated the day Patient #1 was transferred was the first day she (S8HS) cared for Patient #1. She further indicated that based on her total assessment that day, she felt Patient #1 needed to evaluated due to her not eating for several days. She indicated she contacted S5Psych for orders for transfer. S8HS indicated S5Psych should have been notified before this time by the nursing staff. She further indicated the charge nurse was responsible for notifying the physician of Patient #1 not eating. She further indicated that within 24 to 48 hours of Patient #1 refusing to eat, she would have contacted the physician. She further indicated the staff should have found a way to weigh the patient, because they have a scale to weigh patients in wheelchairs. S8HS indicated the MHT documents the "Vital Signs and I&O" record , but the nurse is supposed to review it.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 09/30/17 with a diagnosis of Severe Neurocognitive Disorder. Review of his admit orders received on 09/30/17 at 11:15 a.m. revealed an order to weigh on admit then 3 times weekly, to obtain a routine dietary consult, and to administer Glucerna 1.5, 1 can TID per PEG and to flush with 30 ml water after medications and feeding. Further review revealed an order on 10/01/17 at 5:30 p.m. to flush the PEG with 200 ml water TID. A recommendation was documented in the physician orders by S7RD on 10/03/17 at 4:00 p.m. to increase Glucerna 1.5 to 1 can QID, increase flush to 300 ml water 5 times a day per PEG, and encourage increase po intake with meals and fluids.

Review of S14RN's "Admit Nursing Assessment" performed on 09/30/17 at 12:10 p.m. revealed no documented evidence of the score obtained on the nutritional screen and whether the RD was consulted. Further review revealed the selections checked by S14RN totaled 18 which required a nutritional consult (score of 10 or above required a consult).

Review of S7RD's "Nutrition Assessment" performed on 10/03/17 revealed Patient #3 had poor appetite/intake, poor past intake, swallowing difficulty, and his weight was 185#. Further review revealed his estimated caloric needs were 2100 to 2400, and he was at nutritional risk due to having no intake and Glucerna as ordered not meeting his estimated nutritional needs. S7RD recommended increasing Glucerna 1.5 to 1 can QID, increase flush to 300 ml water 5 times a day, and encouraging increased po intake. Goals included that Patient #3 would consume 75 to 100% of meals and would achieve weight maintenance.

Review of the "Daily Nurse Note" revealed documentation of inadequate nutrition or no documented evidence of whether nutrition was adequate or inadequate on 10/03/1710/05/17, 10/07/17, 10/09/17, 10/10/17, and 10/11/17.

Review of Patient #3's MARs revealed no documented evidence that his PEG was flushed with 300 ml water 5 times a day on 10/07/17, 10/08/17, 10/10/17, and 10/11/17. Further review revealed Glucerna was not administered on 10/06/17 and 10/07/17 at 1:00 p.m. as evidenced by the nurse's initials being circled. There was no documented evidence that the physician was notified of the Glucerna and water flushes that were not administered.

Review of Patient #3's "Vital Signs and I&O" revealed no documented evidence of a weight documented throughout his hospital stay of 13 days. Further review revealed a note of "unable" in the weight space on the record on 10/03/17, 10/05/17, 10/07/17, and 10/12/17. Further review revealed the following intake:
10/01/17 - "0" for breakfast, lunch, supper, and snack;
10/02/17 - refused breakfast and lunch; 50% supper; 100% snack;
10/03/17 - 25% breakfast; refused lunch and supper;
10/04/17 - 25% breakfast; "0" lunch, supper, and snack;
10/05/17 - refused breakfast and lunch; asleep for supper;
10/06/17 - refused breakfast, lunch, and supper; "0" snack;
10/07/17 - refused breakfast and lunch; at the hospital for supper;
10/08/17 - 100% breakfast; 50% lunch; 75% supper; no snack;
10/09/17 - "0" for breakfast, lunch, supper, and snack;
10/10/17 - "0" for breakfast, lunch, supper, and snack;
10/11/17 - refused breakfast, lunch, and supper;
10/12/17 - refused breakfast; was discharged by lunch.
There was no documented evidence that an alternative meal was offered at any time that Patient #3 refused his meal. There was no documented evidence that S5Psych was notified of the decrease in and absence of food intake, assessment of inadequate nutrition by the nurses, and that Patient #3's weight was not assessed as ordered. There was no documented evidence that S7RD was notified of the significant change in Patient #3's nutritional status and the need for reassessment.

Review of Patient #3's nursing care plan revealed a care plan was developed for alteration in perception due to decreased/poor food intake. Further review revealed no interventions were developed for this problem. The short term goals included that Patient #3 would demonstrate an increased ability to maintain nutrition, hydration, and elimination within 7 days and would eat at least 75% of all meals for 3 consecutive days within 10 days. There was no documented evidence that the care plan was revised when these goals were not met.

In an interview on 12/11/17 at 1:25 p.m., S14RN indicated she verbally informs S5Psych when a patient has no food intake, but she doesn't document it in the medical record. When the surveyor informed S14RN of the number of days that Patient #3 had no food intake, while it was recommended by S7RD to encourage increased food intake, S14RN indicated the physician should have been notified.

In an interview on 12/11/17 at 2:00 p.m., S7RD indicated she was expecting some calories to be obtained from meal intake for Patient #3. She further indicated if Patient #3 wasn't eating or drinking, she would have expected to be notified for a reconsult.

In an interview on 12/11/17 at 2:35 p.m., S8HS indicated that within 24 to 48 hours of Patient #3 refusing to eat, she would have contacted the physician. She further indicated the staff should have found a way to weigh the patient, because they have a scale to weigh patients in wheelchairs. S8HS indicated the MHT documents the "Vital Signs and I&O" record , but the nurse is supposed to review it.

In an interview on 12/11/17 at 3:25 p.m., S10RN indicated they talk about nutrition in report, but she doesn't see the physician, because she works nights. She further indicated she could call the physician, but she thinks "it should be a face-to-face thing." She confirmed that Patient #3's nutritional status was something that should have been reported.

In an interview on 12/11/17 at 3:45 p.m., S5Psych indicated he expects weights to be assessed as he orders them and expects to be notified if staff is unable to weigh a patient. He further indicated he didn't recall being told that weights weren't able to be done. S5Psych indicated when he's on the unit he asks if the patient is sleeping and eating alright. He further indicated he would expect to be notified immediately if a patient isn't eating. He would expect to be notified when a patient has not eaten for several days.