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Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as evidenced by 1) failing to conduct cardiac nursing assessments for 4 of 4 patients reviewed for cardiac monitoring (Patient #13, 14, 16, 17) and 2) failed to interpret rhythm strips for 4 of 4 patients (Patient #13, 14, 16, 17) on continuous telemetry monitoring in a total sample of 20.

Findings:

Review of the policy titled, Cardiac Monitoring, revealed in part that monitor techs will place ECG tracings for patients on telemetry monitoring in the patient's chart upon admission, at 4:00 a.m., 10:00 a.m., 4:00 p.m. and with any rhythm change. The nurse will document an interpretation of the ECG tracings in the patient's chart.

Review of the electronic medical records with S7RN revealed that Patients #13, 14, 16 and 17 had orders for continuous telemetry monitoring. Further review of the records revealed that telemetry monitoring strips were placed in the patients' charts twice daily, but there was no documented evidence that the nurses interpreted the telemetry strips.

Further review Patient #13, 14, 16 and 17's electronic medical records revealed twice daily nursing assessments were performed. Review of the nursing assessments for "Cardiac" revealed no evidence that heart rhythm or heart sounds were assessed. The nurses only documented "cardiac monitor in use" on the twice daily nursing assessments.

On 05/18/22 at 1:30 p.m., interview with S3DON revealed that the nurses should be documenting an interpretation of the telemetry strips at least twice daily. Further interview revealed that a cardiac nursing assessment should be performed twice daily which included documentation of heart rhythm and heart sounds.

Based on record review and interview, the hospital failed to ensure that clinical records were maintained as evidenced by the physician failing to date and/or time each entry in the medical record for 4 of 4 patient records reviewed for physician orders (Patient #13, 14, 16, 17) in a total sample of 20.
Findings:

1. Review of Patient #13's medical record revealed the physician wrote orders on the following dates but failed to document a time on the orders: 05/12/22, 05/13/22, 05/14/22, 05/15/22, 05/16/22, 05/17/22 and 05/18/22.

2. Review of Patient #14's medical record revealed the physician wrote orders on the following dates but failed to document a time on the orders: 05/16/22 and 05/18/22.

Further review of the record revealed the admission physician orders and the sliding scale insulin protocol orders were not dated or timed by the physician.

3. Review of Patient #16's medical record revealed the physician wrote orders on the following dates but failed to document a time on the orders: 05/16/22, 05/17/22 and 05/18/22.

4. Review of Patient #17's medical record revealed the physician wrote orders on the following dates but failed to document a time on the orders: 05/10/22, 05/11/22, 05/13/22 and 05/15/22.

On 05/18/22 at 2:00 p.m., S7RN reviewed the above medical records and confirmed that the physician was not dating and/or timing each physician order that was written.

Based on record review and interview, the hospital failed to ensure that each patient had a completed history and physical for 1 (Patient # 16) of 4 patients (Patient #13, 14, 16, 17) reviewed for history and physicals.
Findings:

Review of Patient #16's electronic medical record with S7RN revealed an admit date of 05/16/22. Further review of the record revealed no documented history and physical.

On 05/18/22 at 2:00 p.m., interview with S7RN confirmed there was no documented evidence that a history and physical exam had been completed for the patient.

Based on record review and interview, the CAH failed to ensure that patients receiving SNF (skilled nursing facility) care maintained acceptable parameters of nutritional status by failing to ensure the weight for 1 of 2 SNF patients reviewed (#6) was obtained and monitored as ordered by the physician.

Findings:

Review of the policy and procedure for Swing Bed Nursing Services effective 01/12/21 revealed services included Dietary Services as ordered by the attending physician and prepared under the direction of a qualified dietician.

Review of the policy and procedure for Documentation of Weights effective 01/12/21 revealed: to ensure documentation of . ... weekly weights, . ... for the physician's continuing treatment of their patients and to monitor any changes in the patients's medical status ..... 2. All patients must have an admit height and weight and these must be entered into the correct patient's electronic medical record ...All medical-surgical patients that have an order for daily or weekly weights must be done before 6am each day and entered into the correct patient's electronic medical record. 3. All ... changes in medical status must be reported immediately to the patient's physician.
Review of the medical record for Patient #6 revealed she was admitted to Swing Bed status on 05/04/22 from an acute care hospital with diagnoses including left CVA (cerebrovascular accident) with paralysis, COPD (chronic obstructive pulmonary disease), and multiple myeloma.

Review of the physician's admission orders revealed the following: mechanical soft diet with chopped meats and thin liquids; Weight on admit, then weekly on Wednesdays. On 05/04/22, the patient was evaluated by Speech Therapy and a clinical bedside assessment of swallowing indicated need for minimal to close supervision of swallowing; factors impacting swallowing - cognitive decline and oral motor impairment; prolonged mastication with increased oral prep and transit time. There was no documented evidence that a nutritional assessment was conducted by the dietician.

Review of the documented weights revealed an admit weight on 05/04/22 of 152 pounds. There was no documented evidence that a weight was obtained as ordered on Wednesday 05/11/22. There was no other documented weight until 05/18/22. At that time, patient #6 had a recorded weight of 137 pounds (15 pound/10% loss in 14 days).

Documentation of meal intake from 05/04/22-05/08/22 revealed patient #6 was provided feeding assistance and her intake was between 25-75% of meals. Assistance was changed from full feed to set up assistance. Review of the meal intake from 05/09/22-05/15/22 revealed the following:
05/09/22: Breakfast - 25%; Lunch - 25%; Dinner - 25%
05/10/22: Breakfast - 0%; Lunch - 25%; Dinner - 25%
05/11/22: Breakfast - 50%; Lunch - 0%; Dinner - 0%
05/12/22: Breakfast - 25%; Lunch - 50%; Dinner - 50%
05/13/22: Breakfast - 25%; Lunch - 25%; Dinner - 25%
05/14/22: Breakfast - 0%; Lunch - 25%; Dinner - 50%
05/15/22: Breakfast - 50%; Lunch - 0%; Dinner - 0%
There was no documented evidence that the patient's weight was reassessed or that the physician or registered dietician was notified of weight loss or dietary concerns.

On 05/18/22 at 1:00pm, an interview and review of the record of Patient #6 with S3DON confirmed that Patient #6's weight was not obtained as ordered. S3DON further confirmed that each nurse is responsible for ensuring weights are obtained as ordered and any changes should be reported to the physician. He further reported that the Registered Dietician does not assess all patients upon admission, but gets involved with patients when referred by physician for consultation.