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Based on observation, record reviews, interviews, and review of facility policies, it was determined that the facility did not meet the Condition of Participation for Nursing Services by failing to:


1. Document cardiopulmonary resuscitative interventions sequentially for one patient who was found unresponsive. (A395)

2. Ensure that one patient who was identified with a significant weight loss, aspiration and dehydration risk was assessed and monitored in accordance with physician's orders, hospital protocol and/or clinician recommendations. (A395)

3. Ensure that for five of ten patients that the plan of care was comprehensive to address the individualized needs of the patient and/or that the plan of care was followed. (A396)

4. Ensure medication was administered in accordance with the hospital policy. (A405)

1. Based on a review of the clinical record, staff interviews and a review of the facility policy for one sampled patient (Patient #1), the hospital failed to ensure cardiopulmonary resuscitative (CPR) interventions were documented. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included Idiopathic Parkinson's, Vascular Parkinsonism, and Lewy Body Dementia, Autism Spectrum Disorder with Intellectual Impairment, Schizophrenia, Dysphagia, Gastrointestinal Reflux Disorder, Hypertension, Akathisia and Tardive Dyskinesia. Review of the clinical record identified on 5/27/15 at 4:30 PM Patient #1 was found to be pulseless and not breathing while on constant observation for behavioral and medical conditions. Interview and review of the clinical record with MD #2 on 10/27/15 at 1:00 PM indicated he was the attending physician on site called to the medical emergency and was in charge of the resuscitation. MD #2 identified a finger sweep was conducted as the patient had been eating just prior to the event and approximately one teaspoon of pudding like consistency was noted on the right side of his/her buccal mucosa which was removed. Mouth to mouth resuscitation, chest compressions, abdominal thrusts, the administration of oxygen and an automatic external defibrillator were utilized, however, the facility failed to document each intervention and what time the intervention was implemented. The clinical record also failed to reflect the time in which the on-site attending physician and community emergency medical service arrived to continue resuscitative efforts. Further review of the clinical record identified the patient expired at approximately 5:04 PM.

Interview with Nursing Director #1 on 10/27/15 at 1:25 PM indicated she would expect nursing to document each intervention required for CPR with a corresponding time and was not. The hospital policy entitled Medical Emergency Procedures identified that the recorder (medical licensed staff personnel or designated staff) utilizes the Medical Emergency Monitor form to record events of the emergency and the Emergency Medical Patient Record to record medications given and vital signs taken. The charge nurse ensures the Monitor form is completed and submitted to the division's Chief of Patient Care Services.

2. Based on a review of clinical records, staff interviews, and policies and procedures, for one of three sampled patients' identified at risk for aspiration (Patient #1), the hospital failed to monitor breath sounds in accordance with ST recommendations. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included Idiopathic Parkinson's, Vascular Parkinsonism, Lewy Body Dementia, Autism Spectrum Disorder with Intellectual Impairment, Schizophrenia, Dysphagia, Gastrointestinal Reflux Disorder, Akathisia and Tardive Dyskinesia. Patient #1 was transferred to an acute care hospital on 3/9/15 with a concern related to safe swallowing, aspiration, a poor oral intake and the request for a gastrostomy tube. The patient was hydrated with oral and intravenous fluids. Patient #1's conservator was notified and refused a feeding tube. The hospital documentation further identified there was no criteria for an emergent impatient hospitalization for a feeding tube placement and encouraged the facility to hold an interdisciplinary meeting to discuss these concerns. The patient was discharged back to the facility on the same day. On 3/11/15, Patient #1 was transferred back to the acute care hospital with a fever, swallowing difficulty, a poor oral intake, a risk for dehydration, and a history of aspiration pneumonia. Review of hospital documentation identified the patient was hydrated with intravenous fluids, was treated for a urinary tract infection and his/her psychotropic medications were adjusted. The hospital spoke with the patient's conservator on 3/12/15 and informed the responsible party that Patient #1 failed the swallowing evaluation. The insertion of a feeding tube was discussed and the conservator refused. Patient #1 improved throughout hospitalization, was able to eat and discharged back to facility on 3/20/15. A physician's order dated 3/20/15 directed a chopped diet and thin liquids. Interview and review of the clinical record with Speech Therapist #1 on 10/27/15 at 3:00 PM indicated she attempted a dysphagia evaluation on 3/26/15, 3/31/15, 4/2/15, 4/15/15 however, the patient did not cooperate with the testing. On 5/15/15 the test was completed with findings that included large bites of solids followed by prolonged chewing with abnormal mastication. Speech Therapist #1 identified Patient #1 continued with a poor oral intake regardless of the consistency provided and a twenty five pound weight loss since March of 2015. The recommendations included a gastrostomy tube as soon as possible, monitor lung sounds and monthly chest x-rays to assess for aspiration. Interview and review of the clinical record with Nurse Manager #1 on 10/27/15 at 3:15 PM failed to identify that nursing auscultated lung sounds from 5/16/15 through 5/27/15.

3. Based on a review of clinical records, staff interviews, and a review of the facility policies and procedures, the hospital failed to monitor one of three patient's weight (Patient #1), in accordance with the physician's order. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included in part, Lewy Body Dementia, Schizophrenia, Dysphagia, and Gastrointestinal Reflux Disorder. Patient #1 weighed 184 pounds (lb.) on admission, was not identified as a nutritional risk, was on a regular diet and had an order for monthly weights. The clinical record identified that the patient weighed 171 lbs. on 11/7/14, weighed 166 lbs. on 12/8/14, weighed 165 lbs. on 1/1/15, and weighed 158 lbs. on 3/5/15. A Physician's order dated 3/24/15 directed weekly weights for thirty-days. A nutritional assessment was conducted on 3/26/15 that identified Patient #1's desirable weight was between 140-155 lbs. Interview and review of the clinical record with Nurse Manager #1 on 10/26/15 at 12:00 PM failed to identify that a monthly weight was conducted in February of 2015. In addition from the time period of 3/24/15 through 4/24/15 weekly weights were not conducted on two occasions. Further interview and review of the clinical record with Nurse Manager #1 failed to identify the physician was notified that the patient's weights were not monitored as ordered. The last weight recorded was on 5/10/15 at which time Patient #1 weighed 131 lbs which was 9-24 lbs below the patient's desirable weight.

4. Based on a review of clinical records, staff interviews, and a review of the facilities policies and procedures, the hospital failed to conduct dehydration assessments for one of two patient's (Patient #1), identified at risk in accordance with the facility protocol and/or failed to confer with the physician when fluid requirements were not met. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included Idiopathic Parkinson's, Vascular Parkinsonism, Lewy Body Dementia, Autism Spectrum Disorder, Schizophrenia, Dysphagia, Gastrointestinal Reflux Disorder, and Tardive Dyskinesia.

a. Patient #1 was transferred to an acute care hospital on 3/9/15 with a concern related to safe swallowing, aspiration, and poor oral intake. According to the acute care record, the patient was admitted to the emergency room with dehydration and received oral and intravenous fluids. Hospital documentation further identified there was no criteria for an emergent impatient hospitalization for a feeding tube placement and encouraged the facility to hold an interdisciplinary meeting to discuss these concerns. The patient was discharged back to the facility on the same day. On 3/11/15, the patient was transferred back to the acute care hospital with a fever, swallowing difficulty, and poor oral intake. Review of the acute care record identified that the patient was admitted with profound dehydration and a urinary tract infection. While hospitalized, the patient's conservator was notified that the patient failed the swallowing evaluation, the insertion of a feeding tube was discussed and the conservator refused. Patient #1 improved throughout hospitalization, was able to eat and discharged back to facility on 3/20/15. Review of the patient's oral intake from 3/4/15 through 3/10/15, failed to reflect that the patient met the 24-hour fluid requirements to prevent dehydration (2,154 milliliters daily based on a weight of 158 lbs).

b. A physician's order dated 3/20/15 directed a chopped diet and thin liquids. Patient #1 was seen by Dietician #1 on 3/26/15 with a nutritional assessment changed to high risk. A three day calorie count was ordered on 3/30/15. After a review of the calorie count and fluid intake for Patient #1 it was identified by Dietician #1 that the patient's fluid needs were 1761-2465 milliliters per day. Review of the patient's documented intake intake during the period of 4/2/15 through 5/26/15 identified that the patient failed to meet his/her fluid requirements on forty-four occasions. Dehydration assessments were conducted on nine of those occasions and the physician was notified on five occasions via a medical rounds board due to symptoms of dehydration. Interview and review of the clinical record with Nurse Manager #1 on 10/26/15 at 4:00 PM failed to identify that nursing staff conducted dehydration assessments on thirty-five occasions and when they did conduct the assessments they failed to follow through with the physician to discuss the plan of care when the patient's fluid needs were not met. The hospital's nursing dehydration assessment in part directed whenever a fluid daily intake was less than 1500 milliliters an assessment of the signs and symptoms of dehydration would be completed and reported to the ambulatory care provider via the medical rounds board.

Based on a review of clinical records, staff interviews, and a review of the facilities policies and procedures for five of ten patients' (Patient #1, #2, #3, #4 and #5), the facility failed to develop comprehensive treatment plans to ensure the patient's individualized needs were met. The findings include:

1. Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included Idiopathic Parkinson's, Vascular Parkinsonism, Lewy Body Dementia, Autism Spectrum Disorder with Intellectual Impairment, Schizophrenia, Dysphagia, Gastrointestinal Reflux Disorder and a Dislocated Jaw, and Tardive Dyskinesia.

a. Upon admission, Patient #1 weighed 184 pounds (lb.) and was not determined to be a nutritional risk at that time. Patient #1 received a regular diet and was weighed on a monthly basis. Review of the clinical record identfied that the patient's documented weight on 3/5/15 was 158 lbs, a 26 lb. loss from admission. Patient #1 was transferred to an acute care hospital on 3/9/15 with a concern related to safe swallowing, aspiration, a poor oral intake and the request for a gastrostomy tube. While hospitalized, the patient was hydrated with oral and intravenous fluids with notation that Patient #1's conservator refused the insertion of a feeding tube. Upon discharge on 3/9/15, the hospital encouraged the facility to hold an interdisciplinary meeting to discuss these concerns. Patient #1 was transferred back to the acute care hospital on 3/11/15 with a fever, swallowing difficulty, poor oral intake, a risk for dehydration and a history of aspiration pneumonia. Review of hospital documentation identified the patient was hydrated with intravenous fluids, was treated for a urinary tract infection and had psychotropic medications adjusted. The hospital spoke with the patient's conservator on 3/12/15 and informed the responsible party that Patient #1 failed the swallowing evaluation, however, the conservator refused the insertion of a feeding tube. Patient #1 improved throughout hospitalization, was able to eat and discharged back to facility on 3/20/15. Interview and review of the clinical record with MD #1 on 10/26/15 at 1:20 PM indicated although she was aware of the patient's weight loss and poor intake, she failed to speak with the patient's conservators until 5/19/15 to discuss the need for a gastrostomy tube. Interview with Nurse Manager #1 on 10/26/15 indicated although the facility was aware of the responsible party's hesitation regarding the insertion of a feeding tube, an interdisciplinary meeting should have been conducted immediately following the patient's return to the facility on 3/20/15 in accordance with the recommendations from the acute care setting where the patient was treated for dehydration. On 5/19/15 approval was obtained from the conservator for a gastrostomy tube however Patient #1 expired on 5/27/15 prior to the procedure.

b. Review of the Registered Dietician's note dated 3/26/15 identified that Patient #1 had a 15.8 % weight loss from admission, continued with poor food intake with a concern related to safe swallowing and aspiration risk. Interview with Speech Therapist #1 on 10/27/15 at 1:50 PM indicated she was aware Patient #1 failed the swallowing evaluation in the acute care hospital early March of 2015 and attempted to perform a swallow evaluation with Patient #1 on 3/26/15, 3/31/15, 4/2/15, 4/15/15, however, was unable to do so until 5/15/15 as the patient was uncooperative. Further interview and review of the integrated treatment plans dated 3/4/15 through 5/19/15 with Speech Therapist #1 and Nurse Manager #1 failed to identify aspiration risk as an active problem with interventions that were comprehensive and individualized for Patient #1 and should have been.

2. Review of the clinical record identified Patient #2 was admitted to the hospital on 11/19/08 with diagnoses that included Dementia with behavioral disturbances, gastroesophageal reflux, and a history of recurrent vomiting. Review of the multidisciplinary treatment plan (MTP) dated 10/20/15 indicated the patient continued to lose weight throughout his/her hospitalization and a gastrostomy tube was inserted on 7/24/13 secondary to chronic vomiting. Interview and review of the MTP dated 10/20/15 with Registered Dietician #1 and the Nurse Director #1 on 10/27/15 at 2:00 PM identified although Patient #2's plan of care indicated the patient had a gastrostomy tube the plan failed to direct nursing interventions for patient care related to the feeding tube.

3. Review of the clinical record identified Patient #3 was admitted to the hospital on 7/29/78 with diagnoses that included Dementia, Schizophrenia and Tardive Dyskinesia. Interview and review of the clinical record with Registered Dietician #1 on 10/27/15 at 2:10 PM identified in May and June of 2015, Patient #3 had a poor oral intake with weight loss. Registered Dietician #1 indicated the patient was placed on fluid supplements, a calorie count and pre-albumin testing was conducted. Interview and review of the interdisciplinary plan dated 5/21/15 and 6/17/15 with Nurse Director #1 on 10/27/15 at 2:10 PM indicated although it was identified that the patient had a history of aspiration, choking, and a poor oral intake the plan failed to direct comprehensive nursing interventions that were individualized to address each problem.

4. Review of the clinical record identified Patient #4 was admitted to the hospital on 2/4/15 with diagnoses that included Traumatic Brain Injury and, Esophageal Reflux, with a history of aspiration and a gastrostomy tube. A barium swallow was conducted on 4/22/15 and aspiration continued to be identified. Interview and review of the interdisciplinary treatment plan dated 9/21/15 with Registered Dietician #1 and Nurse Director #1 on 10/27/15 at 2:15 PM identified although the plan of care identified the patient had a feeding tube and was at risk for aspiration the care plan failed to direct individualized nursing interventions for patient care related to the feeding tube and aspiration risk.

5. Review of the clinical record identified Patient #5 was admitted to the hospital on 9/6/15 with diagnoses that included Schizoaffective Disorder. Interview and review of the interdisciplinary treatment plan dated 9/21/15 with Registered Dietician #1 and Nurse Director #1 on 10/27/15 at 2:25 PM identified Patient #5 was hospitalized for dehydration in September of 2015, had a poor oral intake, and was at risk for aspiration and choking. Interview and review of the interdisciplinary treatment plan dated 9/21/15 with Registered Dietician #1 and Nurse Director #1 on 10/27/15 at 2:20 PM failed to identify the potential for dehydration with nursing interventions that where individualized. Subsequent to the surveyors inquiry the facility included dehydration as a problem with interventions that directed an oral intake of 2000 milliliters of fluid per day and monitoring of kidney function tests.

The hospital policy entitled the nursing plan of care directed the registered nurse would develop an individualized nursing care plan in collaboration with the patient, significant others and the interdisciplinary team. The registered nurse would assess the patient and formulate with the physician a plan of care and would review and/or revise the plan as appropriate. The plan of care would reflect individualized treatment needs that address the patient's goals. Changes in interventions, goals, strengths, assets, and barriers would be made by the assigned Nursing staff.

Based on observation, staff interviews and a review of the hospital's policies and procedures for seven of eight patients reviewed for medication administration (Patient #5, #11 #13, #14, #15, #16 and #17), the facility failed to administer medications in accordance with the hospital policy. The findings included:

During a tour of the hospital on 10/26/15 at 4:05 PM it was observed that medications for Patient # 5, #11, #13, #14, #15, 16 and #17 had been prepared for 4:00 PM by LPN #1. The medications were removed from their original package rendering them unidentifiable. Subsequent to the surveyors observation, a facility staff member instructed the nurse to discard the medications and prepare the medications in accordance with the hospital's policies and procedures.

a. Review of the clinical record identified Patient #5 was admitted to the hospital on 9/6/01 with diagnoses that included Schizoaffective Disorder, Hypertension, and Venous Insufficiency. Physician's orders dated 10/22/15 directed in part, Mirapex 0.125 mg PO, Calcium with Vitamin D 500mg/200 International Units, and Tamulosin 0.4 mg at 4:00 PM

b. Review of the clinical record identified Patient #11 was admitted to the hospital on 8/21/15 with diagnoses that included Schizophrenia, Hypertension, Hyperlipidemia, Vascular Dementia and Chronic Kidney Disease. Physician's orders dated 10/15/15 directed in part, Amantadine 100 milligrams (mg) orally (PO), Carbidopa-Levodopa 25mg/100mg PO, Labetalol 300 mg PO, and Acetaminophen 650 mg at 4:00 PM.

c. Review of the clinical record identified Patient #13 was admitted to the hospital on 6/1/11 with diagnoses that included Schizophrenia. Physician's orders dated 10/15/15 directed in part, Clonazepam 0.5 mg PO at 4:00 PM.

d. Review of the clinical record identified Patient #14 was admitted to the hospital on 8/12/05 with diagnoses that included Schizophrenia, Hyperlipidemia, and Mild Cognitive Impairment. Physician's orders dated 10/22/15 directed in part, Clozapine 400 mg PO, Olanzapine 15 mg PO, Divalproex Sprinkles 625 mg PO, Colace 200mg PO, and Senokot two tablets PO at 8:00 PM. The order further directed that medications may be offered from 3:00 PM to 10:00 PM daily.

e. Review of the clinical record identified Patient #15 was admitted to the hospital on 4/30/12 with diagnoses that included Schizophrenia, Hypertension, and Hyperlipidemia. Physician's orders dated 10/15/15 directed in part a Multivitamin one tablet PO at 4:00 PM.

f. Review of the clinical record identified Patient #16 was admitted to the hospital on 5/16/12 with diagnoses that included Schizoaffective Disorder, Hypertension, Chronic Obstructive Pulmonary Disease, Mild Cognitive Impairment, Obesity and Gastroesophageal Reflux. Physician's orders dated 10/9/15 directed in part Quetiapine 100 mg PO at 4:00 PM.

g. Review of the clinical record identified Patient #17 was admitted to the hospital on 11/17/14 with diagnoses that included Alzheimer's disease, Venous Insufficiency, Hypertension and Chronic Obstructive Pulmonary Disease. Physician's orders dated 10/15/15 directed in part Calcium with Vitamin D 500mg/200 International Units (IU) PO and Cholecalciferol 800 IU at 5:00 PM.

Interview with LPN #1 on 10/26/15 at 4:10 PM indicated she prepared the medications out of the packets as a time saving task. Interview with the Director of Nursing on 10/26/15 at 4:15 PM indicated that medications may be pre-poured but must stay in the original package to identify the correct medication at the time of administration. The hospital policy entitled Medication Management Preparation and Administration directed that the nurse would prepare each patient's medication immediately prior to administration and may be removed from the Pyxis Medication Station two hours before they are due. The policy further directed to place the checked medication packet(s) in a medication cup and place the cup in the labeled medication tray. Immediately prior to administering medications, recheck the medication packet against the Medication Administration Record for the correct medication, dosage, time and correct route. Remove the tablets from their packaging just prior to the actual administration.

1. Based on a review of the clinical record, staff interviews and a review of the facility policy for one sampled patient (Patient #1), the hospital failed to ensure cardiopulmonary resuscitative (CPR) interventions were documented. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included Idiopathic Parkinson's, Vascular Parkinsonism, and Lewy Body Dementia, Autism Spectrum Disorder with Intellectual Impairment, Schizophrenia, Dysphagia, Gastrointestinal Reflux Disorder, Hypertension, Akathisia and Tardive Dyskinesia. Review of the clinical record identified on 5/27/15 at 4:30 PM Patient #1 was found to be pulseless and not breathing while on constant observation for behavioral and medical conditions. Interview and review of the clinical record with MD #2 on 10/27/15 at 1:00 PM indicated he was the attending physician on site called to the medical emergency and was in charge of the resuscitation. MD #2 identified a finger sweep was conducted as the patient had been eating just prior to the event and approximately one teaspoon of pudding like consistency was noted on the right side of his/her buccal mucosa which was removed. Mouth to mouth resuscitation, chest compressions, abdominal thrusts, the administration of oxygen and an automatic external defibrillator were utilized, however, the facility failed to document each intervention and what time the intervention was implemented. The clinical record also failed to reflect the time in which the on-site attending physician and community emergency medical service arrived to continue resuscitative efforts. Further review of the clinical record identified the patient expired at approximately 5:04 PM.

Interview with Nursing Director #1 on 10/27/15 at 1:25 PM indicated she would expect nursing to document each intervention required for CPR with a corresponding time and was not. The hospital policy entitled Medical Emergency Procedures identified that the recorder (medical licensed staff personnel or designated staff) utilizes the Medical Emergency Monitor form to record events of the emergency and the Emergency Medical Patient Record to record medications given and vital signs taken. The charge nurse ensures the Monitor form is completed and submitted to the division's Chief of Patient Care Services.

2. Based on a review of clinical records, staff interviews, and policies and procedures, for one of three sampled patients' identified at risk for aspiration (Patient #1), the hospital failed to monitor breath sounds in accordance with ST recommendations. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included Idiopathic Parkinson's, Vascular Parkinsonism, Lewy Body Dementia, Autism Spectrum Disorder with Intellectual Impairment, Schizophrenia, Dysphagia, Gastrointestinal Reflux Disorder, Akathisia and Tardive Dyskinesia. Patient #1 was transferred to an acute care hospital on 3/9/15 with a concern related to safe swallowing, aspiration, a poor oral intake and the request for a gastrostomy tube. The patient was hydrated with oral and intravenous fluids. Patient #1's conservator was notified and refused a feeding tube. The hospital documentation further identified there was no criteria for an emergent impatient hospitalization for a feeding tube placement and encouraged the facility to hold an interdisciplinary meeting to discuss these concerns. The patient was discharged back to the facility on the same day. On 3/11/15, Patient #1 was transferred back to the acute care hospital with a fever, swallowing difficulty, a poor oral intake, a risk for dehydration, and a history of aspiration pneumonia. Review of hospital documentation identified the patient was hydrated with intravenous fluids, was treated for a urinary tract infection and his/her psychotropic medications were adjusted. The hospital spoke with the patient's conservator on 3/12/15 and informed the responsible party that Patient #1 failed the swallowing evaluation. The insertion of a feeding tube was discussed and the conservator refused. Patient #1 improved throughout hospitalization, was able to eat and discharged back to facility on 3/20/15. A physician's order dated 3/20/15 directed a chopped diet and thin liquids. Interview and review of the clinical record with Speech Therapist #1 on 10/27/15 at 3:00 PM indicated she attempted a dysphagia evaluation on 3/26/15, 3/31/15, 4/2/15, 4/15/15 however, the patient did not cooperate with the testing. On 5/15/15 the test was completed with findings that included large bites of solids followed by prolonged chewing with abnormal mastication. Speech Therapist #1 identified Patient #1 continued with a poor oral intake regardless of the consistency provided and a twenty five pound weight loss since March of 2015. The recommendations included a gastrostomy tube as soon as possible, monitor lung sounds and monthly chest x-rays to assess for aspiration. Interview and review of the clinical record with Nurse Manager #1 on 10/27/15 at 3:15 PM failed to identify that nursing auscultated lung sounds from 5/16/15 through 5/27/15.

3. Based on a review of clinical records, staff interviews, and a review of the facility policies and procedures, the hospital failed to monitor one of three patient's weight (Patient #1), in accordance with the physician's order. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included in part, Lewy Body Dementia, Schizophrenia, Dysphagia, and Gastrointestinal Reflux Disorder. Patient #1 weighed 184 pounds (lb.) on admission, was not identified as a nutritional risk, was on a regular diet and had an order for monthly weights. The clinical record identified that the patient weighed 171 lbs. on 11/7/14, weighed 166 lbs. on 12/8/14, weighed 165 lbs. on 1/1/15, and weighed 158 lbs. on 3/5/15. A Physician's order dated 3/24/15 directed weekly weights for thirty-days. A nutritional assessment was conducted on 3/26/15 that identified Patient #1's desirable weight was between 140-155 lbs. Interview and review of the clinical record with Nurse Manager #1 on 10/26/15 at 12:00 PM failed to identify that a monthly weight was conducted in February of 2015. In addition from the time period of 3/24/15 through 4/24/15 weekly weights were not conducted on two occasions. Further interview and review of the clinical record with Nurse Manager #1 failed to identify the physician was notified that the patient's weights were not monitored as ordered. The last weight recorded was on 5/10/15 at which time Patient #1 weighed 131 lbs which was 9-24 lbs below the patient's desirable weight.

4. Based on a review of clinical records, staff interviews, and a review of the facilities policies and procedures, the hospital failed to conduct dehydration assessments for one of two patient's (Patient #1), identified at risk in accordance with the facility protocol and/or failed to confer with the physician when fluid requirements were not met. The finding included:

Review of the clinical record identified Patient #1 was admitted to the hospital on 10/8/14 with diagnoses that included Idiopathic Parkinson's, Vascular Parkinsonism, Lewy Body Dementia, Autism Spectrum Disorder, Schizophrenia, Dysphagia, Gastrointestinal Reflux Disorder, and Tardive Dyskinesia.

a. Patient #1 was transferred to an acute care hospital on 3/9/15 with a concern related to safe swallowing, aspiration, and poor oral intake. According to the acute care record, the patient was admitted to the emergency room with dehydration and received oral and intravenous fluids. Hospital documentation further identified there was no criteria for an emergent impatient hospitalization for a feeding tube placement and encouraged the facility to hold an interdisciplinary meeting to discuss these concerns. The patient was discharged back to the facility on the same day. On 3/11/15, the patient was transferred back to the acute care hospital with a fever, swallowing difficulty, and p