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Based on medical chart review, facility policy review, and interviews, the facility failed to develop and implement a plan of care that addressed ongoing patient needs and responses to interventions for Patient #1, who was transferred to this facility with a surgical wound and a need for rehabilitation, physical and occupational therapy (refer to A 396); the facility failed to assign nurses to the patient who could manage the complexity of Patient #1's care (refer to A 397). These failed practices contributed to dehydration, exacerbation of an urinary tract infection (UTI), the emergent need for bowel disimpaction, low blood pressures and transfer of the patient to a higher level of care.

Based on medical chart review, facility policy review, and interviews, the facility failed to develop and execute a plan of care that addressed ongoing patient needs and responses to interventions for Patient #1, who was transferred to this facility with a surgical wound and a need for rehabilitation, physical and occupational therapy. This failure resulted in severe discomfort and dehydration for the patient, as well as the necessity for a second transfer to a higher level of care at another hospital. The findings are:

A. Review of the medical record for Patient #1 revealed that she was transferred on 07/17/14 from another hospital to this facility for rehabilitation to recover from a right hip replacement. She had a significant medical history of a cerebrovascular accident, osteoarthritis, myocardial infarction 10 years ago, cardiac catheterization, hypertension, renal artery stenosis , gastroesophageal reflux disease, right total shoulder replacement, back surgery with a fusion of the lumbar 4-5, two knee replacements, and an intramuscular rodding of the left hip. The Plan of Care dated 07/18/14 that was developed to address Patient #1's bladder and bowel function consisted of the following:

"Bladder Function Goal: Patient will be continent of bladder. Bladder Function Interventions: Encourage 240 cc of intake every 4 hours; Assess for signs and symptoms of bladder infection and report findings to the physician monitor fluid intake and output every shift; use incontinence pads to prevent wetting of clothing and mats during therapy."

"Bowel Function Goals: Patient will have no bowel accidents or spills/soiling of clothing; Patient will have a bowel movement every 1-3 days; Bowel Function Interventions: Encourage fluid intake of 240 cc every 4 hours; Encourage dietary intake high in fiber; Administer colace medication as ordered by the Physician; Administer laxative if no bowel movement in 3 days; use incontinent pads and absorptive briefs to prevent soiling of clothing and mats during therapy."

B. Review of the Daily Flowsheet Treatment Record (DFTR) for Patient #1 indicated abnormal fluid intake and urine output, much below what is physiologically normal.
1. The DFTR documentation for Patient #1 indicated the following:
a. On 07/18/14, 400 cc fluid intake, 500 cc urine output, and no bowel movement (BM).
b. On 07/19/14 500 cc fluid intake, 600 cc urine output, and no BM.
c. On 07/20/14 480 cc fluid intake, no urine output, and no BM.
d. On 07/21/14 1460 cc fluid intake, 725 cc urine output, and no BM.
e. On 07/22/14 1180 cc fluid intake, 9 urinations (not measured), and no BM.
f. On 07/23/14 750 cc fluid intake, 6 urinations (not measured), and one BM with suppository and disimpaction (removal of hard stool).
g. On 07/24/14 no fluid intake, no urine output, and one BM.
h. On 07/25/14 no fluid intake, no urine output, and no BM.
2. For a geriatric adult 1200 to 1500 cc of fluids is the minimum daily fluid intake and urine output; for a 70 kg adult (144 lbs) normal fluid intake is 2500 cc per day (Medical Physiology, Guyton & Hall, 2006).

C. Review of the Progress Notes in the assessment of Patient #1 by the facility Physician #1, on 7/21/14, 7/22/14, 07/23/14 and the facility Nurse Practitioner #1, on 7/21/14, 07/22/14, 07/23/14, 07/24/14 revealed only "nausea and poor appetite" regarding Patient #1's gastrointestinal status. No progress notes were found addressing fluid intake and urine outputs, bowel movements, bowel sounds, palpation of the abdomen, or an assessment of swallowing difficulties reported by Patient #1 to the family. "If the body lacks fluid (dehydration), the colon will reabsorb an increased amount of water from the stool, leading to a hardened stool." (Medical-Surgical Nursing, Phipps, Long, and Woods, 1987) .

D. Review of the results of a urinary analysis/culture & sensitivity (UA/C&S) on a urine sample obtained on 07/18/14 from Patient #1 revealed that the patient had a positive urinary tract infection (UTI) which was reported to staff on 07/21/14. (The indwelling urinary catheter was removed on 07/19/14.) Intravenous antibiotics (vancomycin and Rocephin) were not started until 07/25/14 when the patient was transferred to another hospital.
1. The facility microbiology report dated 07/21/14 indicated the following:
a. A urine sample collected on 07/18/14 revealed positive results for two gram-negative bacteria, Klebsiella pneumoniae and Escherichia coli, with both susceptible to the antibiotic Ciprofloxacin. Both bacteria populations were estimated between 50,000 to 60,000 colonies per milliliter.
2. Review of the nursing notes for Patient #1 for 07/22/14 indicated urine characteristics as "clear yellow." Also noted for this date was a medication for bladder spasms, "Oxybutynin XL 15 mg by mouth at bedtime for bladder management."
3. The nursing notes for 07/23/14 on the day shift indicated the urine characteristic as "unseen" and "patient complained of urinating the bed over night. Request to be toileted every 2-3 hours and prior to 4 am." On 07/23/14 at 8:00 pm urine characteristics were recorded as "cloudy yellow with strong odor." Under the comments section was the following: "Urine cloudy with strong odor noted. Will notify [Physician #1] in the morning."
4. The nursing notes for 07/24/14 at 7:10 am documented urine characteristics as "clear yellow" and that the patient "denies discomfort." At 9:00 am that day (07/24/14) a second urinary analyis/culture & sensitivity (UA/C&S) was ordered. And at 2:00 pm that day a complete blood count (CBC) and complete metabolic panel (CMP) were ordered. The night shift at 11:55 pm recorded urine characteristics as "not observed."
6. At 7:40 on 07/24/14 a verbal order from the PCP to administer 500 cc of normal saline through the PICC (peripherally inserted central catheter) to Patient #1. Review of the physician's orders for 07/24/14 at 9:00 am indicates an order for a second UA/C&S by Physician #1.
7. Review of Physician #1's progress notes for 07/24/14 revealed no mention of the urine characteristic notes by the nurse, contact by the nurse, or the previous lab results.
8. Review of the facility Nurse Practitioner (NP) notes for 07/24/14 revealed no mention of the urine characteristics, contact by the nurse, or the previous lab results. The 07/23/14 note by the NP indicated "repeat labs to be done" with no further elaboration.
9. On 07/25/14 the results of the CBC and CMP were called to the Primary Care Provider with read-back and indicated a White Blood Count (WBC) of 31.4 k/cmm; normal WBC is between 2.0 and 10.2 k/cmm.
10. The nursing notes for 07/25/14 at 7:05 am recorded the urine characteristics as "clear no strong smells." Later in the morning of 07/25/14 the nursing notes indicated a white blood count (WBC) of 31.4 from the CBC. This value reflected a potential sepsis (global, bloodborne infection). These results were called to the Primary Care Physician (PCP). The PCP ordered blood cultures and a 2-gram dose of Rocephin (antibiotic) to be given intravenously. Shift reports between nurses were not in evidence in the clinical record of Patient #1.
11. Review of the physician's orders for 07/25/14 at 11:00 am indicated orders for 2 blood cultures, if not already done; Vancomycin (antibiotic) 1 gram IV (intravenously) every day, pharmacy to manage dose; Rocephin (antibiotic) 2 grams IV now and then 1 gram in 24 hours; type and match to units of whole blood. At 2:00 pm that day the PCP wrote the order to transfer Patient #1 to a higher level at one of the local hospitals.

E. Review of the medication administration record for Patient #1 at the facility from admission on 07/17/14 to transfer on 07/25/14 revealed the following:
1. From 07/17/14 to 07/22/14 docusate (stool softener) was documented as given twice a day, at 9:00 am and 9:00 pm, every day.
2. Docusate was not documented as given on 07/23/14, when a Biscodyl (stool softener) suppository was given.
3. A standing order was written on admission 07/17/14 for the suppository and Fleets (saline) enema if no bowel movements occurred. The suppository was given once on 07/23/14 during the patient's stay.
4. Lactulose (laxative) was documented twice on 07/18/14 with no result of a BM.

F. The Nursing Notes indicated a BM after a suppository and disimpaction (manually removed hard stool) on 07/23/14. Contrary to the flowsheet, the Nursing Notes indicated a small BM on 07/18/14 or 07/19/14 and 07/24/14 with an enema.

G. Review of the Dietary Consultations dated 07/19/14 and 07/23/14 for Patient #1 indicated a recommendation to monitor the patient's oral intake and weight. However, review of the medical record revealed that the patient's weight was take only once, and that was on admission.
1. The Dietician in the Nutrition Risk Assessment on 07/19/14 indicated "oral intake meets less than 25% of estimated needs." The Dietician's plan stated, "Monitor P O [oral intake] & Fluid intake, wt [weight], labs."
2. The Dietician in the Interdisciplinary Progress Note on 07/23/14 recommended a change in diet to low sodium, mechanical soft with extra sauce and gravy. The order also included the addition of "Ensure Clear on ice three times a day [with] meals." The note also stated, Inadequate po [oral] intake (poor-fair po's) to meet nutritional needs. Appetite poor ... no recent wt [weight] noted."

H. Review of the facility's Policy #FN 030 "Oral, Enteral, and Parenteral Nutritional Support" revealed the following statement: "Patient care encompasses the recognition of both disease and health, prompt intervention in a timely manner, ongoing evaluation and adjustment to the plan of care as needed, patient/family teaching, and medical staff, nursing, and allied health care professionals functioning collaboratively as an interdisciplinary team to achieve optimal patient outcomes."

Based on medical record review and interviews, a registered nurse failed to ensure that nursing staff met the needs of Patient #1. This failed practice contributed to dehydration, exacerbation of an urinary tract infection (UTI), the need for bowel disimpaction (the manual removal of hard stool), and the need to transfer the patient to a higher level of care. The findings are:

A. Review of the Nursing Notes throughout Patient #1's stay at the facility indicated inconsistencies:
1. The Nursing Note dated 07/18/14 indicated a BM but the BM was not documented on the Daily Flowsheet Treatment Record (DFTR) for the same date.
2. The Nursing Note dated 07/19/14 indicated the last BM was listed as 07/14/14 at the previous facility.
3. On 07/19/14 a BM was noted after an enema. Yet the enema was not noted on the MAR, nor was the BM on the Daily Flowsheet. Additional notations in the Nursing Notes on this day displayed "burping, belching, continually ... and poor appetite."
4. The Nursing Note dated 07/20/14 indicated "last BM" on 07/20/14 yet it was not documented on the DFTR.
5. On 07/21/14 1460 cc intake and 725 cc urine output and no BM was indicated.
6. The Nursing Note dated 07/22/14 indicated the "last BM" was recorded on 07/20/14. No BM was documented for this date 07/20/14 on the nursing note or DFTR.
7. The Nursing Note dated 07/23/14 indicated the Primary Care Provider approved disimpaction of the bowel and this was documented as performed. A large BM was indicated. The 07/23/14 Nursing Notes also indicated "Urine Characteristics: strong odor." There was no mention of contacting the physician with the information.
8. The 07/24/14 Nursing Note indicated "a large, soft BM ... nausea and burping often." The Note further indicated a 500 cc intravenous bolus of normal saline for low blood pressure. Again this BM was not recorded on the Flowsheet.
9. The 07/25/14 Nursing Note indicated observations of Patient #1 passing gas and burping as well as a low blood pressure, 81/53, "during therapy with dizziness."

B. Review of the Daily Flowsheet Treatment Record (DFTR) for Patient #1 indicated abnormal fluid intake and urine output, much below what is physiologically normal.
1. The DFTR documentation for Patient #1 indicated the following:
a. On 07/18/14 400 cc fluid intake, 500 cc urine output, and no bowel movement (BM).
b. On 07/19/14 500 cc fluid intake, 600 cc urine output, and no BM.
c. On 07/20/14 480 cc fluid intake, no urine output, and no BM.
d. On 07/21/14 1460 cc fluid intake, 725 cc urine output, and no BM.
e. On 07/22/14 1180 cc fluid intake, 9 urinations (not measured), and no BM.
f. On 07/23/14 750 cc fluid intake, 6 urinations (not measured), and one BM with suppository and disimpaction (removal of hard stool).
g. On 07/24/14, no fluid intake, no urine output, and one BM.
h. On 07/25/14, no fluid intake, no urine output, and no BM.
h. For a geriatric adult 1200 to 1500 cc of fluids is minimum daily fluid intake and urine outputs; for a 70 kg adult (144 lbs) normal fluid intake is 2500 cc per day (Medical Physiology, Guyton & Hall, 2006).

C. Review of the progress notes in the assessment of Patient #1 by the facility Physician #1 on 7/21/14, 7/22/14, & 07/23/14 and the facility Nurse Practitioner on 7/21/14, 07/22/14, 07/23/14, & 07/24/14 revealed only "nausea and poor appetite" regarding Patient #1's gastrointestinal status. No progress notes were found addressing fluid intake and urine outputs, bowel movements, bowel sounds, palpation of the abdomen, or an assessment of swallowing difficulties reported by Patient #1 to family.

D. Review of the results of a urinary analysis/culture & sensitivity (UA/C&S) on a urine sample obtained on 07/18/14 from Patient #1 revealed that the patient had a positive urinary tract infection (UTI) which was reported to staff on 07/21/14. (The indwelling urinary catheter was removed on 07/19/14.) Intravenous antibiotics (vancomycin and Rocephin) were not started until 07/25/14 when the patient was transferred to another hospital.
1. The facility microbiology report dated 07/21/14 indicated the following:
a. A urine sample collected on 07/18/14 revealed positive results for two gram-negative bacteria, Klebsiella pneumoniae and Escherichia coli, with both susceptible to the antibiotic Ciprofloxacin. Both bacteria populations were estimated between 50,000 to 60,000 colonies per milliliter.
2. Review of the nursing notes for Patient #1 for 07/22/14 indicated urine characteristics as "clear yellow." Also noted for this date was a medication for bladder spasms, "Oxybutynin XL 15 mg by mouth at bedtime for bladder management."
3. The nursing notes for 07/23/14 on the day shift indicated the urine characteristic as "unseen" and "patient complained of urinating the bed over night. Request to be toileted every 2-3 hours and prior to 4 am." On 07/23/14 at 8:00 pm urine characteristics were recorded as "cloudy yellow with strong odor." Under the comments section was the following: "Urine cloudy with strong odor noted. Will notify [Physician #1] in the morning."
4. The nursing notes for 07/24/14 at 7:10 am documented urine characteristics as "clear yellow" and that the patient "denies discomfort." At 9:00 am that day (07/24/14) a second urinary analysis/culture & sensitivity (UA/C&S) was ordered. And at 2:00 pm that day a complete blood count (CBC) and complete metabolic panel (CMP) were ordered. The night shift at 11:55 pm recorded urine characteristics as "not observed."
6. At 7:40 on 07/24/14 a verbal order from the PCP to administer 500 cc of normal saline through the PICC (peripherally inserted central catheter) to Patient #1.
7. Review of Physician #1's progress notes for 07/24/14 revealed no mention of the urine characteristic notes by the nurse, contact by the nurse, or the previous lab results.
8. Review of the facility Nurse Practitioner (NP) notes for 07/24/14 revealed no mention of the urine characteristics, contact by the nurse, or the previous lab results. The 07/23/14 note by the NP indicated "repeat labs to be done" with no further elaboration.
9. Review of the Patient Lab Report, Final, dated 07/24/14 from a urine sampled at 2:43 pm indicated a second positive UA: "clarity, cloudy"; "bacteria, many."
10. On 07/25/14 the results of the CBC and CMP were called to the Primary Care Provider with read-back and indicated a White Blood Count (WBC) of 31.4 k/cmm; normal WBC is between 2.0 and 10.2 k/cmm.
11. The nursing notes for 07/25/14 at 7:05 am recorded the urine characteristics as "clear no strong smells." Later in the morning of 07/25/14 the nursing notes indicated a white blood count (WBC) of 31.4 from the CBC. This value reflected a potential sepsis (global, bloodborne infection). These results were called to the Primary Care Physician (PCP). The PCP ordered blood cultures and a 2-gram dose of Rocephin (antibiotic) to be given intravenously. Shift reports between nurses were not in evidence in the clinical record of Patient #1.
12. Review of the physician's orders for 07/25/14 at 11:00 am indicated orders for 2 blood cultures, if not already done; Vancomycin (antibiotic) 1 gram IV (intravenously) every day, pharmacy to manage dose; Rocephin (antibiotic) 2 grams IV now and then 1 gram in 24 hours; type and match to units of whole blood. At 2:00 pm that day the PCP wrote the order to transfer Patient #1 to a higher level at one of the local hospitals.

E. Review of the medication administration record for Patient #1 at the facility from admission on 07/17/14 to transfer on 07/25/14 revealed the following:
1. From 07/17/14 to 07/22/14 docusate (stool softener) is documented as given twice a day, at 9:00 am and 9:00 pm, every day.
2. Docusate was not documented as given on 07/23/14, when a Biscodyl (stool softener) suppository was given.
3. A standing order was written on admission 07/17/14 for the suppository and Fleets (saline) enema if no bowel movements occurred. The suppository was given once on the 07/23/14.
4. Lactulose (laxative) was documented twice on 07/18/14 with no result.
5. One bowel movement was documented on 07/23/14 with the suppository and disimpaction of the bowel.

F. Review of the Plan of Care for Patient #1 dated 07/18/14 for the facility lists 007-Bowel Function Goals: "Patient will have no bowel accidents or spills/soiling of clothing; Patient will have a bowel movement every 1-3 days"; Interventions: "Encourage fluid intake of 240 cc every 4 hours" or 1440 cc per day.

G. On 10/01/14 at 10:30 am during interview, Patient Care Tech #1(PCT #1), when asked if she remembered Patient #1 stated, "Yes, she belched the entire time she was here." PCT#1 stated that she would give Patient #1 ginger ale when she asked for it. PCT #1 did not remember her having abdominal pain or constipation. PCT#1 stated that Patient #1 never complained about the food or water not being able to go down that she could remember. The PCT stated the daughter did ask questions about her mother and she referred her to the nurse.

Based on medical record review and interviews, the facility failed to monitor and adjust the dietary plan for the changing medical condition to meet the needs of Patient #1. This failed practice contributed to dehydration, bowel impaction, exacerbation of a urinary tract infection, and the need to transfer to a higher level of care. The findings are

A. Review of the medical record for Patient #1 indicated an initial Nutritional Risk Screening (NRS) by the Dietician on 07/19/14. An order for a dietary consult on 07/21/14 was ordered by the facility Nurse Practitioner. The consult was performed on 07/23/14.
1. The 07/19/14 NRS indicated that Patient #1 was consuming 25% of daily needs of both food and fluids.

B. Review of the of the 07/23/14 Interdisciplinary Progress Note revealed new dietary recommendations by the Dietician regarding Patient #1.
1."Consult: Inadequate po [by mouth] intake (poor to fair) to meet nutritional needs. Appetite poor. Noted Megace started to stimulate appetite. No recent weight noted. Pt c/o [complained of] GERD [gastrointestinal reflux disease] impacting appetite, also difficulty with dentures - has trouble chewing bacon, some meats like pork; requests extra sauce/gravy with foods. Does not like Ensure Clear [nutritional drink]. (1) change diet to low sodium, mechanical soft with extra sauce/gravy. (2) Ensure Clear on ice three times a day with meals."
2. The notes on 07/19/14 and 07/23/14 by the Dietician were the only dietary notes by the Dietician for Patient #1's stay at the facility.

C. Review of the Daily Flowsheet Treatment Record (DFTR) for Patient #1 indicated abnormal fluid intake and urine output, much below what is physiologically normal.
1. The DFTR documentation for Patient #1 indicated the following:
a. On 07/18/14 #1 400 cc fluid intake, 500 cc urine output, and no bowel movement (BM).
b. On 07/19/14 500 cc fluid intake, 600 cc urine output, and no BM.
c. On 07/20/14 480 cc fluid intake, no urine output, and no BM.
d. On 07/21/14 1460 cc fluid intake, 725 cc urine output, and no BM.
e. On 07/22/14 1180 cc fluid intake, 9 urinations (not measured), and no BM.
f. On 07/23/14 750 cc fluid intake, 6 urinations (not measured), and one BM with suppository and disimpaction (removal of hard stool).
g. On 07/24/14, no fluid intake, no urine output, and one BM.
h. On 07/25/14, no fluid intake, no urine output, and no BM.
2. For a geriatric adult 1200 to 1500 cc of fluids is minimum daily fluid intake and urine outputs; for a 70 kg adult (144 lbs) normal fluid intake is 2500 cc per day (Medical Physiology, Guyton & Hall, 2006).

D. Review of the Plan of Care for Patient #1 dated 07/18/14 revealed the following Bowel Function Goals: "Patient will have no bowel accidents or spills/soiling of clothing; Patient will have a bowel movement every 1-3 days"; Interventions: "Encourage fluid intake of 240 cc every 4 hours" or 1440 cc per day.

E. Review of the facility policy for Admission Assessment and Screen, Policy # PC 080, revealed the following statement: "Additional assessments are to be completed based on the results of physician history and physical and the Interdisciplinary Screen and Nursing Assessment (ISNA)."
1. The first dietary note found in the medical record is the Nutritional Risk Screen
form dated 07/19/14.
a. "[Patient] states has recently loss undesirable weight but unsure how
much."
b. "Intake meets less than 25 % of estimated needs."
c. " Pt interviewed. Has no appetite, < [less than] 25 % of meals; is having serious GERD which causes difficulty."
d. "Nutrition Dx [Diagnosis]: Inadequate oral intake related to GERD [gastroesophageal reflux disease] as evidenced by reported < po [oral] intake ... recommend continue current diet ... monitor PO [oral] and fluid intake, wt., labs."
2. The second note is a Dietary Consult dated 07/23/14. The note indicated: "Consult: Inadequate po [oral] intake, (poor-fair po's) to meet nutritional needs. Appetite poor. Noted megace started to stimulate appetite. No recent wt noted. Pt c/o [complained of] GERD impacting appetite, also difficulty with dentures ... has difficulty chewing bacon, some meats like pork ... "

F. On 10/01/14 at 10:30 am during interview, Patient Care Tech #1 (PCT #1), when asked if she remembered Patient #1, stated, "Yes, she belched the entire time she was here." PCT#1 stated that she would give Patient #1 ginger ale when she asked for it. PCT #1 did not remember her having abdominal pain or constipation. PCT#1 stated that Patient #1 never complained about the food or water not being able to go down that she could remember. The PCT stated the daughter did ask questions about her mother and she referred her to the nurse.