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Based on observation, interview and record review the facility failed to provide organized nursing services which followed the nursing process of identifying and responding to patient needs through assessment, care planning and documentation resulting in unmet care needs for two (#4 and #8) of three patients reviewed for care plans out of a total sample of 13. Findings include:

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A 0396 - Care planning not revised to include noncompliance with needed care and assessments, care plan not consistently implemented, chronic and acute pain not effectively treated.

Based on observation, interview and record review, the facility failed to ensure that Nursing Care Plan Interventions were consistently followed for two (#4 and #8) of three patients reviewed for pressure injuries, out of a total sample of 13, resulting in inadequately treated pain leading to stress and refusal of necessary treatments and assessments for one (#8) and the potential for additional skin breakdown for one (#4) of three reviewed for pressure injuries out of a total sample of 13, leading to the potential for adverse outcomes for both patients involved. In addition, the facility failed to ensure that a nursing care plan for non compliance was initiated for one (#8) of three patients reviewed for pressure injuries out of a total sample of 1, resulting in the potential for undetected care needs and less than optimal outcomes.

On 5/9/18 at approximately 0825, Patient #8's medical record was reviewed with the Director of Quality and Safety Staff A, the Quality and Safety Nurse Staff C and the Clinical Nurse Specialist Staff M, who were also interviewed at this time and revealed the following:

Patient #8 was a 48-year-old female who resided in a skilled nursing facility (SNF), and who was admitted to the facility from 3/11/18 to 3/16/18. Admission diagnoses included Urinary Tract Infection (UTI) and Infected Decubiti (Pressure injuries, bedsores). Other diagnoses included a history of Cerebrovascular Accident (CVA) following Drug Overdose, Transverse Myelitis (inflammation of the spinal cord, which interrupts the messages that the spinal cord nerves send throughout the body. This can cause pain, muscle weakness, paralysis, sensory problems, or bladder and bowel dysfunction), Contractures (joints frozen in bent position due to shortening of muscles and tendons from disuse) of all extremities (arms and legs), Spastic Paralysis, and a large sacral ulcer, and ulcers to both legs. A Progress Note dated 3/11/18 at 1325 documented that Patient #8 had an indwelling urinary catheter and a colostomy (abdominal surgical opening into bowel for bowel movement excretion). The Progress Note also documented that Patient #8 refused a CT scan (computerized axial tomography) of the abdomen and pelvis due to discomfort of trying to make her arms fit inside the machine because of her contracture deformities and spasticity. An ED Nursing Note dated 3/11/18 at 1209 noted that Patient #8 was unable to do the CT due to, "unable to tuck arm down near her sides due to pain. Dr. aware of patient's continued complaints of pain."

An ED Nursing Note dated 3/11/18 at 1858 documented a skin assessment and noted that Patient #8 was unable to turn fully. Three Stage IV wounds were noted on the patient's buttocks. The note documented that Patient #8 also had a dressing on her right posterior shoulder. The area under the shoulder dressing was not documented as assessed, noted or cared for during the rest of Patient #8's stay.

An Admission Physician's History and Physical Assessment dated 3/11/18 at 1250 documented that Patient #8's diagnoses included Sepsis due to an infected Stage IV Decubitus Ulcer (full thickness skin loss, exposing underlying bone and muscle), UTI, Depression, Mental Disorder - Stress, Sleep Disorder, and Protein Calorie Malnutrition.

Patient #8's chronic pain from infected Stage IV pressure injuries, contracted limbs with spasms (spastic paralysis) and Transverse Myelitis was not effectively managed during her stay in the facility. Home medications to treat the chronic pain were discontinued or the dosage reduced, and dosages of pain medications that were less than usually received at home were not consistently given before dressing changes, repositioning or wound assessment. This potentially contributed to the patient's refusal of wound assessments and dressing changes and refusal of repositioning to relieve pressure which resulted in the potential for treatment failure and a less than optimal outcome.

There was no nursing care plan for her skin wounds or for actual alteration in skin integrity.

There was no Nursing Care Plan for Non-compliance. There was no documentation of patient education/counseling on the consequences of her refusals, no documentation of attempts to determine the reasons she refused, and no Nursing Care Plan for Noncompliance with individualized interventions to encourage compliance. One Nurse was successful in getting the patient to allow her to change the dressings. No attempt was made to investigate why Patient #8 allowed this nurse and not others. There was no documentation that any physicians, including the Wound Care Physician were notified that Patient #8 refused her dressing changes, which were supposed to be done bid (twice a day). There was no documentation to indicate that the physicians were aware that the wet to dry dressings were documented as changed by nursing only three times from 3/11/18 through discharge on 3/18/18

End of shift Nursing Care Plan summaries did not accurately reflect Patient #8's status. These documented that Patient #8 was "progressing" (instead of "not met") towards the planned goal of controlled pain, despite shift pain assessments that documented the patient rated her pain as 10 out of 10 on the facility's pain scale.

Home Medications (before admission) to treat pain, depression and anxiety were listed as:
1. buproprion- 100 milligrams (mg) SR twice daily (bid) (a mood stabilizer used to treat depression)
2. Fentanyl - 75 mg per hour patch every 3 days (synthetic narcotic pain reliever),
3. gabapentin - 400 mg bid (an anti-epileptic used to control seizures and treat nerve pain)
4. Lidocaine 5% patch - 2 patches QD (daily)
5. Paroxetine -40 mg daily at bedtime (an antidepressant used to treat major depressive disorder)
6. Mirtazapine - 15 mg daily at bedtime (an antidepressant)
7. Morphine 30 mg tablet - 1 every 4 hours as needed for pain (a narcotic painkiller)
8. Hydrocodone-acetaminophen 10-325 - 1 every 4 hours (q4) as needed (PRN) for pain
9. Hydrocodone-acetaminophen 10-325 - 1 every 6 hours PRN pain
10. Lorazepam - 2 mg q6 (every 6 hours) PRN (an anti-anxiety drug)

Patient #8's scheduled pain medications for chronic pain relief were discontinued in the ED on 3/11/18 and not given again during her admission. Patient #8's fentanyl patch was removed on 3/11/18 in the ED then discontinued. The lidocaine patches were removed in the ED and then discontinued. The home dosage amount of PRN Morphine was decreased on 3/11/18 at 1152 (in the ED) from one 30 mg tablet every 4 hours PRN to one 15 mg tablet every 4 hours PRN, and increased back to 30 mg q 4 PRN. The home prescription of PRN Codeine-Acetaminophen was also not ordered or given while in the facility. Nursing flow sheets from 3/12/18 through 3/18/18 documented that the patient's pain was 10 out of 10 (10 = maximum pain possible) on most days, and routinely documented the patient described her pain as, "unbearable". Lorazepam 0.5 mg was ordered bid (twice daily) on admission (3/11/18) for anxiety and muscle spasms.

Physician's Orders to treat Patient #8's Pressure injury (decubitus ulcer) wounds were as follows:
1. 3/12/18 to 3/18/18 - Infected Stage IV sacral wound - Dakins solution wash, and pack with moist gauze and cover with Abd pad (abdominal gauze pad) bid (wet to dry dressing twice daily).
1. 3/14/18 to 3/18/18 - Right buttocks - Dakins solution wash, and pack with moist gauze and cover with Abd pad (abdominal gauze pad) bid (wet to dry dressing twice daily).
2. 3/12/18 to 3/18/18 - Upper coccyx - Dakins solution wash, and pack with moist gauze and cover with Abd pad (abdominal gauze pad) bid (wet to dry dressing twice daily).
3. 3/14/18 to 3/18/18 - Right (R) heel - clean and paint with betadine cover with kerlex QD (daily).

The dressing changes and wound care for Patient #8's Stage IV sacral and buttock wounds were not documented as done twice daily as ordered. Patient #8 refused dressing changes and refused both the Unit Nurse and the Wound Care Nurse's admission wound assessments on 3/12/18. The Wound Care Nurse was unable to to assess the patient's wounds or change her dressings on 3/12/18 at 1500, as ordered on 3/11/18 for "Wound Care Consult". Review of Medication Administration Records for Patient #8 revealed no pain relief was offered before she was approached for dressing changes or wound assessments on this date. Her regularly scheduled pain medications were discontinued on 3/11/18. and her dose of a PRN pain medication (a 30 mg Morphine pill) was given on 3/12/18 at 0845, 6 ½ hours before she refused the Wound Care Nurse's assessment and treatment. On 3/12/18 despite pain assessments of 10 out of ten on the facility's pain scale, and self-assessed pain described as "unbearable", and multiple documented refusals of wound assessments and dressing changes, no pain medication was given for 6 ½ hours from 0845 until 1516 on 3/12/18. Review of Pain assessments for Patient #8 from 3/11/18 through 3/16/18 revealed consistent documentation that Patient #8 reported unbearable pain. (It was documented that she was asleep during the night after the bedtime doses of PRN pain medication plus the 2 antidepressants and one antianxiety medications were given).

A Nursing note dated 3/12/18 at 0930 documented that the nurse found multiple bottles of prescription pain medications belonging to the patient's significant other in an open purse at the patient's bedside. Patient #8 became very agitated and angry when they were removed and wanted to leave the hospital against medical advice (AMA). There was no documentation to indicate the patient was asked why she had her significant other's pain prescription medications in the room, or any attempt to correlate this with the patient's consistent reports of "unbearable pain", located in her buttocks/sacral area and also generalized throughout her body.

A Physician's Discharge Summary for Patient #8 documented that her discharge diagnoses included Sepsis secondary to Infected Stage IV sacral Decubitus Ulcer, Chronic Osteomyelitis, and History of Chronic Pain.

On 5/9/18 at approximately 1030, the facility Safety and Quality Nurse Staff C was interviewed about Patient #8 and reported that chronic severe pain is usually treated with a scheduled analgesic (pain medicine) such as fentanyl plus additional PRNs on top of the scheduled analgesic to cover breakthrough pain and before wound care. Staff C stated that for someone with such a poor prognosis and such deep wounds and painful muscle spasms, the potential for addiction would be less concerning than the potential for psycho-social changes and non-compliance caused by uncontrolled severe pain.

On 5/9/18 at 1040 the Patient Safety and Quality Director, Staff A was interviewed and stated that their electronic medical record system (EMR) Care plan module did not contain a care plan option for noncompliance.

On 5/9/18 at approximately 1045, the Clinical Nurse Specialist, Staff M was interviewed. Staff M stated, "I only see three times that she allowed the nurse to change the dressing on her Stage IV wounds during the six days of her admission. She didn't have a scheduled pain medication and reported unbearable pain at every assessment. There's a nursing note documenting the patient refused each time the dressing change was due, but no documentation of patient education or an attempt to find out why she refused." When asked about the Nursing Care Plan summaries that documented that Patient #8's Nursing Care Plan for Pain's goal was "progressing", Staff M stated that if the nurse entered that the goal for Pain was, "not met", the EMR would require the nurse to document a "variance" note to explain how and why it was not met, which would lead to extra work.

Staff M was asked at this time to comment on patient noncompliance with care and stated that the nurse should attempt to assess the reasons for refusal, medicate for pain if necessary, and document attempts to educate/counsel the patient on the potential consequences. Staff M stated that the physician should be notified of non-compliance and should document the notification. Staff M noted that there was no documentation that any of these things were done. Staff M stated that when a wet to dry dressing was left in place for multiple days on end, as occurred for Patient #8, it increased the risk for infection and made it harder to treat an existing infection. Staff M stated, "If I was the nurse, I'd talk to the Dr. about what he wanted to do about changing the dressings."

On 5/9/18 at approximately 1145, the wound care nurse, Staff H was interviewed with the Wound Care Manager, Staff N. Staff H stated that patients should be medicated before wound care if they were in pain. When asked if she assessed Patient #8's pain before attempting the wound assessment on 3/12/19 at 1500 (7 hours without PRN pain medication and all regular routine pain medications discontinued), Staff H stated, "often paraplegics don't feel pain."

On 5/9/18 at approximately 1215, the Wound Care Consultant Physician Staff O was interviewed by telephone and stated that he did not remember if Nursing told him that Patient #8 refused dressing changes. Staff O stated that Patient #8 had infected wounds that were open to the bone. Staff O stated that Osteomyelitis (bone and muscle infection) is very difficult to treat and has a very poor chance of recovery, and often results in death. Staff O reported that pain should be managed by the attending physician. An unsuccessful attempt was made to contact Patient #8's attending physician, who could not be reached as he was out of the country during survey.

Patient #8 was placed on Hospice and discharged back to the SNF where she expired.


On 5/8/18 at approximately 1115, a concern with wound assessment and with following orders/care plans for preventing skin wounds was identified during an observation of wound care for Patient #4.

On 5/8/18 at approximately 1115, review of Patient #4's clinical record with her assigned nurse, Staff G revealed the following:

Patient #4 was a 85 year old female who was admitted to the facility on 5/2/18 for Altered Mental Status, and Urinary Tract Infection. Other diagnoses included Dementia, Pancreatic Mass, and Percutaneous Endoscopic Gastrostomy (PEG) tube feeding. The Wound Care Nurse (Staff H) was consulted on 5/3/18 for for one pressure injury wound, which was documented as present on admission on the patient's sacrum (tailbone). The wound nurse's (Staff H) assessment of the wound on 5/3/18 documented the patient had one wound, measuring 2 cm by 0.6 cm by 0.1 cm on Patient #4's sacrum. The wound was described as, "partial thickness" skin loss. Patient #4's wound treatments and preventative skin orders documented on the Treatment orders and Nursing Flow sheet, dated 5/8/18 were reviewed with the patient's assigned nurse, Staff G at this time and included the following Nursing Interventions:

1. Silicone speciality dressing to be applied to the wound every three days and changed when necessary (PRN),
2. barrier cream to be applied to buttocks,
3. float heels off bed (to relieve pressure)
4. no (incontinence) briefs to be worn when in bed

Care for Patient #4 was observed when it was provided by the assigned nursing assistant, Staff I, with Staff G assisting. Patient #4 was found in bed, and was wearing an incontinence brief, and had no barrier cream (white thick zinc paste) applied to her bottom. Her heels were not floated (suspended off the mattress) as required on the Nursing Care Plan but were resting directly on the bed. The specialty dressing applied to her coccyx was undated, wrinkled, and non-occlusive. Chart review revealed it was changed on 5/7/18 (scheduled for change every three days or as needed). Staff G stated that Patient #4 didn't have any barrier cream on, but should have it on, and should not be wearing a brief in bed, per the nursing care plan.

An approximately 2 cm (centimeter) by four centimeter open area with sanguinous (bloody) drainage and a small amount of pale slough at the base was noted on Patient #4's sacral area outside of the dressing at approximately the 3 o'clock position relative to her spine. When asked if this was a new open area, Staff G said that she didn't know, as this was the first day she was assigned this patient. Staff I stated that she didn't notice anything new when she assessed her skin. Staff I did not comment on why the patient was wearing a brief in bed and why she did not have any barrier cream on.

On 5/8/18 at approximately 1125, the Unit Manager, Staff F and Staff G were interviewed, and both stated that the dressing should have the date it was applied written on it.

On 5/8/18 at approximately 1140 The Wound Nurse, Staff H was observed as she did wound care for Patient #4. Three separate, unconnected small open areas were noted on Patient #4's sacrum (including the one observed by the surveyor outside the dressing area.) Staff H took measurements from the edge of one wound to the edge of another and stated, "It's counted as only one wound. It measures 4.5 by 5 cm. I usually measure the whole area and count it as one wound if there are several small wounds, even if they're not connected." Staff H was unable to explain how wound progression could be accurately tracked if she did this and could not explain the size difference from her last assessment.

On 4/9/18 at approximately 1100, the Wound Care Nurse Manager, Staff N was interviewed and stated that if the wounds were not connected they should be counted and measured separately.

On 5/10/18 at approximately 1640 the facility policy entitled, "Skin/Wound Care", dated 6/17 was reviewed and revealed the following, "Initiate nursing orders per guidelines and collaborate with the physician to provide management of the wound and to control underlying medical and nutritional disorders. On Admission, assess the Patient's skin including all pressure points and wounds. Remove all dressings unless otherwise ordered. Skin and wound assessments must also be done with each subsequent assessment or dressing change. Apply skin barrier cream/ointment to protect skin from exposure to urine, stool and wound drainage. Avoid briefs/diapers for incontinent patient at night or while in bed. Float heels at all time while in bed. Perform at least a 1/4 turn and/or reposition immobile patients every 2 hours. Patient/So education: risk factors associated with pressure injuries, pressure redistribution and positioning, importance of nutrition for wound/ulcer healing, need to inspect skin daily, wound care, medical regime/compliance."

On 5/10/18 at approximately 1700, review of the facility policy entitled, "Assessment/Reassessment Policy Medical/Surgical Units", dated 12/17 revealed the following statements, "Care Plan/Education: contact admitting physician to discuss plan or care/obtain orders; every attempt should be made to initiate, individualize and complete the education plan for a patient on the shift the patient was admitted; review the Care Plan and individualize plan of care each shift and as indicated by a change in the patient's condition; all unmet goals require a variance note that includes;problem, intervention, patient response and follow up action; document patient education minimally once each shift."

On 5/10/18 at approximately 1704, review of the facility policy entitled, "Pain management - Adult", dated 12/17 revealed the following statements, "Ineffective pain management is known to have detrimental effects on a patient's physical, psychological social, and spiritual well being. Determine the effect of pain on physical and social functioning. Provide analgesia based on the anticipated pain. Offer analgesics when able 30 minutes before scheduled therapy or planned activity.

Based on interview and record review the facility failed to provide organized Dietary Services to identify, implement and communicate therapeutic nutritional interventions and recommendations to correct or prevent malnutrition for two of two patients reviewed for nutritional needs (#1 and #8) a decline in nutritional status, and the potential for impaired healing for both patients reviewed. Findings include:

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A 0629 - Nutritional needs not met

Based on interview and record review, the facility failed to ensure that nutritional needs were met, and nutritional assessments and patient health status were communicated between dietary staff and health care team members for two (#1 and #8) of two patients reviewed for nutrition concerns out of a total sample of 13, resulting in significant with loss for one (#1) and the potential for impaired healing for both patients reviewed. Findings include:

On 5/8/18 at approximately 1400 interviews and review of the medical record for Patient #1 were conducted with the Director of Patient Safety and Quality, Staff A, the Director of Patient Care services, Staff L, and the Clinical Nurse Specialist, Staff M, and revealed the following information:

Patient #1 was a 38-year old developmentally disabled male who lived in an adult foster care home (AFC) and was transferred from a community hospital to the facility on 3/5/18 for a diagnosis of gastric obstruction with abdominal distention, abdominal pain, vomiting and diarrhea. The patient was non-verbal, with a diagnosis of cerebral palsy, Lower extremity paralysis and contractures of all extremities (arms and legs). The patient was assessed by the physician as being "thin" in the Admission History and Physical, dated 3/5/18. The patient was diagnosed with Aspiration Pneumonia and Duodenal (small intestine) obstruction due to compression by a large renal (kidney) cyst. The patient was made NPO (nothing by mouth) in the Emergency Department (ED) on 3/5/18, and a nasogastric tube connected to suction was placed to remove gastric fluids and gases. The patient was taken to surgery for removal of the renal cyst on 3/8/18.

Patient #1 was NPO with no source of nutrition from admission on 3/5/18 to 3/14/18 when Total Parental Nutrition ( TPN - intravenous feeding) was started, a total of 9 days. The patient had a Speech Therapy (SLP) Evaluation on 3/15/18 and started eating a pureed diet with nectar thick liquids and swallowing precautions (due to a new diagnosis of Dysphagia - swallowing dysfunction) on 3/15/18. The Patient's weight noted in the 3/5/18 ED Nursing documentation was an "estimated weight" of 49.9 kilograms (kg). Per interview of the Director of Clinical Nutrition, Staff Q on 5/9/18 at approximately 1300, this weight was taken from review of the electronic medical record (EMR) and was documented as measured over one year ago, on 3/2017.

Concerns were noted with the facility's Nutritional Risk Assessment process. When queried, Staff L reported at this time that the facility's policy on assessment revealed all patients were to have a nutritional risk assessment done by a Dietary Technician Diet Tech) or the Dietitian within 24 hours of admission.

A Nutrition Risk Screen for Patient #1, performed by Diet Tech Staff T was dated 3/6/18 at 11:15. The following concerns with this were noted:

1. The assessment documented that the patient's admission diagnosis (Gastric Outlet Obstruction) posed no nutritional risk (score = 0). There was no attempt made to determine how long the patient was unable to eat (when the symptoms of gastric obstruction became severe enough to cause blockage), so the score for decreased intake for the past week was documented as "unable to assess" rather than "yes =2".

2. The Body Mass Index (BMI) was calculated as normal weight (>18.5) based on the estimated weight of 49.9 kg documented in the ED, despite the fact that Nursing documented a weight of 41.5 kg on the same day as the assessment. There was nothing to indicate that Staff T had requested Nursing for an accurate weight. Per the BMI calculator on the National Institute of Health (NIH) website (www.nhlbl.nih.gov/health/educational) this more accurate weight of 91.5 resulted in a BMI of 16.7 for Patient #1 (score of 2 = underweight), rather than a normal weight BMI of 20.12 (score = 0) as calculated by Staff T. On 5/9/18 at approximately 1315, the Clinical Dietitian Staff R and the Clinical Nutrition Manager Staff Q were interviewed regarding this and stated that they believed that Staff T had filled completed Patient #1's nutrition screen accurately. When asked why Staff T did not communicate with Nursing to get a more accurate weight for her assessment, and why she did not notice that the patient looked severely underweight, or note that a diagnosis of gastric obstruction posed a nutritional risk, Staff Q stated that Staff T assessed accurately according to what was required on the screening form.

3. The 3/6/18 Admission Nutrition Screen total score for Patient #1 was =1. This assessed Patient #1 as having a "Potential for moderate nutritional risk, NCL II, Diet Tech to follow up in 4 - 7 days". A more accurate score of 2 - 5, NCL III would have triggered an evaluation for a Registered Dietitian to follow up within three days.

A Dietary Progress Note dated 3/11/18 at 0920 (six days after admission) documented a Diet Tech follow-up was done 5 days after the Admission Nutrition Screen, per policy for a patient assessed as NCL II. Staff S documented that Patient #1 had been NPO for 6 days and a referral was made for the Registered Dietitian (RD) to see the patient.

A Dietary Progress Note by Registered Dietitian (RD) Staff R dated 3/12/18 at 1430 documented that the RD was referred to see Patient #1 because he was NPO for 6 days. The RD Progress note documented that she spoke with the RN (nurse) who stated they "hoped to initiate diet soon." The Patient's blood Laboratory values included in the RD note documented that a marker for protein metabolism, Blood Urea Nitrogen (BUN) was a low value of 9 mg /dl (normal 13-22 mg/dl), indicating protein deficiency. The RD calculated Patient #1's BMI as 16.9, with hypoactive lower bowel sounds (indication that intestinal tract was not functioning normally). The enclosed Malnutrition Risk Assessment noted that Patient #1 was high risk for Malnutrition with a score of 4 (>2 = high risk). The RD's Intervention was documented as "Regular Diet, consistency per SLP".

The Patient remained NPO for an additional 3 days (total of 9 days NPO) after this RD evaluation until bowel function returned (bowel movement) and NG drainage decreased to 75 cc cubic centimeters) per shift.

Labs taken on 3/13/18 documented that Patient #1's BUN decreased from 11 mg/dl on 3/11/16 to 6mg/dl on 3/13/18. When asked on 5/9/18 at approximately 1325 what lab values the dietitians monitored for malnutrition assessment, Staff Q and Staff R reported that they looked at BUN levels and considered a low BUN as an indication of malnutrition.

A Physician's Progress Note date 3/12/18 at 0925 documented that the patient would remain with an Nasogastric tube (NG) connected to drainage until bowel function returned.

A Physicians Progress note on 3/12/18 at 1356 documented, "Continue NG tube to be managed by General Surgery."

Physician's Progress Notes dated 3/13/18 at 1525, and 3/14/18 at 1425 noted, "Continue NG tube to be managed by General surgery, per General Surgery, Patient will be given fleets enema to try and stimulate bowel function. No bowel movements documented yet."

Nursing flow sheets and a Physician Progress Note dated 3/12/18 at 1539 documented that the Patient #1 was still draining large amounts of fluid from the NG tube, 350 cubic centimeters (cc) on 3/12/18, the same day that the RD did the Malnutrition Risk Assessment and recommended a regular diet once cleared by SLP. There was no documentation to indicate that the RD reviewed this or spoke to the physicians regarding how long the patient would remain NPO. There is no documentation in the EMR that Staff R, or anyone from the Dietary department discussed Patient #1's malnutritional risk with any of Patient #1's physicians or recommended nutritional support to aide healing from surgery and prevent malnutrition. It was not documented which nurse advised Staff R that the patient's diet would be resumed soon. Nursing flow sheets documented NG tube drainage of 350 cc, and no bowel movements on 3/12/18. When queried on 5/9/18 at approximately 1330, Staff Q and Staff R both stated that a patient would not be advanced to taking food by mouth as long as there was significant drainage from the NG tube and the patient was not having bowel movements. On 5/9/18 at approximately 1330, Staff R was asked to explain why she recommended a regular diet when the physicians notes and nursing flowsheets indicated that no plans or orders to remove the NG tube were noted, and also stated that Pharmacy services did nutritional need calculations and made up the TPN formula once TPN was ordered by the physician. On 5/9/18 at approximately 1335, Staff R was asked if she talked to Patient #1's physicians about the risks of him remaining NPO without some type of nutritional intake, and talked to them about Patient #1's Malnutrition Risk Assessment. Staff R was unable to provide any documentation that this was done. There was nothing to indicate this was done either in Nursing, Dietary, or Physician documentation.

The Patient was started on TPN on 3/14/18 at 0717. The Patient had a bowel movement on 3/14/18 at 1444. NG tube drainage was documented as 75 cc on 3/15/18. The NG tube was disconnected and SLP did a swallowing evaluation on 3/15/18 and the patient had his first meal by mouth on 3/15/18.

There was no order or communication from the Dietary department to Nursing for the patient to be weighed. When asked on 5/9/18 at approximately 1210, Staff L, Staff M and Staff Q all reported Nursing weighed a patient on admission (accurate not estimated weight) per policy but did not weigh patients after that unless the Physician or the Dietitian wrote orders for weights to be done. Nursing obtained the patient's weights despite the lack of orders to do so. Nursing flowsheets documented Patient #1's weights as follows:

3/5/18 = 49.9 kg (reported weight)( 110 lbs)
3/6/18 = 41.5 Kg (bedscale) (91.49 lbs)
3/8/18 = 43.8 kg (bed scale)
3/9/18 = 41.6 kg (bedscale)
3/10/18 = 41.7 kg (bedscale
3/14/18 = 41.7 kg (bed scale) (9 days NPO)
3/16/18 = 39/1 kg. (1 day of eating and 2 days of TPN)

This documented that Patient #1 lost 2.4 kg between admission and 3/16/18, which is a 5.8 % weight loss in 11 days. CMS defines "severe weight loss" as a 5% or greater weight loss in one month.

There were no further weights noted, and the patient was discharged on 3/22/18.

On 5/9/18 Patient #8's clinical record was assessed with the Patient Safety an Quality Director Staff A, The Safety and Quality Nurse Staff C and the Clinical Nurse Specialist Staff B who were also interviewed at this time. The following was revealed:

Patient #8's medical record was reviewed with Staff A, Staff C and Staff M, who were also interviewed at this time. The following was revealed:

Patient #8 was a 48-year-old female who resided in a skilled nursing facility (SNF), and who was admitted to the facility from 3/11/18 to 3/16/18. Admission diagnoses included Urinary Tract Infection (UTI) and Infected Decubiti (Pressure injuries, bedsores). Other diagnoses included Contractures (joints frozen in bent position due to shortening of muscles and tendons from disuse) of all extremities (arms and legs), Spastic Paralysis, and a large sacral ulcer, and ulcers to both legs.

An ED Nursing Note dated 3/11/18 at 1858 documented a skin assessment. Three Stage IV wounds were noted on the patient's buttocks.

An Admission Physician's History and Physical Assessment dated 3/11/18 at 1250 documented that Patient #8's diagnoses included Sepsis due to an infected Stage IV Decubitus Ulcer (full thickness skin loss, exposing underlying bone and muscle), UTI, Depression, and Protein Calorie Malnutrition.

Concerns were identified regarding nutritional support to treat malnutrition and promote wound healing for Patient #8.

A Nutrition Risk Screen Assessment on 3/12/18 at 1255 documented that Patient #8 scored as NCL III (high risk for malnutrition). The Patient had a diagnosis of Protein Calorie Malnutrition on admission. Nursing flow sheet documentation from 3/11/18 through 3/16/18 noted that Patient #8 needed to be fed and refused meals or ate less than 50% of meals.

On 3/13/18 at 1423 the Registered Dietitian (RD) assessed Patient #8 and "highly" recommended supplements to be given with meals, but there was no documentation that this was ever done.

A Registered Dietitian progress note dated 3/15/18 at 1627 documented that Patient #8 ate less than 50% of the two main meals per the food acceptance record and noted that Patient #8 was not meeting her nutritional needs. The RD recommended nutritional supplements at all meals and, "request current weight". There was no documentation to indicate that either of these recommendations were communicated with Nursing or with the Physician.

Patient #8's weight was not monitored after admission. The admission weight was documented as an estimated weight of 82.55 kg. There was no order for weights to be monitored, and per facility guidelines a patient is only weighed after the initial assessment if the Dietitian or Physician writes an order for weights to be taken. At this time, Staff C reported that Nursing is supposed to take an accurate weight on admission, but additional weights after that are not taken unless there is an order to do them.

On 5/9/18 at approximately 1330, the Director of food and Nutrition Staff P, the Clinical Nutrition Manager Staff Q, and Clinical Dietitian Staff R were interviewed regarding Patient #8. When asked if she had communicated with Patient #8's physician or nurses regarding nutritional concerns and recommendations for nutritional supplements and weighing, Staff R stated, "The Nurses and Dr.s can read my progress notes in the electronic medical record." Neither Staff P, Staff Q nor Staff R could explain why no orders for weighing the patient were written and how weight loss was monitored for a patient who was not consuming enough of her meals.

On 5/15/18 at approximately 1800, review of the facility policy entitled, "Nutrition Assessment", dated 1/15/16 revealed the following statements, "Other information as pertinent will be noted: supplements and acceptance of supplements, weight history, bowel/GI problems, GI tests, barriers to learning or oral intake."

On 5/15/18 at approximately 1810, review of the facility policy entitled, "Diet Orders", dated 1/15/16 noted, "The physician has sole responsibility for advancing diet of all post-surgical and NPO patients to appropriate solid textures. The dietitian may initiate, modify or discontinue oral nutritional supplements. The Dietitian may consult with other members of the interdisciplinary team as needed to provide expertise for the patient's plan of care."

On 5/15/18 at approximately 1820, review of the facility policy entitled, "Nutrition Screening", dated 1/18/16 revealed the following notations, "The dietitian is ultimately responsible for overseeing the nutritional care of all patients and works in collaboration with the dietary technician to assure all patients receive timely, appropriate and quality Nutritional Care. Initial visit by the dietitian within 24-72 hours and the follow-up will be at the discretion of the dietitian and per individual patient needs. Screening form instructions: the oral intake/tolerance of food should be taken from the following areas...Nursing flow sheets or progress notes, History and Physical. Calculate BMI. Refer to RD if BMI< 18.5. If a feeding plan has been established, indicate product, portion size and times supplements are given."
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