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Based on medical record review, review of facility policies and procedures and staff interview, the facility failed to ensure adequate supervision by nursing to document complete meal consumption and assistance, ongoing nutrition assessment and notification of nutritional changes to dieticians for 1 (Patient 1) of 9 sampled patients at nutritional risk due to poor meal consumption, pressure ulcer on left elbow, and systemic bacterial infection noted by positive blood cultures. This failed practice has the potential to cause negative outcomes for all inpatients who present to the hospital for care at nutritional risk. The facility inpatient census at the time of entrance was 337.

Findings are:
A. Review of Patient 1's medical record identified the patients weight documented on 3/29/25 at 6:28 PM was 218 lb 3.2 oz. The medical record lacked another weight documented since admission.

Patients 1's medical record by mouth intake (meal) documentation confirmed by RN-C on 5/22/25 at 2:00 PM revealed:
- 03/29/25: no documentation of meal consumption (patient 1 admitted at 3:59 PM)
- 03/30/25: 0% breakfast; 25% at lunch; no documentation for evening meal
- 03/31/25: 20% breakfast; 25% at lunch and 25% evening meal
- 04/01/25: 10% breakfast; 20% at lunch and 30% evening meal
- 04/02/25: 50% breakfast; 50% at lunch and no documentation of evening meal
- 04/03/25: 10% breakfast; no documentation of documentation of lunch meal (patient 1 dismissed 3:59 PM)

Review of Patient 1's consult and progress notes related to left elbow wound revealed:
-3/31/25 3:47 PM - Wound Care Consult Note - "The wound is characteristic of skin tear located left elbow measures 5.0 cm (centimeter) x (by) 4.0 cm x 0.1 cm. This ulcer is considered Full-thickness. The ulcer bed is pink granular and red granular and exposed subcutaneous tissue. The skin flap not adhering, dry and intact and erythematous (redness). There is a minimal amount of serous exudate draining from ulcer." "PLAN: The treatment plan is skin integrity, prevent skin breakdown, pressure prevention measures, improve overall patient well being."
-4/1/25 6:14 AM - Dr B progress note - "Wound care consulted. Wound care noticed some purulence and erythema on 4/1/25 during dressing change."
-4/2/25 6:09 AM - Dr B progress note - "Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue."
-4/3/25 12:41 PM Discharge Summary Note 1 - Dr B stated, "Cellulitis of left upper extremity, pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue."

B. Interview on 5/22/25 at 10:34 AM with Dietitian (RD-A) scheduled on the area that the patient was placed in the hospital. The RD-A stated that this patient was not referred for nutritional intervention. The patient on admission scored on the Malnutrition "At Risk Assessment" scored by nurses was scored as a 0. The policy is "If they score a 2 or greater, the dietitian has to see the pt within 2 days." "If a patient has been here 7 days, they are to be seen by the dietitian." "If a physician requests a nutrition consult." "We do MDR (multidisciplinary rounds) daily and this patient did not come up." Upon review of Pt 1's medical record with RD-A, revealed, the patient appetite was poor, there was a skin tear wound on the left elbow with cellulitis extending to left upper arm that progressed to a pressure ulcer, no supplement provided and positive blood cultures and no repeat weight (which is not required due to the Malnutrition Score of 0). RD-A confirmed that someone should have notified the dietitian of the pt's poor to limited intakes during their stay."

C. Interview on 5/22/25 at 11:36 AM with RN-D that was the nurse manager while Pt 1 was hospitalized 3/29/25-4/3/25. RN-D stated, "I rounded on this patient for leader rounding. The patient didn't communicate, the (child) would tell me, (Pt 1) isn't normally like this." "The patients family was upset because IV was saline locked (IV hub remains in place, no intravenous fluids running), also didn't think was getting enough help eating." The review of the record showed that at that time the patient was eating some of meal. IV fluid was restarted. RN-D confirmed that the patient intake wasn't consistently charted and that there was not a dietitian consult. "I knew the son wanted to take the patient to the other hospital. The doctor came and talked to the family."

D. Review of the policy titled Core Nursing Standards of Practice (effective 1/2025) revealed:
-INTAKE AND OUTPUT; a) Fluid intake and output is recorded every shift if patient condition warrants. b) Meal intake is recorded as a percentage when the patient completes each meal. c) Supplements are recorded according to type and volume when the patient consumes the supplement.
-CARE DELIVERY; a)The registered nurse performs and /or oversees delivers care according to the patient's need, orders and the plan of care to achieve identified outcomes.
-REFERRALS AND CONSULTS; a) Engages members of the interprofessional team according to patient condition, identified outcomes and patients plan of care; referrals include, but are not limited to: Dietitian b) The registered nurse must collaborate with the licensed practitioner to order consults.

Based on record review, policy review and staff interview; the facility failed to develop a nursing care plan to meet the identified nutritional needs for 4 of 11 sampled patients (Patients 1, 4, 6 and 11). The facility census was 337. This deficient practice had the potential to affect all patients admitted to the facility at nutritional risk.

Findings are:

A. Review of the policy titled Core Nursing Standards of Practice (effective 1/2025) revealed:
"1)Plan of Care-"The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes; the registered nurse:
--Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner.
--Integrates inter-professional team partners in implementation of the plan through collaboration and communication across the continuum of care.
--Delegates according to the health, safety, and welfare of the patient and considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations. Institution, and regulatory entities while maintaining accountability for the care.
--Documents implementation, modifications and evaluation of goals; including changes or omission, of the identified plan. The plan of care is reviewed and updated at a minimum of every shift and PRN (and as needed)."

B. A review of the medical record for Patient 1 (admitted 3/29/25 and left AMA 4/3/25) following a ground level fall, history of lewy body dementia, dehydration, infection, left arm wound, poor meal intake and poor oral intake. Patient 1's Plan of Care lacked a nutrition plan of care.

C. A review of the medical record for Patient 4 (admitted 5/4/25 and remains hospitalized as of 5/28/25) with a stroke, malnutrition, aphasia (inability to speak) and dysphasia (difficulty swallowing). The patient received a nutrition assessment by the dietitian with implementation of supplements and accommodations. Patient 4's Plan of Care lacked a nutrition plan of care.

D. A review of the medical record for Patient 6 (admitted 5/9/25 and dismissed 5/21/25) with hepatic encephalopathy (a brain dysfunction due to liver dysfunction which can alter the level of consciousness), hyperammonia (high levels of ammonia in the blood that can be harmful to the nervous system), malnutrition and bacteremia (bloodstream infection). The patient received a nutrition assessment by the dietitian with implementation of supplements and accommodations. Patient 6's Plan of Care lacked a nutrition plan of care.

E. A review of the medical record for Patient 11 (admitted 5/10/25 and remains hospitalized as of 5/28/25) with a history of ground level fall sustaining a fracture humerus (upper arm) and C4 (neck vertebrae), perforation of feeding tube resulting in abdominal surgery, moderate malnutrition, and an open abdominal wound with a wound vac. The patient received a nutrition assessment by the dietitian with implementation of supplements and accommodations. Patient 11's Plan of Care lacked a nutrition plan of care.

F. Interview with the Director of Quality on 5/28/25 at 2:07 PM, verified that the patients at nutritional risk, should have a nutrition plan of care and patients 1, 4, 6 and 11 lack a nutrition plan of care.















































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Based on policy review, medical record review and staff interviews the facility failed to ensure 1 (Patient 1) of 9 sampled patients at nutritional risk following admission to the hospital lacked a nutrition assessment, consistent meal assistance with documentation and notification of nutritional changes to dieticians. This failed practice has the potential to cause negative outcomes for all inpatients who present to the hospital for care. The facility inpatient census at the time of entrance was 337.

Findings are:

A. Review of the medical record revealed Patient 1 was admitted to the hospital 3/29/25 at 3:59 PM from the Emergency Room (9:41 AM-3:59 PM)for a recent ground level fall, history of lewy body dementia (a progressive form of dementia that affects thinking, reasoning and information processing), hypertensive encephalopathy (a rapid and dramatic rise in blood pressure greater than 180/120), dehydration, leukocytosis (elevated white blood cell count indicating infection), left arm wound with cellulitis, systemic inflammatory response syndrome (an overwhelming inflammatory reaction throughout the body that can be triggered by infection and trauma) and positive blood cultures.

Patient 1's vital signs and weight assessment documented on admission and leaving AMA (against medical advice) revealed:
-3/29/25 at 9:42 AM: blood pressure 204/127; pulse 72; temperature 97.3; respirations 16. Weight documented at 6:28 PM was 218 lb 3.2 oz
-4/3/25 prior to leaving AMA at 319 PM: blood pressure 155/85; pulse 85; temperature 97.9; respirations 18. The medical record lacked another weight documented since admission.

Patients 1's medical record by mouth intake (meal) documentation confirmed by RN-C on 5/22/25 at 2:00 PM revealed:
- 03/29/25: no documentation of meal consumption (patient 1 admitted at 3:59 PM)
- 03/30/25: 0% breakfast; 25% at lunch; no documentation for evening meal
- 03/31/25: 20% breakfast; 25% at lunch and 25% evening meal
- 04/01/25: 10% breakfast; 20% at lunch and 30% evening meal
- 04/02/25: 50% breakfast; 50% at lunch and no documentation of evening meal
- 04/03/25: 10% breakfast; no documentation of documentation of lunch meal (patient 1 dismissed 3:59 PM)

Review of Patient 1's provider progress notes revealed:
-3/31/25 11:03 AM -Dr C stated, "(Pt 1) states can eat and drink like normal, though noted that (gender) is unable to feed self." "Discussed with RN (registered nurse) to assist patient with feeding as (gender) is unable."
-4/1/25 6:14 AM and 4/2/25 6:09 AM -Dr B stated, "Cellulitis of left upper extremity, Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue." "Family reports increased alcohol intake and poor oral intake recently (alcohol screen negative on admission)." "Pt had difficulty swallowing liquids on exam." "Discussed with RN to assist patient with feeding as is unable."
-4/3/25 12:41 PM Discharge Summary Note- Dr B stated, "Cellulitis of left upper extremity, pressure ulcer with full thickness skin loss involving damage or necrosis (dead tissue) of subcutaneous tissue." "(Speech Therapy) recommended soft diet and bite sized solids, thin liquids." "Patient was stable and planned for discharge to SNF (Skilled Nursing Facility). On the day of discharge, son had frustrations regarding patient's care and wanted to take patient to (Hospital B-in town) ER (emergency room). After discussions regarding (pt) care, (child) took patient AGAINST MEDICAL ADVICE via personal transportation."

Review of Physical Therapy note 4/3/25 at 9:34 AM revealed, "(child) present at bedside. Voices frustrations with level of care patient is receiving; pt's (child) states the patient will be unable to participate due to being too dehydrated and out of it."

Review of the Case Manager note 4/3/25 at 2:20 PM revealed, "Pt's (child) called and asked me to come to pt room. Reported that had been talking to (pt's) (PCP) primary care physician. Call the PCP while I was in the room and decided that (child) would take (pt) via private vehicle to (Hospital -B)."

Review of the patient 1's Malnutrition Screen completed on 3/29/25 4:00 PM by the nurse on admission was scored as 0. The questions included: Unplanned weight loss in the last 6 months-No - 0; Eating poorly because of a decreased appetite -No- 0; Malnutrition Score =0.

Patient 1's medical record lacked a nutrition assessment, nutrition care plan and nutritional supplement's offered to the patient throughout this hospital stay.

B. Interview on 5/22/25 at 10:34 AM with Dietitian (RD-A) scheduled on the area that the patient was placed in the hospital. The RD-A stated that this patient was not referred for nutritional intervention. The patient on admission scored on the Malnutrition "At Risk Assessment" scored by nurses was scored as a 0. The policy is "If they score a 2 or greater, the dietitian has to see the pt within 2 days." "If a patient has been here 7 days, they are to be seen by the dietitian." "If a physician requests a nutrition consult." "We do MDR (multidisciplinary rounds) daily and this patient did not come up." Upon review of Pt 1's medical record with RD-A, revealed, the patient appetite was poor, there was a wound with cellulitis on the left elbow and left upper arm that progressed to a pressure ulcer, no supplement provided and positive blood cultures and no repeat weight (which is not required due to the Malnutrition Score of 0). RD-A confirmed that someone should have notified the dietitian of the pt's poor to limited intakes during their stay."

C. Review of the policy titled Core Nursing Standards of Practice (effective 1/2025) revealed:
-Intake and Output; a) Fluid intake and output is recorded every shift if patient condition warrants. b) Meal intake is recorded as a percentage when the patient completes each meal. c) Supplements are recorded according to type and volume when the patient consumes the supplement.

D. Review of Patient 1's medical record from Hospital-B's 4/3/25 3:14 PM admission to the emergency department. The Emergency Room doctor
(Dr-X) examined the patient at 3:21 PM, "Family brought here from (Hospital-A), has been deteriorating in health since Sat (3/29/25). Family called (Primary Care Physician) and was told to come here. Arrives confused in hospital gown." "(Family) reports that patient has continued to decompensate, comes more confused. "(Family) reports that patient is now receiving hydration and was not being fed due to mental status changes, unable to eat for self". "(Family) reports specifically worried about dehydration, nutritional status as pt hot been eating or getting fluids. Pt does appear dry on exam." Patient 1 admitted to an inpatient room on 4/3/25 at 6:18 PM. Patient 1's weight on admission was 200 lb's. (Down 18 lb 3.2 oz from admission wt of 218 lb 3.2 oz at Hospital-A on 3/29/25 at 6:28 PM.)