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Based on document review and interview, the facility nursing staff failed to initiate intravenous fluids per hospital policy and protocols for 1 (P1) of 10 medical records reviewed; and failed to document patient intake and output per for 1 (P1) of 10 medical records reviewed.

Findings Include:

1. Facility policy "Documentation Standards", published 08/05/2024, indicated under Section V, General Documentation Standards, 1. Registered Nurses are accountable for the patient's assessment and documentation process.

2. Medical record (MR) review indicated P1's GJ (gastrojejunostomy) tube became clogged on 07/03/2024 at 1000 hours during RN2, Registered Nurse, shift, feeding was paused at this time. An existing tubefeeding orderset provider signed on 06/24/2024 included the facility "Core Diabetes Application" protocol as part of the tubefeeding order set. This indicated that D10W (dextrose) fluids should be started at a rate of 80 mL (milliliter) per hour rate immediately, due to stopping GJ feeding. MR indicated on 6/24/2024 at 1710 hours, intravenous fluids were not started until RN1, Registered Nurse discovered that tube feeding had been paused, and no fluids were running. The MR lacked documentation of patient intake/output as ordered during the timeframe of 07/03/2024 through 07/04/2024, by Facility nursing staff.

3. At 1645 hours on 08/14/2024, per interview with RN2, confirmed they did not run D10W fluids per protocol when the tube clogged on 07/03/2024. RN2, Registered Nurse, stated they had not received instructions to do so, and was unaware of the orderset for tubefeeding that included the facility "Core Diabetes Application" procedure that specifies that D10W should be run at a 80 mL per hour rate when tubefeeds are suspended. Additionally, RN2, Registered Nurse was not able to discuss why P1's intake and output for 07/03/2024 through 07/04/2024 was not documented.

Based on document review and interview, the facility staff failed to provide the patient and receiving facility, accurate information regarding diet and tubefeeding orders for 1 (P1) of 10 medical records reviewed.

Findings Include:

1. Facility policy "Patient Transfers", published 12/13/2022, indicated on page 4, D. External Transfers, 1. Provider responsibilities, c. Enter the discharge order and specify the required transfer team skill level, level of monitoring, etc. d. Complete discharge summary, e. Complete Electronic Discharge Instructions. 2. Sending unit responsibilities, a. Complete RN review of discharge instructions. d. Collaborate with ICM on who will copy all pertinent portions of the medical record to send with the patient.

2. Medical record (MR) review for P1 on 06/12/2024 indicated that the patient was on a clear liquid diet, and was receiving continuous tubefeeding of Osmolite 1.5 with a target rate of 50 mL (milliliter) per hour. P1's discharge order, inpatient discharge instructions, and transfer documentation on 06/12/2024, indicated that P1 was on a regular diet, with no tubefeeding orders or instructions.

3. Review of Facility Risk department incident review indicated on 06/17/2024 it was observed that a regular diet, and no tubefeeding or medication orders were included on the discharge orders by MD1 (Medical Doctor, Internal Medicine) on 06/12/2024.

4. At 1745 hours on 08/14/2024, per interview with A3, Manager, Accreditation and Regulatory, confirmed that MD1's discharge orders, and the inpatient discharge instructions provided to F3 (Extended Care Facility) on 06/12/2024 indicated that P1 was on a regular diet at discharge. The same instructions do not indicate any tubefeeding instructions, when P1 was actually on a clear liquid diet and tubefeedings.