HospitalInspections.org

Based on document review, policy review, record review, and interview, the hospital failed to ensure an effective process was implemented to investigate and resolve all issues involved with complaints/grievances and provided the family with all decisions and/or findings for each issue for one (1) of one (1) (Patient #1) patients' family who filed grievances.

The findings include:

1. Patient #1's son filed two grievances.

Patient #1's son complained that Patient #1 had not been cleaned or changed for 8 or 9 days and developed hospital acquired pressure injuries not identified by the hospital staff.

Review of the hospital's "Patient Complaint and Grievance Policy" with a reviewed date of "1/22" revealed Patients or their representatives have a right to file a grievance. The hospital will investigate the grievance and will report their finding to the appropriate party.

Review of the hospital's "Bathing Guidelines for Adult Patients" with an effective date of "6/2020" revealed, "...to provide baths or assist patients with baths daily..."

Review of the hospital's "Nutrition Screening Assessment and Reassessment " policy with a revision date of "2/20" revealed a nutrition assessment will identify patients who may have a nutrition risks and will have an assessment by a Registered Dietician..."

2. Patient #1 presented to the Emergency Department with complaints of right hip pain on 11/19/2021.

(a) The nursing assessments, physician orders and xrays for Patient #1 revealed the following:
A physician's order on 11/20/2021 revealed an order for Dulcolax 10 mg [miligrams] once a day.

A physician's order on 11/23/2021 revealed an order for Colace 100 mg twice a day to prevent constipation.

A physican's order on 11/28/20-21 revealed an order for Glycolax and Senokot 1 tab at night as a laxative.

Patient #1 had a bowel movement on 11/20/2021 and the next bowel movement was on 11/25/2021 and two day later on 11/28/2021.

Patient #1 developed fecal incontinence.

Patient #1's head to toe assessments from 11/20/2022 - 11/28/2021 revealed no documentation for auscultation of bowel sounds in all 4 quadrants.

A hospitalist daily note on 11/27/2022 revealed that Patient #1's son has issues with Patient #1's care.

Review of Patient #1's abdominal x-ray dated 11/28/2021 revealed gastric distention and stool throughout the colon.

A hospitalist daily note on 11/29/2022 revealed the patient's son was not at the bedside and the doctor discussed the bowel movement with the patient and her nurse.

Case Management notes on 11/29/2021 revealed the son wanted to speak to the nurse about his mother's bowel movements and had complaints about the care the patient was receiving.

In an interview on 2/23/2022 the Nursing Director (ND) stated there was no bowel protocol.

Interview on 3/1/2022 he ND stated, a Gastrointestinal is included in the head to toe assessment completed on each shift.

(b) Patient #1's nursing flowsheets for activities of daily living and bathing needs revealed the following:

Patient #1's functional screen revealed Patient #1 required assistance with bathing.

Patient #1 had a external catheter.

There was documentation in the nursing assessments of two linen changes and two baths from 11/26/2021 through 11/30/2021.

In an interview on 2/23/2022 the ND stated if the patient has a catheter they should be bathed daily.

(c) The Sacrum skin assessment revealed from 11/21/2021 through 11/30/2021 did not reveal the presence of a sacrum pressure injuries.

The nursing assessment for heels revealed from 11/21/2021 through 11/30/2021 did not reveal the presence of a right and left deep tissue injuries.

(d) Patient #1 was discharge on 11/30/2021 to a Skilled Nursing Facility (SNF).

Review of the 11/30/2021 admission assessment to the SNF #1 revealed wounds to the Sacrum, incision to Right Hip, and Deep Tissue Injury to both the right and left Heels.

(e) A grievance/complaint was submitted by Patient #1's son on 12/1/2021.

The hospital send an written response was sent to Patient #1's son on 12/17/2021.

(f) On 1/28/2022 Patient #1's son filed a second grievance.

The hospital send a written response to the second grievance on 2/8/2022.

After further review of Hospital #1's written responses to Patient #1's son revealed all the issues were not addressed.

(g) In an telephone interview with Patient #1's son on 3/6/2022 at 7:00 PM, he stated his mother had been neglected in her care. She was not turned, urine turned black, developed bedsores, no bowel movements and and the hospital was short staffed.

Refer to A118, A385, A392, A395, A396, A618, A629.

Based on policy review, document review and interview, the facility failed to ensure patient grievances were addressed and resolved for one (1) or one (1) (Patient #1) sampled patients with a complaint or grievance.

The findings include:

1. Review of the hospital "Patient Complaint and Grievance Policy" with a reviewed date of "1/22" revealed, "...Patients and /or their representatives have the right to voice concerns verbally or in writing when their expectations are not met...A written complaint is always considered a grievance...If the complaint or concern cannot be resolved, the initial notification/contact and requires further intervention, the issue is considered a grievance and a report is referred for resolution and follow-up...Response to patient and their representatives is concurrent with resolution,,,A letter is generated in response to grievances indication the general conclusion (s) of the investigation..."

Review of the hospital's "Bathing Guidelines for Adult Patients" policy with am effective date of "6/2020" revealed, "...Purpose: To provide guidance for bathing adult patients in the inpatient setting...Provide a daily bath for patients unable to self bathe, unless medically contraindicated, to improve hygiene and promote comfort. More frequent baths may be performed based upon patient request or in response to specific patients needs..."

Review of the hospital's "Nutrition Screening, Assessment and Reassessment" policy with a revision date of "2/20" revealed, "...Patients are initially screened for the presence of nutrition risk upon admission by nursing. The interdisciplinary team provides on-going evaluation for nutrition risk...The nurse is alerted to enter a dietician consult if the patient meets any of the following criteria...Large or non-healing wound, burn, or pressure ulcer...Patients positive for indicators on nursing Nutritional Risk Screen...Consults and Triggers...a nutrition assessment is completed and a nutrition diagnosis is identified on patients determined to be at nutrition risk. The following criteria is taken into consideration for a nutrition assessment and may be included, but not limited to...Adequacy of nutrition intake: current, previous, and required calories and protein..Nutrition implications of selected laboratory test...Hydration status...Pertinent medications and supplements...The patient's PO (oral) intake documented by designated staff will be evaluated and the dietitian will determine if the energy needs are being met...if estimated energy needs are not being met, the dietitian documents the variation and will make recommendations for oral nutrition supplementation...The Registered Dietician develops a nutrition diagnosis and plan of care based on the findings for the nutrition diagnosis and plan of care based on the findings of the nutrition assessment...Interventions and goal are individualized for the patient...A summary of the patient's nutrition care plan is documented on the Patient Care Plan shared by all disciplines. The Registered Dietician will identify and document nutrition discharge needs based on the nutrition diagnosis and plan of care...The patient is followed throughout hospital stay and re-assessed based on their nutrition risk..."

2. Medical record review revealed Patient #1 was admitted on 11/19/2021 with diagnoses including Fracture Neck of Right Femur and the patient had a hip replacement surgery on 11/23/2021.

(a) Review of the nursing assessments, physican orders and xrays for Patient #1's bowel status revealed the following:
On 11/20/2021 the physician ordered for the patient to receive revealed an order for Dulcolax 1 tablet by mouth daily for stool softener [softening stools to make them easier to pass].

On 11/23/2021 the physician ordered Colace 100 mg 1 tablet by mouth two times a day for stool softener.

On 11/28/2021 the physician ordered Glycolax daily for occasional constipation and Senokot 1 tablet by mouth at night as a laxative [helps stimulate bowel movements or loosen up stool to ease its passage].

Patient #1 had a bowel movement on 11/20/2021. The next bowel movement was 4 days later on 11/25/2021. The next bowel movement was 2 days later on 11/28/2021.

Patient #1 developed fecal incontinence [the inability to control bowel movements, causing stool to leak unexpectedly form the rectum...common causes constipation...] on 11/25/2021, 11/26/2021, 11/28/2021 and 11/29/2021.

Patient #1's daily nursing head to toe assessments from 11/20/2021 through discharge on 11/30/2021 revealed no documentation the patient's right and left upper quadrants and right and left lower quadrants were auscultated (assessed by listening for bowel sounds).

A Hospitalist daily note dated 11/27/2021 documented, "...Plan...pain control...Pt's [patient] son irate and yelling today during my encounter. His issues include someone not feeding patient, reports nurses aren't attentive...pt [patient] is in pain...I informed him I would be more than happy to put in an order in for assistance with meals, the pain medications were not scheduled but need to be asked for PRN [as needed]...and that if he had a nursing issue, to ask the front desk for the nursing supervisor's number so that those issues can be addressed. Skin/Integumentary...No Rashes, No Ecchymoses, No Petechiae...Rectal...Deferred..."

Review of the abdominal x-ray on 11/28/2021 revealed, "...There is prominent gaseous distention of the stomach. Gas and stool throughout the colon without significant distention...IMPRESSION Gastric distention [It is typically a symptom of an underlying disease or dysfunction...Constipation causing a build up of feces and back up of digestive content]..."

Review of Hospitalist daily note on 11/29/2021 revealed, Patient #1's...Son not at bedside today...KUB [Kidney, Ureter, and Bladder] with some gastric distension but no obvious obstruction...Continue bowel regimen...Had BM [bowel movement] yesterday...soft abdomen, distension...I have discussed the above plan with the patient and her nurse. Son not at bedside...Reports feeling "lousy" this morning but not able to characterize further. Denies abdominal pain.

Review of Case Management notes on 11/29/2021 at 2:03 PM revealed, "...Son is very agitated and wants to file an appeal with Medicare about discharge. Copy of IMM [Important Message from Medicare] letter provided. Wants to speak with nurse about mother's BM [Bowel Movement]. Nurse Notified..."

In an interview on 2/23/2022 beginning at 1:43 PM, the Nurse Director (ND) was asked do you have a bowel protocol and the ND stated, "No".
The ND was asked how many days should a patient go without a bowel movement and the ND stated, "...That's patient specific...but no cause for alarm if it was 2 to 5 days before they had a bowel movement".

In an interview on 3/1/2022 beginning at 10:00 AM the ND was asked if the nursing assessment for "Gastrointestinal" section was a part of the daily head to toe assessment and the ND stated, "...Yes..." The ND stated the only daily requirement for the gastrointestinal is to listen for bowel sounds in all quads..."

(b) Review of Patient #1's nursing flowsheets for activities of daily living needs and bathing needs revealed the following:

The "functional screen" section of the nursing flowsheets dated 11/20/2021- 11/29/2021 revealed Patient #1 required assistance with bathing.

Review of Patient #1's nursing flowsheet "Genitourinary" section dated 11/20/2021 - 11/30/2021 revealed Patient #1 had an external catheter.

The nursing flowsheets documented only 2 linen changes, and two baths from 11/26/2021 through 11/30/2021.

In an interview on 2/23/2022 beginning at 1:43 PM, the ND stated, "...Baths should be documented..." The ND was asked how often should the patients receive a bath and the ND stated, "...Just depends on the situation...if they have a catheter they should have a bath daily.

(c) Review of the daily nursing assessment flowsheet "Sacrum Skin" section from 11/21/2021 to 11/30/2021 revealed no documentation for the presence of a sacrum pressure ulcer although it did present concerns for sacrum skin problems.

There were no documentation for sacrum skin assessments on the 7:00 AM - 7:00 PM shift on 11/23/2021, 11/26/2021, and 11/28/2021.
There were no documentation for sacrum skin assessments on the 7:00 PM - 7:00 AM shift on 11/22/2021, 11/24/2021, and 11/25/2021.
There were no documentation for sacrum skin assessment on the 7:00 AM - 7:00 PM or the 7:00 PM - 7:00 AM shift on 11/27/2021.

Review of the daily nursing assessment "Heels" (skin) section from 11/21/2021 to 11/30/2021 revealed no documentation for the presence of left or right heel deep tissue injury.
The documentation for heels revealed:
On the 7:00 AM - 7:00 PM shift the heels assessment was documented as "within defined limits" 11/20/2021, 11/23/2021, 11/24/2021, 11/25/2021.
On the 7:00 PM - 7:00 AM shift the heels assessment was documented within defined limits on 11/21 and 11/29/21.
There were no documented assessments for Patient #1's heels on either shift from 7:00 AM - 7:00 PM and the 7:00 PM - 7:00 AM on 11/19/2021, 11/22/2021, 11/26/2021, 11/27/2021, 11/28/2021, 11/29/2021, and 11/30/2021.

(d) Patient #1 was discharged on 11/30/2021 to a Skilled Nursing Facility (SNF) #1 with the following diagnoses: Closed Intra-Articular Fracture of Distal End of Right Radius, Atrial Fibrillation, Hypertension, Dizziness, Unsteady Gait, Cerebral Infarction, Falls, Low sodium levels, and Obesity.

Review of the 11/30/2021 admission assessment to SNF #1 revealed, "...Admit Note...wounds to sacrum, incision to right hip...Site...sacrum; Type: pressure; Length: 10 cm [centimeter]; Width: 19 cm; Stage: Unstageable; Site... Left heel; Type: Pressure; Length: 9.3 cm; Width: 5 cm; Stage: Suspected Deep Tissue Injury; Site...Right heel; Type: pressure; Length: 9 cm; Width: 5 cm; Stage: Suspected Deep Tissue Injury...".

(e) Review of a grievance/complaint submitted by Patient #1's son at Hospital #1 dated 12/01/2021 revealed, "...Patient #1's son alleges pt [patient] received inappropriate care while in the hospital and had unsafe discharge to nursing home. Alleges no BM [bowel movements] for 11 days, several "bedsores", urine is black, bed changed once, only bathed once, staff did not feed her, and falsification of chart. Also alleges nursing home nurse told him pt should not have been discharged and should go back...responder comments, Nurse Leader 4 North dealt with this son multiple times during the patient's hospitalization. He wanted her to stay a few more days after she was discharged by the MD. Staff had the MD [Medical Doctor] speak with him regarding her BM and medical stability. Son became extremely upset that she was not accepted by the facilities of his first choice. I have reviewed this chart specifically looking at the allegation of bed sores. The admission assessment noted skin to be cracked and excoriated. The staff were documenting excoriation and redness throughout her stay. There was no documentation stating it was pressure related. There are no pictures to review. Discharging nurse stated pt [patient] did not have skin integrity concerns at discharge...Interventions or actions taken...Chart reviewed, Referred to dept. [Department] manager, written acknowledgement to complainant...Outcome of Investigation Complaint - Unfounded...Investigation Comments: Initial review of chart notes manager spoke with son. On 11/29, son agitated about d/c [discharge] and wanted to appeal. Documented he wanted to speak with the RN [Registered Nurse] about the BM. On 11/30, documented that son refused [Skilled Nursing Facility #2], but agreed to [Skilled Nursing Facility #1] which is where the pt. was sent. Resolution Date: 12/17/2021".

Review of the written response sent to Patient #1's son on 12/17/2021 revealed, "...We have conducted a through investigation, which revealed the following...Nurse Leader for 4 North, spoke with you multiple times during your mother's hospital stay...The physician discussed with you your mother's bowel movements and her medical stability...Documentation reveals you refused [Skilled Nursing Facility #2] but agreed for your mother to go to [Skilled Nursing Facility #1] Rehab facilities make their own decisions as to whether or not they will accept a patient...Your mother had no skin integrity issues or open wounds when she was discharged from the hospital and a hospital dietitian was following your mother to support her nutritional needs..."

(f) On 1/28/2021 Patient #1's son filed a second grievance/complaint at Hospital #1. Review of the second grievance/complaint revealed, "...Via email Case Management to [name of Risk Management person], "Patient #1's was previously admitted from 11/19/2021-11/30/2021. Patient was discharged to skilled nursing facility. Patient's son has alleged that Baptist "neglected and abused" patient during her previous stay. Son stated that patient went 12 days without being moved or cared for. Patient #1's son states that patient was discharged from Baptist with a urinary tract infection and bed sores...Responder comments: Director of Risk Management (DRM) spoke with Patient #1's son. Son's complaints are the same as the previous concern...Pt's [patient's] mother is currently inpatient ..."

Review of the written response sent to Patient #1's son on 2/8/2022 revealed, "...While your mother was in the Emergency Department recently, you shared the same concerns from your mother's previous hospitalization. As documented in my letter to you dated December 17, 2021, a thorough investigation was conducted and all of your concerns from your mother's previous hospitalization were addressed with you during your mother's hospitalization".

After further surveyor review of Hospital #1's written responses on 12/17/2021 and 2/8/2022 to Patient #1's son revealed all the issues were not addressed such as, inappropriate care, unsafe discharge, black urine, bed changed only once, only bathed once, staff did not feed her and falsification of chart. When addressing the bowel movement it stated the physician discussed the bowel movement with the son. In the hospitalist note dated 11/29/2021 it stated the son was not there and it was discussed with the patient and her nurse. In the investigation the Nurse Leader 4 North stated on admission the skin was noted to be cracked and excoriated. There was no documentation for treatments for interventions for the cracked and excoriated skin. In the reply back to the son it stated no skin integrity issues. The skin integrity issues started on admission and developed further while hospitalized as proof of the pressure injuries found on admission to SNF #1 on 11/30/2021. Patient #1's son's second complaint/grievance on 1/28/2021 went unnoticed.

(g) In a telephone interview on 3/6/2022 beginning at 7:00 PM with Patient #1's son, the son was asked what was his concerns about Patient #1 not having a unsafe discharge and Patient #1's son stated, "... Because she had been neglected in her care and not turned, black urine, bedsores, no bowel movements...on Thanksgiving there was one nurse for the whole floor...one male nurse that was there at the end before mother was discharge came in and apologized to me because he was the only nurse on the floor, mother was lucky if he came in once a night...she was just left there not turned, no baths, nothing...it is not the staff's fault because they are short staffed but the management of that hospital need a awakening.."
Patient #1's son stated, "I never talked to a doctor about my mother's bowel movements and I talked to a nurse about her not having a bowel movement right at the last of her stay right before she was discharge and they ordered an x-ray and started her on some type of medication..."

Based on policy review, document review, record review and interview, the hospital failed to ensure nursing services met the needs of all patients and conducted ongoing assessments of patients'; and each patients' current care plan reflected the goals and the nursing care to be provided to meet the patients' needs ensure all patients' for three (3) of three (3) (Patients #1, #2 and #3) sampled patients.

The findings include:

1. Review of the hospital's "Bathing Guidelines for Adult Patients" with a effective date of "6/2020" revealed, "...to provide baths or assist patients with baths daily".

Review of the hospital's "Pressure Injury and Wound Treatment Guidelines" last reviewed on "7/20" revealed, "...Each patient is assessed for potential and actual skin breakdown on admission, daily, and as needed if patient's condition changes".

Review of the hospital's "Pressure Injury Basic Care Reference Chart (Adult) revealed, "...Implement the appropriate pressure injury prevention guidelines based on the patient's Braden Risk Assessment Score [Braden score is a tool used to help determine the risks of a patient developing a pressure injury]..."'

The Braden Scale for Predicting Pressure Score Risk chart for positioning includes: Turn and reposition every one to two hours, Post turning schedule, Teach or do frequent small shift of body weigh. Elevate heels.

Review of the Assessment/Reassessment Policy dated "12/20" revealed, "...Collection of the following information initiated upon admission and completed within 2 hours of inpatient admission..."

Review of Addendum 1 revealed, "...Reassessments...At a minimum, focused reassessments are completed and documented every 8 hours...The Registered Nurse creates an initial plan of care, treatment, and services appropriate to the patient's specific assessed needs and revises or maintains the plan based on the patient's responses..."

Review of the hospital's Pain Management Guidelines with a revision date of "1/21" revealed, "...The patient's right to pain management is recognized, respected, and supported...Patients have the right to have pain assessed and managed or referred for treatment, including managing pain aggressively and effectively...".

Review of the hospital's "Fall Assessment and Management" (Adult)" policy with a review/revision date of "7/19" revealed, "... the patient has a right to a safe environment...Based on the patient's assessments and specific needs, individualize the plan of care to include High Risk Fall Precautions and interventions to address this patient's problem...".

Review of the hospital's "Restraint of the Non-Violent/Non-Self Destructive Patient" policy with a review/revision date of "7/20" revealed, "...A physician order is written for each episode when restraints are required...".

2. Medical record review revealed Patient #1 was admitted to Hospital #1 on 11/19/2021 with a diagnosis of a Fracture of the Neck of the Right Femur which required surgical intervention. Patient #1 required repositioning, assistance with activities of daily living, and pain medications.

Review of the physician's orders, nursing assessments and the patient care plan revealed no documentation the patient had issues with pain, ADLs and no pressure injuries were identified during the patient's hospital stay from 11/19/2021 - 11/30/2021.

On 11/30/2021, Patient #1 was discharged from the hospital and admitted to a skilled nursing facility (SNF). Review of the SNF admission nursing assessment revealed Patient #1 had numerous unstageable and deep pressure injuries upon admission form the hospital.

The patient's son had complained the patient was not being cared for properly and was not offered assistance with activities of daily living (ADLs). Review of the nursing flowsheets revealed the patient only had 2 baths during the hospital stay.

The patient complained of pain during the hospital stay and required pain medications. Review of the nursing flowsheets, nursing assessments revealed the nursing staff failed to assess the patient's pain every 2 hours per physician orders, and failed to reassess the patient's pain following the administration of pain medications.
Refer to A-0395.

Patient #1 had orders for medications to prevent constipation. The patient developed constipation during the hospital stay. Review of Patient #1's current care plan dated 11/21/2021 revealed no care plan developed or implemented to prevent constipation.

3. Medical record review revealed Patient #2 was admitted to Hospital #1 on 1/30/2022 with diagnoses including Recurrent Syncope, Chronic Anticoagulation, Hypokalemia, COVID-19, and Chronic Atrial Fibrillation.

Review of Patient #2's fall monitoring and interventions to prevent falls revealed the patient was at a high risk for falls.

On 2/21/2022 at 11:05 AM, Patient #2 experienced a fall.

Review of Patient #2's care plan dated 1/31/2022 through 2/21/2022 revealed, "...Goal: Absence of Fall and Fall Related Injury.." There was no documentation of treatments or interventions to prevent Patient #2 from falls.

Patient #2 was put into a restraint. There was no documentation of a physician order for the restraint.

Patient #2 required Parenteral nutritional support and supplements. There was no documentation of an individualized plan of care to manage the patient's poor nutritional intake.

4. Medical record review revealed Patient #3 was admitted on 1/21/2022 with diagnoses including Rectal Bleeding, Stage 3 Pressure Ulcer to Sacrum, Stage 2 Pressure Ulcer to Left heel, Urinary Retention and Rectal Fecal Impaction.

The Gastrointestinal (GI) Specialist progress note dated 1/25/2022 revealed, "the GI Specialist had ordered for the patient's oral intake be documented. There was no documentation the nursing staff documented the patient's oral intake as ordered.

Review of Patient #3's current care plan dated 2/7/2022 revealed, "...Problem: Oral Intake Inadequate Goal: Improved Oral Intake". There was no documentation of treatments or interventions for Patient #2's poor nutritional status.

Refer to A 385, A392, A 395, A 396, A 618, A629.

Based on policy review, record review and interview, nursing services failed to ensure nursing personnel provided nursing care as needed for patients requiring assistance with bathing and oral care for two (2) of three (3) (Patient #1 and #2) patients reviewed for hygiene needs; and failed to ensure nursing services re-positioned patients at least every two (2) hours for three (3) of three (3) (Patient #1, #2 and #3) sampled patients requiring repositioning.

The findings include:

1. Review of the hospital's "Bathing Guidelines for Adult Patients" policy with an effective date of 6/2020 revealed, "...Purpose: To provide guidance for bathing adult patients in the inpatient setting...Provide a daily bath for patients unable to self bathe, unless medically contraindicated, to improve hygiene and promote comfort. More frequent baths may be performed based upon patient request or in response to specific patients needs..."

In review of the Braden Scale for Predicting Pressure Score Risk chart for positioning in planning care for the prevention of pressure injuries include: Skin assessment and inspection every shift. Turn and reposition every one to two hours, Post turning schedule, Teach or do frequent small shift of body weigh. Elevate heels.

2. Medical record review revealed Patient #1 was admitted on 11/19/2021 with a diagnosis of Fracture of Neck of Right Femur. Patient #1 had a hip right hip replacement surgery on 11/23/2021.

(a) Review of Patient #1's the nursing flowsheets "functional screen" section dated 11/20/2021- 11/29/2021 revealed Patient #1 required assistance with bathing; and the patient had an indwelling catheter.

Review of Patient #1's nursing flowsheet "Hygiene" section dated 11/23/2021 revealed, "...Perineal Care...diaper changed; perineum cleansed; absorbent pad changed".

Review of the flowsheet on 11/25/2022 under hygiene care revealed, "...absorbent pad changed..."

Review of the flowsheet on 11/26/2022 under hygiene care revealed, "...absorbent pad changed...3:49 AM...bath,chlorhexidine; dressed/undressed; bath, complete; linen changed...7:56 AM..."

Review of the flowsheet on 11/30/2022 under hygiene care revealed, "...bath, complete; incontinent care; linen changed...Perineal Care...diaper changed; absorbent pad changed; perineum cleansed..."

There was no other documentation Patient #1 received another bath.

In an interview on 2/23/2022 beginning at 1:43 PM, the Nurse Director (ND) stated, "...Baths should be documented..."
The ND was asked how often should patients receive a bath and the ND stated, "...Just depends on the situation...if they have a catheter they should have a bath daily.

(b) Review of Patient #1's daily nursing assessment "Positioning" section from 11/21/2021 through day of discharge on 11/30/2021 revealed the following:
(a) 11/21/2021 - 8:06 AM - turned
(b) 11/23/2021 - 12:38 PM -Supine
(c) 11/23/2021 - 4:52 PM -"Head of Bed...HOB at 30-45 degrees".
(d) 11/27/2021 - 12:57 AM - "Body Position...weight shift provided...Head of Bed HOB 30-45 degrees".

There was no documentation in the nursing assessments under the title "Positioning" for the following dates: 11/19/2021, 11/20/2021, 11/24/2021, 11/25/2021, 11/26/2021, 11/28/2021, 11/29/2021 and 11/30/2021.

On 11/27/2021 under the title "Positioning" there was no documentation on the day shift from 7:00 AM- 7:00 PM.

On 11/21/2021 under the title "Positioning" there was no documentation for the night shift from 7:00 PM - 7:00 AM.

There was also no documentation the heels were elevated from 11/19/2021 through 11/30/2021.

Review of the Physical Therapy Assistant (PTA) notes dated 11/26/2021 at 9:58 AM revealed Patient #1 was supine in bed with family present prior to treatment and post treatment.

Review of the Physical Therapy (PT) note dated 11/27/2021 at 9:02 AM revealed Patient #1 was supine in bed prior to treatment and post treatment.

Review of the PTA note on 11/27/2021 at 1:11 PM revealed Patient #1 was supine in bed with family present prior to treatment and post treatment.

Review of the PT Treatment Note dated 11/28/2021 at 9:35 AM revealed Patient #1 was supine in bed prior to treatment and post treatment.

Review of the PT Treatment Note dated 11/29/2021 at 12:22 PM revealed Patient
#1 was supine in bed prior to treatment and post treatment.

Review of the PTA notes on 11/30/2021 at 9:54 AM revealed Patient #1 was supine in bed present prior to treatment and post treatment.

Review of the Occupational Therapy notes on 11/30/2021 at 1:57 PM revealed Patient #1 was supine in bed present prior to treatment and post treatment.

There was no documentation Patient #1 was turned and repositioned every 2 hours per the Braden scale and no documentation the patient's heels were elevated.

3. Medical record review revealed Patient #2 was admitted on 1/30/2022 with diagnoses including Recurrent Syncope, Chronic Anticoagulation, Hypokalemia, COVID-19, and Chronic Atrial Fibrillation.

(a) Review of the nursing assessment "Functional Screen" section from 1/30/2022 through discharge 2/22/2022 revealed Patient #2 needed assistance with ambulation, transferring, toileting, bathing, dressing, and eating.

Review of the nursing assessment "Hygiene" section on 1/30/2022 through 2/22/2022 revealed no documentation that Patient #2 received any oral hygiene.

In an telephone interview on 3/9/2022 beginning at 10:27 AM with Patient #2's son, the son stated when Patient #2 first came out of isolation that Patient #2's tongue "looked like a tire on a vehicle that had been in the dessert" and it was cracked and different colors and had blisters on his lips. The son stated the staff had neglected the patient's mouth care.

(b) Review of the nursing flowsheet "Skin Interventions" section titled "Positioning" and the "Restraint" section revealed Patient #2 was not turned or repositioned every 2 hours from 1/30/2022 though discharge on 2/22/2022. There was no documentation of the heels being elevated.

4. Medical record review revealed Patient #3 was admitted on 1/21/2022 with a diagnoses including Rectal Bleeding, Stage 3 Pressure Ulcer to Sacrum, Stage 2 Pressure Ulcer to Left heel, Urinary Retention and Rectal Fecal Impaction.

A physician's order dated 1/23/2022 revealed an order to turn patient every 2 hours.

A physician's order dated 1/24/2022 revealed an order for Protector Heel Prevalon.

Review of the Physical Therapy/Nurse Practitioner Wound Care on 1/24/2022 revealed, "...Chief complain Right heel and sacrum...presents for evaluation of Sacral wound and right heel. Her son states...that the pressure ulcers began 2-3 month(s) ago when she was in the hospital. The patient denies any pain at present...Son is appreciative that wound care is coming to address the wounds. Pt [Patient] and son agree to bedside debridement...Comments: Stage 3 pressure ulcer to sacrum with exposed fat layer, slough, and full thickness injury. Stage 2 pressure ulcer to left heel with pink wound bed. No exposed underlying structures. No purulence, no slough. No signs and symptoms of infection. measures 3 x 4 cm [centimeters], Persistent, non-blanchable deep purple. maroon discoloration to right heel with area of eschar to the superior region of the wound. Measures 6.5 x 6 cm..."

Review of the nursing assessment flowsheet documented on 1/30/2022 though 2/22/2022 revealed Patient #3 was not turned every two hours and there was no documentation of the Protector Heel Prevalon being used as ordered by the physician. Under the area titled "Heels" section, the nursing assessment was defined as "WDL [within defined limits]". There was no documentation of elevating the heels to help in the healing and prevention of the present bilateral deep tissue injury on the heels or the sacrum pressure injury.

Based on policy review, document review, record review and interview, the hospital failed to ensure nursing services performed skin assessments, developed and implemented measures to prevent the development of preventable pressure injuries, and failed to identify actual skin breakdown until severe tissue injury occurred for one (1) of three (3) (Patient #1) patients who developed hospital acquired pressure injuries; failed to document oral input to ensure the patient's needs were met for three (3) of three (3) (Patient #1, #2, and #3) patients reviewed; failed to provide ongoing assessments of patient's pain and monitor/access the effectiveness of the interventions for 1 of 3 (Patient #1) of sampled patients who were experiencing pain; failed to adhere to a physican's order and to check Orthostatic vital signs for one (1) of three (3) (Patient #2) sampled patients for Orthostatic vital signs; and and failed to obtain a physican's order and correct documentation related to restraints for one (1) of three (3) (Patient #1) sampled patients for restraints.

The findings include:

1. A review of the hospital's "Pressure Injury and Wound Treatment Guidelines" last reviewed on "7/20" revealed, "...Each patient is assessed for potential and actual skin breakdown on admission, daily, and as needed if patient's condition changes. Once assessed, prevention/treatment begins in a timely manner. Obtain order to implement Pressure Injury and Wound Basic Care reference chart as indicated...Skin assessment is performed from head to toe with particular attention to the bony prominences...If a pressure injury is present the staff nurse obtains an order from the physician to implement the appropriate level of treatment...The staff nurse obtains physician's order for Wound/Ostomy Nurse/Physical Therapist consult for patients with a Stage 3 or 4 pressure injury, deep tissue injury or unstageable pressure injury as available and indicated...Documentation...dates and times...Assessment/skin appearance...interventions...Nutritional support...Moisture control/incontinence management...Specific location...Size in centimeters, using measuring device...Dressing changes...Drainage...Character/color of wound...Stage...Nutritional support"

A review of the Adult Skin Care Product Reference revealed, "...Implement the appropriate skin protection. prevention guidelines based on RN assessment..."

A review of the hospital's "Pressure Injury Basic Care Reference Chart (Adult) revealed, "...Implement the appropriate pressure injury prevention guidelines based on the patient's Braden Risk Assessment Score [Braden score is a tool used to help determine the risks of a patient developing a pressure injury]...Obtain Physician order for wound care according to the guidelines below. Nutrition Consult...Encourage PO (oral) intake. Obtain Dietician order and encourage intake of arginine, glutamine, and HMB [Hydroxymethylbutyrate] supplement BID (twice per day). Obtain Dietician order and encourage intake of high calorie, high protein supplement...Stage III (3) & (and) Stage IV b(4) or Unstageable...Obtain Physician order: Wound nurse, nutrition, and physical therapy consult..."

A review of the Braden Scale for Predicting Pressure Score Risk revealed, "...Score Interpretation: Score 15-18 = mild risk, Score 13-14 =moderate risk, Score 10-12 = high risk, Score
Review of the Braden Scale for Predicting Pressure Score Risk chart for positioning in planning care for the prevention of pressure injuries included Skin assessment and inspection every shift, turn and reposition every one to two hours, and elevate heels.

A review of the Assessment/Reassessment Policy dated "12/20" revealed, "...Collection of the following information initiated upon admission and completed within 2 hours of inpatient admission...vital signs...height and weight (actual)...Collection of the following information initiated upon admission and completed within 12 hours of inpatient admission...physical assessment...nutrition status...pain assessment...skin assessment...A registered nurse (RN) completes a head to toe assessment...at the beginning of each nurses shift...upon receiving a patient post operatively...transfer from another level of care...Reassessment occurs...at regular intervals (see Addendum 1)".
Review of Addendum 1 revealed, "...Reassessments...At a minimum, focused reassessments are completed and documented every 8 hours...The Registered Nurse creates an initial plan of care, treatment, and services appropriate to the patient's specific assessed needs and revises or maintains the plan based on the patient's responses..."

Review of the hospital's Pain Management Guidelines with a revision date of "1/21" revealed, "...The patient's right to pain management is recognized, respected, and supported...Patients have the right to have pain assessed and managed or referred for treatment, including managing pain aggressively and effectively...A comprehensive pain assessment is conducted as appropriate to the patient's condition and scope of care, treatment and services provided...Pain assessment includes:...A pain intensity rating scale appropriate for the patient population...Location...Quality...Onset...Duration...Aggravating/relieving factors...Relieving Medications...A pain goal is developed related to function and activities of daily living. The patient is involved in developing realistic expectations and goals that are understood by the patient for the degree, duration and reduction of pain. Reassessment of intervention effectiveness occurs based on type/route of medication, method of pain management...The reassessment is documented...Document pain assessment, interventions and reassessment in the medical record..."

Review of the hospital's "Nutrition Screening, Assessment and Reassessment" policy with a revision date of "2/20" revealed, "...Patients are initially screened for the presence of nutrition risk upon admission by nursing...The nurse is alerted to enter a dietician consult if the patient meets any of the following criteria...Large or non-healing wound, burn, or pressure ulcer...Patients positive for indicators on nursing Nutritional Risk Screen...Consults and Triggers...a nutrition assessment is completed and a nutrition diagnosis is identified on patients determined to be at nutrition risk. The following criteria is taken into consideration for a nutrition assessment and may be included, but not limited to...Adequacy of nutrition intake: current, previous, and required calories and protein..Nutrition implications of selected laboratory test...Hydration status...Condition that may affect ingestion, digestion, absorption or utilization of nutrients...Pertinent medications and supplements...The patient's PO (oral) intake documented by designated staff will be evaluated ...A summary of the patient's nutrition care plan is documented on the Patient Care Plan shared by all disciplines...".

Review of the hospital's "Fall Assessment and Management" (Adult)" policy with a review/revision date of "7/19" revealed, "... the patient has a right to a safe environment...Unobserved falls...The type of fall is often referred to as being "found down" or "found on the floor"...Based on the screening or assessment of the patient, the patient may be placed in a higher risk for falls...based on the patient's assessment and specific needs, individualize the plan of care to include the appropriate level of Fall Precautions and interventions to address this patient's problem (s)...Fall Risk Assessment criteria is used as a guideline by clinical staff to assess for patients' risk to fall. Fall risk indicators, with assigned risk point values, are added for a total risk score...Fall risk scores of 14 or greater, indicate placement in High Risk Fall precautions (Red zone)...Patients are re-assessed every shift, post procedure and when there is an acute change of the patent's physical or mental status...Based on the patient's assessments and specific needs, individualize the plan of care to include High Risk Fall Precautions and interventions to address this patient's problem...Increase frequency of purposeful rounding. Goal is every hours or more as needed. Increase safety toileting with staff within arm's reach of the patient. Discuss indications for sitters with chain of command...Use available alarms as indicated...Activate electronic bed alarm/chair alert device as appropriate...Confusion, impulsive behavior, unable to follow directions, at high risk for injury or bleeding, mobile but confused, recent falls (within last 3 months), attempts to get out of bed alone, short term memory, impulsivity, Patient unable to get up alone without assistance and/or required use of assistive device (s) Non-compliance, Incontinence/urgency, Medications, weakness...Upon notification or discovery of a patient fall (inpatient or outpatient), the appropriate person (s) or fall response team is notified and respond to the area of patient need. Use available safe patient handling equipment to return a patient on the floor to the bed...A patient assessment, vital signs, and neuro checks are performed and an appropriate physician is notified of findings...The Post-Fall order set is implemented in addition to any physician orders received...Electronic Occurrence Reports should be completed for patient falls... The hospital monitors and evaluated the effectiveness of all fall reduction activities including assessment, interventions, outcomes, and education".

Review of the hospital's "Restraint of the Non-Violent/Non-Self Destructive Patient" policy with a review/revision date of "7/20" revealed, "...A physician order is written for each episode when restraints are required and after alternative measures have been considered, implemented as appropriate and have been determined to be ineffective. An appropriately trained Registered Nurse (RN) may initiate restraints...A order for restraints is time limited and written for a specific episode including start and end times...When restraint is warranted the physician is notified as soon as possible (within an hour) after the restraint is applied for an order. The attending physician or covering physician is consulted as soon as possible (within an hour) if the attending physician did not order the restraint. Verbal and telephone orders are counter signed with 24 hours of initiating restraints...Orders for the restraint include...Date and time restraint initiated...Type of restraint...Reason of clinical justification for restraint...Criteria for release...Physican name, date and time...An order for restraint is time limited and written for a specific time...Monitoring and Observation...Visual observation of the patient occurs a minimum of every 1-hour or more frequently based on the patient's condition and includes: Patient position and comfort...Restraint device properly applied...Assessment and reassessment of the individual in restraint occurs a minimum of every 2 hours or more frequently based on the patient's condition...Recognition of when to contact a physician in order to evaluate and/or treat the patient's physical status..."

2. Medical record review revealed Patient #1 was admitted to Hospital #1 on 11/19/2021 with a diagnosis of a Fracture of the Neck of the Right Femur which required surgical intervention.

(a) Review of Patient #1's skin assessments and skin monitoring at Hospital
#1 revealed the following:

Review of the Patient #1's Braden scores from 11/20/2021 - 11/30/2021 revealed a range from 16 (mild risk) to a 11 (high risk) for developing skin issues. There was no documentation of appropriate pressure injury prevention interventions based on Patient #1's Braden Risk Assessment Score. When requested the hospital was unable to provide guidelines based on the Braden Risk Assessment Score.

Review of the daily nursing assessment flowsheet "Sacrum Skin" section from 11/21/2021 to 11/30/2021 revealed no documentation for the presence of a sacrum pressure ulcer.

There were no documentation for sacrum skin assessments on the 7:00 AM - 7:00 PM shift on 11/23/2021, 11/26/2021, and 11/28/2021.

There were no documentation for sacrum skin assessments on the 7:00 PM - 7:00 AM shift on 11/22/2021, 11/24/2021, and 11/25/2021.

There were no documentation for sacrum skin assessment on the 7:00 AM - 7:00 PM or the 7:00 PM - 7:00 AM shift on 11/27/2021.

Review of the daily nursing assessment "Heels" (skin) section from 11/21/2021 to 11/30/2021 revealed no documentation for the presence of left or right heel deep tissue injury.

Review of the heels assessments revealed the following:
On the 7:00 AM - 7:00 PM shift the heels were assessed as within defined limits (WDL) on 11/20/2021, 11/23/2021, 11/24/2021, 11/25/2021.
On the 7:00 PM - 7:00 AM shift the heels were assessed as within defined limits on 11/21/201 and 11/29/2021.
There were no documented of assessments of Patient #1's heels on either shift from 7:00 AM - 7:00 PM and the 7:00 PM - 7:00 AM on 11/19/2021, 11/22/2021, 11/26/2021, 11/27/2021, 11/28/2021, 11/29/2021, and 11/30/2021.

Review of Patient #1's current care plan dated 11/21/2021, 11/23/2021, and 11/26/2021. revealed, "...Problem: Skin Care Injury Risk Increased Goal: Skin Health and Integrity Outcome: Ongoing..."There was no documentation of treatments of interventions for Patient #1.

Review of the daily nursing assessment flowsheet "Skin Interventions" section from 11/21/2021 - 11/30/2021 revealed a total of four (4) assessments from 7:00 AM - 7:00 PM and a total of two (2) from 7:00 PM - 7:00 AM. The was no documentation for skin interventions on 11/19/2021, 11/20/2021, 11/21/2021, 11/22/2021, 11/23/2021, 11/26/2021, and 11/28/2021.
In an interview on 2/23/2022 beginning at 1:43 PM, the Nurse Director (ND) stated that skin interventions should be charted daily on each shift.

On 11/29/2021 Patient #1's heels assessment were documented as, "...WDL..."

On 11/30/2021 the day of Patient #1's discharge, the patient's sacrum skin assessment was documented as, "...Sacrum Skin: WDL: Sacrum Skin Color/Characteristics: maroon/purple - Sacrum Skin Elasticity: slow to return elasticity original state - Sacrum Skin Integrity: Excoriation; skin tear".

Patient #1 was discharged on 11/30/2021 to a Skilled Nursing Facility (SNF) #1 with the following diagnoses: Closed Intra-Articular Fracture of Distal End of Right Radius, Atrial Fibrillation, Hypertension, Dizziness, Unsteady Gait, Cerebral Infarction, Falls, Low sodium levels, and Obesity.

Review of the 11/30/2021 admission assessment to SNF #1 revealed,
"...Admit Note...wounds to sacrum...Site...sacrum; Type: pressure; Length: 10 cm [centimeter]; Width: 19 cm; Stage: Unstageable;
Site... Left heel; Type: Pressure; Length: 9.3 cm; Width: 5 cm; Stage: Suspected Deep Tissue Injury;
Site...Right heel; Type: pressure; Length: 9 cm; Width: 5 cm; Stage: Suspected Deep Tissue Injury...".

On 12/2/2021 Patient #1 was transferred from the SNF #1 to Hospital #2.
Review of the 12/2/2021 history and physical admission to [Named Hospital #2] revealed, "...A 91-year old female brought to the Emergency Room from Skilled Nursing Facility...Patient #1 was hospitalized at [Named Hospital #1] prior to her admission to rehab after she fell and broke her hip and needed surgery. She only spent 2-3 days (SNF #1) there. Family reported Patient #1 has not been eating, has not been taking medication. she is getting worse since then and developed multiple sores to her legs, back...Multiple wound with bedsore to her left heel and her hip areas...Urinalysis was normal...Impression...Dehydration...Leukocytosis [condition in which the white cell is about the normal range in the blood]...Multiple bedsores, probably superimposed infection..."

Hospital #1 had failed to perform interventions to reduce the risk of pressure injuries and failed to perform accurate assessments and identify patient injuries which resulted in Patient #1 developing unstageable and deep tissue pressure injuries.

(b) Review of Patient #1's intake and output monitoring at Hospital #1 revealed the following:

The nursing assessment "Intake and Output" from 11/19/2021 - 11/30/2021 revealed no monitoring for input or output on 11/19/2021, 11/20/2021, and 11/22/2021.
There was no documentation of oral intake recorded for 11/26/2021, 11/27/2021, 11/29/2021 and 11/30/2021.
On 11/21/2021 a meal intake of 75% was documented with no oral intake documented.
On 11/25/2021 a meal intake was record as "25%" and "75%".
A 50% supplement was documented on 11/28/2021 with no oral intake recorded. On 11/24/2021, 11/26/2021, 11/27/2021, and 11/28/2021 there was no documentation output was recorded.

Patient #1's current care plan dated 11/24/2021 revealed, "...Problem: Oral Intake Inadequate Goal: Improved Oral Intake There was no documentation of treatments or interventions for Patient #1.

In an interview on 2/23/2022 beginning at 1:43 PM, the ND was asked to review the flowsheets for Intake and Output and was asked if the recorded Intake and Output was documented correctly and the ND stated, "...No".
The ND was asked when the nurses are documenting on the Braden Risk Assessment what do they go by to judge if the Nutrition is adequate and the ND stated, "...Well that is just a subjective judgement...example are they eating well..."

In an interview on 3/1/2022 beginning at 12:38 PM, the Wound Ostomy Nurse (WON) #1 stated, "...if the Braden score is at high risk it would automatically trigger a nutrition consult for the Registered Dietician [RD] and also for certain nursing assessment under the "Nutrition" section...When a nurse finds a stage 3 or 4 or Unstageable wound they would consult the physician and wound ostomy nurse, that is how we are made aware of these types of pressure injuries..."
WON #1 was asked what lab values would you look at to determine a patient's nutritional status and the WON stated she would look at Albumin and pre-Albumin.

In an e-mail correspondence on 3/16/2021 at 12:36 PM, the Director of Risk Management (DRM) was asked who's responsibility was it to record the Intake and Output and the DRM's emailed response was, "...The recording of I&O [Intake and Output] is a team effort including the RN [registered nurse], PCA [Patient Care Assistant], and dietary staff. The staff that assists the patient with I&O would be responsible for recording the results. The RN would have oversight that I&O is completed for the patients in their care."

Hospital #1's Discharge History and Physical for Patient #1 dated 11/30/2021 and sent to SNF #1 revealed, "...11/27/2021 through 11/30/2021 - Intake milliliters (ml) Total = 0, Output (mL) Total = 1700, Net (mL) = - 1700..." (Net mls is the measurement of the fluids that enter the body (input) and the fluids that leave the body (output). The two measurements should be equal).

(c) Review of Patient #1's pain assessments and medication management related to Patient #1's fractured right hip and status post hip repair on 11/23/2021 at Hospital #1 revealed the following:

A physician's order dated on 11/19/2021 revealed an order for Morphine 4 milligrams (mgs) once Intravenous (IV).

A physician's dated 11/20/2021 revealed an order for Morphine 2 mg IV every 2 hours PRN (as needed) for severe pain ( a 7-10 on a scale of 1 - 10 with 10 being the most painful).

A physician order dated 11/20/2021 revealed an order for Hydrocodone-Acetaminophen 1 tablet every 4 hours PRN (as needed) for moderate pain (4-6).

Review of Patient #1's Medication Administration Record (MAR) on 11/20/2021 at 9:13 PM revealed 1 tablet of Hydrocodone-Acetaminophen 5-325 mg was administered by mouth to Patient #1. There was no documentation of a pain assessment for the administration of the Hydrocodone-Acetaminophen 5-325 mg. There was no documentation of an reassessment for the Hydrocodone-Acetaminophen 5-325 mg.

On 11/21/2021 at 4:49 AM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 6 or moderate pain.
Patient #1's Medication Administration Record (MAR) on 11/21/2021 at 4:49 AM revealed 1 tablet of Hydrocodone-Acetaminophen 5-325 mg were administered by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Hydrocodone-Acetaminophen 5-325 mg.

On 11/21/2021 at 8:43 AM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 4 or moderate pain. Review of Patient
#1's MAR on 11/21/2021 at 8:48 AM revealed 1 tablet of Hydrocodone-Acetaminophen 5-325 mg was administered by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Hydrocodone-Acetaminophen 5-325 mg.

On 11/21/2021 at 3:17 PM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 10 or severe pain.
Review of Patient #1's MAR on 11/21/2021 at 3:17 PM revealed Morphine 2 mg was administered IV to Patient #1 for pain. There was no documentation Patient #1 was reassessed for the effectiveness of pain medication.

On 11/21/2021 at 9:51 PM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level 6 or moderate pain.
Review of Patient #1's MAR on 11/21/2021 at 9:51 PM revealed 1 tablet of Hydrocodone-Acetaminophen 5-325 mg was administered by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Hydrocodone-Acetaminophen 5-325 mg.

On 11/22/2021 at 3:55 PM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain an a level 4 or moderate pain. Review of Patient #1"s MAR on 11/22/2021 at 3:55 PM, revealed 1 tablet of Hydrocodone-Acetaminophen 5-325 mg by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Hydrocodone-Acetaminophen 5-325 mg.

On 11/22/2021 at 9:26 PM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 6 or moderate pain. Review of Patient's #1 MAR on 11/22/2021 at 9:25 PM, revealed Oxycodone 5 mg was administered by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

Review of Patient #1's MAR on 11/22/2021 at 11:44 PM revealed Morphine 2 mg/ml was administered IV to Patient #1. At 11:45 PM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 8 or severe pain. Patient #1 was reassessed for the effectiveness of the Morphine 2 mg on 11/23/2021 at 12:12 AM at which time Patient #1 continued to complaint of pain level of 8 or severe pain. There was no documented interventions of further interventions for the patient's pain level of 8 or severe pain.

On 11/23/2021 at 9:03 AM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 7 or severe pain. Review of Patient's #1's MAR on 11/23/2021 at 9:03 PM revealed Oxycodone 5 mg was administered by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

Physician orders dated 11/23/2021 revealed the following revisions for the pain medications:
Demerol 25 mg IV every 10 minutes PRN.
Morphine 2 mg IV every 2 hours PRN.
Morphine 2-4 mg IV every 10 min PRN for severe pain (7-10).
Oxycodone 5 mg by mouth every 4 hours PRN for moderate pain (4-6).

A physician's order dated on 11/23/2021 at 7:04 PM revealed, "...Assess and Document Pain...every 2 hours while awake...If pain mild (less than or equal to 4/10 for 24 hours) assess and document every 4 hours..."

On 11/23/2021 at 9:03 PM a pain assessment was performed on Patient #1 at which time the patient rated her pain at a level of 7 or severe pain. Review of Patient #1's MAR on 11/23/2021 at 9:25 AM revealed Morphine 2 mg IV was administered to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Morphine 2 mg.

On 11/24/2021 at 5:23 AM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 6 or moderate pain.
Review of Patient's #1's MAR on 11/24/2021 at 5:23 AM, revealed Oxycodone 5 mg was administer by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

On 11/25/2021 at 9:42 PM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 6 or moderate pain. Patient #1 was administered Oxycodone 5 mg was administered by mouth to Patient #1. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

On 11/26/2021 at 6:27 AM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 6 or moderate pain. Patient #1 was administered 1 tablet of Oxycodone 5 mg by mouth for the pain. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

Review of Patient #1's MAR on 11/26/2021 at 3:10 PM revealed Oxycodone 5 mg was administered by mouth to Patient #1. There was no documentation Patient #1 was assessed for this pain medication and no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

Review of Patient #1's MAR on 11/26/2021 at 7:50 PM revealed Oxycodone 5 mg was administered by mouth to Patient #1. At 7:52 PM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 8 or severe pain. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

On 11/27/2021 at 1:22 AM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 6 or moderate pain. Patient #1 was administered Oxycodone 5 mg by mouth. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

Review of Patient #1's MAR on 11/27/2021 at 10:15 AM revealed Oxycodone 5 mg was administered by mouth to Patient #1. There is not a pain assessment documented for the 10:15 AM for the administration of this pain medication. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

Review of the Hospitalist daily note on 11/27/2021 revealed, "...Plan...pain control...Pt's [patient] son irate and yelling today during my encounter...reports nurses aren't attentive...pt [patient] is in pain...the pain medications were not scheduled but need to be asked for PRN [as needed]...and that if he had a nursing issue, to ask the front desk for the nursing supervisor's number so that those issues can be addressed....".

On 11/28/2021 at 6:03 AM a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 5 or moderate pain. Patient #1 was administered Oxycodone 5 mg by mouth. There was no documentation Patient #1 was reassessed for the effectiveness of the Oxycodone 5 mg.

The nursing staff failed to assess the patient's pain every 2 hours per physician orders, and failed to reassess the patient's pain following the administration of pain medications.

(d) Review of Patient #1's bowel status monitoring and assessment at Hospital #1 revealed the following:

Physician orders on 11/20/2021 revealed an order for Dulcolax 10 mg 1 tablet by mouth daily for stool softener, and Colace 100 mg 1 tablet by mouth two times a day for stool softener.

Physician orders on 11/28/2021 revealed an order for Glycolax (oral powder) packet 17 grams once daily for occasional constipation and Senokot 8.6 mg 1 tablet by mouth a night as a laxative (helps stimulate bowel movements or loosen up stool to ease its passage).

Patient #1 had a bowel movement on 11/20/2021, and again 5 days later on 11/25/2021. The patient's next bowel movement was on 11/28/2021.

Patient #1 had fecal incontinence (the inability to control bowel movements, causing stool to leak unexpectedly form the rectum - common causes constipation) on 11/25/2021, 11/26/2021, 11/28/2021 and 11/29/2021.

Review of Patient #1's daily head to toe assessments from 11/20/21 through discharge on 11/30/2021 revealed no documented evidence that nursing assessed the the patient's right and left upper or the right and left lower quadrants (assessed by listening for bowel sounds).

Review of the abdominal x-ray performed on Patient #1 on 11/28/2021 revealed, "...Abdominal distension COMPARISON: November 20, 2021 FINDINGS: Frontal view abdomen. There is prominent gaseous distention of the stomach. Gas and stool throughout the colon without significant distention...IMPRESSION Gastric distention [It is typically a symptom of an underlying disease or dysfunction...Constipation causing a build up of feces and back up of digestive content]..."

Review of Patient #1's current care plan dated 11/21/2021 revealed no care plan developed or implemented for constipation/elimination.

In an interview on 2/23/2022 beginning at 1:43 PM with the Nurse Director (ND), the ND was asked do you have a bowel protocol and the ND stated, "No".
The ND was asked how many days should a patient go without a bowel movement and the ND stated, "...That's patient specific...but no cause for alarm if it was 2 to 5 days before they had a bowel movement".

Interview on 3/1/2022 beginning at 10:00 AM the ND was asked if the nursing assessment for "Gastrointestinal" section was a part of the daily head to toe assessment and the ND stated, "...Yes..." The ND stated the only daily requirement for the gastrointestinal is to listen for bowel sounds in all quads..."

3. Medical record review revealed Patient #2 was admitted to Hospital #1 on 1/30/2022 with diagnoses including Recurrent Syncope, Chronic Anticoagulation, Hypokalemia, COVID-19, and Chronic Atrial Fibrillation.

Review of the History of Physical note dated 1/30/2022 revealed, "...[Patient #2] is a 90-year-old gentleman...brought to the emergency department... after 2 syncopal episodes occurred earlier today. During patient's work up was noted to be COVID positive. He has been admitted for further evaluation and treatment. He has a history of atrial fibrillation. Apparently the patient was admitted at [Named Hospital #2] on January 20th where he was found to be COVID positive. He was diagnosed with COVID-10 pneumonia and was subsequently discharged home on January 24th. He return to the emergency department on January 29th brought by his family due to increased weakness. He lives along with his children checking on him. He was discharged from ER and then was brought to [Named Hospital #1]...Neurological: Positive for syncope...Active Hospital Problems...Recurrent syncope...Chronic anticoagulation...Hypokalemia...COVID-19...Chronic atrial fibrillation...dementia...Will ask Physical and Occupational therapy to see. Will ask Neurology to see as well..."

(a) Review of Patient #2's fall monitoring and interventions to prevent falls revealed the following:

The fall risk assessment dated 1/30/2022 at 7:18 AM revealed a fall risk score of 40 (High Risk).

Patient #2 fell on 2/21/2022 at 11:05 AM.

Review of the Post Fall Huddle Tool on 2/21/2022 at 11:05 AM revealed, "...Are hourly rounds documented every hour...Yes...
Was bed/chair alarm activated...No...
Was tether [clips to patient's clothing] on...No...refuse...
Was Post Fall Order Set utilized...Yes...
If patient was attempting to get up why...Confusion...
What do you think could be been done to prevent a future fall (not answered)...
List new fall precautions to be implemented...already doing everything we can do...
Was the Care Plan updated after fall...Yes...
Present at Huddle (not answered)...
Type of fall...Accidental..."

There was no documentation of new intervention developed and implemented following the patient's fall.

Review of the "Post Fall Standing Orders" revealed the following:
Vital signs - Orthostatic vital signs are to be done 1 minute post falls and 3 minutes post fall - not done following Patient #2 fall.
Vital signs Routine every 15 minutes x (times) 4 then every 30 minutes x 2 then every hour x 2 then every 4 hours x 5 - not done following Patient #2's fall.
Neuro Checks - Routine Per Unit Routine - every 15 minutes x 4 then every 30 minutes x 2 then every hour x then every 4 hours x 5 - not done following Patient #2's fall.
Notify physician of patient's fall and verify with physician if Computed Tomography (CT), x-rays or labs are needed - Physican was no

Based on policy review, medical record review, the hospital failed to ensure the nursing staff developed and/or implemented a nursing care plan which reflected individualized patient needs and the care to be provided for three (3) of three (3) patients (Patient #1. #2 and #3) patients reviewed.

The findings include:

1. A review of the hospital's "Pressure Injury Basic Care Reference Chart (Adult) revealed, "...Implement the appropriate pressure injury prevention guidelines based on the patient's Braden Risk Assessment Score [Braden score is a tool used to help determine the risks of a patient developing a pressure injury]...Obtain Physician order for wound care according to the guidelines below. Nutrition Consult...Encourage PO (oral) intake. Obtain Dietician order and encourage intake of arginine, glutamine, and HMB [Hydroxymethylbutyrate] supplement BID (twice per day). Obtain Dietician order and encourage intake of high calorie, high protein supplement...Stage III (3) & (and) Stage IV b(4) or Unstageable...Obtain Physician order: Wound nurse, nutrition, and physical therapy consult..."

A review of the hospital's "Pressure Injury and Wound Treatment Guidelines" last reviewed on "7/20" revealed, "...Obtain order to implement Pressure Injury and Wound Basic Care reference chart as indicated...Skin assessment is performed from head to toe with particular attention to the bony prominences...If a pressure injury is present the staff nurse obtains an order from the physician to implement the appropriate level of treatment...Planning of care, treatment, and services involves using an interdisciplinary approach when warranted and involves the patient and family to the extent possible..."

Review of the hospital's Pain Management Guidelines with a revision date of "1/21" revealed, "...The patient's right to pain management is recognized, respected, and supported...Patients have the right to have pain assessed and managed or referred for treatment...A pain goal is developed related to function and activities of daily living. The patient is involved in developing realistic expectations and goals that are understood by the patient for the degree, duration and reduction of pain...".

Review of the hospital's "Fall Assessment and Management" (Adult)" policy with a review/revision date of "7/19" revealed, "... Based on the patient's assessments and specific needs, individualize the plan of care to include High Risk Fall Precautions and interventions to address this patient's problem...Increase frequency of purposeful rounding. Goal is every hours or more as needed. Increase safety toileting with staff within arm's reach of the patient. Discuss indications for sitters with chain of command...Use available alarms as indicated...Activate electronic bed alarm/chair alert device as appropriate...".

Review of the hospital's "Restraint of the Non-Violent/Non-Self Destructive Patient" policy with a review/revision date of "7/20" revealed, "...Monitoring and Observation...Visual observation of the patient occurs a minimum of every 1-hour or more frequently based on the patient's condition and includes: Patient position and comfort...Restraint device properly applied...Assessment and reassessment of the individual in restraint occurs a minimum of every 2 hours or more frequently based on the patient's condition...Recognition of when to contact a physician in order to evaluate and/or treat the patient's physical status..."

Review of the hospital's "Nutrition Screening, Assessment and Reassessment" policy with a revision date of "2/20" revealed, "...The Registered Dietician develops a nutrition diagnosis and plan of care based on the findings for the nutrition diagnosis and plan of care based on the findings of the nutrition assessment...Interventions and goal are individualized for the patient...A summary of the patient's nutrition care plan is documented on the Patient Care Plan shared by all disciplines...The Registered Dietician will identify and document nutrition discharge needs based on the nutrition diagnosis and plan of care...A summary of the patient's nutrition care plan is documented on the Patient Care Plan shared by all disciplines...".

2. Medical record review revealed Patient #1 was admitted to Hospital #1 on 11/19/2021 with a diagnosis of Fracture of Neck of Right Femur which required surgical intervention.

(a) Patient #1 was ordered anti-constipation medicines in order to prevent constipation.
Patient #1 became constipated during the hospitalizations evidence by an abdominal xray dated 11/28/2021 which revealed, "...There is prominent gaseous distention of the stomach. Gas and stool throughout the colon without significant distention...IMPRESSION Gastric distention [It is typically a symptom of an underlying disease or dysfunction...Constipation causing a build up of feces and back up of digestive content]..."

Review of Patient #1's current care plan dated 11/21/2021 revealed no care plan developed or implemented for constipation.

(b) Review of Patient #1's skin assessments and skin monitoring at Hospital #1 revealed the patient was risk of developing pressure injuries

Review of the daily nursing assessment flowsheets revealed no documentation Patient #1 had any pressure injuries to the sacrum and heels from 11/21/2021 - 11/30/2021. On 11/30/2021, Patient #1 was discharged to a Skilled Nursing Facility (SNF). Upon admission to the SNF, Patient #1 had unstageable and deep pressure injuries.

There was no documentation on Patient #1's most current hospital care plan dated 11/21/2021, 11/23/2021 and 11/23/2021 of interventions developed and implemented in order to prevent pressure injuries.

(c) Review of Patient #1's pain assessments and medication management related to Patient #1's fractured right hip and status post hip replacement on 11/23/2021 at Hospital #1 revealed the following the patient required frequent pain medications for pain.

Review of the Hospitalist daily note on 11/27/2021 revealed, "...Plan...pain control...Pt's [patient] son irate and yelling today during my encounter...reports nurses aren't attentive...pt [patient] is in pain...the pain medications were not scheduled but need to be asked for PRN [as needed]...and that if he had a nursing issue, to ask the front desk for the nursing supervisor's number so that those issues can be addressed...."

There was no documentation on the patient's most current plan of care dated 11/21/2021 of interventions developed and implemented for the patient's pain.

(d) Review of the nursing assessments, physican orders, registered dietician's notes revealed Patient #1 had a poor nutritional status and required Parenteral nutrition.

Review of Patient #1's current care plan dated 11/24/2021 revealed, "...Problem: Oral Intake Inadequate Goal: Improved Oral Intake". There was no documentation of treatments or interventions for Patient #1's poor nutritional status.

3. Medical record review revealed Patient #2 was admitted to Hospital #1 on 1/30/2022 with diagnoses including Recurrent Syncope, Chronic Anticoagulation, Hypokalemia, COVID-19, and Chronic Atrial Fibrillation.

(a) Review of Patient #2's fall monitoring and interventions to prevent falls revealed the patient was at a high risk for falls.

On 2/21/2022 at 11:05 AM, Patient #2 experienced a fall.

Review of Patient #2's care plan dated 1/31/2022 through 2/21/2022 revealed, "...Goal: Absence of Fall and Fall Related Injury.." There was no documentation of treatments or interventions to prevent Patient #2 from falls.

(b) Review of the nursing notes on 1/31/2022 revealed, "...Pt [Patient #2] has gotten up out of bed multiple times despite administration of ativan, very confused/restless and unable to follow commands. Pt found on occation [occasions] wandering around hallway. Pt high fall risk. Orders obtain for restraints..."

Review of Patient #2's care plan dated 2/1/2021 through 2/21/2022 revealed "...Goal: Removal of restraints when clinically safe..." There were only 3 interventions listed on the initial plan of care for the use of restraints. Patient #1 was on restraints from 1/31/2022 through 2/12/2022. The care plan was not developed until 2/1/2022 at 3:15 PM. The plan of care was not maintained or updated and not discontinued when the restraints were discontinued on 2/21/2022.

(c) Review of Patient #2's nutritional status revealed the following the patient had poor oral intake and required supplements and Parenteral nutrition.

Review of Patient #2's current care plan dated 2/7/2022 through 2/21/2022 revealed, "...Problem: Parenteral Nutrition...Intervention: Optimize Nutrition, Fluid and Electrolyte Intake". There was no documentation of an individualized plan of care to manage the patient's poor nutritional intake.

4. Medical record review revealed Patient #3 was admitted on 1/21/2022 with diagnoses including Rectal Bleeding, Stage 3 Pressure Ulcer to Sacrum, Stage 2 Pressure Ulcer to Left heel, Urinary Retention and Rectal Fecal Impaction.

Review of the patient's Albumin value dated 1/25/2022 revealed the patient's Albumin level had dropped to 2.0 (normal 3.4 - 5.4; a low Albumin can mean malnutrition).

Review of the GI Specialist progress notes dated 1/25/2022 revealed, "...[Patient #1] is currently on a regular diet which she is tolerating. I asked for PO [oral] intake amount to be documented on 1/24 but not yet done...unsure how much she is eating. albumin down to 2.0 today. Ordering calorie count now. Will continue diet and monitor/encourage PO intake. Electrolyte replacement PRN..."

Review of Patient #3's current care plan dated 2/7/2022 revealed, "...Problem: Oral Intake Inadequate Goal: Improved Oral Intake". There was no documentation of treatments or interventions for Patient #2's poor nutritional status.

Refer to A385, A392, A395, A396, A618, A629.


















.

Based on policy review, record review and interview, the hospital's dietetic services failed to provide appropriate assessments and interventions for patients with a compromised nutritional status for three (3) of three (3) (Patient #1, #2 and #3) sampled patients.

The findings include:

1. Review of the "Nutrition Screening, Assessment and Reassessment" policy with a revision date of "2/20" revealed Patients are initially screened for the presences of a nutrition risk upon admission by nursing. The interdisciplinary team provides on-going evaluation for nutrition risk throughout the patient's length of stay.

Patient #1, #2 and #3 had a plan of care on the finding for the nutrition diagnosis and based on those finding had a nutrition assessment and interventions and goals were individualized but the nursing staff and the dietary staff did not document Intake/Output or Nutritional risks or follow through with the interventions for inadequate intake. Patient #2 and #3 had 3 day calorie counts that were not documented.

A review of the Assessment/Reassessment Policy dated "12/20" revealed, "...Collection of the following information initiated upon admission and completed within 12 hours of inpatient admission...physical assessment...nutrition status..."

The nursing staff did not assessment and reassess Patient #1, #2 and #3, on a daily basis and document nutritional risk assessment and Intake/Output. The Registered Dietician did not assess and monitor documented the nutrition status for oral intake and calorie counts and fluid restrictions.

A review of the hospital's "Pressure Injury Basic Care Reference Chart (Adult) revealed, "...Nutrition Consult...Obtain Dietician order and encourage intake of high calories, high protein supplement..."

Patient #1 had a hospital acquired pressure injury that went untreated and unnoticed so therefore Patient #1 did not receive the proper diet.

Refer to A 395 and A396

2. Patient #1 presented to the Emergency Department with complains of right hip pain due to a fractured right hip on 11/19/2021.

A physician's order 11/23/2021 revealed an order for Albumin 5 % [percent] intravenous Intra-Op [Intraoperative].

A physician's order 11/24/2021 revealed an order for a dietician consult.

On 11/24/2021 the Registered Dietician (RD) requested for Patient #1 to receive a dietary supplement.

The Clinical Nutrition Summary dated 11/24/2021 revealed a plan to initiate an oral supplement (Ensure) twice a day and to monitor oral intake.

The Medical Nutrition Therapy note dated 11/24/2021 revealed the RD would find the preference of flavor for the Ensure and update the records.

Review of Patient #1's on 11/24/2021 care plan revealed no documentation of treatment or interventions.

A physician's order 11/27/2021 revealed an order to assistance in feeding Patient #1.

The Clinical Nutrition Summary dated 11/29/2021 revealed 0% intake documented x [times] 1 meal, will continue to send Ensure and monitor oral intake.

The Medical Nutrition Therapy dated 11/29/2021 revealed a low Hemoglobin, Hematocrit and Albumin and the Nutrition interventions were oral supplements.

Review of the nursing assessment flowsheet documentation from 11/19, 11/20, 11/21/2021 revealed no oral intake was not documented or output was documented. On 11/26/2021, 11/27/2021, 11/28/2021, 11/29/2021 and 11/30/2021 no oral input was recorded. On 11/24/2021, 11/26/2021, 11/27/2021 and 11/28/2021 on output was recorded.

Review of the Discharge History and Physical on 11/30/2021 that the SNF received on admission revealed Patient #1 had a net total of 0 intake and a net total of 1700 ml of output for 11/27/2021 throught 11/30/2021.

The (RD) did four Dietary assessment on Patient #1 out of the 11 days of hospitalization there were 2 days of meal percentages.

Interview on 2/23/2022 beginning at 1:43 PM, the Nursing Director stated the Intake and Output documented for Patient #1 was incorrect.

Interview on 2/23/2022 beginning at 2:02 PM, the Clinical Nutrition Manager stated, "...We no longer look at labs for nutritional values..."

Interview on 3/1/2022 beginning at 12:28 PM, the Wound Ostomy Nurse stated we look at PreAlbumin more that Albumin.

In a telephone interview on 3/6/2021 at 7:00 PM, Patient #1's son stated he never talked to a Dietician and his mother was always in the room.

Patient #1 was discharged to a Skilled Nursing Facility (SNF) on 11/30/2021 without a diagnosis of pressure injuries.

The SNF admission note dated on 11/30/2021 revealed Patient #1 had her own teeth and marked under nutritional status was Patient #1 has pressure injuries.

Refer to A395 and A396

3. Patient #2 presented to the Emergency Department with complains of increased weakness on 1/30/2022.

The Internal Medicine Progress note on 2/2/2022 revealed there were no Intake/Output documentaion on the last three shifts.

A Physician order on 2/3/2022 revealed an order for Clinimix (a Intravenous (IV) source of calories and protein).

The Medical Nutritional Therapy note dated 2/4/2022 revealed Patient #1 was seen due to Peripheral Parenteral Nutrition...Clinimix ordered at a rate of 75 ml [milliliters]/hr [hour]..."

A physician's order dated 2/4/2021 revealed an order to add dietary supplements for breakfast, lunch and dinner.

The Nutrition notes on 2/4/2022 revealed Patient #2's weight was a stated weight not an actual weight.

In an e-mail correspondence on 3/11/2022 the Director of Risk Management (DRM) stated a stated weight is not an actual weight.

A physician's order on 2/15/2022 revealed an order for a calorie count for 3 days.

Review of the Internal Medicine Progress note on 2/15/2022 revealed Patient #2 is not eating.

Review of the Medical Nutritional notes on 2/16/2022 revealed calorie count x 3 days in progress.

Review of the Medical Nutrition Therapy Clinical Nutrition Summary on 2/17/2022 revealed calorie count in progress.

There was no documentation of the calorie count ordered for 2/16, 2/17, and 2/18/2021.

In an e-mail correspondence on 3/11/2022 revealed calorie counts are order by physician and documented in the Registered Dietician notes.

In an e-mail correspondence on 3/14/2022 the DRM was confirming that Patient #2 and Patient #3 had calorie counts and where it would be documented.

In an 3-mail correspondence on 3/14/2022 the DRM revealed she had reviewed the charts for Patient #2 and Patient #3 for calorie counts and e-mailed the notes to this surveyor.

This surveyor reviewed the attached notes from the 3/14/2022 e-mail correspondence and confirmed the calorie counts were ordered and there was no documented calorie counts for either patient.

Patient #2's Height and Weight on 1/30/2022 that was entered into Patient #2's chart was an estimated height and a stated weight.

In an e-mail correspondence on 3/11/2022 the DRM stated a stated weight is not the actual weight.

4. Patient #3 presented to the Emergency Department with complains of vaginal versus rectal bleeding on 1/21/2022.

The Emergency Department (ED) note dated 1/24/2022 revealed the ED estimated Patient #'s weight of 190 pounds (lbs).

Review of the Medical Nutrition note on 1/24/2022 revealed a plan to initiate an oral supplement and to monitor oral (PO) intake.

The Gastrointestinal physician had requested the PO intake on 1/24/2022 be documented.

Review of the Gastrointestinal Specialist Progress notes on 1/25/2022 revealed the doctor had requested the PO intake be documented for 11/24/2022 and it had not been documented on the nursing flowsheet.

A physician's order on 1/25/2022 revealed an order for a 3 day calorie count.

Review of the Gastrointestinal Specialist Progress note on 1/26/2022 revealed he was unsure of how much Patient #3 is eating and a calorie count had been ordered.

Review of the Medical Nutrition Therapy note on 1/26/2022 revealed calorie count through 1/28/2022 and for it to be assessed on 1/29/2022.

Review of the Medical Nutrition Therapy note on 1/27/2022 revealed encouraged po intake on all meals, calorie count through "1/28".

Review of the Gastrointestinal Specialist Progress note on 1/28/2022 revealed the Dietician is following the calorie count through "1/28".

Review of the Medical Nutrition Therapy note on 1/28/2022 revealed unsure of how much food and drink Patient #3 consumed from son during visit. Three day calorie count ordered information incomplete.

There was no documentation to verify family or friend had received any education on how to keep up with intake and output or calorie count.

In an e-mail correspondence on 3/11/2022 with the Director of Risk Management (DRM) she never confirmed if the family received education.

In an e-mail correspondence on 3/14/2022 this surveyor asked the DRM to confirm calorie counts on Patient #2 and Patient #3.

In an e-mail correspondence on 3/14/2022 the DRM stated, "...I will review and see if either patient had calorie counts ordered. Per the RD, calorie counts are done upon physician order and the results would be documented in the RD notes. Let me look at both patients chart to see if they had orders.

In an e-mail correspondence on 3/14/2022 the DRM stated, "...I reviewed both charts and attached are the notes for each in regards to calorie counts..."

This surveyor review the attached notes from the DRM in the 3/14/2022 e-mail the notes revealed both had orders from a physician for calorie counts

There was no documentation of a completed calorie count for the following days 1/26/2022, 1/27/2022 and 1/28/2022.

In an e-mail correspondence on 3/11/2021 the DRM stated, "...Calorie count is typically done upon order of the physician and/or dietician recommendation.

A physician's order on 2/10/2022 revealed an order for a 1500 mL [milliliters] fluid restrictions.

Review of the Daily Medicine Progress notes on 2/11/2022 revealed Patient #1 Hyponatremia was improved.

Review of the Daily Medicine Progress notes on 2/14/2022 revealed Patient #1 maintain reasonable fluid intake with 1.5 L [liters] per day.

Review of the Medical Nutrition Therapy note on 2/15/2022 revealed receiving a regular diet with 1500 ml [milliliter] fluid restriction.

Review of the Daily Medicine Progress notes on 2/15/2022 revealed documented Intake and Output for the last 3 shifts Intake was blank had not been filled out and Output documented, "...Out: 302 [Urine 300; Other 2]..."

Based on policy review, medical record review and interview, the hospital failed to ensure individual patient nutritional needs were meet for three (3) of three (3) (Patient #1, Patient
#2 and Patient # 3) sampled patients for nutritional status.

The findings include:

1. Review of the hospital's "Nutrition Screening, Assessment and Reassessment" policy with a revision date of "2/20" revealed, "...Patients are initially screened for the presence of nutrition risk upon admission by nursing. The interdisciplinary team provides on-going evaluation for nutrition risk...The nurse is alerted to enter a dietician consult if the patient meets any of the following criteria...Large or non-healing wound, burn, or pressure ulcer...Patients positive for indicators on nursing Nutritional Risk Screen...Consults and Triggers...a nutrition assessment is completed and a nutrition diagnosis is identified on patients determined to be at nutrition risk. The following criteria is taken into consideration for a nutrition assessment and may be included, but not limited to...Adequacy of nutrition intake: current, previous, and required calories and protein..Nutrition implications of selected laboratory test...Hydration status...Condition that may affect ingestion, digestion, absorption or utilization of nutrients...Pertinent medications and supplements...The patient's PO (oral) intake documented by designated staff will be evaluated and the dietitian will determine if the energy needs are being met...if estimated energy needs are not being met, the dietitian documents the variation and will make recommendations for oral nutrition supplementation...The Registered Dietician develops a nutrition diagnosis and plan of care based on the findings for the nutrition diagnosis and plan of care based on the findings of the nutrition assessment...Interventions and goal are individualized for the patient and dietitian collaborates with other clinical disciplines as appropriate. A summary of the patient's nutrition care plan is documented on the Patient Care Plan shared by all disciplines. The Registered Dietician will identify and document nutrition discharge needs based on the nutrition diagnosis and plan of care...The patient is followed throughout hospital stay and re-assessed based on their nutrition risk..."

Review of the Assessment/Reassessment Policy dated "12/20" revealed, "...Collection of the following information initiated upon admission and completed within 2 hours of inpatient admission...vital signs...height and weight (actual)...Collection of the following information initiated upon admission and completed within 12 hours of inpatient admission...physical assessment...nutrition status...pain assessment...skin assessment...".

Review of the hospital's "Pressure Injury Basic Care Reference Chart (Adult) revealed, "...Nutrition Consult...Encourage PO [oral] intake. Obtain Dietician order and encourage intake of arginine, glutamine, and HMB [Hydroxymethylbutyrate] supplement BID [twice per day]. Obtain Dietician order and encourage intake of high calorie, high protein supplement...Stage III 3 & [and] Stage IV or Unstageable...Obtain Physician order: Wound nurse, nutrition, and physical therapy consult..."

2. Medical record review revealed Patient #1 was admitted on 11/19/2021 with a diagnoses of Fracture of Neck of Right Femur had hip replacement surgery on 11/23/2021.

A physician's order dated 11/23/2021 revealed an order for Albumin 5% 12/5 g (gram) in 250 mL (milliliter) continuous as needed (PRN) intravenous. This Albumin was given at 1:20 on 11/23/2022.

A physician's order dated 11/24/2021 revealed a order for a Registered Dietician (RD) consult.

On 11/24/2021 the RD requested/ordered for Patient #1 to receive a dietary nutrition supplement at breakfast and dinner which was authorized/signed by the physician.

Review of Patient #1's Clinical Nutrition Summary dated 11/24/2021 at 12:24 PM revealed, "...Diet: Regular...Pt [patient] is unavailable at time of visit...75% PO (oral) Intake documented on 11/21...No skin breakdown noted...Will order Ensure BID [twice a day] for added nutrition support...RD following...Colace, Dulcolax, Synthroid on MAR [Medication Administration Record]...Plan Initiate oral supplement, Ensure BID, Monitor/encourage po (oral) intake...Reason for Assessment: LOS [length of stay].

Review of Patient #1's Medical Nutrition Therpy (consult) notes on 11/24/2021 at 1:23 PM revealed, "Spoke with patient and friend regarding food preferences - Pt's [patient] friend reports pt with dentures and poor dentition but does not wish to change from Regular diet because "patient wouldn't want that" Rec' [recommend] SLP [Speech-Language Pathology] consult if needed...will place food preferences in Computrition and honor as possible...Ensure Enlive flavor preference obtained and updated...Plans for RD [Registered Dietician] follow up on 11/29 - RD available if needed sooner..."

Review of Patient #1's current care plan dated 11/24/2021 revealed, "...Problem: Oral Intake Inadequate Goal: Improved Oral Intake". There was no documentation of treatments or interventions for Patient #1's poor oral intake.

On 11/27/2021 the physician ordered to assist with feeding the patient.

Review of the Clinical Nutrition Summary on 11/29/2021 at 3:25 PM revealed, "...Diet: Regular...Pt unavailable x multiple attempts to visit...0% intake documented x 1 meal. 11/28 + BM [bowel movement] 11/28...no skin breakdown noted...Will continue to send Ensure...PLAN: Monitor/encourage po (oral) intake...Continue Ensure BID...Assist with meals as needed.."

Review of the Medical Nutrition Therapy on 11/29/2021 revealed an follow up assessment, "...pt [patient] unavailable at time of visit...Estimated Kcal [calories] Needs 1612-1880 kcal/day...Estimated PRO [protein] 72-91 g [grams] day...Fluid Needs: 1612-1880 mL [milliliters]/day or per MD [medical doctor] (1 mL/kcal - RDA [recommended daily allowance])...Labs...HGB [Hemoglobin (a protein in red blood cells that carries oxygen throughout the body)] 9.5 L [low]...HCT [Hematocrit (too few red blood cells in the body)] 29.2 L [low]...BUN [Blood Urea Nitrogen (elevated BUN can be due to dehydration, resulting from not drinking enough fluids)] 39 H [high]...Albumin 2.6 L [low] (a lower albumin level may be malnutrition on have an inflammatory disease)...ALT [Alanine Transaminase ( a lower than normal ALT level could indicate a Vitamin B6 deficiency]...Fluid status: adequate...Nutrition Physical Findings: n/a [not applicable]...Skin intact...Nutrition Intervention: oral supplements...Monitoring/Evaluation Goal: not met...Goals: consume at least 50 % of meals and oral supplement acceptance..."

Review of the nursing assessment in the section titled "Intake and Output" revealed the following:
On 11/19/2021, 11/20/2021 and 11/22/2021 there was no documentation of intake or output recorded.
On 11/26/2021, 11/27/2021, 11/28/2021, 11/29/2021 and 11/30/2021 there was no documentation of intake recorded.
On 11/21/2021 a meal intake of 75% was documented with no oral intake documented.
On 11/24/2021, 11/26/2021, 11/27/2021, 11/28/2021 there was no documentation output was recorded.

Patient #1 was discharged to a Skilled Nursing Facility (SNF) on 11/30/2021. Review of the hospital's Discharge History and Physical dated 11/30/2021 that was send to the SNF revealed, "...Intake/Output 11/27/2021 thought 11/30/2021 - Intake (mL) Total = 0, Output (mL) Total = 1700, Net (mL) = - 1700..." (the measurement of the fluids that enter the body (input) and the fluids that leave the body (output). The two measurements should be equal). The SNF admission note revealed Patient #1 had her own teeth and had a history of weight loss and under her Nutritional status was Patient #1 was noted to have pressure ulcers.

The RD had 4 visits with Patient #1 concerning her nutritional status of the 11 days of the patient's hospitalization there were 2 days of meal percentages documented and on 11/29/2021 the Clinical nutrition summary stated that the patient's Fluid status was adequate.

In an interview on 2/23/2022 beginning at 1:43 PM the ND was asked to review the flowsheet for Input and Output with this surveyor and the ND was asked if the documented Input and Output was documented correctly and the ND stated, "...No". The ND was asked when the nurses were documenting on the Braden Risk Assessment what do they go by to judge if the Nutrition was adequate and the ND stated, "...Well that is just a subjective judgement...example are they eating well..."

In a interview on 2/23/2021 beginning at 2:02 PM the Clinical Nutruiton Manager (CNM) was asked if the patients' labs values were reviewed by the nutritional department in order to determine the patients' nutritional needs and the CNM stated, "...We no longer look at labs for nutritional values if we look at anything if would be the patient's electrolytes..."
The CNM was asked in reviewing the RD notes did the RD actually ever see Patient #1 and the CNM stated, "...We have Registered Dietician's on the floors now and if the patient is not available we can get out information from the nurses, family or friends that might be in the room..."

In an interview on 3/1/2022 beginning at 12:38 PM the Wound Ostomy Nurse (WON) #1 stated, "... [if] Braden score is at high risk it would automatically trigger a nutrition consult for the Registered Dietician [RD] and also for certain nursing assessment under the "Nutrition" section...When a nurse finds a stage 3 or 4 or Unstageable wound they would consult the physician and wound ostomy nurse, that is how we are made aware of these types of pressure injuries..."
WON #1 was asked what lab values would you look at to determine a patient's nutritional status and the WON #1 stated, "...We would look at the PreAlbumin if it has been ordered, also the Albumin, the Albumin give you a long term shot in what they look like nutritionally, we would look at blood sugars..."

In a telephone interview on 3/6/2021 beginning at 7:00 PM, Patient #1's son was asked if he or a friend ever talked to a Registered Dietician. Patient #1's son stated, "...No..."
Patient #1's son was asked if Patient #1 had dentures and poor dentition and Patient #1's son stated, "....has her on teeth on the bottom and on top she upper plate that has about 2 teeth missing and it has never stopped her from eating..."
Patient #1's son was asked if the patient was out of her hospital room a lot for test, and/or procedures and Patient #1's son stated, "...No...she just laid in the bed I'm telling you they just let her lay there..."

3. Medical record review revealed Patient #2 was admitted on 1/30/2022 with a diagnoses of Recurrent Syncope, Chronic Anticoagulation, Hypokalemia, COVID-19, and Chronic Atrial Fibrillation.

Review of the Internal Medicine progress note on 2/2/2022 revealed, "...Intake/Output last three shifts: No Intake/output data recorded (1/30/2022, 2/1/2022, 2/2/2022).

A physician's order dated 2/3/2022 at 3:48 PM revealed an order for Clinimix (a source of calories, protein, and electrolytes for patients requiring Parenteral nutrition when oral or enteral nutrition is not possible or insufficient) infusion at 75 milliliters (ml) continuous infusion Intravenous.

Review of the Medical Nutritional Therapy notes dated 2/4/2022 revealed, "...Patient #2 seen for a nutrition assessment d [due]/t [to] receiving PPN [Peripheral Parenteral Nutrition]...Clinimix ordered on 2/3 at rate of 75 ml/hr. Weight is a "stated" weight. Plan: monitor/encourage po (oral) intake of diet and supplements...assistance with meals...Continue PPN until PO intake...obtain new weight Visited RN [Registered Nurse] Reported: patient in isolation room...% [percent] PO (oral) intake: 0%...Method of feeding: oral diet/modified diet and PPN...Alternate Nutrition Therapy: PPN @ [at] 75...Weight: 200 lb [pounds]...stated weight...Fluid Status: adequate..Nutritional Diagnosis: inadequate oral intake...Goal consume at least 50% of meals, oral supplement acceptance and wean PPN..."

A physician's order dated 2/4/2022 at 1:01 PM revealed an order for Dietary nutrition supplements breakfast, lunch, and dinner Glucerna shake.

This Nutrition notes on 2/4/2022 revealed Patient #2's weight in the chart is a stated weight not an actual weight. The plan was to obtain an actual weight. There was no documentation an actual patient weight was obtained.

Review of the Adult Daily progress notes on 2/12/2022 revealed, "...Intake/Output last 3 shifts: No Intake/Output data recorded (2/10/2022, 2/11/2022, 2/12/2022).

A physician's order on 2/15/2022 at 6:02 PM revealed an order for a routine calorie count for 3 days.

Review of the Internal Medicine progress note on 2/15/2022 revealed, "...Confused, Oriented x [times] 0 tonight...he still is not eating on Clinimix..."

Review of Medical Nutritional Notes on 2/16/2022 revealed, "...Calorie Count x 3 days in progress. Next scheduled follow up for 2/17...Estimated Kcal [calories] Needs...MSJ [Mifflin-St. Jeor equation (calculates your basal metabolic rate, and its results are based on an estimated average)] x [times] 1.2-1.4, actual body weight, maintenance)...Estimated PRO [protein]...1-1.2 g [grams]/kg [kilogram] based on actual body weight, maintenance)..."

Review of the Medical Nutrition Therapy Clinical Nutrition Summary on 2/17/2022 at 3:15 PM, revealed, "...follow up assessment today. Pt [patient] with confusion, agitation, uncooperative, Pulled midline out multiple times and attempts to get out of bed. Noted MD [Medical Doctor] ordered to leave IV [Intravenous] out...PPN [Peripheral Parenteral Nutrition] dc'd [discontinued]. RN [Registered Nurse] reports that fed pt lunch; ate 95% of meal and drank all of oral nutritional supplement...Calorie Count in progress...Monitor/encourage po (oral) intake...Monitor WTs [weight's]...Weight: 200 lb [pound]...stated...Estimated Kcal [calories] Needs...(MSJ [Mifflin-St. Jeor equation] x [times] 1.2-1.4, actual body weight, maintenance)...Estimated PRO [protein]...(1-1.2 g [grams]/kg [kilogram] based on actual body weight, maintenance)...Fluid Status: Hypervolemia [the liquid portion of the blood (plasma) is too high...Nutrition Physical Findings: chewing/swallowing issues...Goal not met...Goals: consume at least 75% of meals and oral supplement acceptance...Follow-up date 2/22/2022..."

There was no documentation of a complete Calorie count for 2/16/2022, 2/17/2022 and 2/18/2022 in the Medical Nutrition Therapy notes.

In an e-mail correspondence on 3/11/2022 at 2:28 PM, the DRM was asked where is the calorie count documented. The DRM stated, "...Calorie count is typically done upon order from physician and/or dietician recommendation. I have reached out to the RD director to verify so I will send you the confirmation when she verifies this.

In an e-mail correspondence on 3/14/2022 at 8:50 the DRM wrote, " I'm looking for [name of Patient #2] and [name of Patient #3] documentation on calorie counts.

In an e-mail correspondence on 3/14/2022 the DRM stated, "...I will review and see if either patient had calorie counts ordered. Per the RD, calorie counts are done upon physician order and the results would be documented in the RD notes. Let me look at both patients chart to see if they had orders.

In an e-mail correspondence on 3/14/2022 the DRM stated, "...I reviewed both charts and attached are the notes for each in regards to calorie counts.

Review of the attached notes sent in the e-mail correspondence sent on 3/14/2022 at 10:36 AM, the Medical Nutrition Therapy notes revealed, "... 2/16/2022 at 9:32 PM, calorie count x [times] 3 days in progress..." 2/17/2022 at 2:58 PM, calorie count in progress..."

Review of the Patient #2's Height and Weight on 1/30/2022 at 7:23 AM revealed and estimated height of 6 feet, 182.9 centimeters (cm), and a stated weight of 200 pounds (lbs) or 90.7 kilograms (kg).

In an e-mail correspondence on 3/11/2022 at 2:58 PM the Risk Management (DRM) was asked what does it mean the patient's weight was "stated" and the DRM answered, "...This means the weight entered is what the patient/family has reported as the weight. Actual weight is the weight obtained by weighing the patient [scale, bed scale, etc.]..."

4. Medical record review revealed Patient #3 was admitted on 1/21/2022 with diagnoses including Rectal Bleeding, Stage 3 Pressure Ulcer to Sacrum, Stage 2 Pressure Ulcer to Left heel, Urinary Retention and Rectal Fecal Impaction.

Review of the Emergency Department note dated 1/21/2022 at 1:28 PM revealed Patient #3 had an estimated weight of 190 lbs.

Review of the Medical Nutruiton Therapy Note dated 1/24/2022 revealed, "...Plan: Initiate oral supplement...Monitor/encourage po (oral) intake...% [percent] PO [oral] Intake: not charted..."

Review of the Gastrointestinal (GI) Specialist progress notes dated 1/25/2022 revealed, "...[Patient #1] is currently on a regular diet which she is tolerating. I asked for PO [oral] intake amount to be documented on 1/24 but not yet done...unsure how much she is eating. albumin down to 2.0 today. Ordering calorie count now. Will continue diet and monitor/encourage PO intake. Electrolyte replacement PRN..."

There was no documented PO (oral) intake after the physician GI had requested that it be documented on the nurse's flowsheet.

A physician's order dated 1/25/2022 revealed an order for a Calorie count for 3 days.

Review of the GI [Gastrointestinal] Specialist progress notes on 1/26/2022 revealed, "...unsure how much she (Patient #3) is eating...calorie count
ordered on 1/25..."

The Medical Nutruiton Therapy Note on 1/26/2022 revealed, "...3 day calorie count ordered.

The Medical Nutruiton Therapy Note on 1/27/2022 revealed, "...Encourage po (oral) intake all meals. Calorie count through 1/28...Next follow up note: 1/28/22..."

Review of the GI [Gastrointestinal] Specialist progress notes on 1/28/2022 revealed, "...Dietitian following, calorie count through 1/28..."

Review of the Medical Nutrition Therapy Clinical Nutrition Summary on 1/28/2022 revealed, "...Son bringing food and protein shakes for patient...3 day calorie count ordered. Information Incomplete Unsure how much food and drink she consumed from son during his visit..."

There was no documentation to verify that family or friends received any education on how to record Patient #2's calorie count or Intake/Output.

In an e-mail correspondence on 3/11/2022 the DRM was asked if the family was educated on how to keep up with the patient's Intake/Output and calories and the DRM stated, "...I have reached out to the RD director to verify so I will send you the confirmation when she verifies this. This surveyor has not received a reply back from the DRM.

There were no documentation of a complete Calorie count for 1/26, 1/27/, and 1/28/2022 in the RD Clinical Nutrition Summary notes. There was no documentation the Calorie count was assessed on 1/29/2022 per the Medical Nutrition Therapy note.

In an e-mail correspondence on 3/11/2022 the DRM was asked stated, "...Calorie count is typically done upon order from physician and/or dietician recommendation..."

In an e-mail correspondence on 3/14/2022 at the DRM was asked I'm looking for Patient #2 and Patient #3's documentation on calorie counts.

In an e-mail correspondence on 3/14/2022 at 8:55 AM, the DRM stated, "...I will review and see if either patient had calorie counts ordered. Per the RD, calorie counts are done upon physician order and the results would be documented in the RD notes. Let me look at both patients chart to see if they had orders.

In an e-mail correspondence on 3/14/2022 at 10:36 AM, the DRM stated, "...I reviewed both charts and attached are the notes for each in regards to calorie counts.

Review of the attacked notes sent in the e-mail correspondence sent on 3/14/2022 at 10:36 AM, the Medical Nutrition Therapy notes revealed, "...1/26/2022 8:23 AM, 3 day calorie count ordered "1/26 - 1/28"...calorie count to be assessed on "1/29". "...1/27/2022 at 11:59 AM...Calorie count through 1/28..." "...1/28/2022 at 1:25 PM...3 day calorie count ordered...Information incomplete..."

There were no documentation of a complete Calorie count for 1/26/2022, 1/27/2022 and 1/28/2022 in the Medical Nutrition Therapy notes.

In an e-mail correspondence on 3/11/2022 at 2:28 PM, the DRM was asked where is the calorie count documented. The DRM stated, "...Calorie count is typically done upon order from physician and/or dietician recommendation. I have reached out to the RD director to verify so I will send you the confirmation when she verifies this.

In an e-mail correspondence on 3/14/2022 at 8:50 AM, the DRM was asked I'm looking for Patient #2 and Patient #3's documentation on calorie counts.

In an e-mail correspondence on 3/14/2022 at 8:55 AM, the DRM stated, "...I will review and see if either patient had calorie counts ordered. Per the RD, calorie counts are done upon physician order and the results would be documented in the RD notes. Let me look at both patients chart to see if they had orders.

In an e-mail correspondence on 3/14/2022 at 10:36 AM, the DRM stated, "...I reviewed both charts and attached are the notes for each in regards to calorie counts.

Review of the attacked notes sent in the e-mail correspondence sent on 3/14/2022 at 10:36 AM, the Medical Nutrition Therapy notes revealed, "... 2/16/2022 at 9:32 PM, calorie count x [times] 3 days in progress..." 2/17/2022 at 2:58 PM, calorie count in progress..."

A physician's order on 2/10/2022 revealed an order for 1500 mL [milliliters] fluid restrictions

Review of the Daily Medicine Progress notes on 2/11/2022 revealed, "...Hyponatremia: improved after salt tabs and lasix... maintain reasonable fluid intake with 1.5 L [liters] per day...Input/Output: I/O last 3 completed shifts: In: [Blank] Out: 1550 [Urine: 1550]..."

Review of the Daily Medicine Progress notes on 2/14/2022 revealed, "...Hyponatremia: improved after salt tabs and lasix. maintain reasonable fluid
intake with 1.5 L [liters] per day...Input/Output: I/O last 3 completed shifts: In: [Blank] Out: 550 [Urine: 550]..."

Review of the Medical Nutrition Therapy Clinical Nutruiton Summary on 2/15/2022 revealed, "...Receiving a Regular Diet with 1500 ml [milliliter] fluid restriction. 50 % po [oral] intake observed this am. Last BM [bowel movement] charted 2/12. Stage 2 left heel, stage III sacral, Unstageable right heel. Juven supplement ordered BID [twice a day] to aid in wound healing..."

Review of the Daily Medicine Progress notes on 2/15/2022 revealed, "...Input/Output: I/O last 3 completed shifts: In: (was blank) Out:302 [Urine: 300; Other 2]..."












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