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Based on interview, and record review, the facility's physicians failed to review and provide appropriate services when the physician's orders were not completed or the physician failed to provide complete care orders,

- medical record did not reflect the requested, physician ordered, daily weights, (Patients #3, #8)

- the medical record did not include a therapeutic diet order, (Patients #3, #4, #6)

- the medical record did not include the isolation status for a patient suspected of having an infectious disease, (Patient #4)

- the medical record did not reflect the patient's advance directives, (Patient #9)

- the medical record did not reflect the activity status for a patient with a fractured femur. (Patient #6)

Findings include:

Review of Patient #3 's medical record reflected a 68-year-old female was admitted to the facility's swing bed unit on 2/24/22, for a Urinary Tract Infection. The physician's order, dated 2/24/22, reflected, "Daily weights." The patient was discharged on 3/16/22. The medical record did not contain a record of the daily weight. The medical record did not reflect a therapeutic diet order.

Review of Patient #4's medical record reflected a 68-year-old male was admitted to the facility's swing bed unit on 3/16/22, with an order to test for C DIFF toxin. The medical records do not reflect an order to place on Contact Precautions and there was no therapeutic diet ordered.

During an interview on the afternoon of 6/28/22, in the administrative conference room, Staff #3, CNO, confirmed the findings and stated in part, "She should have been placed in isolation until the test comes back...The nurses should clarify the orders."

Review of Patient #6's medical record reflected an 82-year-old female was admitted to the facility swing bed unit on 6/13/22, for a fractured left femur. The physician's order dated 6/13/22, did not reflect a therapeutic diet order or the patient's activity status.

Review of Patient #8's medical record reflected an 81-year-old female was admitted to the facility's swing bed unit on 1/31/22 and discharged on 2/7/22, for a Urinary Tract Infection. The physician's orders dated 1/31/22 reflected, "Daily Weights." The medical records reflected the weight was only recorded on the day of admission.

Review of Patient #9's medical record reflected an 89-year-old female admitted on 2/25/22 for pneumonia. The patient's records contained an out-of-hospital advance directive detailing her as a Full Code. The facility's medical record did not reflect a physician's order for the Code status, in the event of a cardiac arrest; the physician wrote an order for a hospice referral. The facility staff did not clarify the code status.

During the record review, on the morning of 6/28/22, in the nursing station, Staff #20, RN confirmed the findings.


Review of the facility provided policy Nutritional Services (effective 10/2016) reflected,
"C. The patient will be weighed upon admission to Swing Bed and weekly or more often as ordered by the physician.
D. Dietary will be notified if the patient exhibits weight fluctuations of greater than five (5) pounds.
E Based on the assessment of the patient and physician orders, patients nutritional plan is designed to ensure the patient maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the patients clinical conditions demonstrates that this is not possible."