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Based on document review and interview, the hospital failed to ensure diets were provided in accordance with physician orders and/or followed up on and documented in the medical record (MR) as per their policy for 4 of 10 patients (P2, P3, P4 and P10).

Findings include:

1. Review of facility policies and procedures (P&P) indicated the following:
The P&P titled "Patient Meal Tray Delivery and Pick-up", Revised 8/1/19:
POLICY: Patient meals will be delivered by Food and Nutrition Services to patients at bedside. The patient must be present in their room to receive their meal tray.
PROCEDURE: Nursing records meal intakes in the EMR (Electronic Medical Record)
The P&P titled Failsafe Procedure for Missed Meals, Revised 7/9/19:
PURPOSE: To ensure all patients receive nourishment to meet their needs.
POLICY: Patients who have not placed meal orders by the end of the established meal times will be visited by "CARE Cuisine Ambassadors" and prompted to place an order.
PROCEDURE:
If patients do not order meals by the following times, contact will be initiated by the "CARE Cuisine Ambassador":
Breakfast: 9:00 a.m.
Lunch: 1:00 p.m.
Dinner: 6:00 p.m.
"CARE Cuisine Ambassadors" will visit all patients who have not placed a meal order and prompt them to order. "CARE Cuisine Ambassadors" will document on the "Missed Meal Report" if patient refuses to place an order for that meal period.
*Refused Meal - If a patient refuses to order, the "CARE Cuisine Ambassador" will place a "Refused Order" for the patient in "Room Service Choice" and "R/O" will be documented on the report.
Patients are allowed to refuse one meal per day. When a patient refuses their second meal, the patient protocol will be changed to "non-select" until the patient or patient's caregiver/companion is able to order.

2. Review of patient MRs for patients P2, P3, P4 and P10 lacked documentation of meals having been provided in accordance with physician order and/or P&P as follows: (based on 3 meals/day as noted in policy)
Patient P2, admitted on 7/21/19 at 1708 hours and discharged on 7/31/19 at 1858 hours, lacked documentation of 4 meals as indicated by the following.
On 7/22/19 at 1132 hours, the patient was ordered a Heart Healthy (HH) diet and between 7/23/19 at 1804 hours until 7/25/19 at 0854 hours, the patient was ordered to be NPO (nothing by mouth) and the HH diet resumed after that. The MR lacked documentation of meal intake as follows:
On 7/23/19, prior to the NPO order, 2 meals were missed.
From 7/26/19 at 1905 hours until 7/27/19 at 1355 hours, 1 meal was missed.
From 7/27/19 at 1700 hours until 7/28/19 at 1355 hours, 1 meal was missed.
The MR lacked documentation of reason meals/intakes were not documented/provided and lacked documentation of a "CARE Cuisine Ambassador" having visited the patient.

Patient P3, admitted on 8/5/19 at 1328 hours and discharged 8/15/19 at 2058 hours, lacked documentation of 22 meals as indicated by the following:
On 8/5/19 at 1336 hours, the patient was ordered NPO. On 8/6/19 at 0354 the diet was ordered NPO except sips with medications and ice chips. On 8/6/19 at 0903 hours thru 8/13/19 at 0113 hours, a "Diabetic/consistent Carbs" (carbohydrates) diet was ordered. On 8/13/19 at 0114 hours, the patient was again ordered to be NPO. Between 8/13/19 at 0114 hours and 8/15/19 to discharge, the diet orders fluctuated between NPO and "Diabetic/consistent Carbs" at multiple times. *Note: NPO orders are considered in calculation of missed documentation of meals indicated by the following:
Between 8/6/19 at 0903 hours until 8/7/19 at 1400 hours, 4 meals were missed.
Between 8/7/19 at 1400 hours and 8/9/19 at 1330 hours, 5 meals were missed.
Between 8/9/19 at 1330 hours and 8/10/19 at 0929 hours, 1 meal was missed.
Between 8/10/19 at 0929 hours and 8/15/19 at 1804 hours, 12 meals was missed. (See NPO/diet order notes below)
The MR lacked documentation of NPO orders for 8/10/19 through 8/13/19 at 0114 hours. On 8/13/19 at 1736 hours, the NPO was discontinued and the patient was ordered a "Diabetic/consistent Carbs" diet accounting for 2 meals not provided/documented. On 8/14/19 at 0146 hours, the "Diabetic/consistent Carbs" was discontinued (DC'd) and NPO was ordered and remained until 8/14/19 at 1822 hours when the NPO order was DC'd and a "Diabetic/consistent Carbs" diet was ordered. The NPO order period accounted for 2 missed meals. The "Diabetic/consistent Carbs" was DC'd on 8/14/19 at 2345 hours. On 8/15/19 at 0952 hours, an order to discontinue NPO was entered, an active NPO order was not noted to be in place at that time, and at 0953 hours a "Diabetic/consistent Carbs" was ordered. The MR lacked documentation of a diet order between the 8/14/19 at 2345 hour discontinuation of the "Diabetic/consistent Carbs" diet and the new order for a "Diabetic/consistent Carbs" diet on 8/15/19 at 0953.
The MR lacked documentation of reason meals/intakes were not documented/provided and lacked documentation of a "CARE Cuisine Ambassador" having visited the patient.

Patient P4, admitted 7/18/19 at 1733 hours and discharged on 7/25/19 at 1803 hours, lacked documentation of 7 meals as indicated by the following:
The MR indicated the patient was NPO upon admission. The first diet/food order was on 7/19/19 at 0928 hours for a clear liquid (CL) diet. On 7/22/19 at 2213 hours, the patient was advanced to a low residual diet.
Between 7/19/19 at 0928 hours and 7/20/19 at 1309 hours, the MR lacked documentation of a diet having been provided; 4 missed meal documentations.
Between 7/22/19 at 0800 hours and 7/23/19 at 1045 hours, the MR lacked documentation of a diet having been provided; 2 missed meal documentations.
Between 7/23/19 at 1500 hours and 7/24/19 at 1100 hours (indicated as breakfast), the MR lacked documentation of a diet having been provided; 1 missed meal documentation.
The MR lacked documentation of reason meals/intakes were not documented/provided and lacked documentation of a "CARE Cuisine Ambassador" having visited the patient.

Patient P10, admitted on 7/29/19 at 0932 hours and discharged 8/7/19 at 1744 hours, lacked documentation of 4 meals as indicated by the following:
On 7/29/19 at 1233 hours, the patient was ordered a "Diabetic/consistent Carbs" diet and on 8/3/19 at 1609 hours the diet was changed to "renal" "Diabetic/consistent Carbs". No orders for NPO were noted.
Between 8/3/19 at 1457 hours and 8/5/19 at 1329 hours; 2 meal documentations missed
Between 8/5/19 at 1848 hours and 8/6/19 at 1336 hours; 1 meal documentation missed
Between 8/6/19 at 1336 hours and 8/7/19 at 1015 hours; 1 meal documentation missed
The MR lacked documentation of reason meals/intakes were not documented/provided and lacked documentation of a "CARE Cuisine Ambassador" having visited the patient.

3. Electronic review of dietary meals provided and missed meals indicated the following:
Patient P2 did not have refused/missed meals documented in the (dietary) system.
Patient P3 meals were documented as provided by dietary as follows:
On 8/6/19, the patient was provided breakfast and dinner. Lunch was marked "refused" with the following note: patient is off floor for multiple tests family will help order once back. The logs lacked documentation of lunch having been provided.
On 8/7/19; the patient was provided breakfast, lunch and dinner.
On 8/8/19; the patient was provided breakfast, lunch, and dinner.
On 8/9/19; the patient was provided breakfast, lunch and dinner.
On 8/10/19; the patient was provided breakfast, lunch and dinner.
On 8/11/19; the patient was provided breakfast and lunch. Dinner was marked "refused" with the following note: not hungry.
On 8/12/19; the patient was provided breakfast. Lunch was marked "refused" with the following note: "lunch". Dinner was marked "refused" with the following note: "dinner".
On 8/13/19; the log lacked documentation of breakfast, lunch or dinner having been provided. The log lacked documentation of breakfast notes with a reason no meal was provided. Lunch was marked "refused" with the following note: "lunch". Dinner was marked "refused" with the following note: "dinner".
On 8/14/19; the patient was provided breakfast and dinner. The log lacked documentation of lunch notes with a reason no meal was provided.
On 8/15/19; the patient was provided breakfast and dinner. The log lacked documentation of lunch notes with a reason no meal was provided.
Patient P4's dietary log/record lacked documentation of the patient having been provided breakfast on 7/20/19 and 7/21/19. The log lacked documentation of the patient having been provided lunch on 7/21/19 and lacked documentation of the patient having been provided dinner between 7/19/19 through 7/23/19.

4. On 8/29/19, between approximately 3:45 p.m. and 4:15 p.m., A11, Registered Dietician, indicated that the dietary department maintained a record of missed meals for 30 days. A11 indicated it is the responsibility of nursing to document meals and to order for patients who missed meals. A11 also indicated that patients are allowed to miss/refuse 1 meal. During electronic review of meal history as provided by A11 for patients P2, P3, P4 and P5; he/she noted/verified that the log indicated the following:
Patient P2 did not have refused/missed meals documented in the (dietary) system.
Patient P3 meals were documented as provided by dietary as follows:
On 8/6/19, the patient was provided breakfast and dinner. Lunch was marked "refused" with the following note: patient is off floor for multiple tests family will help order once back. The logs lacked documentation of lunch having been provided.
On 8/7/19; the patient was provided breakfast, lunch and dinner.
On 8/8/19; the patient was provided breakfast, lunch, and dinner.
On 8/9/19; the patient was provided breakfast, lunch and dinner.
On 8/10/19; the patient was provided breakfast, lunch and dinner.
On 8/11/19; the patient was provided breakfast and lunch. Dinner was marked "refused" with the following note: not hungry.
On 8/12/19; the patient was provided breakfast. Lunch was marked "refused" with the following note: "lunch". Dinner was marked "refused" with the following note: "dinner".
On 8/13/19; the log lacked documentation of breakfast, lunch or dinner having been provided. The log lacked documentation of breakfast notes with a reason no meal was provided. Lunch was marked "refused" with the following note: "lunch". Dinner was marked "refused" with the following note: "dinner".
On 8/14/19; the patient was provided breakfast and dinner. The log lacked documentation of lunch notes with a reason no meal was provided.
On 8/15/19; the patient was provided breakfast and dinner. The log lacked documentation of lunch notes with a reason no meal was provided.
Patient P4's dietary log/record lacked documentation of the patient having been provided breakfast on 7/20/19 and 7/21/19. The log lacked documentation of the patient having been provided lunch on 7/21/19 and lacked documentation of the patient having been provided dinner between 7/19/19 through 7/23/19.

5. On 8/29/19, between approximately 5:30 p.m. and 7:00 p.m., A1 confirmed that the MR of patient P10 lacked documentation of meals having been provided as noted above.

Based on document review and interview, the hospital failed to ensure family members or interested persons were counseled to prepare for post-hospital care by failing to inform family members/interested persons of the patients discharge prior to transfer for 2 of 2 patients with documented request of notification to family members and/or interested persons (P1 and P2) and failed to ensure 10 of 10 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10) were provided discharge instructions for post-hospital care in accordance with their policy.

Findings include:

1. Review of hospital policies and procedures (P&P) indicated the following:
P&P titled Care Coordination, Revised & Effective Date 8/21/19:
The Case Manager (CM) and/or social worker, in cooperation with nursing and...coordinates and facilitates discharge planning.
Care Coordination interviews the patient, family members, and/or other involved parties to gather psychosocial, financial information, and information regarding post-discharge care needs.
The patient's right of self-determination is a primary concern throughout the discharge planning process.
Care Coordination helps execute the discharge plan and coordinates communication among the healthcare team, family, payer, and resource agencies.
Care Coordination will reassess the patient's post-hospital needs as necessary and communicate any change in discharge plan to the agency or facility, patient family member, and healthcare team members.
P&P titled Discharge Instructions, Revised & Effective 4/2019:
Discharge to Home:
Provide patient education and document in EMR (electronic medical record).
Review completed instructions and education with patient/patient representative. Have patient/patient representative sign a copy to include in medical record (MR).
Place signed copies in patient's chart to be scanned by HIM (Health Information Management)
Discharge to Extended Care Facility (ECF): Follow above instructions with the exception of the following:
Place Discharge Instructions in packet to go to ECF.
Call the patient representative or emergency contact to let them know that the patient is being discharged to ECF.

2. MR review indicated the following:
Patient P1 was admitted 8/8/19 and was discharged as a transfer to a LTACH (Long Term Acute Care Hospital) on 8/24/19. MR documentation indicated that the patient's son/daughter was DPOA/POA (Durable Power of Attorney/Power of Attorney) of the patient. The MR lacked documentation of the patient's representative/family member/POA having been notified of the patient's discharge/transferred on 8/24/19. The Discharge Summary dated 8/24/19 at 3:12 PM indicated the following: Patient's son/daughter presented to hospital after transfer... The MR also lacked validation that the patient and/or POA received discharge instructions due to lack of signed discharge instructions for P1.
Patient P2 was admitted 7/21/19 and was discharged to home on 7/31/19. The MR lacked documentation of signed discharge instructions for P2.
Patient P3 was admitted 8/5/19 and was discharged as a transfer to a SNF (Skilled Nursing Facility) on 8/15/19. MR nursing note dated 8/9/19 at 7:16 PM indicated the following: The Registered Nurse (RN)documenting the note (S9) add the following care plan "Goal" under "Individualization and Mutuality": "Patient Specific Preferences". "Patient wants all updates to be given to both (son/daughter) and (spouse). (Spouse) is forgetful." Case Management (CM) note dated 8/15/19 at 1:44 PM indicated the following: "Discussed in AM rounds with Social Services, plan to transfer to..." Updated physician, said cardiology plans to review "cath" films with "CV" (cardiovascular) surgery prior to transfer. Nursing note dated 8/16/19 at 1:15 PM indicated the following: Date of Service: 8/15/19 7:00 PM. Call placed to patients (spouse)...to notify him/her that patient was being discharged to (SNF). (Spouse) did not answer so a message was left for him/her with the call back number for questions. The MR lacked documentation of the patient's requested family member (son/daughter) having been notified of the patient's discharge/transferred on 8/15/19. The MR lacked documentation of communication with the patient or any family member of the update in the discharge plan for discharge to occur on that date (8/15/19). The MR also lacked documentation of signed discharge instructions for P3. The MR also lacked documentation of catheterization "cath" films having been reviewed with "CV surgery" prior to transfer.
Patient P4 was admitted 7/17/19 and was discharged to home on 7/25/19. The MR lacked documentation of signed discharge instructions for P4.
Patient P5 was admitted 7/27/19 and was discharged to home on 7/27/19. The MR lacked documentation of signed discharge instructions for P5.
Patient P6 was admitted 7/7/19 and was discharged to home on 7/16/19. The MR lacked documentation of signed discharge instructions for P6.
Patient P7 was admitted 8/9/19 and was discharged to home on 8/12/19. The MR lacked documentation of signed discharge instructions for P7.
Patient P8 was admitted 8/7/19 and was discharged to home on 8/9/19. The MR lacked documentation of signed discharge instructions for P8.
Patient P9 was admitted 7/26/19 and was discharged to home on 7/27/19. The MR lacked documentation of signed discharge instructions for P9.
Patient P10 was admitted 7/29/19 and was discharged to home on 8/7/19. The MR lacked documentation of signed discharge instructions for P10.

3. Interviews:
On 8/27/19, between approximately 1:45 PM and 3:15 PM, A8, Informatics Specialist, confirmed MR findings for patients P1 and P2.
On 8/28/19, between approximately 10:00 AM and 1:30 PM, A8 verified MR findings for patient P3.
On 8/29/19, between approximately 10:00 AM and 12:30 PM, A8 verified MR findings for patients P4 and P5.
On 8/29/19, between approximately 4:30 PM and 7:30 PM, A1, Director of Medical Staff and Accreditation, verified MR findings for patient's P6, P7, P8, P9 and P10.