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Based on record review and interview, the registered nurse failed to supervise and evaluate the nursing care for 1 of 1 patients (Patient #1) in accordance with the patient's needs, in that the registered nurse failed to obtain a weight upon admission and failed to assess and document the amount of meal consumption. The facility failed to follow policy.

Findings included:

Record review of patient #1 medical record indicated weight was not assessed and documented upon admission to the unit.

During an interview with Personnel #17 on 01/04/2024, Personnel #17 confirmed Patient #1 did not have a weight assessment performed upon admission to the unit. Personnel #17 stated it is facility policy to obtain height and weight on all patients admitted to the unit.

Review of patient #1 medical record reflected Strict Input & Output measurement was ordered on 12/13/2023 at 1:16 PM.

A review of the medical record for patient #1 revealed the facility's Daily Nursing Assessment, performed every 12 hours reflected no documented meal consumption on the following days:
1. 12/12/2023 No documented meal consumption for dinner.
2. 12/13/2023 No documented meal consumption for lunch or dinner.
3. 12/14/2023 No documented meal consumption for lunch or dinner.
4. 12/15/2023 No documented meal consumption for dinner.
5. 12/16/2023 No documented meal consumption for breakfast.
6. 12/17/2023 No documented meal consumption for breakfast, lunch, or dinner.
7. 12/18/2023 No documented meal consumption for breakfast, lunch, or dinner.
8. 12/19/2023 No documented meal consumption for breakfast, lunch, or dinner.

During an interview with Personnel #17 on 01/04/2023, confirmed meal consumption is required and is part of the nutritional assessment.

During an interview on 01/04/2024 with Personnel # 1, 2, 3, and 4 confirmed there was no documented weight upon admission and no documentation for percentage of meal consumption on patient #1.

Review of facility Policy and Procedure titled Documenting the Provision of Care, CS.300, effective January 2018, " ...documentation in the electronic health record is focused on patient care activities, clinical decisions and patient response to care ...key elements of the patient-centered electronic health record are: history, screening and risk assessment, individual considerations for care, Assessment, plan of care, care activities ...Routine care activities include: admission history, assessment, vital signs/height & weight/measurements, safety/risk/regulatory, intake & output, pain management, manage/notify/refer, teach/educate, lines/drains and airways, activities of daily living (hygiene care/meals/ambulation(repositioning).

Review of facility Policy and Procedure titled Standards of Care, HAH109, effective 01/01/2020, reviewed 02/2022, " ...I & O, twice a day for all patients including but not limited to: 1. IV Intake, 2. Oral Intake, 3. Urine output, 4. Foley output. 5. Drain output. Assessment /Reassessment ...3. Focus re-assessments are performed based on patient condition and documented when there is a change in condition.

Based on record review and interview the facility failed to provide necessary therapeutics to maintain healthy albumin and protein levels on 1 of 1 patient (Patient #1); after a 13-day stay the patient was transferred to a higher level of care with low levels of albumin and overall protein to sustain health for patient #1 who suffered from Sepsis, Acute on chronic hypoxic respiratory failure, Bilateral multilobar pneumonia, Hypertension, and Hypothyroidism

Findings included:

Record review of patient #1 medical records reflected an albumin level of 3.3 on 12/08/2023. Four days later on 12/12/2023, Albumin level was 3.2.

Record review of patient #1 medical record reflected a protein level of 7.2 on 12/08/2023 and 6.9 on 12/12/2023.

Review of Patient #1 medical record reflected a diet order was placed on 12/11/2023 that consisted of a regular diet with supplemental drinks three times a day (TID) with every meal.

Review of patient #1 medical record from 12/11/2023 to 12/20/2023 revealed no documentation to ensure the supplemental drinks were provided.

Review of Patient #1 medical record reflected a Nutrition/dietitian consult was ordered on 12/18/2023 at 3:24 PM for "Eval and Recommend, Reason: education; Comment: patient has requested supplement drinks.

During an interview with Personnel #6 on 01/04/2024 confirmed he was unable to provide documentation Patient #1 received her supplemental drinks.

During an interview with Personnel #6 on 01/04/2024 stated when a change in a diet order has been made the order automatically prints to the kitchen. A kitchen employee is responsible for entering the revised order into Comp Nutrition. Personnel #6 stated the order for the supplemental drinks was not modified in Comp Nutrition therefor the patient did not receive her supplemental drinks.

During an interview with Personnel #10 on 01/04/2024 confirmed there was no process to ensure a nutrition consult was completed within 48 hours as policy states.

During an interview with Personnel #1, 2, and 3 on 01/04/2024 confirmed the above findings.

Facility policy titled "Standards of Nutrition Care", FNS.040, effective June 1996, reviewed 12/2023," ...Purpose: To establish basic standards of care for patients' optimal nutrition care regardless of physical condition or disease state. Policy: All patients will receive quality nutrition care."

Facility policy titled "Modified Diets", FNS.046, effective May 1996, reviewed 12/2023, " ...Purpose: The purpose of this procedure is to provide diets in accordance with the patient's physiological needs/disease state ...Policy: The Food and Nutrition Services department provides therapeutic diets as prescribed by the physicians. Procedure: A. patient is provided with the appropriate therapeutic diet as prescribed by his/her physician."