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Based on observation, record reviews, interviews, and review of facility policies, it was determined that the facility did not meet the Condition of Participation for Nursing Services by failing to:


1. Ensure that meals were provided in accordance with physician orders for four of five patient's (#1, 2, 4 and #5 ) which put one patient (R# 4) at risk for choking. (A395)

2. Ensure that the nutritional and/or fluid intake was monitored for two of five patients' (#1 and 3) at risk for altered nutrition/hydration. (A395)

1. Based on a review of clinical records, observation, interview and policy review, the facility failed to supervise dining services to ensure four of five patient's (#1, 2, 4 and 5) received the prescribed diet and/or that sodium restrictions were followed. The findings include the following:

a. Patient #1 was admitted to the facility on 1/22/15 with diagnoses that included dementia with behavioral disturbances. Review of the clinical record identified a physician's order that directed a heart healthy diet. Review of the dietary policy book indicated that a heart healthy diet is a diet "low" in sodium. On 2/5/15 at 12:20 PM, the Patient was observed eating lunch in the dining room. Patient #1 requested and was provided a salt shaker from a staff member to season his/her meal.

b. Patient #2 was admitted on 1/22/15 with diagnoses that included dementia with behavioral disturbances. Review of the physician's order dated 1/22/15 directed a regular, lactose, gluten free diet. Patient #2 was observed on 2/5/15 at 10:30 AM being fed by a CNA. The CNA was feeding the patient eggs, fruit and non-fat yogurt. Interview with the CNA indicated that the yogurt was provided by the patients wife.

c. Patient #4 was admitted to the facility on 1/12/15 with diagnoses that included dementia and depression with behavioral disturbances. Review of a physician's order dated 1/12/15 directed a regular, pureed diet. During tour of the facility on 12/5/15 at 12:15 PM with the QA coordinator, the patient was observed in the dining room awaiting lunch. A bowl of turkey gumbo soup was placed in front of the patient and when asked how the soup was, the patient stated "I need puree". Interview with the patient on 2/5/15 at 12:15 PM stated s/he needed puree secondary a problem with chewing. Interview with NA #5 on 2/5/15 at 1:00 PM stated that staff should verify the patient's diet against the diet slip to ensure the patient receives the correct diet.

d. Patient #5 was admitted to the facility on 2/4/15 with diagnoses that included dementia with behavioral disturbances. Review of a physician's order dated 2/4/15 directed a heart healthy diet. On 2/5/15 at 12:30 PM, the Patient was observed eating lunch in the dining room. Patient #5 requested and was provided a salt shaker from a staff member to season his/her meal.

On 2/5/15, the Department requested an immediate action plan to address the aforementioned concerns. The facility identified that staffing in the dining room will be increased from 2 to 3 staff, tables will be assigned to one staff member, as the patients enter the dining room, soup and plates will be distributed using the printed resources (CNA assignment sheet or census sheet) as a reference for the correct diet order, staff would be educated on diet orders, and this process would be audited/monitored by leadership staff.

2. Based on a review of clinical records, interviews, and policy, the hospital failed to monitor caloric and/or fluid intake for two of five patients' reviewed (#1 and 3) to ensure adequate nutrition and hydration. The findings include:


a. Patient #1 was admitted on 1/22/15 with diagnoses that included dementia with behavioral disturbances. Review of the dietary evaluation completed on 1/23/15 indicated that the patient required 1,700 calories per day and 1,125 cc's of fluids daily. Review of the care plan dated 1/22/15 identified a potential problem for altered nutrition with interventions that included, monitor nutritional intake and offer choices if the patient consumes less than 50% of the meal, monitor fluid intake, if less than 1125 cc's per day for 2 days assess for dehydration, report to the physician and document in the nurse's notes. Review of the patients' intake and output (I&O) records identified that the patient was unable to meet the daily fluid requirements from 1/28/15 through 2/2/15. Review of the record with the QA Coordinator failed to provide evidence that the patient was assessed for signs and symptoms of dehydration and/or that the physician was updated.


b. Patient #1 had an admission weight of 112 pounds (lbs.). Review of the nurse aide (NA) flow sheets during the period of 1/23/15 through 2/3/15 failed to reflect documentation of the patients food intake for 13/33 meals. For 3 of the 33 meals, documentation indicated that the patient's intake was 25% or less, absent documentation that the patient was offered alternative meals choices per the plan of care. Review of the record identified that the patient's weight was 110 lbs on 2/4/15, a two pound loss from 1/22/15.


c. Patient #3 was admitted to the facility on 1/6/15 with diagnoses that included dementia with behavioral disturbances. A nutritional assessment completed on 1/7/15 indicated that the patient required 1,440 cc's of fluid per day. Review of the care plan dated 1/6/15 identified a potential problem for alteration in nutrition related to inadequate/variable oral intake with interventions that included 50%, monitor fluid intake and if less than 1,125 cc's per day for 2 days assess for dehydration, report to the physician and document in the nurse's notes. Review of the clinical record dated 1/23/15, 1/24/15, 1/25/15, 1/26/15 1/27/15, 1/28/15, and 1/29/15 (7 day period) reflected the patient failed to meet the identified fluid requirements. A nurse's note dated 1/26/15 indicated that the patient did no meet the fluid requirement. Review of lab testing on 1/19/15 identified the patient had a BUN of 17 (normal 8-21) and a creatinine (normal 0.4-1.1) of 1.3. Repeat labs on 1/22/15 indicated the BUN increased to 22 and the creatinine increased to 1.4. Repeat labs on 1/26/15 indicated that patient's BUN had risen to 27 and creatinine remained elevated at 1.4. Although the patient failed to meet his/her daily fluid requirements and the BUN and creatinine levels were elevated, the record lacked evidence that the patient was assessed for signs and symptoms of dehydration.


d. Record review and interview with the Manager and QA Coordinator on 2/5/15 at 11:30 AM identified that although Patient #3's lab results dated 1/26/15 were circled with notation to have the BUN and creatinine repeated in five (5) days, the record lacked evidence the labs were drawn. Interview further indicated that the notations on the lab results from 1/19/15, 1/22/15, and 1/26/15 appeared to have been made by the medical hospitalist, however, the record lacked evidence of a medical assessment.


Review of the Intake and Output policy identified that I&O is accurately monitored to insure adequate hydration levels and that nursing staff are responsible for recording and monitoring the I&O totals. Review of the Professional Staff policy indicated that progress notes should be completed to document a patients progress.