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Based on record reviews and interviews the facility failed to ensure the patient received care in a safe setting for one of three patients reviewed. Patient #1.

Findings:

Patient #1 was a new admission to the hospital on 12/27/2021. Chief Complaint: Edema (Swelling of his legs.) Additional Diagnosis includes: High blood pressure, Obesity. Acute Kidney Injury that required the patient to start Dialysis.
Patient #1 was a full code. He was alert and oriented upon arrival to the facility. The patient expired in the hospital on 1/28/2022.

The patient had orders for strict intake and outputs, and daily weights to start on 12/29/2021. Documentation of the strict intakes and outputs, daily weights was incomplete. Clinical record review did not show complete documentation of meal percentages consumed for this patient. A review of the Dietitians recommendation dated 1/24/2022 read for the patient to start on Total Parenteral Nutrition (TPN). There was no documentation that the Dietitians recommendation was addressed by a physician.

During an interview on 3/24/2022 at 12:37 PM, with Staff B a Registered Nurse (RN) If TPN is ordered, there usually an order for a team (1 person) that inserts Peripherally Inserted Central Catheter (PICC) lines in house. The PICC line does not require surgical intervention. I am not sure why there is a three day delay in starting patient #1 TPN there is no nurses notes to say why. staff b states that the beds in the facility weighs patients. I do not why the weights would not have been recorded. I don't know why the Intakes and outputs would not be recorded. There should not be a reason that I&O ( Intake/Output), weights, and meal percentages are not recorded. This is a nurses responsibility to record this information. In the Intensive Care Unit (ICU) the ICU nurse would have documented everything. If less than 30 ML output the physician should be notified and it should be documented in the patient's chart.

During an interview on 3/24/2022 at 1:04 PM, with Staff C an RN stated, night shift does the daily weights and are supposed to put these weights in the computer. Techs are able to document weights. The beds have scales, there are stand up scales, and chair scales. There is no reason that I & O's are not documented. The nurse is responsible for this documentation. If the patient only had a 2 cc output it should have been reported to the physician, either the primary care or nephrologists. There should be documentation to show how much of the patients meal was consumed, PICC line policy has to be followed.

During an interview on 3/24/2022 at 4:45 PM with Staff D RN, Director of Medical Surgical, stated, there should be documentation for I&O's, weights, there is limited documentation in medical record for patient # 1. Night shift typically get weights in the early AM. If day shift sees that it is not done they can assist with getting weights. It is passed on in report that patient's to have daily weights. Nurses should review orders. Chart audits are supposed to be done every shift. Each bed has a scale to weigh patients. I&O's should be recorded throughout the shift. Record as it happens. I can't say why this was not done in December weights, intakes and outputs, or meal percentages.

During an interview on 3/24/2022 at 8:30 AM, with Staff F Certified Nursing Assistant (CNA) stated, when I started here three years ago I was told the day shift CNA's were supposed to obtain the morning weights when they did their vital signs. The nurse is supposed to tell the CNA if the patient is a daily weight. The nurse will have to let us know the CNA if a patient is supposed to be on strict I&0. The CNA's tell each other during shift report and we are told by the nurse. The patients have bed scales that we use to weigh the patient. I cannot recall this patient specifically but this is supposed to be our usual process. I do understand though that in the last two to three weeks each shift is supposed to ensure that the weights, I&O's are documented.

During an interview on 3/24/2022 at 8:55 AM, with Staff E a CNA stated, I don't really remember this patient. The usual process is for patients on dialysis to receive daily weights. Sometimes we do not know if the patient is on strict I&O's, or daily weights. There is nowhere for the CNA to tell if the patient is supposed to be on daily weights or to have strict I&O's completed. The nurse is supposed to notify the CNA's if patients need something done specifically. Normally the night shift does the daily weights. If the night shift cannot get the weights, the day shift CNA is supposed to get the weight.

During an interview on 03/25/2022 at 11:47 AM, with physician Staff I Hospitalist stated, the nurses should have been recording the intakes and outputs (I&O's). weights. I cannot tell you why the patient did not start the TPN on the 24th of January as recommended by the Dietitian. He was on multiple pressors. Labs should have been reviewed to show signs of dehydration. The Dietitian at this facility can write recommendations for diets but they cannot write orders for diets. The doctor has to review the recommendations and write the order.

During an interview on 3/25/22 at 2:49 PM, with the Director of Nursing (DON), stated , "I think we were going thru a pandemic and we were very busy. It is important that we document patient care. I have no excuse for why there was no documentation of his (patient #1) I & O's, weights, or his meal percentages except for staff being real busy during COVID. Of course it is expected that the nursing staff follow the physicians orders.

During an interview on 3/25/22 at 2:53 PM, with Staff J stated, since this patient was a new dialysis patient it is very important that the I&O's are documented, Daily weights should be obtained for patients that are newly starting Dialysis. Daily weights are very important so we can know what the dry weight will be. Check weight pre and post dialysis. Prevent fluid volume overload. The amount of fluid removal in dialysis should be documented. I know sometimes the nurses do not document the I & O's or the weights.

During an interview on 3/29/22 at 9:39 AM, with physician L a hospitalist stated, the patient #1 told me he was eating less . I ordered the PICC line because he was such a hard stick not for him to receive TPN. I don't think we talked about nutrition with the family that day. I did not put this in my notes. The Dietitian may have texted me about the TPN or not, I cannot remember. I can't recall if the patients family had agreed with the Dietitians recommendation. Continued interview at 11:45 AM she stated, the nursing staff should have documented the patients I&O's, weights that were ordered. Meal percentages should be documented by the nursing staff. It is the facility's expectation for nursing staff to follow physicians orders.

The patient had an order from the nephrologist ARNP( Advanced Registered Nurse Practitioner) dated 12/28/2021 for the patient #1 be on daily weights. The patient also had additional orders for daily weights. 12/29/21, 12/30/21/1/4/2022.
There were no weights documented on patient # 1 for the following dates.
December 12/28 thru 12/31/2021.
Weights were not recorded from 1/02 to 1/09,2022.
Weights were not recorded for 1/11/2022.
Weights were not recorded for 1/13 thru 01/14/2022
Weights were not recorded for 1/16/2022.
Weights were not recorded from 1/18 to 1/20/2022.
Weights were not recorded for 1/22 to 1/28/22.

The patient had an order from the nephrologist ARNP dated 12/28/2021 for the patient #1 be on strict intake and outputs (I & O's).
There were no I & O's documented on the patient #1 for the following dates.
Intake and outputs were not recorded from 1/02/2022.
Intakes were not recorded for patient #1 for 1/6/2022.
Intakes were not recorded for patient #1 for 1/9 thru 10 2022.
Intakes were not recorded for patient #1 for 1/12/2022.
Outputs were not recorded for 1/10 thru 01/15/2022.
Outputs were not recorded for 1/17/2022.
Outputs were not recorded for 1/18/2022.
Intake was not recorded for 1/19/2022.
Outputs were not recorded for 1/21 thru 1/23/2022.
Outputs were not recorded from 1/24/2022.
Intakes and outputs were not recorded for 1/25/2022.

A review of the Dietitians recommendation dated 1/24/2022 at 11:26 AM read, Nutrition order Renal standard diet. Nutrition intake Not eating. The patient is not receiving nutrition support. Physical assessment; patient not wanting to eat. Yesterday he was able to drink a supplement. Pertinent medications Rocephin, Oxycodone. Pertinent labs; on 1/23/22 sodium 133. Liver enzymes elevated. Chloride: 94. Glucose 65. BUN ( Blood Urine Nitrogen) 57. WBC ( White Blood Count)14.5, CR ( Creatine): 7:02, Phos ( Phosphorus) 8.1. Inadequate pro-cal diet. Not eating at all. Etiology due to acute illness. Supplement and appetite stimulant last resort. Patient will eat 50-75% of meals consistently. At 12:41 PM the Dietitian note read, he throws up a bit, when he gets food into his mouth. His appetite started getting worse after he started on the antibiotics. Patient does not have any fluids going. RN reports patient's legs swollen and weeping. Patient also has a liver mass. A midline cathether is to be placed. Recommend a PICC line so he can get all nutrition via TPN/Lipids. the physician is agreeable. Nutrition intervention: PICC line for TPN/Lipids. Patient will receive adequate nutrition to recover and heal. Nutrition monitoring; labs, tolerance to TPN/Lipids. Nutrition related diagnosis; Morbid obesity. Nutrition diagnosis details: Body mass index (BMI) 40 or more. Nutrition prescription: Nephro bid since he is not eating well here. PICC line for TPN/Lipids; TPN: 5% AA, 15% Dextrose 25 ML every 24 hours to goal of 100 ML/hr. Add Thiamine 100 MG daily. May need to individualize Multi Vitamin (MVI) and trace elements due to renal labs. Lipids 20% of 250 ML daily (start on second day).

A review of the physician's orders dated 1/24/22 at 5:43 PM by Staff L read to insert PICC line. No TPN order written.
A review of the nurse's notes read the PICC line was inserted on 1/24/2022 at 5:00 PM.
On 1/27/22 at 2:42 PM, physician Staff I wrote an order for the patient to start on TPN. Patient expired on 1/28/2022 at 12:06 PM.

A review of the Registered Nurses Job description read, supports, maintains, and provides an environment which is supportive of quality patient care throught effective use of resources and personnel.

Based on record reviews and interviews the facility failed to ensure a registered nurse supervised and evaluated nursing care for each patient. Patient #1.

Findings:

Patient #1 was a new admission to the hospital on 12/27/2021. Chief Complaint: Edema (Swelling of his legs.) Additional Diagnosis includes High Blood Pressure, Obesity. Acute Kidney Injury that required the patient to start Dialysis.
Patient #1 was a full code. He was alert and oriented upon arrival to the facility.
The patient Expired in the hospital on 1/28/2022.

The patient had orders on 12/29/2021, for strict intake and outputs, daily weights. Documentation of the strict intakes and outputs I&O's, daily weights, and meal consumption was incomplete.

During an interview on 3/24/2022 at 12:37 PM, with Staff B an Registered Nurse (RN) If the TPN ( Total Parenteral Nutrition) was ordered there is a team (1 person) team that inserts Peripherally Inserted Central Catheter (PICC) lines in house. The PICC line does not require surgical intervention. I am not sure why there is a three day delay in starting patient #1 TPN there is no nurses notes to say why. The beds in the facility weighs patients. I do not why the weights would not have been recorded. I don't know why the Intakes and outputs would not be recorded. There should not be a reason that I&O, weights, meal percentages are not recorded. This is a nurses responsibility to record this information. In Intensive Care Unit (ICU) the ICU nurse would have documented everything. If less than 30 ML output the physician should be notified and it should be documented in the patient's chart.

During an interview on 3/24/2022 at 1:04 PM, with Staff C an RN stated, night shift does the daily weights and are supposed to put these weights in the computer. CNA( Certified Nurses Aide) are able to document weights. The beds have scales, there are stand up scales, and chair scales. There is no reason that I & O's are not documented. The nurse is responsible for this documentation. If the patient only had a 2 cc output it should have been reported to the physician either the primary care or nephrologist. There should be documentation to show how much of the patients meal was consumed, PICC line policy has to be followed.

During an interview on 3/24/2022 at 4:45 PM, with Staff D an RN, Director of Medical Surgical Unit, stated the documentation for I&O's, should be documented. I am new to this role of Unit Manager. Night shift typically get weights in the early AM. If day shift sees that it is not done they can assist with getting weights. It is passed on in report that patient's or to have daily weights. Nurses should review orders. Chart audits are supposed to be done every shift. Each bed has a scale to weigh patients. I&O's should be recorded throughout the shift. I can't say why this was not done in December but the weights, intakes and outputs, or meal percentages should be documented.

During an interview on 3/24/2022 at 8:30 PM, with Staff F an Certified Nursing Assistant CNA stated, when I started here three years ago I was told the day shift CNA's were supposed to obtain the morning weights when they did their vital signs. The nurse is supposed to tell the CNA if the patient is a daily weight. The nurse will have to let us know (CNA) if a patient is supposed to be a strict I&0. The CNA's tell each other during shift report to each other provided we are told by the nurse. The patients have bed scales that we use to weigh the patient. I cannot recall this patient specifically but this is supposed to be our usual process. I do understand though that in the last two to three weeks each shift is supposed to ensure that the weights, I&O's are documented.

During an interview on 3/24/2022 at 8:55 PM, with Staff E an CNA stated, I don't really remember this patient. The usual process is for patients on dialysis to receive daily weights. Sometimes we do not know if the patient is on strict I&O's, or daily weights. There is nowhere for the CNA to tell if the patient is supposed to be on daily weights or to have strict I&O's completed. The nurse is supposed to notify the CNA's if patients need something done specifically. Normally the night shift does the daily weights. If the night shift cannot get the weights the day shift CNA is supposed to get the weight.

During an interview on 03/25/2022 at 11:47 AM, with physician Staff I a Hospitalist stated, the nurses should have been recording the intakes and outputs (I&O's). weights. I cannot tell you why the patient did not start the TPN on the 24th of January as recommended by the Dietitian. He was on multiple pressors. Labs should have been reviewed to show signs of dehydration. The Dietitian at this facility can write recommendations for diets but they cannot write orders for diets. The doctor has to review the recommendations and write the order.

During an interview on 3/25/22 at 2:49 PM, with the Director of Nursing DON, stated ,"I think we were going thru a pandemic and we were very busy. It is important that we document patient care. I have no excuse for why there was no documentation of his (patient #1) I & O's, weights, or his meal percentages except for staff being real busy during COVID. Of course it is expected that the nursing staff follow the physicians orders.

During an interview on 3/25/22 at 2:53 PM with Staff J, stated, since this patient was a new dialysis patient it is very important that the I&O's are documented, Daily weights should be obtained for patients that are newly starting Dialysis. Daily weights are very important so we can know what the dry weight will be. Check weight pre and post dialysis. Prevent fluid volume overload. The amount of fluid removal in dialysis should be documented. I know sometimes the nurses do not document the I & O's or the weights.

During an interview on 3/29/22 at 9:39 AM, physician L an hospitalist stated, the patient told me he ( Patient # 1) was eating less. I ordered the PICC line because he was such a hard stick not for him to receive TPN. I don't think we talked about nutrition with the family that day. I did not put this in my notes. The Dietitian may have texted me about the TPN or not I cannot remember. I can't recall if the patients family had agreed with the Dietitians recommendation. Continued interview at 11:45 AM she stated, the nursing staff should have documented the patients I&O's, weights that were ordered. Meal percentages should be documented by the nursing staff. It is the facility's expectation for nursing staff to follow physicians orders.

Review of the facility's job descripition for Registered Nurse effective date 01/2020 shows that under Essential Functions, Number 6; Plans and implements patient care and teaching based on a total assessment and the age of the patient. Number 7: Evaluates and documents patient response: monitors and recognizes changes in physiological and psychosocial status: Takes appropriate action based on assessment of the patient. Under Performance Outcomes , Number 4: Health/Safety/Security of knoweldge of all policies and procedures that affect the outcomes of patient care, employee rights and responsibilities.