HospitalInspections.org

Based on a review of medical records, facility policy and procedures and interview with administrative staff it was determined the facility failed to include the patient or family in the development of an individualized treatment care plan to meet their needs.
This had the potential to affect all patients served by the facility and did affect Medical Record (MR) #3, 4, 10, 11, 12, 17, 20 and 23.


Facility Policy: Multidisciplinary Treatment Team- Senior Care
Reviewed 7/23/2009

Objectives: To provide consistent, quality treatment for all patients by developing an individualized plan of care on admission that is based on interdisciplinary clinical assessments.

Procedure: A. On admission, the admitting nurse consults with the admitting physician and any other staff involved in the intake process. Based on the intake information and the nursing assessment, the admitting nurse initiates the Data Integration and Treatment Priority Identification tool.
1. Patients participate in a daily treatment program...
2. Treatment planning is a structured process by which identified patient problems are resolved via specific goal-oriented treatment interventions.
There are basically two treatment plans which are developed during the patient's stay:
a. Master Treatment Plan
b. Continuing Care Plan
3. Key elements essential to all stages of treatment planning include the following:
a. Problems, goals, and objectives are written in observable, measurable terms.
b. Treatment plans are based on systematic evaluations of patient's strengths and weaknesses.
c. Treatment plans specify the frequency of each treatment procedure...
d. Treatment plans specify discharge criteria...

C. Master Treatment Plans:
2. The Master Treatment Plan serves as the general plan for the remainder of treatment. The plan is reviewed at the initial Multi-disciplinary treatment plan meeting (staffing) which is held within 72 hours of admission and includes the Psychiatrist, RN (Registered Nurse), SW (Social Worker) and AT (Activities).
3. The patient and/or family is involved/informed (pending patient's consent) of his/her treatment plan at initial development and at ongoing review treatment meetings.

Medical Record Findings:

1. Medical Record (MR) # 12 was admitted on 7/15/10 with diagnosis of Dementia, not otherwise specified, with recent behavioral disturbances.

The diagnosis on the initial evaluation included:
Axis I: Dementia
Axis II: No diagnosis
Axis III: 1. Left testicular hydrocele
2. Gastroesophageal reflux disease
3. Arthritis
4. Recent hypernatremia
5. Anemia
6. Recent hematuria
7. Suspected skin cancer, unspecified type on his nose
8. History of stroke, December 2007.
Axis IV: Moderate to severe stressors related to advancing dementia.
Axis V: Global assessment functioning on admission 20, global assessment functioning on discharge 25.

A review of the multidisciplinary treatment team plan: data integration, dated 7/16/10 identified on initial assessments were Cognitive Impairment and Falls. The master problem list included Cognitive Impairment and Falls with date initiated 7/15/10. There was no information for admitting diagnosis, assets, limitations or precautions. The treatment team signatures included the psychiatrist, social worker,admitting nurse and occupational therapist. There was no signature and no documentation of the patient or family being given the opportunity to participate in planning on the Patient/Guardian statement.

The Master Treatment Plan review and recertification dated 7/29/10 failed to document on the Patient/Guardian statement any signature by the family or patient. The section was marked "no" the patient was not present for the treatment team review.

2. MR# 10 was admitted on 8/27/09 with a diagnosis of Delusional Disorder, Paranoid type.

A review of the multidisciplinary treatment team plan: data integration, dated 8/28/09 identified on initial assessments were Cognitive Impairment, Delusional, Depression and Diabetes. The master problem list included the same. The treatment team signatures included the psychiatrist, social worker, admitting nurse and occupational therapist.

The physician ordered 9/1/09, " Isolation precautions for MRSA(+) eye infection."

On 9/3/09, 9/10/19 and 9/17/10 the Master Treatment plan review and recertification was completed and signed by the psychiatrist, social worker,nurse and occupational therapist. There was no documentation of the patient being on isolation precautions or how this might affect her participation in attending group activities within the milieu. There was no documentation of the family or guardian participation in the treatment plan.

3. MR # 23 was admitted on 9/28/10 with a diagnoses of Bipolar Disorder NOS and Dementia NOS with Behavioral Disturbances.

A review of the multidisciplinary treatment team plan: data integration, dated 9/28/10 identified on initial assessment was Disruptive Behavior. The treatment plan was signed by the social worker, admitting nurse and occupational therapist on 9/29/10. The psychiatrist had not signed the treatment plan as of 10/1/10 at 12:30 PM. The patient had not participated in the development of the treatment plan.



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4. MR # 4 was admitted on 7/15/10 with diagnosis of Alzheimers Disease and behaviors of anger and combativeness with family.

The diagnosis on the initial evaluation included:
Axis I: Dementia
Axis II: No diagnosis-deferred
Axis III: Recent UTI (Urinary Tract Infection), Status post Right hip fracture
Axis IV: Severe psychosocial stressors related to increased assistance at home.

A review of the multidisciplinary treatment team plan: data integration, dated 7/16/10 revealed no problems identified on initial assessments were documented. The master problem list included Cognitive Impairment with date initiated 7/15/10. There was no information for admitting diagnosis, assets, limitations or precautions. The treatment team signatures included the psychiatrist, social worker and occupational therapist. There was no signature of the admitting nurse and no documentation of the patient or family being given the opportunity to participate in planning.

This patient sustained a fall on 7/15/10. A review of the x-ray reports dated 7/16/10 revealed, "Procedure Left Hip two views. Findings: Total left hip prosthesis projected in satisfactory alignment and position. No acute bone or joint abnormality. Procedure Right Hip two views. Findings: No acute bone or joint abnormality."

A review of the nurse progress notes, dated 7/18/10 documented at 9:00 AM included, "Grimaces with pain when we move her, stays in wheelchair in dayroom, also naps in recliner and bed."

A review of the Medication Administration Record revealed no pain medication was ordered or administered until 7/20/10.


5. MR # 3 was admitted on 7/7/10 with diagnosis of Alzheimers Disease and behaviors including confusion and paranoia.

A review of the admission history and physical, dated 7/7/10 included the past medical surgical history of non-insulin dependent diabetes mellitus (NIDDM), chronic low back pain, recurrent esophageal spasm with dysphagia with recent treatment with Botox injections of distal esophageal sphincter (6-25-10).

A review of the Multidisciplinary Treatment Team Plan: Data Integration, dated 7/8/10 included problems of Cognitive Impairment, high risk falls and NIDDM. The problems identified did not include esophageal spasms with dysphagia.

An initial Nutrition Assessment was completed on 7/8/10 with risks identified with intake, chewing/swallowing, constipation and weight loss.
The recommendations included, Fiber supplement, nursing assist with meals, and daily weights. The comments included Monitor weight status for accurate trend, encourage good intake of meals, follow with ST (speech therapy) for diet modifications and appropriate diet, if intake low, consider PO (by mouth) supplement to best meet needs.

A review of the patient notes, dated 7/8/10 revealed "very difficult time with swallowing. Difficult to take meds even when crushed." 7/9/10 "He refused to eat breakfast but was able to get to go to breakfast. When I gave him medication I crushed them with ice cream and he threw them up. 7/9/10 Speech therapist came to evaluate. ..would not participate in the evaluation. He refused to drink or eat for her. She suggested IV fluids or even a NG (nasogastric) tube. 7/9/10 Occupational Therapy visit. Pt. refused to participate actively stating he just wants to die and is going to do so by not eating or drinking......Pt refused any juice or other liquid and any food, again stating he wanted to die and go see his wife in Heaven."

A review of this patients weights revealed on 7/7/10 weight was 195 lbs per standing scales and 165 lbs on 7/12/10 per standing scales.

There was no documentation of IV therapy intervention and no order for supplements.




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6. Medical Record (MR) # 20 was admitted to the hospital on 7/15/10, there were two hospital admissions that were reviewed during the survey, with diagnoses to include Dementia not otherwise specified with behavioral disturbance, Atrial Fibrillation, Hypothyroidism, Hypertension, Obstructive sleep apnea, Coronary artery disease, Osteoarthritis, Benign prostatic hypertrophy with incontinence and history of kidney stones.

A review of the multidisciplinary treatment team plan, dated 7/16/10, failed to include the Registered Nurse, Occupational Therapist, Patient or Guardian. The treatment plan failed to include any precautions for assaults, falls, observations of the patient for safety, family education and if the environment was inspected for safety.

During the course of the 7/15/10 hospital admission MR # 20 on 7/17/10 was found lying on the floor, 7/19/10 slid to the floor attended by a staff member, 7/20/10 hit a staff member, 7/22/10 assaulted a staff member and 7/23/10 attempted to hit a staff member. He was admitted for inpatient psychiatric admission due to increased confusion and agitation.

Written questions were given to the hospital staff on 9/30/10 and were asked why the multidisciplinary treatment plan was not signed by activities or nursing. There was no response from the hospital.


7. Medical Record (MR) # 17 was admitted to the hospital on 5/04/10 with diagnoses to include Advance Vascular Dementia with Mood Disturbances and Psychosis.

A review of the multidisciplinary treatment team plan, completed on 5/05/10, included on the master problem list depression and cognitive impairment. There was no documentation in the Patient/Guardian section of the treatment plan to show that the patient or family were included in the planning process. In addition, there was no signature on the treatment plan by the Registered Nurse.

A review of the master treatment plan dated 5/11/10, 7 days after she was admitted, did not have a signature of the Registered Nurse or the Occupational Therapist. There was no documentation in the Patient/Guardian section of the treatment plan to show that the patient or family were included in the planning process.

In response to written questions concerning the treatment plans, given to the hospital staff on 9/30/10, hospital staff only gave a written response of, "You have."

Based on a review of medical records, facility policy and procedure, observation and interview with administrative staff it was determined the facility failed to:
1. Respect the patient's comfort and dignity by ensuring they had clean clothes to wear and that the clothes were their clothes.
2. Provide a safe environment free from falls.


This had the potential to affect all patients served by the facility and did affect medical record (MR) # 12, 13, 14, 16, 19 and 20.

Findings include:

Policy: Quality Assurance Reporting
Reviewed 2/2010
Definition: An event is defined as... an event or situation which may or may not result in damage to property or an illness or injury to a patient or visitor.

Objective: To maintain a safe environment through the systematic process for QA ( quality assurance)/ Occurrence reporting.
To document all event/ incident involving patients, visitors or property damage.

Procedure:
1. Any occurrence as defined above shall be reported through the completion of a QA form.
8. The person first on the scene, observing, discovering or directly involved shall complete the QA form.
a) Complete the form in ink.
e) Date of incident- the date the event/illness/injury occurred.
f) Type of incident- check only the section that is applicable.
9. Occurrences involving patients:
a) The attending physician and the appropriate supervisor must be notified of the occurrence when applicable.
b) Any treatment rendered must also be documented on the QA form.

Policy: Fall Assessment/ Precautions
Last revised May 2009.

Policy: During hospitalization, patient care will be provided in a safe and therapeutic environment.

Objectives: To provide a process for identifying patients who are at high risk for falls, to promote patient safety by preventing and reducing falls, and to identify post-fall guidelines.

Procedure: Assessment
1. The nurse will use the Fall Risk Assessment:
Initially on admission
Each shift
When there is a change in patient status
When the patient is transferred to another unit
When a fall occurs.

Preventive Measures: Based on the above factors, a fall risk score is generated. Preventative measures are implemented based on the fall risk score.
Fall Precautions (High Risk) Protocol
1. Implemented on all patients who score 20 or greater on the Fall Risk Assessment.
2. These measures are in addition to the Fall Prevention measures and Low Risk Fall precautions already in use.
3. High risk fall precautions include:
Apply chair/ wheelchair alarm
Consider the need for 1:1 patient observation by caregiver.
Locate patient closer to nurses' station if possible.

Post Fall Management Strategies:
If a patient who was not identified as low or high risk experiences a fall, the patient will immediately be placed on fall precautions with the same preventative measures implemented. Fall Management team will review and discuss/report to Performance Improvement Safety Committee monthly.

Fall follow-up: If a patient falls a Registered Nurse or designee will:
Notify supervisor, physician, family, and/or caregiver.
Assess for orthostatic blood pressure changes.
Assess for mental status changes.
Collect urine for urinalysis.
Check blood glucose if diabetic.
Observe for possible injuries not evident at the time of the fall.
Follow any new orders given by physician.
Within 24 hours, if indicated, notify the pharmacist to check for possible drug interactions or undesired medication effects that may increase the risk of falls.

Medical Record findings:

1. Medical Record (MR) #12 was admitted on 7/15/10 with diagnosis of Dementia, not otherwise specified (NOS), with recent behavioral disturbances.

In a note dated 7/19/10 at 1629 the social worker documented, " She (spouse) was concerned that the clothes he had on yesterday when she visited were not his. SW (social worker) to relay this to the nurse."
There was no documentation in the medical record of the nurse being notified of the clothes.

The patient was discharged 7/30/10 with the daughter to return home. The Patient's Possessions Accountability Record documented, " Daughter would not go over his clothes." The daughter stated, " What is in here is in here, what isn't just isn't." The patient was discharged at 12:21 PM. The daughter called back at 1720 and stated, " We have not supplied toothpaste and brush, his lotion and his TED's."

During a tour of the unit 9/28/10 with the Nurse Manager, Employee Identifier (EI) # 1, the surveyor observed a small room with numerous paper bags with clothes in them. The surveyor asked EI # 1 what all of the bags were doing in the room. EI # 1 stated that the patients would go home and forget them and they were working on a system to return them.

On 9/29/10 at 8:00 AM the surveyor observed MR # 23 at the breakfast table with disposable blue paper scrubs on and his shirt underneath the top. The psychiatrist met with the nurse in charge for the day at 8:30 AM and asked why MR # 23 had on disposable scrubs as she had told the staff to wash his clothes when he came in yesterday.
The surveyor observed MR # 23 and MR # 22 at 4:30 PM on 9/29/10 in the group room both in disposable scrubs.

On 9/30/10 at 8:00 AM the surveyor observed MR # 23 and MR # 22 in the group dining room in disposable scrubs.

A tour of the laundry room at 10:00 AM on 9/30/10 revealed one wet load of laundry in a washing machine and a paper sack of clothes labeled with MR # 23's name in the corner. A form on a clip board in the laundry room documents the following:
Documentation requires the following: Date of current day. Sign in sheet will be changed daily. Patient first name and initial of last name. Time load entered, time load removed, signature of staff cleaning the inside of the washing machine. In the event patient has infection please see charge RN (Registered Nurse) to determine any change in the cleaning of the unit. The form was dated 9/28/10, load in 1225 and load out 0650.

2. MR # 16 was admitted on 8/10/10 with a diagnosis of Major Depressive Disorder.

The assessment documented 8/18/10 at 1424 documented, " She is in scrubs for now, but her clothes are in the wash, she will get dressed when they are dry." The patient had been in the facility 8 days and no one had maintained clean clothes for her to wear.

3. MR # 13 was admitted on 10/26/09 with a diagnoses of Dementia, NOS and Anxiety Disorder, NOS.

The patient was scored at a 55 on the Fall Risk Assessment on admission which placed her in the high risk for falls.

A review of the multidisciplinary treatment team plan dated 10/28/09 listed under the master problem list four items, the last problem listed was falls. There was no care plan for this problem in the medical record.

The patient had a fall documented 11/10/09 at 16:48 in the physician progress notes. The note documented, " Pt (patient) seen post fall this afternoon. Fell out of her wheelchair onto floor. No signs of injury or distress noted, will increase her to CVO (Continuous Visual Observation)."

The hospitalist documented 11/11/09, " Med (medical) consult- Evaluate fall from w.c. (wheelchair) no LOC (loss of consciousness) or obvious injury."

In written questions provided to facility staff 9/30/10 at 4:30 PM the surveyor asked for the incident report from the 11/10/09 fall. Employee Identifier (EI) # 2, the Program Director, provided the surveyor with written answers to the questions on 10/01/10 at 10:30 AM. The written answer documented, " No fall." A post fall assessment was documented in the electronic record 11/10/09 at 8:00 PM.

4. MR # 14 was admitted on 5/7/10 through 5/27/10 and returned for a second admission 5/28/10 with a diagnosis of Dementia, not otherwise specified with behavioral disturbance.

On 5/8/10 at 2109 the nurse documented, " Becoming anxious as patients are going to bed. Continue to walk and wander. Does not want any assistance though unsteady. Irritated at being redirected out of other patient rooms. Swearing, getting louder. PRN (as needed) Ativan given for anxiety."
The next entry at 2145 documented, "Fall. Patient got out of bed. Fell to floor. Landed on front hitting right side of face...Uncooperative with vital signs, combative with assistance to toilet. MD (medical doctor) on call notified. Orders obtained for CT of head. Husband notified."

A review of the fall QA (Quality Assurance) occurrence report documented that MR # 14 had a fall on 5/8/10: Patient got out of bed. Fell to floor. Landed on front hitting right side of face. The department manager follow-up section documented, " Contributes history: Agitated and irritable. Takes redirection poorly. Patient was agitated and acting out. She was oriented to person only.

There was no mention of the fact the patient had just received PRN Ativan. It was documented on the report actions taken to prevent recurrence were, "CVO through P.M. shift."

A review of the QA occurrence report for 6/5/10, documented, " Patient drank about 5 cc's( cubic centimeters) of liquid Dial soap when the staff were cleaning her up into clean underwear. Poison control was notified. They suggested giving her water to drink. She may vomit in next few hours or have diarrhea. House supervisor called and told, in A.M. (suggested by supervisor) No need to call tonight unless her condition changes."

The risk manager follow-up section documented under follow-up comments, " None, handled by nursing staff, reported to supervisor and manager of floor."

There was no follow up documented by the floor staff or nurse manager to provide the patient with a safe environment.

Documentation in the electronic record for 6/5/10 at 2031 physician notification, " Patient became choked on piece of honey bun. Had to have Heimlich maneuver performed." Interventions implemented, " N.(no)" Comment, " Continue to observe patient and verified that she was on pureed diet with honey thickened liquids."

The surveyor asked Employee Identifier # 1, the nurse manager, for an incident report related to the choking 9/29/10. EI # 1 stated that she could not find an incident report for this incident.


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5. Medical Record # 20 was admitted to the hospital on 7/15/10 with diagnoses to include Dementia not otherwise specified with behavioral disturbance, Atrial Fibrillation, Hypothyroidism, Hypertension, Obstructive Sleep Apnea, Coronary Artery Disease, Osteoarthritis, Benign prostatic hypertrophy with incontinence and history of kidney stones.

A review of the nursing notes documented on 7/17/10 at 5:00 PM, MR # 20 was found lying on the floor in front of the nurses desk. The hospital staff was given written questions about MR # 20's chart and was asked for the incident report. The hospital responded, "None."

Medical Record # 20 was readmitted to the hospital on 7/30/10 with diagnoses to include Advance Dementia of the Alzheimer's type with behavioral disturbance, Failure to thrive - physical debilitation, Atrial Fibrillation, Hypothyroidism, Hypertension, Obstructive sleep apnea, Coronary Artery Disease, Osteoarthritis, Benign prostatic hypertrophy with urinary incontinence, history of kidney stones and allergic rhinitis.

A review of the medical record revealed that on 8/02/10 at 7:09 PM, MR # 20 was on 1:1 observation and he struck the staff member assigned to him in the mouth. The nurse documented that MR # 20 lost his balance and fell to the floor. MR # 20 struck his back on a safety rail and his elbow on the floor. The record showed he had a bruise medially on his back that was approximately 5 centimeters (cm) in length and a small abrasion on his elbow and a reddened area on his head.

On 8/06/10 at 7:20 PM the nurse documented MR # 20 when first approached was attempting to hit a staff member, grimaces when he takes a deep breath or when his side is touched. On 8/07/10 at 8:20 AM, the physician's progress note documented MR # 20 had two left rib fractures.

On 8/07/10 at 9:15 PM, the nurse documented MR # 20 had a "large area" of bruising on his right posterior thigh, buttock and side. There was no description of the bruising or size documented.

On 8/08/10 at 5:09 PM, the nurse documented MR # 20 had a large ecchymotic area to his right flank and thigh area and "some bruising also noted to testicles." There was no documentation of the color, size or notification of the physician or family of the testicular bruising. The Registered Nurse (RN), Employee Identifier (EI) # 3, that made this entry was interviewed on 9/30/10 at 3:10 PM. EI # 3 was shown the nursing documentation entry and asked when this was noticed. EI # 3 stated she and a male Mental Health Tech (MHT) toileted MR # 20 and she noticed during this time that his testicles were bruised. EI # 3 was asked what color the bruising was and she stated, "I don't remember, it was dark (color) not yellow or green like it was old. This had to be more recent (the bruising to MR # 20's testicles)."

On 8/11/10 the nurse noted that MR # 20 was incontinent of urine and peri care was provided. There was no documentation of MR # 20's bruising that was present 3 days earlier. The hospital staff responded to written questions about the 8/11/10 nurse note and their written reply was, at 8:45 PM the skin assessment was within normal limits. A review of the printed assessment for MR # 20 at 8:45 PM documented the skin assessment was not within normal limits. The skin appearance was documented as ecchymotic, a discoloration due to a bruise. There was no other documentation in the note about the size, location or color of the bruised skin area.

There was no documentation in the medical record of the physician or family being notified of the genital bruising. There was no documentation of what caused the new bruising.

In response to written questions about this documentation in the medical record the hospital staff responded, "continuous aggressive behavior. 1:1 staff."

The hospital staff was asked for the incident report for the 8/02/10 fall. A copy of an incident report was forwarded to the state agency, but the report was not completed until 10/01/10, while the surveyors were onsite. There was no review of this fall by the pharmacy. In an interview with the Employee Identifier # 4, the hospital Administrator, on 9/30/10 at 2:30 PM she stated all falls are reviewed by the fall team, which includes pharmacy.

The hospital's policy on abuse was requested and reviewed. The policy reads in part as follows:

Objective:
3. To protect those who are unable to adequately care for themselves or protect themselves from others.

Policy: Pursuant to applicable law, Shoals Hospital will report suspected and confirmed abuse or neglect cases to appropriate authorities. These cases are identified by an indicator-driven referral system.

Definitions:
2. Abuse - the willful infliction of physical pain, injury, or mental anguish or the willful deprivation by a caretaker or other person or services necessary to maintain mental and physical health.

II. Elder Abuse/Neglect
C. Sexual Abuse Indicators
1. Bruises on breasts or genital area.

The hospital policy was not followed by hospital staff in regards to MR # 20 who was identified by the Registered Nurse to have testicular bruising that was not in conjunction with the fall he sustained on 8/02/10. There was no report of potential abuse and no investigation to determine the cause of the genital bruising. The hospital failed to follow its own process for fall review and completing the incident report at the time it occurred for MR # 20. In response to written questions about MR # 20 the hospital staff was asked if the family was notified about his fall on 8/02/10 and they responded there was no documentation. The hospital was asked if the bruising noted to his testicles was reported to the physician and family. There written response did not answer these questions.

Medical Record # 20 was transferred out of the Senior Care Unit and placed on hospice in the hospital and expired on 8/19/10.


6. Medical Record #19 was admitted to the hospital on 4/20/10 with diagnoses to include Alzheimer's and Dementia.

A review of the multidisciplinary treatment team plan listed under the master problem list four items, the last two problems listed were hypertension and falls. There were no care plans for these two problem areas listed.

A review of the fall occurrence report documented that MR # 19 had a fall on 4/23/10, she was found by staff lying on the floor beside her bathroom door. The department manager follow-up section documented no change in interventions to prevent MR # 19 from having another fall. It was documented on the report actions taken to prevent recurrence were, "Yellow socks put on patient." This intervention was already in place prior to the 4/23/10 fall.

On 4/27/10, four days later, MR # 19 sustained another fall. The nurse note documented at 5:15 AM a loud noise was heard from the patient's room. MR # 19 was found in the floor on top of the garbage can with urine beside the bed and near the can. MR # 19 sustained an injury to her right upper thigh near the fold of her groin area, which required 13 sutures to close. The same interventions that were in place prior to the second fall were the same interventions in place after the fall with injury.

There was a physician's order dated 4/27/10 at 3:15 PM to place MR # 19 on Continuous Visual Observation (CVO) at night related to her two falls. There were no new nursing interventions or documentation of a multidisciplinary team meeting to discuss MR # 19's repeated falls.

Based on review of medical records, facility policy and procedure and interview with administrative staff it was determined the facilty failed to reassess patients with weight loss. This had the potential to affect all patients served by the facility and did affect Medical Record (MR) # 3 and 13.

Findings include:

Policy: Nutrition Assessment
All patients identified via nutrition screening mechanism by nursing, Continuous Nutrition Monitoring criteria, or physician consult will receive appropriate nutrition care.
Procedure:
1. A patient identified via nursing nutrition screening triggers will be seen within 48 hours of referral; a physician consult will be seen within one day of referral by the clinician.
4. During the nutrition evaluation process, the clinician will classify a patient's nutrition status using age specific Nutrition Care Priority Points. Points are assigned using the Nutrition Status Classification Worksheet.
7. A nutrition assessment will be completed if the patient's Nutrition Status Classification is determined to be severely (Status 4) or moderately (Status 3) compromised.

The Nutrition Care Priority Points: Adult
Category: Unintentional weight loss-
> 10% in 6 months or
> 7.5% in 3 months or
> 5 % in 1 month or
> 2 % in 1 week = a priority points of 4.


1. Medical Record # 13 was admitted on 10/26/09 with a diagnoses of Dementia, Not Otherwise Specified (NOS) and Anxiety Disorder, NOS.

The patient's weight was recorded on admission as 275 pounds by standing scale. The patient was weighed 11/02/09 for the weekly weight and it was recorded as 218.6 pounds by chair scale. This is a 20.5 % weight loss in a week according to the documentation recorded in the electronic medical record.

In written questions provided to facility staff 9/30/10 at 4:30 PM the surveyor asked about the weight loss. Employee Identifier (EI) # 2, the Program Director, provided the surveyor with written answers to the questions on 10/01/10 at 10:30 AM. The written answer documented, " On admission weighed on standing scale- next weight on 11/2 was on sitting scale." The patient was not weighed again prior to her discharge 11/13/09. There was no documentation of a nutritional assessment completed by a dietitian in the medical record.


2. MR # 3 was admitted on 7/7/10 with diagnosis of Alzheimers Disease and behaviors including confusion and paranoia.

A review of the admission history and physical, dated 7/7/10 included the past medical surgical history of non-insulin dependent diabetes mellitus (NIDDM), chronic low back pain, recurrent esophageal spasm with dysphagia with recent treatment with Botox injections of distal esophageal sphincter (6-25-10).

A review of the Multidisciplinary Treatment Team Plan: Data Integration, dated 7/8/10 included problems of Cognitive Impairment, high risk falls and NIDDM. The problems identified did not include esophageal spasms with dysphagia.

An initial Nutrition Assessment was completed on 7/8/10 with risks identified with intake, chewing/swallowing, constipation and weight loss.
The recommendations included, Fiber supplement, nursing assist with meals, and daily weights. The comments included Monitor weight status for accurate trend, encourage good intake of meals, follow with ST (speech therapy) for diet modifications and appropriate diet, if intake low, consider PO (by mouth) supplement to best meet needs.

A review of the patient notes, dated 7/8/10 revealed "very difficult time with swallowing. Difficult to take meds even when crushed." 7/9/10 "He refused to eat breakfast but was able to get to go to breakfast. When I gave him medication I crushed them with ice cream and he threw them up. 7/9/10 Speech therapist came to evaluate. ..would not participate in the evaluation. He refused to drink or eat for her. She suggested IV fluids or even a NG (nasogastric) tube. 7/9/10 Occupational Therapy visit. Pt. refused to participate actively stating he just wants to die and is going to do so by not eating or drinking......Pt refused any juice or other liquid and any food, again stating he wanted to die and go see his wife in Heaven."

A review of this patients weights revealed on 7/7/10 weight was 195 lbs per standing scales and 165 lbs on 7/12/10 per standing scales (a 15% weight loss).