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Based on record review and interview, the hospital failed to identify and implement a system of nursing care and services that would identify, monitor and supervise nursing staff's documentation in individual patient plans of care and tube feeding administration and reassessments of patients with significant weight fluctuations for 7 of 20 sampled records reviewed (Patients #1, 5, 8, 11, 12, 13 and 14). The hospital's failure created the potential for patients to receive inadequate nutrition and hydration, and possible avoidable weight loss.

Findings include:

- Review of the CNO's (Chief Nursing Officer) job description on 2/14/11 at 9:00am revealed the CNO holds full responsibility for the quality of nursing care provided. The job description directed the CNO:
- to develop policies and procedures that describe how patients' needs for nursing care, treatment and services are assessed, evaluated and met;
- to oversee supervision and coordination of nursing personnel and the delivery of nursing service; and
- to implement effective, ongoing programs to measure, assess and improve nursing care, treatment and services provided.

The CNO failed to assure nursing staff reassessed Patienta #1, 8, and 13 whose weight gains or losses would require further nursing intervention to determine the accuracy of the weights nursing staff recorded in the medical records. See specific patient information about weight loss at citation A-0395. Licensed nursing staff failed to reassess these patients' inconsistent weights. The failure of the CNO to monitor nursing staff's accuracy of the evaluation of these patient's weights placed these patients at risk for unintentional weight loss and dehydration.

The CNO failed to monitor nursing staff's tube feeding documentation on the Daily Flowsheet/Treatment record to ensure staff followed the hospital's Enteral Feeding and Tube Management policy to ensure these patient's received adequate nutrition and hydration.
See specific information about licensed nursing staff's failure to document the length of time tube feedings were administered and the total nutritional formula intake for five of five patients who received tube feedings (Patients #1, 5, 11, 13 and 14) at citation A-0464.

The CNO failed to monitor nursing staff's care plans were current for Patients #1, 4, 5, 11, 13 and 14. The CNO failed to ensure all staff provided care to assure patient safety, and received appropriate treatment for patients at risk for skin breakdown. See specific care plan information for these patients at citation A-0396.

The CNO failed to ensure licensed nursing staff included in the plan of care the use of protective helmets for two patients (Patients #1 and 14) who required protective helmets. See specific care plan information for Patient #1 and 14 at citation A-0396.

The CNO failed to assure licensed nursing staff who assessed four patients as high risk for skin breakdown included skin breakdown prevention/interventions in the plan of care for four patients (Patients #5, 11, 13 and 14). See specific information about Patients # 5, 11, 13 and 14 at A-0396.

Staff B, RN (Registered Nurse)/CNO, interviewed on 2/16/12 at 2:31pm verified nursing administration identified inconsistent and incomplete nursing documentation on the Interdisciplinary Daily Documentation/Daily Nursing Assessment form but had not corrected the problems.

The hospital reported a census of 73 patients with 20 patient medical records included in the sample. Three patients of the 20 medical records sampled experienced a weight change. Based on record review and staff interview, the hospital failed to have an RN (registered nurse) evaluate and re-evaluate on an ongoing basis patients whose weight showed a significant increase or decrease for 3 of 3 patients with weight change as directed by facility policy. The RN's failure to evaluate the nursing care provided each patient with weight change placed the patients at risk for unintentional weight loss or gain (Patient's #1, 8, 12).

Findings include:

- Policy 6.001- Weights, Patient, reviewed on 3/2/12 at 3:30pm, instructed nursing staff to weigh patients within 24 hours of admission, then weigh weekly unless otherwise ordered by the physician. Procedure #3 states, "Any patient with a weight more than 5 pounds different from the previous weight will be reweighed to verify the current weight and the nurse will be notified of the weight change."

- The rehabilitation hospital admitted Patient #12 on 2/2/12. Documentation revealed he/she transferred from another facility after major multiple traumas and respiratory failure as a result an automobile accident. The patient's PEG (percutaneous endoscopic gastrostomy) feeding tube was for flushing (usually of water) only and not for administration of a tube feeding (a combination of substances in liquid form that provide calories and nutrients when a person is unable to eat a sufficient amount of food by mouth).

Documentation of the patient's weights on the graphic flowsheet showed the following:

1/27/12- preadmission weight - 263 pounds
2/02/12- nursing assessment weight- 269 pounds
2/02/12- graphics chart weight- 254.2 pounds (a difference of about 15 pounds on the same day)
2/06/12- graphics chart weight- 271.2 pounds (an increase of 17 pounds in 4 days)
2/10/12- graphics chart weight- 257.4 pounds (a decrease of 14 pounds in 4 days)
2/12/12- graphics chart weight -258.4 pounds

The record lacked documentation the RN (professional registered nurse) acknowledged the weight variations for Patient #12 and failed to identified if the variations were actual weight loss, weight gain, or due to faulty equipment or the manner in which staff weighed the patient from 2/2/12 to 2/12/12. Review of documentation failed to find that staff reweighed the patient to verify the current weight and then notify the nurse of the weight change as directed by hospital policy. The failure to determine if the weight loss and gains were actual or unintentional placed patient #12 at risk for malnutrition and unintentional weight loss or gain.

A significant weight change of 5% within one month, 7.5% within three months or 10% within six months increases the patient"s likelihood of decline or death (resources for weight loss http://www.cmaj.ca/content/172/6/773.full - review by the Canadian Medical Association, http://researchnews.osu.edu/archive/old.htm - study of weight loss of 10% in nursing home residents in six months, and http://www.nature.com/ijo/journal/v34/n6/full/ijo201041a.html - weight loss of 15% or more).

Administrative nursing Staff B, interviewed on 2/15/12 at 3:30pm, reviewed Patient #12's graphic flowsheets, then confirmed the inconsistencies in the patient's weights. Staff B indicated the scales may have been in error but it was the responsibility of the RN to acknowledge the weight variations and evaluate the cause as directed by hospital policy 6.001.

- The rehabilitation hospital re-admitted Patient #1 on 12/19/11 with the following diagnoses: spindle cell carcinoma of the sphenoid sinuses and post craniotomy debulking resection as well as radiation therapy with craniotomy defect. Documentation of the patient's weight showed the following on the graphic flowsheets :

12/19/11 weight - 130 pounds
12/28/11 weight - 156 pounds (a gain of 26 pounds in 9 days)
1/3/12 weight - 127.5 pounds (a weight loss of 28.5 pounds in 5 days)
1/8/12 weight - 164.9 pounds (a weight gain of 37.4 pounds in 5 days)

The record lacked documentation the RN acknowledged the weight variations in weight for Patient #1 and failed to identify if the variations were actual or related to faulty equipment or the manner in which staff weighed the patient from 12/19/11 to 1/08/12. Staff failed to reweigh to verify the current weight and failed to notify the nurse of the weight change as directed by hospital policy. The failure to determine if the weight loss and gains were actual or unintentional placed the patient at risk for malnutrition and unintentional weight loss or gain. A significant weight change of 5% within one month, 7.5% within three months or 10% within six months increases the patient"s likelihood of decline or death.

- The rehabilitation hospital admitted Patient #8 on 2/7/12 following cholecystectomy surgery at another facility. Patient #8 had multiple co-morbidities one being morbid obesity. Documentation of the patient's weight showed the following:

2/7/12, their admission on the graphic chart weight - 453 pounds
2/12/12, their weight on the graphic chart - 420.5 pounds

The record lacked evidence staff reweighed Patient #8 to verify the current weight and notify the nurse of the weight change as directed by hospital policy. The RN failed to acknowledged the patient's significant weight loss of 32.5 pounds in five days. The RN failed to identify if the loss was actual or related to faulty equipment or the manner in which staff weighed the patient (a 5% weight change within one month increases the patent's likelihood of decline or death).

Administrative nursing Staff B, interviewed on 2/15/12 at 3:30pm, acknowledged the weight loss for Patient #8 and indicated the scales may have been in error but it was the responsibility of the RN to evaluate the patient and determine if the weight loss was actual or related to faulty equipment or technique in weighing the patient.

The hospital reported a census of 73 patients. The survey sample included 18 open and two closed records. Based on record review and staff interview licensed nursing staff failed to develop plans of care for 2 of 2 patients who wore protective helmets (Patients #1 and 14). Licensed nursing staff failed to develop plans of care for 4 of 4 patients' with Braden scale scores (skin assessment) less than 16 per nursing policy (Patients #5, 11, 13 and 14). The failure to develop and keep current a nursing plan placed all patient's at risk for inadequate nursing care.

Findings include:

- The rehabilitation hospital admitted Patient #1 on 12/2/11 to 12/15/11 and again on 12/19/11 to 1/16/12 with the following diagnoses: spindle cell carcinoma of the sphenoid sinuses and post craniotomy debulking resection as well as radiation therapy with craniotomy defect. Review of physician's history and physical revealed the patient wore a protective helmet and it was ill-fitting. The physician instructed therapy staff to adjustment the helmet or order a new helmet. However, review of the patient's POC (plan of care) dated 12/2/11 revealed licensed nursing failed to address the patient's use of a helmet in the POC.

Review of the patient's second admission from 12/19/11 to 1/15/12 revealed a physician's order dated 12/19/11 that directed the patient was to wear a helmet when up. However, review of the patient's POC dated 12/19/11 revealed licensed nursing staff failed to address the patient's use of a helmet in the POC.

Staff B, the CNO (Chief Nursing Officer), interviewed on 2/15/12 at 4:00pm, verified nursing staff failed to develop a plan of care that included interventions/instructions and set goals for the use of the Patient #1's helmet.

- The rehabilitation hospital admitted Patient #14 on 1/18/12. Documentation revealed he/she transferred from another facility after a left craniotomy and insertion of a feeding tube as a result of an automobile accident. Documentation in the transfer orders revealed the patient wears a helmet at all times when up to protect their head. Review of the POC dated 1/18/12 revealed licensed nursing staff failed to address the patient's use of a helmet in the POC.

Administrative nursing staff B, interviewed on on 2/15/12 at 3:30pm, verified goals, interventions/instructions for the patient's use of a helmet should be in the patient's plan of care.

- The rehabilitation hospital admitted Patient #5 on 2/10/12. Record review revealed the patient had the following diagnosis: Cerebral Vascular Accident (stroke).
Documentation in the initial nursing assessment showed the patient's skin assessment score (Braden scale) at 15, indicating the patient was at risk for skin breakdown. However, review of the patient's POC dated 2/10/12 revealed licensed nursing staff failed to include in the plan of care goals, interventions/instructions to decrease the patient's risk for skin breakdown.

Administrative nursing staff B, interviewed on 2/15/12 at 3:30pm, confirmed Patient #5's Braden scale at 15. Staff B verified nursing staff failed to address the patient's high risk for skin breakdown in the nursing plan of care. Staff B stated the hospital's policy for any patient with a Braden scale score of 18 or below should have goals, interventions/instructions to lessen the patient's risk for skin breakdown (development of pressure sores) as part of the POC, so all staff caring for the patient would be aware of the patient's risks.

- The rehabilitation hospital admitted Patient #11 on 1/22/12. Documentation revealed he/she transferred from another facility after a cerebral vascular accident (CVA) resulting in right-sided weakness and insertion of a feeding tube. Documentation in the initial nursing assessment showed the patient's skin assessment score (Braden Scale) at 14 indicating the patient at risk for skin breakdown. However, review of the patient's POC dated 1/22/12 revealed licensed nursing staff failed to include a plan for decreasing the risk of skin breakdown in the patient's POC.

During an interview on 2/15/12 at 3:30pm administrative staff B confirmed Patient #11's Braden scale score of 14. Staff B stated the hospital's policy for any patient with a Braden scale score of 18 or below should have goals, interventions/instructions to lessen the patient's risk for skin breakdown (development of pressure sores) as part of the POC, so all staff caring for the patient would be aware of the patient's risks. Staff B verified nursing staff failed to address Patient #11's high skin risk for skin breakdown (pressure sores) in the nursing care plan.

- The acute care rehabilitation hospital admitted Patient #13 on 1/12/12. Documentation revealed he/she transferred from another facility with diagnoses including respiratory failure, encephalopathy, myocardial infarction and insertion of a feeding tube. Documentation in the initial nursing assessment showed the patient's skin assessment score (Braden Scale) at 15 indicating the patient was at risk for skin breakdown. Howwever, review of the patient's POC dated 1/12/12 revealed licensed nursing staff failed to include a plan for decreasing the risk of skin breakdown in the patient's POC.

During an interview on 2/15/12 at 3:30pm administrative staff B confirmed the patient's Braden scale score of 15. Staff B verified nursing staff failed to address Patient #13's high risk for skin breakdown (pressure sores) in the nursing plan of care. Staff B stated the hospital's policy for any patient with a Braden scale score of 18 or below should have goals, interventions/instructions to lessen the patient's risk for skin breakdown (development of pressure sores) as part of the POC, so all staff caring for the patient would be aware of the patient's risks.

- The rehabilitation hospital admitted Patient #14 on 1/18/12. Documentation revealed he/she transferred from another facility after a left craniotomy and insertion of a feeding tube as a result of an automobile accident. Documentation in the initial nursing assessment showed the patient's skin assessment score (Braden Scale) at 11 indicating the patient at risk for skin breakdown. Review of the patient's POC dated 1/18/12 revealed licensed nursing staff failed to include a plan for decreasing the risk of skin breakdown in the patient's POC.

During an interview on 2/15/12 at 3:30pm administrative staff B confirmed the patient's Braden scale score of 11. Staff B verified nursing staff failed to address Patient #14's high risk for skin breakdown (pressure sores) in the nursing care plan. Staff B stated the hospital's policy for any patient with a Braden scale score of 18 or below should have goals, interventions/instructions to lessen the patient's risk for skin breakdown (development of pressure sores) as part of the POC, so all staff caring for the patient would be aware of the patient's risks.

- On 2/15/12 review of the hospital's "Wound Prevention and Skin Care " policy last revised/reviewed on 2/1/12 stated:

"All patients admitted to Mid-America Hospital will be screened for risk of skin breakdown and for alteration in skin integrity by a Registered Nurse, utilizing the Interdisciplinary Assessment. The Skin Breakdown Prevention Protocol is initiated for any patient who has a Braden score of less than 16 on admission: "B. The RN initiates a customized plan of care that includes An Alteration in Skin Integrity if the patient....is identified as being at risk for skin breakdown by scoring less than 16 on the Braden Scale."

The hospital reported a census of 73 patients. The survey sample included 18 open and two closed records. Based on record review and interview the hospital's staff failed to document appropriate findings and follow hospital policies for documentation in the patient's medical record. Licensed nursing staff failed to document the total amount of each tube feeding administered to 5 of 5 patients who received nutrition through tube feedings (Patients #1, 5, 11, 13, and 14). Licensed nursing staff failed to document information in the medical record for for 1 of 2 patients who wore protective helmets (Patients #1 and 14).

Findings include:

- On 2/15/12 review of the hospital's "Enteral Feeding and Tube Management" policy last revised/reviewed on 1/31/12 reads:

PROCEDURE: "4.b....Continuous tube feeding: A maximum of six hours of feeding may be hung at any time ...6 All tubes are flushed with 50 cc of water after feedings unless otherwise ordered...8. Tube feeding administration is documented on the Daily Flowsheet/Treatment Record".

- The rehabilitation hospital admitted Patient #1 on 12/2/11 to 12/15/11 and again on 12/19/11 to 1/16/12 with the following diagnoses: spindle cell carcinoma of the sphenoid sinuses and post craniotomy debulking resection as well as radiation therapy with craniotomy defect. Review of physician orders dated 12/2/11 to 12/15/11 directed licensed nursing staff to provide Two Cal HN (high nitrogen) liquid feedings via a gastronomy feeding tube. (TwoCal HN provides two calories per cubic centimeter.) The orders directed licensed nursing staff to administer the tube feeding at 80cc (cubic centimeters) per hour, overnight from 7:00pm to 5:00am.

Review of the MAR (Medication Administration Record) from 12/2/11 to 12/15/11 revealed nursing staff documented when they hung the tube feeding. However, review of the MAR and the IDD (Interdisciplinary Daily Documentation)/Daily Nursing Assessment records/forms revealed licensed nursing staff failed to document when the tube feeding ended and the total amount of intake the patient received. Survey staff were unable to determine the hospital followed the physician orders for the amount of feeding and the time ordered.

Review of the patient's re-admission on 12/19/11 to 1/16/12 revealed the following physician's orders: the physician on 12/19/11 ordered licensed nursing staff to administer Two Cal HN at 80 cc/hour from 8:30pm to 6:00am. Staff obtained a clarification of the order on 12/23/11 which verified the name of the tube feeding, amount and total time for 10 hours from 8:30pm to 6:30am. On 1/5/12, the physician ordered licensed nursing staff to increase the tube feeding to 85cc an hour.

Staff received an additional physician order on 1/2/12 that directed licensed nursing staff to increase the amount of Two Cal HN to 85cc an hour for 12 hours per day. The order instructed staff to be sure the patient received a full 12 hours of tube feeding at 85cc an hour.

Review of the MAR from 12/19/11 to 1/16/12 revealed nursing staff documented when the tube feeding started but lacked an end time or the total amount of feeding. Review of the MAR and the IDD/Daily Nursing Assessment records/forms revealed licensed nursing staff failed to document when the tube feeding ended and the total amount of intake the patient received.

- The acute care rehabilitation hospital admitted Patient #5 on 2/10/12 with the diagnosis of a CVA (Cerebral Vascular Accident)/stroke and the patient received nutrition through a feeding tube. Physician orders dated 2/10/12 directed licensed nursing staff to administer Jevity 1.5 (liquid nutritional formula that provides 1.5 calories per cc) through the feeding tube 60cc/hour from 7:00pm to 7:00am.

Review of the MAR and the IDD/Daily Nursing Assessment records from 2/10/12 to 2/12/12 revealed nursing staff documented when they started the tube feeding but failed to document the end time and the total amount of nutritional formula given to the patient.

Administrative nursing staff B interviewed on 2/15/12 at 3:30pm verified the nursing documentation lacked an end time and total amount of nutritional formula given to the patient on the IDD form or the MAR.

- The rehabilitation hospital admitted Patient #11 on 1/22/12. Documentation revealed he/she transferred from another facility after a cerebral vascular accident (CVA) resulting in right-sided weakness and insertion of a feeding tube. A physician order dated 1/22/12 directed nursing staff to administer Jevity 1.2 (liquid nutritional formula that provides 1.2 calories per cc) continuously at 80cc an hour through the patient's peg tube. Review of the patient's MAR revealed nursing staff failed to document when they started a new bag of Jevity and failed to document the amount of formula and water given. Instead the MAR read "See Kardex for details". Further review of the medical record revealed nursing staff failed to document the patient's total intake of tube feedings including the water used to flush the tube.

Administrative staff B interviewed on 2/15/12 at 3:30pm verified nursing documentation for Patient #11 lacked a start time for each new bag of formula or total amount of feeding on the IDD form and the patient's MAR. Staff B indicated the Kardex used by the nursing staff is not part of the patient's medical record rather a tool used for reporting to next shift.

- The rehabilitation hospital admitted Patient #13 on 1/12/12. Documentation revealed he/she transferred from another facility with diagnoses including respiratory failure, encephalopathy, myocardial infarction and insertion of a feeding tube. A physician order dated 1/31/12 directed nursing staff to administer Vital 1.5 (liquid nutritional formula that provides 1.5 calories per cc) at 55cc an hour continuously through the patient's feeding tube.

Review of the patient's MAR revealed nursing staff failed to document when they hung a new bag of Vital and failed to document when the feedings finished on February 4, 5, 6, 11, and 15, 2012. Instead the MAR read "See Kardex for details". Further review of the medical record revealed nursing staff failed to document the patient's total intake of tube feedings including the water used to flush the tube on these dates.

Administrative staff B interviewed on 2/15/12 at 3:30pm verified the nursing documentation lacked a start time and/or end time of the patient's tube feedings and also verified nursing failed to document the patient's total tube feedings on the IDD form and the patient's MAR. Staff B indicated the Kardex used by the nursing staff is not part of the patient's medical record rather a tool used for reporting to next shift.

- The rehabilitation hospital admitted patient #14 on 1/18/12. Documentation revealed he/she transferred from another facility after a left craniotomy and insertion of a feeding tube as a result of an automobile accident. A physician order dated 1/18/12 directed nursing staff to administer Jevity 1.5 at 65 milliliters per hour continuously per the patient's feeding tube. Review of the patient's MAR revealed nursing staff failed to document when the feedings finished from 2/1/12 through 2/15/12. Further review of the medical record revealed nursing staff failed to document the patient's total intake of tube feedings including the water used to flush the tube.

Administrative staff B interviewed on 2/15/12 at 3:30pm verified the nursing documentation lacked an end time of the patient's tube feedings and also verified nursing failed to document the patient's total amount of formula given on the IDD (Interdisciplinary Daily Documentation) form and the MAR.

- The rehabilitation hospital admitted Patient #1 on 12/2/11 to 12/15/11 and again on 12/19/11 to 1/16/12 with the following diagnoses: spindle cell carcinoma of the sphenoid sinuses and post craniotomy debulking resection as well as radiation therapy with craniotomy defect. Review of physician's history and physical revealed the patient wore a protective helmet and it was ill-fitting. The physician instructed therapy staff to adjustment the helmet or order a new helmet.

Review of the hospital's IDD/Daily Nursing Assessment forms and specifically under the safety section from 12/2/11 to 12/15/11 revealed nursing staff failed to document whether the patient wore a protective helmet when up.

Review of the hospital's IDD/Nursing Daily Assessment forms and specifically under the safety section from 12/19/11 through 1/16/12 revealed the following:

Nursing staff failed to document whether the patient wore the helmet on the following dates 12/19/11 through 12/26/11, 12/28/11 through 1/2/12, 1/4/12 through 1/13/12 and 1/15/12 (a total of 25 days that nursing staff failed to ensure they documented the patient wore the helmet when up).