HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to ensure a registered nurse monitored the care received by 1 of 1 patients (Patient #1) who was documented as not eating or drinking for 4 days. This deficient practice resulted in the patient having to be transferred to an ER in a state of severe dehydration.

Findings were:

Facility policy entitled "Hydration Management Texas," effective date 1/11/2016, included the following:
"Purpose:
To ensure timely screening of nutritional and hydration risk factors with determination and implementation of interventions. The purpose of hydration management is to:
1. Address the patient's individual needs with respect to fluid intake.
2. Initiate appropriate strategies and interventions to prevent dehydration ...
Nursing is responsible for obtaining a physician's order for consults for dietary and hydration management recommendations ...
Monitoring of intake/output and accurate weights is imperative to hydration management ..."

A review of the clinical record of Patient #1 revealed he was an 81-year-old Caucasian male admitted to Oceans Behavioral Health of Abilene on 9/27/17 at 12:30 a.m. A Comprehensive Integrated Assessment Intake Screen and Initial Level of Care Determination on 9/26/17 at 11:45 p.m. included the following:
"81 y/o male presents to Oceans [with] medical clearance @ [local hospital]. Pt has Dx (diagnosis) of Alzheimer's Dementia with [increased] aggressive behaviors. Pt reported to have woken up today unable to identify family members & seems combative per son. Pt has fallen several times this morning. Pt is A&O x [zero]. Confused, unable to answer questions. Rambling word salad. Calm sitting in w/c (wheelchair). Incont (incontinent) of bowel & bladder. Unable to keep clothes on ..."

A Psychiatric Evaluation on 9/27/17 at 10:00 a.m. included the following:
"History of Present Illness ...: transferred to Oceans after medical clearance at [hospital. Said to have awakened [with] [increased] confusion and assaulted son. Paranoid. Speaking word salad. Unable to answer questions. Hard to understand when he does speak ...rambles non-sensical, thinks he's about 84 or 59 ...hard of hearing ...responding to internal stimuli ...threatened to kill son. Attacked police. Threatened ER dr ...[decreased] orientation, [decreased] memory ...
Admitting Diagnosis ...
1. Major neurocognitive dis (disorder) ..."

A review of Vital Signs & I&O (intake & output) sheets included documentation that Patient #1 was eating and drinking intermittently until 10/4/17. On that date, all meals were documented as refused and zero liquid intake was documented. This same pattern repeated on 10/5/17, 10/6/17, 10/7/17 and 10/8/17. Vital signs continued to be within normal parameters with the exception of several readings of slightly elevated blood pressure. Patient #1 was transferred to a nearby emergency room per physician order at 5:00 a.m. on 10/9/17.

Relevant nursing notes and physician orders included in the medical record were as follows:

Nursing 10/9/17 at 2:20 a.m.: "[Nurse Practitioner] called due to pt appearing very dry with [increased] confusion. Pt vitals [illegible] to be: 168/911, 117, 97.8, 18, 94%. FNP [Nurse Practitioner] [illegible] pt has been refusing his po meds for a couple of days, psych notified. Also, pt has not been accepting water and/or food for a couple of days ...Pt mental status shows a shift [increased] confusion. Received orders for lab work: UA (urinalysis) ..."

Physician Order 10/9/17 at 5:00 a.m.: Send pt to higher level of care ...ER for evaluation for possible dehydration."

Nursing 10/9/17 at 5:24 a.m.: "Pt being sent out to ...ER for evaluation per order from FNP [Nurse Practitioner]. Pt is exhibiting dry oral mucosa, [increased] mental confusion, agitation and is showing skin turgor diminished at bilateral arms/legs. Vitals assessed 97.8, 114, 158/89, 94% RA (room air), pt will transport 911, MHT with patient and will be sent at 0545."

Nursing 10/9/17 at 9:15 a.m.: "Attempted to contact wife about transfer to [hospital]. No answer x 2 ...Spoke to ER... Waiting for labs and report. Still waiting in ER ..."

Physician 10/9/17 at [appears to be 9:00 p.m.]: Sent over to [hospital] ER this AM, because of concerns re: presentation, possibly dehydration. They have yet to get back [with] results. Later, call back - pt admitted to [hospital] ..."

Physician Order 10/9/17 at [appears to be 9:00 p.m.]: "Discharged. Admitted to [hospital]."

Abnormal lab results reported on 10/9/17 at 3:33 a.m. from [hospital] included the following:
Sodium 158 H Normal 136-145
Chloride 118 HH Normal 100-110
Glucose 170 H Normal 60-110
BUN 56 H Normal 5-24
Calcium 11.1 H Normal 8.5-10.1

The above findings were all confirmed in an interview with the facility Administrator and Assistant Director of Nursing on the afternoon of 12/5/17 in the facility conference room. They agreed the information regarding Patient #1's lack of intake appeared not to have been reported upward and not to have been addressed by the facility resulting in Patient #1 being transferred to an acute care hospital ER.