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PLANTATION GENERAL HOSPITAL 401 NW 42ND AVE PLANTATION, FL 33317 Sept. 8, 2016
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review the facility failed to assess/monitor for the nutritional status; and implement interventions for weight loss, and the development of a stage 2 pressure ulcer for 1 of 12 sampled patients (SP) #1.

The findings:
Review of the medical record of Sampled Patient (SP) #1 revealed that he was found unresponsive on the street and was brought to the ED on 02/18/16. Per the physician progress notes dated 02/18/2016, the patient is extremely hypotensive and was started on IV fluids. The patient appears dehydrated.
Observation of SP#1 with the Charge Nurse 6th Floor on 9/7/16 at 10:40 am showed that the pt. was non-verbal and does not follow any commands. A Peg tube was noted with dry dressing and dated. The peg tube is clamped and noted not connected to any feeding or formula. Observation of the buttocks revealed the healing of a Stage 2 sacral pressure ulcer without drainage and it was covered with a dressing.

Review of the Nursing Shift Assessment of SP#1 dated 02/23/16 revealed Integumentary System assessment was pale, warm, and dry. There was no skin breakdown documented involving the sacral area. The pressure ulcer risk assessment (Braden Skin Score:10). The skin risk interventions include: assess and manage nutrition status and obtain nutritional consult prn (as needed). Monitor all body folds for moisture, rash and irritation.
Review of SP#1 Physician Progress notes dated 9/7/16 revealed SP #1 has Sacral Pressure Ulcer stage 2.
Review of the Clinical Dietician Notes from [DATE] to Sept. 1, 2016 revealed that SP#1 initial weight on: 2/18/16 was 190 (pounds)lbs.; on 2/23/16 = 201 lbs.; on 3/3/16 = 196 lbs.; on 5/4/16 = 179 lbs.; on 7/30/16 = 157 lbs. (33 lbs. difference)

Review of the Nursing Notes of SP#1 on 7/30/16 revealed there was no communication with the physician of the weight loss.
Interview with Manager of Clinical Nutrition on 9/7/16 at 11:15 am revealed that she was aware of SP#1 nutritional status and stated he was receiving bolus feedings of 4 cans a day and is unaware of the reason of the bolus feedings. Further interview revealed that SP#1 weight was not being monitored. The Manager of Clinical Nutrition stated that SP#1 should have been weighed weekly as part of the protocol.

Review of the Policy Description: " Assessment and Reassessment, " (revised 4/16) revealed that patients found to be at nutritional risk receiving a comprehensive nutritional assessment may also receive an individualized nutrition therapy plan. The assessment may include anthropometrics: height and weight. The patient identified as whether a nutritional risk as high, moderate, and low risk should be reassessed to determine that the needs are identified and are met. The policy also states on page 3 of 91 that the following considerations are followed by the health care providers in the design of a discipline specific assessment. The assessment process will be collaborative to facilitate, identify, and prioritize the patient ' s needs and determine care. The facility failed to follow its policy and procedure.