The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTHWEST HOSPITAL CENTER 5401 OLD COURT ROAD RANDALLSTOWN, MD 21133 March 27, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of 5 open records and 9 closed records it was determined that the hospital failed to protect patient's rights as evidenced by the deficiencies cited at:
A 144 due to the delay in obtaining needed treatment for patient #5;

A 131 due to the failure to determine Patient's # 1 capacity to make informed decisions about his care;

A 154 for the failure to release 3 patients from restraints or seclusion at the earliest possible time;

A 175 for the failure to document toileting and range of motion for a patient in restraints;

A 179 for the failure to complete thorough face to face evaluations for four patients placed in restraints or seclusion; and

for the failure to meet the nutritional needs of patient #1 as cited at A 630
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of five open and nine closed medical records, the hospital failed to determine one patient's competence to make his own decision prior to gaining consent for procedures from a family member.

Patient #1 is a [AGE]-year-old nonverbal individual with intellectual disability and [DIAGNOSES REDACTED] Patient #1 has a history of recurrent urinary tract infections, gastrointestinal disorders associated with gastric emptying and digestion, and difficulty swallowing. Patient #1 developed a large right kidney stone, and was scheduled to have a percutaneous nephrolithotomy (an invasive procedure to remove the kidney stone). Before this could be performed, the renal stone moved from his kidney to block his ureter, the connection between the kidney and the bladder, an extremely painful condition requiring urgent intervention. According to information from the patient's group home, patient #1 is considered to be his own decision maker, although his brother has been contacted for major medical decisions. The group home had been unable to reach the patient's brother for some months, and the hospital could not reach him for consent for the nephrolithotomy. On 3/18/13, patient #1 received a right nephrostomy tube placement, consented by the patient's stepmother. While it was apparent that patient #1 lacked capacity to make decisions about his care, no capacity statements were completed prior to rendering care.

On 3/28/13, the patient's stepmother completed an affidavit making her the surrogate decision maker. Up until that point, consents had been provided by the staff at the patient's group home, who, while they certainly knew the patient and were intimately inviolved with his care, had no legal standing to grant consent.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of five open and nine closed records, it is determined that there was a delay in evaluation for patient #5 who was severely assaulted by another patient and suffered multiple blows to the head.


Patient #5 was a [AGE]-year-old male admitted on [DATE] due to aggression. On the morning of 3/4/13, patient #5 was verbally abused, and then physically attacked by patient #9. The therapist note of 1427 describes the aggressor's attack on patient #5 in part as, "(Patient #9) stated 'You ain't gonna talk about my family members, n--,' then proceeded to hit (patient #5) in the face. The patient who was hit tried to stand up to defend himself but fell on the floor with this patient (#9) on top of him. Patient (#9) repeatedly attacked this patient (#5) in the head, face and body numerous times. Attempts were made to stop this patient from further attacks by several staff members. Security called to assist ... "


An RN note of 1334 (approx. 2.5 hours after the asault) states in part, "Patient got off the floor and nose and mouth was bleeding ....and face-to-face completed by Dr. __ at initiation of seclusion. Ice compress applied to nose ..." The physician face-to-face form has several conditions to check as desired, in addition to an area for writing other findings. The physician checked the box stating, "Patient not offering/denies physical complaints such as but not limited to pain, difficulty breathing, and difficulty moving." No assessment of any kind addressed the fact that patient #5 was bleeding from the nose and mouth.


Patient #5 received prolixin 5 mg and Benadryl 50 mg IM at 1130 when seclusion was initiated. He stated to staff, "When I get out of here, I am going to kill him." While patient #5 threatened to kill his attacker, his attacker was also in seclusion. Additionally, patient #5 was able to eat lunch, and per a social worker note of 1240, "Met with patient briefly in his room after the physical altercation, and Patient gave me verbal consent of..." An RN entry of 1315 states in part, "Patient received lunch. Patient declined to use bathroom. Patient continues to be disorganized. Patient rambling to self. Patient irritable. Patient continues to have no insight into reason for seclusion, or inappropriateness of fighting on the unit. Will continue to monitor."


Patient #5 was not assessed until 1445, more than three hours following the severe assault, when a PA-C assessed patient #5's nose, head and mouth. An X-ray was ordered, and an ice compress was placed on patient #1's nose. At 1624, approximately five hours following the assault, patient #5 went to x-ray, where it was determined he had a broken nose.


The face-to-face done within one hour of seclusion should have addressed patient #5's injuries. It did not. Consequently, patient #5 waited five hours for an evaluation of a potential head injury without justification for such a delay. Placing patient #5 in seclusion for an attack he did not instigate, and keeping him there while he was apparently calm enough to eat lunch and interact with the social worker led to a delay in assessment and treatment.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of five open and nine closed records, it is determined that patients #5, #6, and #8 were not released from restraints or seclusion at the earliest possible time. This is evident in three of five restraint records reviewed.

Patient #5 is a [AGE]-year-old male admitted on [DATE] due to aggression. On the morning of 3/4/13, patient #5 was verbally abused, and then physically attacked by patient #9. The therapist note of 1427 describes the aggressor's attack on patient #5 in part as, "(Patient #9) stated 'You ain't gonna talk about my family members, n--,' then proceeded to hit (patient #5) in the face. The patient who was hit tried to stand up to defend himself but fell on the floor with this patient (#9) on top of him. Patient (#9) repeatedly attacked this patient (#5) in the head, face and body numerous times. Attempts were made to stop this patient from further attacks by several staff members. Security called to assist ... "


Both patient #9 and patient #5 were placed in separate seclusion rooms. An RN note of 1334 states in part, "Patient got off the floor and nose and mouth was bleeding ....and face to face completed by Dr. __ at initiation of seclusion. Ice compress applied to nose ... " The physician face-to-face form has several conditions to check as applicable, as well as an area for writing other findings. The physician checked the box stating, " Patient not offering/denies physical complaints such as but not limited to pain, difficulty breathing, and difficulty moving." No assessment of any kind addressed the fact that patient #5 was bleeding from the nose and mouth.

Patient #5 received prolixin (an antipsychotic) 5 mg and Benadryl 50 mg (a sedating antihistamine) IM at 1130 when seclusion was initiated. He stated to staff, "When I get out of here, I am going to kill him." Both patients were in seclusion. Additionally, patient #5 was able to take lunch, and per a social worker note of 1240, "Met with patient briefly in his room after the physical altercation..." An RN entry of 1315 states in part, "Patient received lunch. Patient declined to use bathroom. Patient continues to be disorganized. Patient rambling to self. Patient irritable. Patient continues to have no insight into reason for seclusion, or inappropriateness of fighting on the unit. Will continue to monitor." While insight is desirable, no patient should be required to gain insight into the reasons for seclusion in order to be able to leave seclusion. In addition, while secluding a patient briefly after being attacked may be appropriate, it is not appropriate to maintain the seclusion of the victim of an attack, especially when he does not exhibit dangerous or harmful behaviors.


Five hours after the attack, patient #5 was calm enough to go to x-ray with staff. When he returned to the unit, he was placed back into seclusion without justification. The physician face to face indicates that patient #5 was combative/assaultive at 1705. However, there is no supporting documentation. The "comments" section of the 15-minute flow sheet states only, "Off unit at 1624 for x-ray. Back on unit at 1651 and returned to LDS "locked door seclusion)." Seclusion was not ended until 1830.


Documentation on the fifteen-minute flows reveals that patient #5 was alternately "agitated," and for the last hour, "quiet." Patient #5 was kept in seclusion for seven hours excepting when he was taken to x-ray without apparent continuing justification. Patient #5 was not released at the earliest possible time.

Patient #6 is a young adolescent who presented on emergency petition due to aggressive behaviors towards others. During her evaluation, patient #6 was restrained after becoming combative with staff. Patient #1 was in 4-point restraint from 1/18/13 at 2150 through 1/19/13 at 0023. Restraints were renewed at 2330 though documentation indicates that patient #6 was only "restless." No other behaviors are documented which demonstrate imminent dangerousness. Therefore, patient #6 was not released at the earliest possible time.


Patient #8 is a [AGE]-year-old who presented on emergency petition to the emergency department due to aggressive, unstable behaviors. Patient #8 was restrained in the ED on 1/19/13 at 1828 when she attempted to elope and became aggressive. Patient #8 was seen face-to-face at 1846 and given a full assessment.

However, the order for restraint was not made until 2027, approximately two hours following the initial restraint. Fifteen-minute flows reveal patient #8 was calm or sleeping from 2015 until release at 2227. Although the flow sheet states the patient was calm, no 2-hour RN assessment is noted in the record at 2027 which would have resulting in patient #8's release from restraint. Further, it is only a note written in the margin of the fifteen minute flows that indicates when patient #8 came out of restraint. Patient #8 was kept in restraints for 2.5 hours past the point when she ceased her dangerous and harmful behavior.

Patient #8 was placed in restraint again on 1/20/13 at 1019 when she attempted to elope by running out of the room. No 2-hour RN assessment is noted. Fifteen minute flows reveal that patient #8 was sleeping at 1030 for approximately ? hour, and is then noted to be "calm" for the remainder of the restraint time. There is no documentation of the time she was released from restraint. A nursing note of 1455 states, "Pt is calm and says she will not act up, pt went back to sleep." Presumably, this is about the time when patient #8 was taken out of restraint. While it cannot be determined exactly when patient #8 came out of restraint, she was kept in for at least four hours past the point at which she ceased her dangerous behavior.

Patient #8 was restrained again on 1/21/13 at 1315 when she became aggressive and turned over her tray. No 2-hour RN assessment is noted. Fifteen minute flows state that patient #8 was "combative" from 1315 through 1500, and then was noted to be sleeping. Again, there is no documentation specifying when patient #8 was released from restraints. One RN entry of 1505 documents that she was given a meal and one RN entry at 1841 documents that patient #8 was transferred to the unit via wheelchair. No RN notes are found after 1841 which address patient #8's restraint status. Therefore, it is not possible to tell if patient #8 was released at the earliest possible time.

The tendency of staff to leave patients in restraints or seclusion while they are calm or sleeping coupled with a lack of documentation about release times indicates that staff are keeping patients in restraint or seclusion for, in some case, hours longer than necessary to protect that patient, other patients in the milieu, or staff.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of one open and four closed seclusion/restraint records, and staff training, it was determined that the hospital failed to document range of motion, toileting, fluids, or other care consistent with regulation and policy throughout multiple restraint episodes for one patient.


Patient #8 is a [AGE]-year-old who was brought to the emergency department on an emergency petition due to aggressive, unstable behaviors. Patient #8 was restrained in the ED on 1/19/13 at 1828 when she attempted to elope and became aggressive. Patient #8 was seen face-to-face by the physician at 1846 and given a full assessment.


Fifteen-minute flows reveal patient #8 was noted to be calm or sleeping from 2015 until release at 2227. No range of motion or toileting is noted throughout the four hours of restraint. Additionally, no 2-hour RN assessment is noted in the record, due at 2027. Further, were it not for a note written in the margin of the fifteen minute flows, no documentation indicates when patient #8 came out of restraint.

Patient #8 was placed in restraint again on 1/20/13 at 1019 when she attempted to elope by running out of the room. No 2-hour RN assessment is noted. No range of motion or toileting is noted. Additionally, no fluids were given until 1440, more than four hours following the initiation of restraint.

Patient #8 was restrained again on 1/21/13 at 1315 when patient #8 became aggressive and turned over her meal tray. No 2-hour RN assessment is noted. No Range of motion or toileting is noted. Additionally, no fluids are noted as being given.

One RN entry of 1505 documents a "meal set-up" and one RN entry at 1841 documents when patient #8 was transferred to the unit via wheelchair, but no RN notes written after 1841 which address patient #8's restraint status.

Review of staff training reveals that staff do receive appropriate training in order to monitor and provide care to individuals who require seclusion and restraint. However, for patient #8, the hospital failed to document adequate care delivery during multiple restraining events
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of one open seclusion record and four closed restraint records, it is determined that the face to face assessments for four patients (#5, 6, 8, and 14) were not complete and do not meet regulatory requirements.

Patient #5 is a [AGE]-year-old male admitted on [DATE] due to aggression. On 3/4/13, patient #5 was in a physical altercation with patient #9. Both patient #9 and patient #5 were placed in separate seclusion rooms. An RN note of 1334 states in part, "Patient got off the floor and nose and mouth was bleeding ....and face to face completed by Dr. __ at initiation of seclusion." The physician face-to-face form has several conditions to check as applicable, in addition to an area for writing other findings. The physician checked the box stating, "Patient not offering/denies physical complaints such as but not limited to pain, difficulty breathing, and difficulty moving." The face to face assessment did not address the fact that patient #5 was bleeding from the nose and mouth.

Patient #6 is a young adolescent who was brought to the ED on emergency petition due to aggressive behaviors towards others. During her evaluation, patient #6 was restrained after becoming combative with staff. Patient #1 was in 4-point restraint from 1/18/13 at 2150 through 1/19/13 at 0023. Restraints were renewed at 2330 though documentation indicates that patient #6 was only "restless." No other behaviors are documented which demonstrate imminent dangerousness.

Additionally, no licensed independent practitioner documentation within one hour of restraint is found that meets the regulatory elements of a face to face. Patient #6 did have a full assessment 3 hours and 25 minutes after the initiation of restraint.

Patient #8 is a [AGE]-year-old who was brought to the emergency department on emergency petition due to aggressive, unstable behaviors. Patient #8 was restrained in the ED on 1/19/13 at 1828 when she attempted to elope and became aggressive. Patient #8 was seen face to face at 1846 and given a full assessment.

Patient #8 was placed in restraint again on 1/20 at 1019 when she attempted to elope by running out of the room. No face to face is noted in the record. Patient #8 was restrained again on 1/21 at 1315 when patient #8 became aggressive and turned over he tray. No face to face is noted in the record.

Patient #14 is a 20 yo male who presented on emergency petition to the ED due to aggressive behaviors. Patient #14 was restrained twice in the ED for inappropriate boundaries presenting a danger to staff, and for other disruptive behaviors. Patient #14 was admitted to the behavioral health unit where he was restrained twice again for aggression and inappropriate boundaries presenting a danger to staff. Excepting a face to face for the initial episode in the ED, no other face to face assessments are noted.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of policy, 5 open and 9 closed patient records, and other documentation, it was determined that the hospital failed to accurately assess patient #1's nutritional status and existing risks, failed to administer adequate nutrition, and failed to account for the patient's unique nutritional and feeding needs in the patient care plan.

Patient #1 was a [AGE]-year-old nonverbal individual with intellectual disability and [DIAGNOSES REDACTED] admitted in March, 2013 from a group home where he had been total care, bedridden, and contracted in all extremities. While in the group home, patient #1 had to be fed. Patient #1 has a history of recurrent urinary tract infections, gastrointestinal disorders associated with gastric emptying and digestion, and difficulty swallowing.


The initial nursing assessment performed shortly after admission stated patient #1 "needed assistance" with feeding, but had "no difficulties" eating and had "no" nutritional risk factors. This assessment was clearly incorrect in that it did not mention the severe contractures that would have made it impossible for patient #1 to feed himself, and did not mention the inability to clear his own oral secretions or the vomiting he'd had for 24 hours. The patient was not accompanied by anyone who could give the RN a history. Because the assessment was inaccurate and downplayed the patient's nutritional risk, it failed to meet the threshold for an automatic referral for a nutritional consult. Patient #1's Braden score (a measure of the risk of skin breakdown) was assessed as 15, which is high risk. This assessment also should have triggered a nutritional consult, but did not. In fact, patient #1 did not have a nutritional assessment by a registered dietician until hospital day 10, after the feeding tube was inserted.



The patient's care plan was started the day after admission. Under the category "Nutrition and Hydration," the pre-printed form lists four possible interventions, (1) Dietary consult, (2) Assess hunger/ability to eat, (3) Assess for aspiration, and (4) Evaluate for IV fluid need. Only the fourth choice was marked.


Two days after admission, patient #1 had a swallowing evaluation by a speech-language pathologist (SLP). The SLP noted that patient had been seen in December 2012 by SLP and at that time, the evaluation could not be completed because the patient refused most oral intake and spit it out. During the current assessment, the SLP noted that the patient had significant upper and lower extremity contractures, he was non-verbal and non-vocal, and he could not follow commands, including the command to cough. The SLP further noted that the patient had a lot of "spillage," an absent swallowing reflex, and a lot of tongue thrusting. The SLP's concusion was that the patient demonstrated "severe oral-pharyngeal dysphagia with significant risk of aspiration." The recommendations included continuing the pureed diet with 100% feeding by staff and strict aspiration precautions. The SLP entered specific feeding instructions to maximize the patient's intake while minimizing the risk of aspiration. There is no nursing documentation indicating that these instructions were followed.


On that same day, nursing documentation details that at 0800, patient #1 ate 15% of his meal, at 1000 ate 10% of his meal, and at 1400, ate 20% of the offered meal. The medical record contains a per-meal assessment of the patient's nutritional intake. There are seven instances during the first seven days of the patient's hospitalization where it is noted that he was either independent with eating or required minimal assistance. It is difficult to understand how this could be so, considering patient #1's physical and mental condition.

On day seven of patient #1's hospitalization , the discharge planner was in the process of finding placement. The group home was unable to take him back because he required a urinary catheter and a ureteral drain. The note written by the case manager indicated a phone call with the on-call physician about the patient's feeding status. The note says, in part, "Patient will not accept food from nurse or nurse tech. No plan for PEG [feeding tube] placement. Patient cannot discharge to a skilled facility without a plan." Another case manager, on the same day, noted that "RN called the group home and requested someone come to feed him as he is particular about for whom he eats. Awaiting their arrival for further plan. Pt. cannot discharge without nutritional status."

On day seven, patient #1's weight was documented at 80 lb 11 oz.

The patient had a repeat SLP evaluation on day nine of his hospitalization , following surveyor intervention during the on-site survey. This evaluation found patient #1 to have copious oral secretions pooled in, and pouring out of his mouth. The SLP's conclusion was that patient #1 was unable to accept oral intake or manage his own secretions. The SLP recommended an alternative means of nutrition such as a feeding tube.

Also on day nine, the patient's albumin was 2.3 g/dl and his total protein was 6.4 g/dl. His albumin and total protein had not been checked since hospital day five.

The patient's care plan was signed off as being updated on days four, six, and eight but the nutritional status was not updated or revised, despite the SLP evaluations, the patient's weights and labs, his frequent vomiting episodes, or the fact that other documentation indicated he frequently refused oral medications and food. The failure to maintain an accurate and up-to-date care plan meant the staff lost one more opportunity to intervene with patient #1 and ensure his needs were being met.
VIOLATION: DIETS Tag No: A0630
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of five open and nine closed medical records along with other documentation, it was determined that the hospital failed to meet the nutritional needs of one patient.

Patient #1 was a [AGE]-year-old nonverbal individual with intellectual disability and [DIAGNOSES REDACTED] admitted in March, 2013 from a group home where he had been total care, bedridden, and contracted in all extremities. While in the group home, patient #1 had to be fed. Patient #1 has a history of recurrent urinary tract infections, gastrointestinal disorders associated with gastric emptying and digestion, and difficulty swallowing. On admission, patient #1 was 4'3" tall and weighed 85.9 lbs. His admitting labwork included an albumin level of 3.5 g/dl (3.9-5.0 g/dl) and total protein of 8.2 g/dl (6.3-7.9 g/dl). Albumin and total protein are rough indicators of nutritional status and albumin in particular tends to drop quickly when nutritional intake is poor.


The initial nursing assessment performed shortly after admission stated patient #1 "needed assistance" with feeding, but had "no difficulties" eating and had "no" nutritional risk factors. This assessment was clearly incorrect in that it did not mention the severe contractures that would have made it impossible for patient #1 to feed himself, and did not mention the inability to clear his own oral secretions or the vomiting he'd had for 24 hours. The patient was not accompanied by anyone who could give the RN a history. Because the assessment was inaccurate and downplayed the patient's nutritional risk, it failed to meet the threshold for an automatic referral for a nutritional consult. Patient #1's Braden score (a measure of the risk of skin breakdown) was assessed as 15, which is high risk. This assessment also should have triggered a nutritional consult, but did not. In fact, patient #1 did not have a nutritional assessment by a registered dietician until hospital day 10, after the feeding tube was inserted.



Two days after admission, patient #1 had a swallowing evaluation by a speech-language pathologist (SLP). The SLP noted that patient had been seen in December 2012 by SLP and at that time, the evaluation could not be completed because the patient refused most oral intake and spit it out. During the current assessment, the SLP noted that the patient had significant upper and lower extremity contractures, he was non-verbal and non-vocal, and he could not follow commands, including the command to cough. The SLP further noted that the patient had a lot of "spillage," an absent swallowing reflex, and a lot of tongue thrusting. The SLP's concussion was that the patient demonstrated "severe oral-pharyngeal dysphagia with significant risk of aspiration." The recommendations included continuing the pureed diet with 100% feeding by staff and strict aspiration precautions. The SLP entered specific feeding instructions to maximize the patient's intake while minimizing the risk of aspiration. There is no nursing documentation indicating that these instructions were followed.


On that same day, nursing documentation details that at 0800, patient #1 ate 15% of his meal, at 10:00 ate 10% of his meal, and at 1400, ate 20% of the offered meal. The medical record contains a per-meal assessment of the patient's nutritional intake. There are seven instances during the first seven days of the patient's hospitalization where it is noted that he was either independent with eating or required minimal assistance. It is difficult to understand how this could be so, considering patient #1's physical and mental condition.


On day seven of patient #1's hospitalization , the discharge planner was in the process of finding placement. The group home was unable to take him back because he required a urinary catheter and a ureteral drain. The note written by the case manager indicated a phone call with the on-call physician about the patient's feeding status. The note says, in part, "Patient will not accept food from nurse or nurse tech. No plan for PEG [feeding tube] placement. Patient cannot discharge to a skilled facility without a plan." Another case manager, on the same day, noted that "RN called the group home and requested someone come to feed him as he is particular about for whom he eats. Awaiting their arrival for further plan. Pt. cannot discharge without nutritional status."


On day seven, patient #1's weight was documented at 80 lb 11 oz. The weight loss of nearly six pounds did not trigger a nutritional assessment.


The patient had a repeat SLP evaluation on day nine of his hospitalization , following surveyor intervention during the on-site survey. This evaluation found patient #1 to have copious oral secretions pooled in, and pouring out of his mouth. The SLP's conclusion was that patient #1 was unable to accept oral intake or manage his own secretions. The SLP recommended an alternative means of nutrition such as a feeding tube.


Also on day nine, the patient's albumin was 2.3 g/dl and his total protein was 6.4 g/dl. His albumin and total protein had not been checked since hospital day five, and the 50% drop in his albumin did not trigger a nutritional consult.


In summary, patient #1 was not accurately assessed for his nutritional risk on admission, and was not referred for a dietary consult based on his medical condition/assistance needs and his high Braden score. In addition, throughout patient #1's hospitalization , nursing and medical staff downplayed his nutritional risks, ignored labs and assessments, failed to document the amount eaten on all but two meals, and inappropriately called a past care-giver to feed the patient. The medical record contains numerous entries by nursing and physicians relating to "poor intake" and refusing medications and nutrition but no definitive intervention happened until day ten after it became clear that no post-hospital facility would take the patient without at least a nutritional plan. On day 10, patient #1 had a feeding tube surgically inserted and, once he tolerated tube feedings, was transferred to a skilled nursing facility on day 14. The hospital failed to accurately assess patient #1's nutritional status and existing risks, failed to administer adequate nutrition as evidenced by his weight loss and lab results, failed to consult a dietician about how best to meet his nutritional needs until the feeding tube was inserted, and failed to account for the patient's unique nutritional and feeding needs.