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.

CLEVELAND CLINIC 9500 EUCLID AVENUE CLEVELAND, OH 44195 Aug. 29, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, hospital policy review and staff interview, the hospital failed to ensure nursing care was delivered as ordered by the physician and in accordance with hospital policy for six of 16 medical records reviewed (Patient #'s 3, 6, 7, 9 ,10 and 16) as it relates to obtaining and recording the patients' weight daily. Additionally, the hospital failed to follow hospital policy for recording the volume of tube feeding intake for one (Patient # 3) of 16 medical records reviewed. The current census at the time of the survey was 1094.

Findings include:

1) Medical record review for Patient # 3 revealed the patient was admitted to the hospital MICU (medical intensive care unit) on 7/01/14. Patient # 3 was admitted with diagnoses that included [DIAGNOSES REDACTED]. The patient's weight on admission was 65.2 kilograms (143 pounds). On 7/03/14 the patient was weighed and documentation on the nursing flow sheet revealed a patient weight of 59.1 kilograms (130 pounds). The patient was not weighed again until 7/13/14 at which time the nursing documentation revealed the patient weighed 59.1 kilograms. Ten days later the patient was weighed again and the weight on the nursing documentation revealed the patient weighed 54.2 kilograms (119 pounds). Approximately one month later on 8/21/14 the patient's recorded weight was 45.8 kilograms (101 pounds).

During record review on 8/26/14 at 3:15 PM Staffs B and C confirmed nursing documentation did not reveal patient #3 was weighed daily as ordered.

Patient # 3's medical record revealed the patient had a nasogastric feeding tube in place at the time of admission as the patient was transferred from an outside hospital. According to hospital policy "Enteral Tubes for Feeding/Medication Administration...Care of the Patient with" effective date 1/29/14, the documentation in the medical record is to include the volume and type of enteral feeding given. On 7/12/14 at 8:00 PM the nursing documentation reveals the feeding tube is patent and continuous. At 10:08 PM on 7/12/14 the nursing documentation reveals two attempts were made to declog the patient's feeding tube. The nursing documentation for 7/12/14 did not reveal the volume of intake through the feeding tube. Staff H confirmed this finding during record review on 8/28/14 at 2:30 PM.

2) Medical record review conducted on 08/26/14 revealed Patient #6 was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]. A physician's order was given on 08/23/14 at 11:00 PM for daily weights. The medical record was silent to a daily weight on 08/24/14 and 08/25/14. This was confirmed with Staff E and Staff F on 08/26/14 at 2:15 PM. The surveyor asked what the patient currently weighed, and Staff E stated they would weigh the patient, and inform the surveyor of the current weight. At 2:20 PM, this staff member stated the patient's current weight was 102.4 kg. The admission weight for this patient was 104.4 kg. Staff E and F confirmed patient # 6's weight loss of 2 kg and lack of weights on a daily basis.

The facility policy titled Routine Care MICU G50 G51 G60 G61 G62 Protocol, approved on 11/07/13, stated weigh patients daily. Perform weights on 2300-0700 shift unless contraindicated or as ordered by physician.

3) On 08/26/14, Patient #7's medical record was reviewed with Staff F. This patient was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]
The medical record contained a physician's order, written on 08/25/14 at 11:07
PM, for daily weights. The medical record was silent to a weight daily except
on 08/15/14, 08/19/14, 08/20/14, and 08/25/14. The patient's weight at the time
of admission was 128.5 kg, and on 08/25/14 the patient weighed 116.8 kg, a decrease of 11.7 kg.

The findings of a lack of daily weights and a decrease of 11.7 kg in 10 days were confirmed with Staff F, E and D on 8/26/14 who were present during the record review.







4) Patient #10 was admitted to the facility on [DATE] with diagnoses which included [DIAGNOSES REDACTED] and history of radiation. The patient had a physician's order for weights to be obtained everyday. The medical record revealed the patient's admission weight was recorded on 07/31/14 as 50 kilograms (110 pounds). The medical record review revealed the facility had failed to follow physicians order to obtain daily weights on 08/01/14 through 08/08/14 or an elapsed time of one week. Again the medical record reflected no recorded weights for a four day stretch between 08/13/14 and 08/18/14. The recorded weight documented on 08/26/14 was 70.4 kilograms (154.88 pounds) or a weight gain of 44.88 pounds over a four week period of time.

Interview with Staff G on 08/28/14 at 12:05 PM confirmed the hospital staff failed to document the physicians ordered daily weight values.


The medical record review for Patient #10 revealed the patient had an unstageable pressure ulcer to his/her coccyx on 08/06/14 that measured 3 centimeters (cm) long by 1.5 cm wide by 0.2 cm deep. On 08/15/14 the wound measured 4 cm long by 2.5 cm wide by 0.1 cm deep.

Patient # 10's medical record review revealed a physician's order dated 08/15/14 at 12:45 P.M. that required the wound to be dressed with a thin layer of Medihoney gel and covered with life foam dressing, and to change the dressing daily. The medical record review revealed the dressing was changed on 08/16/14. The medical record review revealed the dressing was not changed again until five days later on 08/21/14 at 6:00 A.M.

Patient # 10's medical record review revealed 08/22/14 the wound was measured to be 5.5 cm long by 5.5 cm wide by 0.1 cm deep.

Patient # 10's medical record review revealed a physician's order dated 08/22/14 at 11:15 A.M. that directed staff to spread a layer of Medihoney gel on to a proprietary contact layer, and then cover with a life foam dressing. The order called for the wound dressing to be changed daily.

Patient # 10's medical record review revealed the dressing was changed on 08/22/14 and again on 08/23/14, but not again until three days later on 08/26/14.

Patient # 10's medical record review revealed wound care consult team notes for 07/31/14, 08/06/14, 08/15/14, and 08/22/14 directing staff to perform side by side turns only, to offload sacral area.
Patient # 10's medical record review revealed on 08/22/14 he/she was placed on his/her back on these times and dates:
A. 08/22/14, 4:00 A.M., 8:00 A.M., 9:00 A.M., 12:00 P.M., 1:00 P.M. , 4:00 P.M. , 5:00 P.M.
B. 08/23/14, 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.
C. 08/24/14 at 12:00 A.M. , 4:00 A.M., 10:00 A.M., 11:00 A.M., 2:00 P.M., 3:00 P.M., 6:00 P.M., 7:00 P.M., and 10:00 P.M.
D. 08/25/14 at 4:00 A.M., 8:00 A.M., 9:00 A.M., 12:00 P.M., 1:00 P.M., 6:00 P.M., 7:00 P.M., 9:00 P.M. and 10:00 P.M.
E. 08/26/14 at 1:00 A.M., 2:00 A.M., 5:00 A.M., 6:00 A.M., 10:00 A.M., 11:00 A.M., 4:00 P.M., 5:00 P.M., 10:00 P.M., and 11:00 P.M.

The medical record review revealed on 08/27/14 the wound measured 7.6 cm long by 7 cm wide by 0.2 cm deep.

On 08/29/14 at 1:30 P.M. in an interview, Staff A confirmed the days when the dressing wasn't changed and confirmed the patient was not to be placed on his/her back.


5) The medical record review for Patient #16 was completed on 08/29/14. The clinical record review revealed the patient was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED].M. to weigh the patient every day. The medical record review revealed the patient weighed 160 lbs on 08/08/14, and was not weighed again until five days later on 08/13/14 and weighed 156 lbs, and not again until 08/24/14 and weighed 151 lbs, and again on 08/26/14 for 158 lbs.

The medical record review revealed a physician's order dated 08/22/14 to have the head of bed elevated 30 degrees. The head of the bed was not shown to be at 30 degrees until 08/28/14.

The medical record review revealed a nursing entry dated 08/28/14 at 2:00 P.M. that stated the patient had an indeterminable staged pressure ulcer to the coccyx 2.5 cm long by 1.0 cm wide.

On 08/29/14 at 11:30 A.M. in an interview Staff K confirmed the findings of missed daily weights, no documentation for the elevation of the head of the bed and a coccyx wound.

This deficiency substantiates the allegations in Substantial Allegation Number OH 588.








6) Review of the medical record revealed Patient #9 was admitted to the facility on [DATE] with diagnoses which included dysphagia, hypertension and respiratory failure. The patient had a physician's order for daily weights to be obtained. The medical record documented the patient had an admission weight of 94.7 kilograms (208 pounds). A weight was recorded on 08/22/14 as 96.5 kilograms (212 pounds). The medical record failed to document any weights on 08/23/14, 08/24/14, and 08/25/14. The next patient weight recorded was on 08/26/14 when the patient's weight was recorded as 90.9 kilograms (199.98 pounds). This reflected a 12 pound weight loss over three days. The nursing notes failed to document any notification of the physician of the patient's weight loss or initiation of a dietary consult to address the patient's weight loss until the patient was seen by the dietician on 08/27/14.

Review of the facility's policy and procedure entitled Admission Assessment and Interdisciplinary Screening Consults for adult patients Protocol with a last approved/Reviewed date of 03/22/13 directed that any risk factors identified per patient screenings will warrant referral to the attending physician.

Review of the facility's policy for Weight Measurement revised 4/04/14 reveals a weight change of more than 1 kilogram per day is to be reported to the physician.

Interview with Staff G on 08/28/14 at 11:14 AM confirmed the lack of documented daily weights as per physician orders as well as the lack of notification of unintended weight loss to the physician.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, staff interview and review of facility policy and procedure the facility failed to develop nursing care plans that addressed the patient's alternative nutritional needs for two of three patients (Patient #7 and #9) reviewed who were receiving enteral nutrition. The sample size was 16. The current census at the time of the survey was 1094.

Findings include:

On 08/26/14, Patient #7's medical record was reviewed with Staff F. In attendance during the medical record review were Staff E and Staff D. This patient was admitted on [DATE] with a diagnosis of hypoxia. A continuous orogastric tube feeding was
ordered by a nurse practitioner on 08/18/14 at 1:30 PM. A physician's order dated 08/25/14 at 2:45 PM directed staff to connect the feeding tube to low intermittent
wall suction. A physician's note, dated 08/26/14, written at 6:35 AM, and filed at 3:18 PM, revealed the patient was experiencing bowel issues, no bowel movement, had to have an enema, and had colonic distension. The patient was not permitted to have any tube feeding beginning on 08/25/14 at 2:45 PM, per physician's order.


Patient # 7's medical record contained a physician's order, written 08/25/14 at 11:07
PM, for daily weights. The medical record was silent to a weight daily except
on 08/15/14, 08/19/14, 08/20/14, and 08/25/14. The patient's weight at the time
of admission was 128.5 kg, and on 08/25/14 the patient had lost weight and
weighed 116.8 kg.


A dietician's note, dated 08/22/14, stated the patient's tube feeding was
changed related to weight loss. This note also documented the patient was
admitted with edema (swelling).


A review of Patient # 7's plan of care, on 08/26/14, revealed the facility failed to
include the patient's tube feeding, nothing by mouth status, edema, or weight
loss. The only identified problems on the plan of care were for respiratory,
safety, and skin.


The facility failing to include the patient's tube feeding, nothing by mouth status, edema, and weight loss was confirmed with staff members D, E and F during the medical record
review. At 3:55 PM, Staff D stated patients with tube feedings
should have a plan of care for aspiration. This patient was observed on 08/26/14 with an orogastric feeding tube attached to intermittent wall suction.





Review of the medical record revealed Patient #9 was admitted to the facility on [DATE] with diagnoses which included dysphagia, hypertension and respiratory failure. The patient had a nasogastric (NG) tube (used for providing liquid nourishment) present at the time of admission and a physician's order for tube feed of Isoursource 1.5 at 45 milliliters per hour via the nasogastric tube.

Review of the patient's plan of care from the start of care 08/21/14 revealed the facility had failed to initiate a plan of care to address the specific patient needs of a patient receiving enteral tube feedings such as assessing the tube for patency, positioning of patient to prevent aspiration of tube feed, monitoring of stomach residuals (amount of food in stomach), confirmation of tube placement into the esophagus.

Interview with Staff G on 08/28/14 at 11:14 AM confirmed the lack of a plan of care which directed the nursing care for the patient's NG tube and tube feeds.