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Based on record review and interview staff failed to notify the physician of inadequate fluid intake for 1 of 3 patients (Patient #1) at risk for dehydration; failed to document tube feeding intake for 2 of 4 patients (Patient #6, #9) receiving tube feeding, and failed to review STAT lab results within 4 hours of the order in 1 of 1 patients (Patient #1) in a total of 10 medical records reviewed.

Findings include:

Staff failed to monitor and notify the physician of inadequate fluid intake per facility protocol and physician orders. See tag A-0395.

Staff failed to review STAT lab results within 4 hours per facility policy. See tag A-0395.

Based on record review and interview staff failed to monitor and notify the physician of inadequate fluid intake for 1 of 3 patients (Patient #1) at risk for dehydration; failed to document tube feeding intake for 2 of 4 patients (Patient #6, #9) receiving tube feeding, and failed to review STAT lab results within 4 hours of the order in 1 of 1 patients (Patient #1) in a total of 10 medical records reviewed.

Findings Include:

A review of the facility's policy titled, "Reassessment" effective 03/2023 revealed, "...Patient needs, response to treatments/interventions, and change in condition or diagnosis are reassessed at least every 12 hours and when warranted by a change in the patient's condition...the RN (registered nurse) will perform reassessment and will direct patient care through a variety of mechanisms including notification of the change to the physician, change to plan of care, and other interventions based on the patient need. An interdisciplinary team throughout the organization assesses and reassesses the patients need for care, treatment and/or intervention..."

A review of the facility's Work Instruction titled, "One More Sip Hydration Program" no date, revealed, "...Age group and medical condition = risk for dehydration...Identify all patients 'at risk' on admission and during stay. Review at team conference by dietician. Utilize 'One More Sip program'...continuous throughout stay...Intake of less than 1000mls (ML milliliters) per day considered [at risk for dehydration]...Interdisciplinary team need to document fluids on the I&O (Intake and Output) record..."

A review of the facility's policy titled, "Critical Tests & Response" effective 03/2023 revealed, "...Critical tests are those tests ordered by the physician as either "now" or "STAT" (immediately). Tests ordered "now" or "STAT" will have results reported within 4 hours of the order..."

A review of Patient #1's medical record revealed that Patient #1 was admitted to the facility on 4/17/2025 following a stroke.

A review of Patient #1's medical record "Orders" on 4/18/25 revealed, "One More Sip Daily ...All staff Encourage hydration with every pt (patient) interaction."

A review of Patient #1's medical record "Adult Nutritional Assessment" on 4/18/25 at 12:45 authored by Dietician E revealed, "...Estimated Fluid Needs 1200 - 1500 ML [daily]..."

A review of Patient #1's medical record "Intake Flowsheet" revealed "Fluid Amount Shift Totals" 4/18/25 - 4/26/25: "Total for [9-day] Admission: 2,129 ML (milliliters)." There was no documentation of fluid intake on 4/19/25 Day Shift, 4/20/25 Day Shift, 4/21/25 Day Shift, 4/22/25 Night Shift, 4/23/25 Night Shift, 4/24/25 Night Shift, or 4/25/25 Day Shift.

A review of Patient #1's medical record "Output Flowsheet" revealed that Patient #1 was incontinent, and without a urinary catheter. There was no urination documentation or other fluid output documentation on 4/18/25, 4/19/25, 4/23/25, 4/24/25, or 4/25/25.

A review of Patient #1's medical record "Nursing Reassessments" revealed that RNs assessed Patient #1 each 12-hour shift 4/18/25 - 4/26/25. There was no documented evidence of changes in condition, abnormal vital signs, or signs or symptoms of dehydration noted in nursing assessments or physician notes leading up to the date and time of transfer.

Patient #1's fluid intake was documented as less than 1000 ML daily and there was no evidence that the physician was notified or additional interventions were implemented to address inadequate intake and output.

A review of Patient #1's medical record "Orders" on 4/26/25 at 4:06 PM signed by MD B revealed, "Urinalysis...Comprehensive Metabolic Panel...Complete CBC w/auto diff wbc...STAT"

A review of Patient #1's medical Record "Comprehensive Metabolic Panel" on 4/26/25 at 7:30 PM revealed, "...BUN 104 (normal range 6-20), Creatinine 3.19 (normal range 0.51 - 0.95)..."

A review of Patient #1's medical record "Registered Nurse Note" on 4/26/25 at 10:44 PM authored by RN L revealed, "Between the hours of 1900 (7:00 PM) and 2000 (8:00 PM) tonight, I received a call from the daughter of [Patient #1]. She called inquiring about the [Patient #1]'s most recent lab work. I informed her that [Patient #1]'s labs had not been resulted yet and she agreed to call back around 2100 (9:00 PM). At that time, [Patient #1's daughter] called back but I could not see [Patient #1]'s lab work. [Patient #1's daughter] stated that she would look for the labs on MyChart (patient portal) and call back tomorrow with any questions. At approximately 2200 (10:00 PM) as I was performing a dressing change in another patient's room, I received word from another RN that the paramedics were at the nurse's station. The RN stated that the paramedics had been called and sent by [Patient #1]'s son, who is a doctor per the family, to be taken to the ER for dehydration. Apparently, [Patient #1's son] had diagnosed the patient with dehydration based on her lab values. At 2208 (10:08 PM), I called [MD B] to express [Patient #1]'s family's concerns to her. Once [MD B] looked at the [Patient #1]'s labs, she agreed that [Patient #1] needed to be evaluated emergently based on an elevated BUN and creatinine."

A review of Patient #1's medical record revealed that Patient #1's STAT lab results were reported to MD B 6 hours and 2 minutes after they were ordered.

Patient #1 was transferred to an acute care hospital for a higher level of care on 4/26/25 for dehydration.

A review of Patient #6's medical record revealed that Patient #6 was admitted on 5/3/2025 and discharged on 5/24/2025. A review of Patient #6's medical record "Orders" on 5/5/2025 revealed, "Jevity 1.5 (tube feeding supplement)...Daily at 1900 (7:00 PM)...Nocturnal Feed...G-Tube (feeding tube)...Rate 84 ml (milliliters)/hr (hour)."

A review Patient #6's medical record revealed no intake documented for 4 days (5/8/2025 - 5/11/2025).

A review of Patient #9's medical record revealed that Patient #9 was admitted on 4/24/2025 and discharged on 5/4/2025. A review of Patient #9's medical record "Orders" on 4/29/2025 revealed, "275 ml of Jevity 1.5 4 times daily...by gravity over 30 minutes"

Review of Patient #9's medical record revealed no intake documented for 1 day (4/30/2025).

An interview was conducted on 8/12/25 at 11:15 AM with DON (Director of Nursing) N. When asked if fluids offered to patients are documented in the patient's medical record, DON N stated PCTs (Patient Care Technicians) usually document total shift fluid intake in the medical record after meals or at the end of shifts. When asked who reviewed the Intake and Output totals, DON N stated that it was the nurse's responsibility to review during reassessments, as well as the physician or Nurse Practitioner on daily rounding.

An interview was conducted on 8/12/25 at 4:00 PM with MD B. When asked if a creatinine of 3.19 was emergent for Patient #1, MD B stated that it was, as Patient #1's baseline creatinine was in the normal range.

An interview was conducted on 8/12/25 at 4:30 PM with Director of Quality (DOQ) O. DOQ O stated that the facility did not have a policy, procedure, or work direction for monitoring fluid balance or documenting intake and output.

An interview was conducted on 8/13/25 at 9:00 AM with DON N. DON N stated that it is the expectation that PCTs and RNs escalate all changes in condition and concerns to the physician or Nurse Practitioner.

Based on record review and interview, the facility failed to ensure discharge summaries were completed and retained in the medical record within 30 days of discharge for 4 of 8 discharged patients (Patient #1, #6, #7, and #9) in a total sample of 10 medical records reviewed.

Findings Include:

A review of Patient #1's medical record revealed Patient #1 was admitted to the facility on 04/17/2025 and discharged 04/26/2025. There was no discharge summary found within the closed medical record.

A review of Patient #6's medical record, Patient #6 was admitted on 5/3/25 and discharged on 5/24/25. There was no discharge summary found within the closed medical record.

A review of Patient #7's medical record, Patient #7 was admitted on 4/14/25 and discharged on 5/4/25. There was no discharge summary found within the closed medical record.

A review of Patient #9's medical record, Patient #9 was admitted on 4/24/25 and discharged on 5/4/25. There was no discharge summary found within the closed medical record.

An interview was conducted on 8/13/25 at 10:40 AM with MD (medical doctor) B. MD B stated that discharge summaries should be completed within 30 days.