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Based on document review, observation, medical record review, and staff interview, the hospital's nursing staff failed to adequately assess each patient, then plan and implement care for changes in patient needs, and comply with the hospital's policies and procedures to assure the provision of adequate nursing care for 1 (of 1) severely compromised elderly patient suffering from Parkinson's disease with dementia and Bipolar Disorder (Patient #1). Medical record review included 3 of 6 open records and 7 closed records chosen from patients cared for on the Older Adult Behavioral Health Unit.

Findings include:

The hospital's nursing management staff failed to ensure nurses, assigned to the Older Adult Behavioral Health Unit, assured the following.

1. Nursing staff completed and documented a comprehensive nursing assessment at admission or at the time of any change in condition for Patient #1, a severely compromised 87-year-old patient with Parkinson's Disease with dementia and Bipolar Disorder, on a consistent basis. (See A-392)

2. Nursing staff monitored, reported, and documented Patient #1's intake to ensure adequate intake of food and fluids daily to prevent the development of severe dehydration, severe malnutrition, and acute renal failure. (See A-395)

3. Nursing staff monitored, reported, and documented changes in Patient #1's physical condition including changes of an increasing refusal to eat or drink, significant weight loss within a two month period of time, and the patient's declining physical condition. (See A-395)

4. Nursing staff failed to maintain a current nursing care plan for Patient #1 showing it was updated to include all patient needs and planned interventions. (See A-396)

5. Management staff failed to ensure the unit's nursing staff followed hospital policies regarding nursing assessments, providing nursing care based on patient needs, documentation, and care plan development. (See A-392, A-395, and A-396)

The cumulative effect of these systemic failures and deficient practices resulted in the hospital's nursing staff failing to adequately assess or recognize the significance of Patient #1's changes in condition and failure to plan appropriate interventions to address the health changes of Patient #1 during his/her stay in the Older Adult Behavioral Health Unit. These failures of the nursing staff placed Patient #1 at high risk for dehydration, malnutrition, and development of life threatening illnesses or death. After a two month stay, the patient was transferred to the Intensive Care Unit and diagnosed with dehydration, malnnutrition, and in renal failure.

Based on policy/procedure review, medical record review, and staff interviews, the hospital failed to ensure nursing staff in management positions and those on the Older Adult Behavioral Health Unit failed to ensure nursing staff conducted ongoing assessments of the immediate and changing care needs for Patient #1 during his/her two month stay on the unit. The unit staff reported an average daily census of 6 inpatients.

Failure of the nursing staff to assure the Registered Nurse (RN) conducted nursing assessments for Patient #1, an 87-year-old patient resulted in the patient's eventual transfer to the Intensive Care Unit (ICU) in acute renal failure with severe dehydration, severe malnutrition, and eventually led to the patient's transfer from the ICU to a hospice. The patient died a week after the transfer.

Findings include:

1. Review of hospital policy titled "Patient Care", reviewed 2/11, revealed the following:
"The RN [Registered Nurse] is responsible and accountable for obtaining the initial assessment upon admission of the patient .... Time frames and guideline for reassessments is determined by ...patients' care guidelines... Additional or more in-depth assessments are done under the following circumstances: Changes in the patients'...vital signs, critical lab values...unexpected changes in weight and unexpected changes in intake and output."

2. Review of hospital policy titled "Documentation", reviewed 11/10, revealed the following:
"Nursing documentation in the medical record reflects the nursing process and includes the following critical elements: 1. Initial assessment/evaluation performed by an RN, and all required reassessments specific to the patients' condition...3. Nursing interventions planned or nursing standards used to address... the patients' needs...The RN is responsible for the patient:...assures that all information pertinent to the care of the patient is included in the medical record:..."

3. Review of Employee Job Description, Title RN-Acute, date reviewed June 2005, revealed in part: "Provides nursing care for patients...Collaborates with physicians and other health care workers to assess, plan, implement, and evaluate patient care while maintaining standards for professional nursing practice in the clinical setting."

4. Nursing staff reported that staffing for the unit was usually 2 Registered Nurses and 2 Patient Care Technicians for the day and evening shifts and 1 Registered Nurse and 1 Patient Care Technician on the night shift.

5. Review of Patients #1's medical record revealed it did not include evidence that nursing staff provided essential nursing care based on ongoing assessments of Patient #1's medical condition, significant weight loss, and changes in the patient's behavior. Review of Patient #1's medical record revealed the Patient #1 was admitted to the Older Adult Behavioral Health Unit on 11/10/11 for treatment of Bipolar Disorder, dementia secondary to Parkinson's disease, and diabetes. Patient #1 transferred to the unit from a long term care nursing facility due to increasing agitation, aggression, and changes in behavior.

Review of long term care Facility G's transfer form, dated 11/10/11, revealed the following patient care needs at the time of the patient's admission to the Older Adult Behavioral Health Unit: the patient needed the assistance of one for activities, was independent in eating/drinking, was alert, had some short-term memory loss, and was incontinent.

The Physician History and Physical, completed on 11/11/11, revealed in part:
- Mental Status: Upon arrival the patient was agitated, requiring multiple doses of Ativan (anti anxiety medication), as well as soft, wrist restraints in a geri chair (chair equipped with a tray used to prevent a patient from standing up).
- Physical Examination: The patient is a 87-year-old elderly male who appears well nourished. Patient is confused and not orientated to person, place, or time. Vital Signs: Pulse 105, Respirations 16, and Blood Pressure 127/89. Ambulation is unsteady and patient is to be up with assistance of two.

Review of the Adult Mental Health Daily Care Record (completed twice daily), from 11/11/11 to 1/11/12, revealed in part: Nursing staff documented Patient #1's vital signs, weights, activities, and appetite at meals. Over the patient's two month length of stay on the unit, Patient #1's medical record revealed a consistent decline in his appetite but lacked any documentation of the patient's fluid intake.
During this two month period, nursing staff documented the following rapid weight loss in Patient #1's medical record,
201 pounds on 11/11/11; 198 pounds on 11/14/11 ; 189 pounds on 11/25/11; 187 pounds on 12/5/11; 185 pounds on 12/12/11 (a loss of 16 pounds in about one month or 8%);183 pounds on 12/23/11; 174 pounds on 1/6/12; and 162 pounds on 1/11/12, at the time of the patient's admission to the ICU (a loss of another 23 pounds or 12.4 %)..
From the time of admission to the Older Adult Behavioral Health Unit on 11/11/11 to the time of the patient's transfer to the ICU on 1/11/12, Patient #1 had a significant and involuntary weight loss of 39 pounds, became severely malnourished, and developed severe dehydration. The patient's ICU physician documented the patient was low 5 liters of body fluids.
Review of the Daily Assessment Record, from 11/11/11 to 1/11/12, revealed in part: Nursing staff used the Daily Assessment Record to document mental health assessments (mood, behavior, safety, memory, judgement, physical concerns, etc) once on the day shift and once on the evening shift. Patient #1's record lacked consistent daily documentation of nursing assessments regarding Patient #1's food and fluid intake or any nursing interventions planned or implemented to encourage or assist the patient to increase his /her food and fluid intake.

On 1/11/12 hospital Dietician B completed a nutrition assessment on Patient #1 in the ICU. Dietician B documented the following: Chart reviewed due to weight loss of over 38 pounds in the past 60 days. Intakes during admission to Older Adult Behavioral Health Unit were consistently inadequate. Status: Patient meets criteria for severely malnourished status due to intake, weight loss, and malnutrition.

During an interview on 3/7/11 at 11:00 AM, Dietician B reported that nursing assessment of a patient on admission will determine if a dietary consult is requested. If a patient does not receive a dietary assessment on admission, dietary will see the patient after 30 days of hospitalization. Dietician A assessed Patient #1 on 12/11/11 for an initial assessment as the patient had been in the Older Adult Behavioral Health Unit over 30 days. Dietitian A recommended adding milk shakes on each tray and directed the unit nursing staff to encourage Patient #1 to drink the shakes.

Dietician B also stated Patient #1 experienced involuntary weight loss. The patient lacked the mental ability to recognize that he/she was losing weight. He/she needed efforts, by nursing staff, to try to encourage him/her to eat at every meal. The nurses' documentation revealed the patient refused to eat or drink and had a steady decrease in the amount of food and fluids consumed during his/her two month hospital stay. The medical record lacked documentation that nursing staff was aware of the weight loss, addressed the weight loss, or attempted to prevent the patient's continued weight loss and severe dehydration.

Patient #1's medical record lacked documentation showing the nursing staff assessed the patient's weight loss and lack of fluid intake. Nursing staff failed to document any interventions to increase the patient's intake or of reporting the patient's declining physical condition and weight loss to the patient's physician or to consult with a hospital dietician for assistance to increase the patient's intake.

6. During an interview, on 3/7/12 at 9:00 AM, Staff C, RN stated that nursing staff is responsible for completion and documentation of the daily nursing assessment. Staff C also reported that the nursing assessment is a complete "head to toe" assessment of the patient including any physical and/or mental changes. These change would include changes in appetite, refusal of meals or fluids, and weight loss. Staff C agreed that Patient #1's medical record lacked evidence that nursing staff documented any of the above.

7. During an interview, on 3/7/12 at 11:00 AM, Staff E, RN reported that hospital policy requires nursing staff to complete and document a complete "head to toe" assessment of every patient on the Older Adult Behavioral Health Unit. Staff E continued that the RN assesses the patient and is responsible to document any physical and/or mental changes. These changes would include changes in vital signs, appetite, refusal of meals or fluids, and weight loss. Staff E agreed that Patient #1's medical record lacked evidence that nursing staff documented any of the above.

8. During an interview, on 3/7/12 at 1:00 PM, Staff F, RN stated that nursing staff are responsible for documentation of all nursing assessments. This includes vital signs, food and fluid intake, and any changes in the patients' condition. Staff F reported that this information is documented in the Daily Assessment Record and the Adult Mental Health Daily Care Record. Staff F agreed that Patient #1's medical record lacked evidence of complete nursing assessments that included changes in his/her condition.

9. During an interview, on 11/7/11 at 3:00 PM, Staff H, Director of Behavioral Health Services, acknowledged that Patient #1's medical record lacked consistent daily nursing assessments that addressed the patient's decrease in eating/drinking, significant weight loss, and declining physical condition. Staff H also acknowledged that nursing staff are responsible for providing nursing care specific to the patient's needs, documentation of the nursing care, and communicating pertinent information to other healthcare providers.

Based on policy/procedure review, observations, medical record review, and staff interviews, the hospital failed to ensure a Registered Nurse conducted ongoing assessments, implemented interventions, and documented Patient #1's changing needs during the patient's two-month hospitalization. 3 of 6 open medical records and 7 closed medical records, chosen from patients cared for on the Older Adult Behavioral Health Unit, were reviewed.

Over a two-month period, failure of Registered Nurses (RN) to assure staff provided appropriate nursing care to a physically and mentally compromised 87-year-old patient contributed to the patient's transfer to the Intensive Care Unit (ICU) in acute renal failure with severe dehydration and severe malnutrition.

Findings include:

1. Review of hospital policy titled "Patient Care", reviewed 2/11, revealed the following:
"The RN is responsible and accountable for obtaining the initial assessment upon admission of the patient ....Time frames and guideline for reassessments is determined by ...patient care guidelines... Additional or more in-depth assessments are done under the following circumstances: Changes in the patients'...vital signs, critical lab values; ...unexpected changes in weight and unexpected changes in intake and output."

2. Review of hospital policy titled "Documentation", reviewed 11/10, revealed the following:
"Nursing documentation in the medical record reflects the nursing process and includes the following critical elements: 1. Initial assessment/evaluation performed by an RN, and all required reassessments specific to the patients' condition...3. Nursing interventions planned or nursing standards used to address the patients' needs... The RN is responsible for the patient:...assures that all information pertinent to the care of the patient is included in the medical record...."

3. Observations on 3/5/12 at 2:30 PM, with the Staff H, Acting Manager of the Older Adult Behavioral Health Unit, revealed a central day room and patient rooms that lacked drinking cups, water pitchers, or any other drinks/beverages readily available to the patients. In addition, 4 of the 6 inpatients were observed sitting in the day room in recliners with their feet elevated. During the one hour spent on the Older Adult Behavioral Health observation did not find nursing staff offering water or any other fluids to the patients.

At the time of the observation, Staff H confirmed the above observation and reported it is nursing staff's responsible to provide drinks to patients who are unable to walk to a drinking fountain or to their bathroom sink. Staff H also reported that patients in recliners or geri chairs are patients who are unable to ambulate unassisted and they rely on nursing staff to provide meals/drinks to them or would have to request a drink from the nursing staff. Staff H acknowledged that many patients on the Older Adult Behavioral Health Unit would not be capable of requesting fluids due to their psychiatric diagnosis or their inability to identify the need for sufficient fluids due to the aging process.

4. Review of the transfer form that accompanied Patient #1 from a long term care facility to the hospital, dated 11/10/11, revealed that in the nursing home the patient needed the assist of one staff for activities, was alert and independent in eating, but had some short-term memory loss and was incontinent.

The hospital admitted Patient #1 to the Older Adult Behavioral Health Unit on 11/10/11 for treatment of Bipolar disorder, dementia secondary to Parkinson's disease, and diabetes. Patient #1 transferred to the unit due to increasing agitation, aggression, and a change in behavior.

On admission the initial assessment of Patient #1 was held (not immediately completed) due to his/her striking two staff members. As a result, nursing staff administered Ativan (anti anxiety medication also used to reduce aggressive behaviors). Nursing assessment on 11/11/11 revealed Patient #1 ate at least three-fourths to all of his/her meals that day and was able to feed himself/herself.

The Physician History and Physical, completed on 11/11/11, revealed in part: Mental Status: Upon arrival the patient was agitated, requiring multiple doses of Ativan as well as soft, wrist restraints in a geri chair [a chair equipped with a tray used to prevent a patient from standing up].

Physical Examination: The patient is a 87-year-old elderly [person] who appears well nourished. Patient is confused and not orientated to person, place, or time. Vital Signs: Pulse 105, Respirations 16, and Blood Pressure 127/89. Ambulation is unsteady and patient is to be up with assistance of two.

Review of the Behavioral Health Attending Physician Daily Progress Notes from 11/12/11 to 1/9/12 revealed a Psychiatrist evaluated Patient #1 daily and documented this evaluation on the Daily Progress Notes. However, Progress Notes lacked identification of Patient #1's weight loss until 12/7/11 (27 days after admission) when the Psychiatrist documented, "Family concerned about weight loss but patient was [189 pounds] on 11/28/11 and [188.5 pounds] on 12/5/11". The Psychiatrist failed to document that Patient #1 weighed 201 pounds on admission (11/11/11) and that would have shown a 13 pound weight loss in a 3 week time period. The Daily Progress Notes lacked further assessment of Patient #1's weight loss.

On 1/4/12, the Psychiatrist noted under "Treatment Plan: 1.) [Increase] fluids". Review of the Physician Order Sheet for 1/4/12 lacked evidence that the Psychiatrist ordered the increase in fluids or in anyway notified nursing staff to increase fluids for Patient #1.

Review of the Adult Mental Health Daily Care Record (completed twice each day), from 11/11/11 to 1/11/12, revealed that nursing staff documented Patient #1's vital signs, weight, activities, and appetite at meals. Over the patient's two-month length of stay on the unit, Patient #1's medical record revealed a consistent decline in his appetite but did not include any documentation of the patient's fluid intake.

Over a two-month period nursing staff documented the following weights for Patient #1:
201 pounds on 11/11/11; 198 pounds on 11/14/11 ; 189 pounds on 11/25/11; 187 pounds on 12/5/11; 185 pounds on 12/12/11 (a loss of 16 pounds in about one month or 8%);183 pounds on 12/23/11; 174 pounds on 1/6/12; and 162 pounds on 1/11/12, at the time of the patient's admission to the ICU (a loss of another 23 pounds or 12.4 %).

From the time of admission to the Older Adult Behavioral Health Unit on 11/11/11 to the time of the patient's transfer to the ICU on 1/11/12, Patient #1 had a significant and unplanned weight loss of 39 pounds in a two month period (19.4%), was severely malnourished, and so severely dehydrated that the patient's ICU physician documented the patient was low 5 liters of body fluids. (Review of studies regarding unintentional weight loss in elderly people by the Canadian Medical Association Journal on March 15, 2005 included that significant weight loss of 4-5% or more within one year is associated with increased likelihood of death. Guidelines for Long Term Care Facilities for the past 20 years has also identified that a loss of 5% body weight in one month or 7.5% in three months is significant.)

Review of the Daily Assessment Record, from 11/11/11 to 1/11/12, revealed in part: Nursing staff used the Daily Assessment Record to document mental health assessments (mood, behavior, safety, memory, judgement, physical concerns, etc.) once on the day shift and once on the evening shift. However, Patient #1's record did not include consistent daily documentation of nursing assessments regarding Patient #1's food and fluid intake or any nursing interventions planned or implemented to encourage or assist the patient to increase his/her food and fluid intake. Nursing staff did document that the patient ate three-fourths to a full meal at admission, but in the weeks prior to Patient #1's transfer to the Intensive Care Unit nursing staff documented that Patient #1 ate/drank bites at meal time or refused to eat/drink at all.

On 1/11/12, when the patient had been transferred to ICU, hospital Dietitian B completed a nutrition assessment on Patient #1. Dietitian B documented the following: Chart reviewed due to weight loss of over 38 pounds in the past 60 days. Intakes during admission to Older Adult Behavioral Health Unit were consistently inadequate. Status: Patient meets criteria for severely malnourished status due to intake, weight loss, and malnutrition.

During an interview on 3/7/11 at 11:00 AM, Dietitian B reported that nursing assessment of a patient on admission will determine if a dietary consultation is requested. If a patient does not receive a dietary assessment on admission, dietary will see the patient after 30 days of hospitalization. Dietitian A assessed Patient #1 on 12/11/11 for an initial assessment as the patient had been a patient in the Older Adult Behavioral Health Unit for over 30 days. Dietitian A recommended adding milk shakes on each tray for Patient #1 and directed the unit nursing staff to encourage Patient #1 to drink the shakes.

Dietitian B also stated Patient #1 experienced involuntary weight loss (which meant that Patient #1 was not trying to lose weight). The patient did not have the mental ability to understand that by not eating or drinking he/she was becoming malnourished and dehydrated. The patient needed efforts by nursing staff to try to encourage him/her to eat at every meal. The nurses' documentation revealed the patient refused to eat or drink and had a steady decrease in the amount of food and fluids he/she consumed during his/her two month hospital stay. However, Patient #1's medical record did not include that nursing staff provided the patient the shakes with his/her meals, what percentage of the shake was consumed, or if this information was reported to dietary and/or the physician. Documentation did not include other actions taken by staff to prevent the patient's continued weight loss or dehydration.

Patient #1's medical record did not include nursing staff documentation of interventions to increase the patient's intake, report of continued weight loss to the patient's physician, or consultation with a hospital dietitian for additional methods to increase the patient's intake and weight.

After the patient transferred to ICU, staff gave Patient #1 IV (intravenous) fluids but the patient remained in critical condition. Patient #1's family decided to transfer Patient #1 to hospice for end-of-life care. At discharge, on 1/13/12, Patient #1 was critically ill, but stable. Patient #1 died on 1/20/12.

During an interview, on 3/7/12 at 9:00 AM, Staff C, RN, stated that nursing staff document the patient's intake at every meal. Staff C also stated that all patients are weighed weekly and that if the patient is losing weight or has a change in condition the nurses will notify the physician and ask for a medical and/or dietary consult. However, Staff C agreed that Patient #1's medical record did not include evidence that nursing staff documented any of the above information.

5. During an interview, on 3/7/12 at 11:00 AM, Staff E, RN, stated that nursing staff are responsible for documentation in the patient's medical record. This includes vital signs, food/fluid intake, and any changes in the patient's condition. The physician is called with any change in the patient's condition including changes in vital signs, appetite, weight, behavior, or refusal of medication. Staff E stated, "There is no schedule for walking patients or for offering them drinks. The patients get food and drinks at meal times only." Staff E agreed that most of the patients on the unit are not able to make their needs be known, but rely on staff to meet their needs. Staff E reported, "We [i.e., nursing staff] do not do a good job of documentation. A lot of things that we do for the patients is not in the medical record. There just isn't time."

6. During an interview, on 3/7/12 at 1:00 PM, Staff F, RN, stated that nursing staff are responsible for documentation in the patient's medical record. This includes vital signs, food/fluid intake, and any changes in the patient's condition. The physician is called with any change in the patient's condition including changes in vital signs, appetite, weight, behavior, or refusal of medication. Staff F stated, "The patients get food and drinks at meal times only. We do not offer food or drinks between meals except at medication time." Staff F agreed that most of the patients on the unit are not able to communicate their needs to staff, but rely on staff to meet their needs. Staff F reported that these patients, "Are elderly and at the end stage of their diseases. They may get malnourished or dehydrated, but there isn't much we can do about it."

7. During an interview on 3/7/12 at 1:00 PM, Physician C reported responding to the Older Adult Behavioral Health Unit as the nurses were concerned about the medical condition of Patient #1 on 1/11/11 at 3:00 AM . Patient #1 was unresponsive and breathing very quickly. The patient was transferred to the ICU and was immediately given Intravenous (IV) fluids. The physical exam and lab tests determined that the patient was severely dehydrated. His/her body was lacking at least 5 liters of fluid, was severely malnourished, and the patient was in acute renal failure.

Based on policy/procedure review, document review, and staff interviews, the hospital failed to ensure that nursing staff updated changes in Patient #1's condition on the nursing care plan as the patient lost weight and refused to eat or drink. Medical record review included 3 of 6 open records and 7 closed records (as well as care plans), chosen from patients cared for on the Older Adult Behavioral Health Unit.

The care plan provides direction for the individualized care of each patient and is used to communicate these directions to nursing, physicians, and other health care professionals to ensure continuity of care. Failure of the nursing staff to update the plan of care for a physically and mentally compromised elderly patient led to the patient's transfer to the Intensive Care Unit (ICU) in acute renal failure caused by severe dehydration and severe malnutrition following a two month inpatient stay on the Behavioral Health Unit.

Findings include:

1. Review of the hospital policy titled "Patient Care", reviewed 2/11, revealed the following:
"Plan of Care... The scope of the plan is determined by anticipated needs of the patient and is reviewed and revised, as the patient needs change. Documentation in the medical record shall reflect the plan of care."

2. Review of the hospital guidelines "Quick Guide to Patient Checks/Frequency, Minimum Guidelines", provided by the Director of Adult Behavioral Health Services on 3/8/11, revealed the following: "Behavioral Inpatient...Care Plan - Admission and progress towards goals each day and evening."

3. Review of the hospital policy titled "Nursing Services", reviewed 2/11, revealed the following: "Nursing Care Planning ...Plans of care are developed within 24 hours of admission for all patients except for those in observation status. The plan of care is updated as patient needs change."

4. Review of Patient #1's medical record revealed:

An initial nursing assessment, completed on 11/10/11 at 8:00 PM, documented Patient # 1's "...supper tray taken into room - patient did sit up and eat a small amount...." Nursing staff also documented that the patient was unsteady on his/her feet and required assistance of two staff to ambulate. Staff documented Patient #1 needs assistance with all activities of daily living (ADL) including eating and drinking.

Over a two month period nursing staff documented the following weights for Patient #1:
201 pounds on 11/11/11; 198 pounds on 11/14/11 ; 189 pounds on 11/25/11; 187 pounds on 12/5/11; 185 pounds on 12/12/11 (a loss of 16 pounds in about one month or 8%);183 pounds on 12/23/11; 174 pounds on 1/6/12; and 162 pounds on 1/11/12, at the time of the patient's admission to the ICU (a loss of another 23 pounds or 12.4 % in one month).

From 11/11/11 to 1/11/12, Patient #1 had an unplanned, significant weight loss of 39 pounds within two months (19.4%), became severely malnourished, and so severely dehydrated that the ICU physician documented the patient was low 5 liters of body fluids at the time of the patient's transfer to the ICU.

Dietician A assessed Patient #1 on 12/11/11 and recommended adding milk shakes on each meal tray and directed the unit nursing staff to encourage Patient #1 to drink the shakes. However, review of Patient #1's written care plan did not include an update that required nursing staff to provide the shakes with meals, to document what percentage of the shake was consumed, or if this information was reported to dietary and/or the physician.

Review of the "Priority Problem" list for Patient #1, dated 11/10/11, revealed "Altered Physical Status... Intervention: Provide food items/nutritional supplements as needed, Monitor intake and output...Responsible Discipline: ... Nursing." However, nursing staff failed to document Patient #1's progress towards the "Priority Goal" each day or to update the care plan at any time in response to Patient #1's significant weight loss and refusal to eat or drink. The care plan also lacked documentation of possible nursing interventions to encourage Patient #1 to eat or drink.

(Review of studies regarding unintentional weight loss in elderly people by the Canadian Medical Association Journal on March 15, 2005 included that significant weight loss of 4-5% or more within one year is associated with increased likelihood of death. Guidelines for Long Term Care Facilities for the past 20 years has also identified that a loss of 5% body weight in one month or 7.5% in three months is significant.)

5. During an interview, on 3/7/12 at 9:00 AM, Staff C, RN (Registered Nurse), stated unit nursing staff are responsible for the initiation of the patients' care plan within 24 hours of admission. The RN is responsible for identifying potential problems based on the RN's initial assessment, identifying short term goals, and possible interventions. Staff C reported that the care plan is reviewed twice a day and the patient's progress towards the short term goal is evaluated. Staff C stated that nursing staff document the progress or lack of progress in the Daily Assessment Record. Staff C agreed that Patient #1's medical record lacked evidence that nursing staff documented Patient #1's progress towards the "Priority Goal" each day and failed to update the care plan in response to Patient #1's continuous and significant weight loss and refusal to eat or drink even though it was listed as a Priority Problem for Patient #1.

6. During an interview, on 3/7/12 at 11:00 AM, Staff E, RN, stated that nursing staff are responsible for the initiation of the patients' care plan. The RN is responsible for identifying potential problems, identifying short term goals, and listing possible interventions. Staff E reported that the care plan is reviewed twice a day and each patient's progress towards the short term goal is evaluated and documented in the Daily Assessment Record. Staff E agreed that Patient #1's medical record lacked evidence that nursing staff documented Patient #1 s' progress towards the "Priority Goal" each day and failed to update the care plan in response to Patient #1's significant weight loss and refusal to eat or drink. Staff E also reported that the care plans "are not used by nursing staff to assist with patient care. The care plans are initiated on admission and then closed at the patient's discharge. We just do not have the time."

7. During an interview, on 3/7/12 at 1:00 PM, Staff F, RN. stated that according to hospital policy nursing staff are responsible for the initiation of the patients' care plan. The RN is responsible for identifying potential problems, identifying short term goals, and listing possible interventions. Staff F reported that the care plan is supposed to be reviewed twice a day and the patient's progress towards the short term goal is evaluated and documented in the Daily Assessment Record. Staff F agreed that Patient #1's medical record lacked evidence that nursing staff documented Patient #1's progress towards the "Priority Goal" each day and failed to update the care plan in response to Patient #1's significant weight loss and refusal to eat or drink. Staff F also reported that care plans, "Honestly are a waste of time and they are not used by nursing staff. The care plans are initiated on admission and then closed at the patient's discharge."