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Based on medical record review, staff interview and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care of patients (A395).

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a physician order was obtained for the implementation of non-violent restraints for one of two medical records reviewed for patients with restraints (Patient #4). The total sample was ten patients. The facility census was 33.

Findings include:

Review of the medical record of Patient #4 revealed the patient was admitted to the facility on 05/29/22 with a diagnosis of acute hypoxemic respiratory failure status post tracheostomy following a motorcycle accident. A nurse's note on 05/29/22 at 1:00 PM revealed that the patient arrived from an outside hospital with bilateral wrist and mitt restraints in place due to "pulling medical devices off." The decision was made that the restraints should remain in place as the patient was noted to be cognitively impaired. A physician order on 05/29/22 at 4:16 PM directed it was "okay to place bilateral wrist and mitt restraints."

A nurse's note on 06/09/22 at 8:00 PM stated the patient was found on the floor after a fall. The physician was notified and a STAT x-ray and CT scan were ordered as the patient was noted to be grimacing and complaining of back pain. A fall report revealed that although soft bilateral wrist restraints were on, neither were secured to the bed as required. Review of the restraint packet in the medical record revealed that although a restraint flowsheet was completed by staff nurses every two hours as required by facility policy, there was no physician order for the restraints on 06/09/22.

The facility policy titled, Restraints, last revised on 03/04/22, was reviewed on 11/29/22 at 9:00 AM. According to the policy, restraints are to be limited to situations in which an unsafe condition exists and alternative measures have been unsuccessful. A restraint is initiated only upon the order of a physician or other licensed independent practitioner responsible for the patient's care and authorized to order restraint use. The need for restraints must be reevaluated and orders to renew the use of restraints must be entered at least once every calendar day. The policy instructs staff nurses to observe the patient in restraints and document the following every two hours: Restraint status (released for comfort/safety, then reapplied); Ensure proper placement; Range of motion (ROM)/Ambulation; Position; Fluid/Nourishment; Toileting; Personal Hygiene; Behavior Observation; Level of consciousness/orientation.

Staff D was interviewed on 11/30/22 at 3:15 PM. It was confirmed that the medical record lacked documentation of a physician order on 06/09/22.

Based on medical record review, staff interview and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for two of ten patients reviewed (Patient #1 and #2). The facility census was 33.

Findings include:

1. Review of Patient #1's medical record revealed an initial bedside swallowing evaluation completed by the speech and language pathologist on 06/07/22 at 1:43 PM. The patient was identified as a high aspiration risk due to dysphagia. Per the documentation the patient developed dysphagia following self extubation of mechanical ventilation. Per the assessment the patient had decreased anterior/superior laryngeal movement during the pharyngeal phase and decreased lingual range of motion during the oral phase. The recommendation was 1:1 feeding assistance with a pureed diet texture and honey thick liquids. The goal was intake trials by mouth with supervision, and to increase laryngeal strength and range of motion. A dietary consult was recommended.

Per the physician documentation a consult for nutrition care was placed on 06/07/22 at 6:06 AM. The registered dietitian completed the initial nutrition consult on 06/07/22 at 12:21 PM and noted a current admission weight of 117 pounds with chewing difficulties, poor appetite, and poor oral intake. The patient was also noted to have wounds to the right ischium, coccyx, peri area/scrotum, right medial foot, and left and right heels. Per the evaluation the patient had an 8.2 percent weight loss since January 2022 with third degree severe malnutrition due to chronic injury/illness. The diet recommendation was level one with honey thick liquids and no straws, and one on one assist with all oral intake. This physician was in agreement with the recommendations.

Review of the weekly nutrition follow up completed by the registered dietitian dated 06/10/22 at 8:52 AM revealed not being able to assess oral intake due to missing documentation. On 06/07/22, 06/08/22, and 06/09/22 there was no percentage of intake documented for dinner.

Review of the weekly nutrition follow up completed by the registered dietitian on 06/15/22 at 8:58 AM revealed not being able to assess oral intake due to missing documentation. On 06/10/22 there was no percentage of intake documented for any meals, on 06/11/22 there was no percentage of intake documented for dinner, on 06/12/22 and 06/13/22 there was no percentage of intake documented for breakfast/lunch, and on 06/14/22 there was no percentage of intake documented for any meals.

Review of the weekly nutrition follow up completed by the registered dietitian on 06/21/22 at 9:02 AM revealed not being able to assess oral intake due to missing documentation. On 06/18/22 and 06/19/22 there was no percentage of intake documented for any meals, and on 06/20/22 there was no percentage of intake documented for lunch/dinner.

Review of the weekly nutrition follow up completed by the registered dietitian on 06/28/22 at 9:34 AM revealed not being able to assess oral intake due to missing documentation. The patient was noted to be on a potassium restricted diet and water restricted to 1200 milliliters/day. On 06/24/22 there was no percentage of intake documented for any meals, 06/25/22 and 06/26/22 there was no percentage of intake documented for dinner, and no percentage of intake documented for any meals on 06/27/22.

Review of the weekly nutrition follow up completed by the registered dietitian on 07/08/22 at 10:09 AM revealed not being able to assess oral intake due to missing documentation. On 07/05/22 and 07/06/22 there was no percentage of intake documented for any meals, and no percentage of intake documented for dinner on 07/07/22.

Review of the weekly nutrition follow up completed by the registered dietitian on 07/13/22 at 3:35 PM revealed not being able to assess oral intake due to missing documentation. On 07/10/22 there was no percentage of intake documented for dinner, and on 07/11/22 and 07/12/22 there was no documented percentage of intake for any meals.

Review of the weekly nutrition follow up completed by the registered dietitian on 07/19/22 at 10:21 AM revealed on 07/14/22 and 07/15/22 there was no percentage of intake documented for lunch, on 07/16/22 there was no percentage of intake documented for dinner, and on 07/18/22 there was no percentage of intake documented for any meals.

Review of the weekly nutrition follow up completed by the registered dietitian on 07/27/22 at 11:36 AM revealed on 07/25/22 there was no percentage of intake documented for breakfast/lunch and 25% intake of dinner. Review of the nursing documentation at 5:00 PM the patient reported to the nurse he was not hungry. The registered nurse noted at 9:00 PM family was at the bedside feeding the patient.

Further review of the bedside clinical care record throughout the entire hospitalization (06/06/22 through 08/08/22) revealed no documentation that the patient was assisted one on one with all meals as recommended/ordered. The documentation consistently lacked evidence of the percentage of meal intakes for a proper nutrition assessment.

Further review of Patient #1's medical record revealed the patient arrived to the hospital with a urinary catheter and later transitioned to a urinal. The patient had episodes of spilling the urine and agreed to a condom catheter with incidents of bowel incontinence noted. Review of the patient care records from 06/07/22 through 08/08/22 revealed a box for staff to initial for an hourly incontinence care check. The following dates lacked evidence the nurse conducted the hourly rounding as described:

* 06/08/22 no documentation from 7:00 AM through 8:00 PM
* 06/09/22 no documentation from 7:00 AM through 6:00 PM
* 06/10/22 no documentation from 7:00 AM through 6:00 PM
* 06/29/22 no documentation from 7:00 AM through 4:00 AM
* 07/01/22 no documentation from 8:00 AM through 6:00 PM
* 07/05/22 no documentation from 7:00 AM through 6:00 PM
* 07/06/22 no documentation the entire day
* 07/09/22 no documentation from 7:00 AM through 6:00 PM
* 07/15/22 no documentation from 7:00 AM through 6:00 PM
* 08/01/22 no documentation from 6:00 PM through 6:00 AM
* 08/03/22 no documentation the entire day
* 08/07/22 no documentation from 7:00 PM through 6:00 AM

An interview was conducted with Staff C on 11/29/22 at 1:31 PM who confirmed the percentage of meal intakes was not documented. Staff C stated the expectation was that meal intakes would be documented and supervision provided. Further interview with Staff C reported the the facility implemented hourly rounding to include the 5 P's which included pain, position, potty, periphery, and pump. The patient care technicians rounded on even hours and the nurses rounded on the odd hours. Staff C confirmed the lack of documentation that hourly rounding was completed. Staff C reported the expectation was that staff documented hourly rounding. It was further stated it may have been done and just not documented.


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2. Review of the medical record of Patient #2 revealed the patient was admitted on 08/05/22 at 10:20 PM for continued treatment of multiple pressure injuries including back, buttocks, bilateral heels, and an infected stage 4 sacral decubitus ulcer (a deep wound reaching the muscles, ligaments, or bones) with underlying osteomyelitis (bone infection) with resistant Acinetobacter and Enterobacter urinary tract infection. The nursing assessment on admission revealed the patient was 6 feet 6 inches tall and weighed 226 pounds. The attending physician ordered for nursing staff to weigh the patient daily and also ordered nursing staff to monitor strict intake and output. The patient was ordered a carbohydrate controlled diet. A consult note composed by a facility dietician on admission stated the goal was for the patient's oral intake to be greater than 50 percent as the patient had been diagnosed with severe malnutrition. Among other recommendations, the dietician's plan included encouragement and document percentage of oral intake and to monitor weight.

The intake/output flowsheets and graphic records from 08/05/22 through 09/07/22 were reviewed. The top 1/4 of the flowsheet provided space for nutrition information, including breakfast, AM snack, lunch, afternoon snack, dinner, and PM snack percentages consumed. Meal/snack consumption percentages were also noted at the bottom of the graphic record.

Staff D was interviewed on 11/29/22 at 5:40 PM. Staff D stated that nursing staff were required to document nutrition information on at least one of the forms but not both. On 08/07/22 the graphic record noted the patient consumed 50 percent of breakfast, refused lunch, and was silent to the dinner consumption. On 08/09/22 the graphic record was again silent to the patient's dinner consumption and noted the patient consumed 25 percent of breakfast. Neither the graphic record nor intake/output flowsheets noted the dinner consumption on 08/10/22. From 08/11/22 through 08/13/22, the graphic record revealed that the patient refused all meals/snacks. The medical record lacked documentation a provider was notified. On 08/17/22 neither the intake/output flowsheet nor the graphic record noted a meal/snack consumption percentage. On 08/23/22, again neither the intake/output flowsheet or the graphic record noted a meal/snack consumption percentage. On 08/24/22 the intake/output flowsheet noted only that breakfast had been set up and the patient consumed 75 percent of the meal. There was no documentation of lunch, dinner, or snack consumption percentage noted.

A dietician's note dated 08/24/22 stated that the patient complained that a breakfast tray containing scrambled eggs, toast, bacon, and milk was dropped off in the morning, however, it became cold as he was sleeping and no one woke him up to eat it. The patient reported that he did not eat any of the breakfast. Again on 08/31/22 and 09/01/22 neither the intake/output flowsheets nor the graphic records noted consumption percentages for any meals. The last two days of this patient's hospitalization, 09/06/22 and 09/07/22, also lacked documentation of any meal consumption percentage.

The patient was transferred to another facility on 09/07/22 for a gastrointestinal evaluation and possible colonoscopy due to a sudden drop in his hemoglobin. The patient was admitted to the facility again on 09/11/22. A physician's note on readmission stated it was felt that the patient's anemia was likely due to malnutrition and chronic underlying disease. A physician again ordered for staff to monitor intake and output strictly. Review of both the intake/output flowsheet and graphic record during the second admission revealed there were no meal consumption percentages documented. The patient was discharged to a skilled nursing facility on 09/15/22.

On admission, on 08/05/22, Patient #2 weighed 226 pounds. Although a physician ordered for the patient to be weighed daily, the medical record lacked documentation the patient was weighed until 08/14/22, nine days later. The patient weighed 206 pounds. A staff member weighed the patient again 11 days later, on 08/25/22. The patient weighed 203 pounds. The patient was weighed on 09/03/22 and 09/04/22, and weighed 203 pounds.

The facility policy titled, Guidelines for Nursing Care (NSG 24), last revised on 3/28/22, was reviewed on 11/29/22 at 9:20 AM. According to the policy, in order to ensure quality patient care, certain standards of care must be upheld. Nursing tasks listed under nutrition and fluids instructed nursing staff to weigh patients on admission and as ordered by a physician. The policy also instructed nursing staff to total patient intake and output as ordered by a physician.

Staff A was interviewed on 11/29/22 at 2:30 PM. Staff A stated that strict intake and output meant that all patient intake and output must be monitored and documented as it occurred. It was confirmed that strict intake and output was not performed by staff as the medical record lacked documentation of daily percentages of meals consumed. It was also confirmed that the medical record lacked documentation the patient was weighed daily as ordered by a physician.

This deficiency represents non-compliance investigated under Substantial Allegation OH00136709.