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Based on document review and interview, the facility failed to communicate patient's plan of care in 1 out of 10 (Patient 4) medical records reviewed.

Findings Include:

1. Facility policy titled, "Patient Rights and Responsibilities" PolicyStat ID 13517670, last approved 04/2023, indicated family and/or agent, when appropriate, be informed of your care including unanticipated outcomes in order to participate in current and future decisions affecting the patient's care and to participate in the development and implementation of your plan of care.

2. Review of Patient 4's medical record lacked documentation of notification to patient's family of changes in medical condition and plan of care as follows:
a. Patient's diet change on 02/12/2024 from a regular diet to mechanical soft diet due to choking concerns.
b. Intravenous (IV) infusions were ordered on 02/14/24 and 02/21/24; IV access was placed by nursing personnel on 02/14/24 and 02/21/24; fluids administered per provider order.
c. Patient's refusal to eat or drink fluids and take medications from 02/15/2024 through 02/22/2024.

3. Interview with S1 (Clinical Therapist) on 03/20/24 at approximately 2:55 p.m. confirmed Patient 4's medical record lacked documentation of notification to patient's family of change in medical condition prior to 02/21/24.

4. Interview with A4 (Director of Clinical Services) on 03/20/24 at approximately 3:10 p.m. confirmed Patient 4's medical record indicated that patient was psychologically stable for discharge on 02/14/2024 and medical record lacked documentation of ongoing communication between social services and family regarding patient's placement after discharge after care conference on 02/06/2024.

5. Interview with P1 (Nurse Practitioner) on 03/21/24 at approximately 1:00 p.m. confirmed recommendation for hospice care due to patient's declining medical condition and the medical record lacked documentation of communication with patient's family prior to 02/21/24.

Based on document review and interview, nursing services failed to document daily hygiene care in 9 of 10 (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9) medical records reviewed; failed to document weekly weights per policy in 9 of 10 (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9) medical records reviewed; failed to document patient signature upon admission and discharge of personal belongings in 7 of 10 (Patients 2, 3, 4, 5, 6, 7, and 10) medical records reviewed, and failed to document removal of intravenous catheter prior to discharge in 1 of 10 (Patient 4) medical records reviewed.

Findings include:

1. Facility policy titled, "Patient Personal Care", PolicyStat ID 12197137, last approved 08/2022, indicated all patients shall be encouraged or assisted daily in grooming daily or more often as needed and patients who are incontinent shall be assisted with cleaning or bathing and in a manner that respects privacy.

2. Facility policy titled, "Vital Signs and Weights", PolicyStat ID 12386461, last approved 09/2022, indicated weights will be taken a minimum of once a week, unless diagnosis deems need for increased frequency weighing and the provider orders a more frequent schedule. Record vital signs and weekly weights in the patient's medical record.

3. Facility policy titled, "Management of Patient Belongings" PolicyStat ID 13950524, last approved 07/2023, indicated upon admission staff will inventory all patient belongings and sign Personal Belongings Inventory Form and patient will sign form.

4. Review of Patient 1's medical record lacked documentation of hygiene on 01/10/24, 01/11/24, 01/12/24, 01/13/24, 01/14/24, 01/15/24, 01/16/24, 01/17/24, 01/18/24, 01/19/24, 01/20/24, 01/21/24, 01/22/24, and 01/23/24 and documentation of weekly weights per policy on 01/10/24 and 01/17/24.

5. Review of Patient 2's medical record lacked documentation of hygiene on 01/16/24, 01/17/24, 01/18/24, 01/19/24, 01/20/24, 01/21/24, 01/22/24, 01/23/24, and 01/24/24; lacked documentation of weekly weights per policy on 01/17/24 and 01/24/24; and lacked documentation of patient's signature on Patient Personal Effects Inventory and documentation patient received personal items upon discharge.

6. Review of Patient 3's medical record lacked documentation of hygiene on 01/27/24, 01/28/24, 01/29/24, 01/30/24, 02/01/24; lacked documentation of weekly weights per policy on 01/31/24; and lacked documentation patient received personal items upon discharge.

7. Review of Patient 4's medical record lacked documentation of hygiene on 02/02/24, 02/03/2024, 02/04/24, 02/05/24, 02/06/24, 02/07/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24, 02/14/24, 02/15/24, 02/16/24, 02/17/24, 02/19/24, 02/20/24 and 02/22/24; lacked documentation of weekly weights per policy on 02/07/24, 02/14/24, and 02/21/24; lacked documentation patient received personal items upon discharge and was discharged without their hearing aids and upper dentures; lacked documentation that intravenous catheter was removed prior to discharge.

8. Review of Patient 5's medical record lacked documentation of hygiene on 02/07/24, 02/10/24, 02/11/24, 02/12/24, 02/14/24; lacked documentation of weekly weights per policy on 02/07/24 and 02/14/24; and lacked documentation of patient's signature on Patient Personal Effects Inventory and documentation patient received personal items upon discharge.

9. Review of Patient 6's medical record lacked documentation of hygiene on 02/11/24, 02/13/24, 02/14/24, 02/15/24, 02/16/24, 02/17/24, 02/20/24, and 02/21/24; lacked documentation of weekly weights per policy on 02/14/24 and 02/21/24; and lacked documentation of patient's signature on Patient Personal Effects Inventory and documentation patient received personal items upon discharge.

10. Review of Patient 7's medical record lacked documentation of hygiene on 02/24/24, 02/25/24, 02/26/24, 02/27/24, 02/28/24, 02/29/24, 03/01/24, 03/02/24, 03/03/24, 03/04/24, 03/05/24, 03/06/24, 03/07/24, 03/09/24, 03/10/24, and 03/13/24; lacked documentation of weekly weights per policy on 02/28/24, 03/06/24, and 03/13/24; and lacked documentation patient received personal items upon discharge.

11. Review of Patient 8's medical record lacked documentation of hygiene on 02/24/24, 02/25/24, 02/26/24, 02/27/24, 02/28/24, 02/29/24, 03/01/24, 03/03/24, and 03/04/24; and lacked documentation of weekly weights per policy on 02/28/24.

12. Review of Patient 9's medical record lacked documentation of hygiene on 03/08/24, 03/09/24, 03/10/24, 03/11/24, 03/14/24, 03/15/24, 03/16/24, and 03/17/24; and lacked documentation of weekly weights per policy on 03/13/24.

13. Review of Patient 10's medical record lacked documentation patient received personal items upon discharge.

14. Interview with A2 (Director of Quality and Risk) on 03/20/24 at approximately 4:00 p.m. confirmed the following:
a. Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9 lacked documentation of daily hygiene care as mentioned on the above dates and staff should document daily on the Patient Observation Form.
b. Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9 lacked documentation of weekly weights as mentioned on the above dates. Staff should document weekly weights on Wednesdays and document the weight on the Patient Observation Form.
c. Patients 2, 3, 4, 5, 6, 7, and 10 lacked documentation of confirmation of personal belongings upon admission and receipt of personal belongings upon discharge.