HospitalInspections.org

Based on record review and interview, the facility failed to meet the requirements for the Condition of Participation of Patient Rights. The facility failed to:

A. Monitor and assess a patient placed in seclusion (see tag A-175);

B. Ensure seclusion orders were not written as PRN for 1 of 2 patients (see tag A-169);

C. Ensure Restraint/Seclusion orders were renewed after four hours (tag A-171);

D. Obtain orders for seclusion for 1 of 2 patients (tag A-168); and

E. Develop and implement a policy that fully addressed required regulatory requirements for monitoring and assessing patients placed in seclusion (see tag A-175).

Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Nursing Services. This failure had the potential to affect all patients receiving services in the hospital.

RN nursing staff failed to :

a. Perform & accurately document patient assessments : infection control screening and skin / wound assessments;

b. Accurately document post-fall information;

c. Develop and implement a hydration policy for high-risk geriatric patients on the 100 hallway.

[refer to Tag A-0395]

Based on record revew and interview, nursing staff failed to provide patient care as ordered for 2 of 2 patients ( Patient IDs # 7, 9); diagnostic studies were not perfomed or were not completed in a timely manner.

[refer to Tag A-0392]

Based on record review and interview, the facility failed to obtain an order for seclusion for 1 of 2 patients who were placed in seclusion (Patient #10).


Findings included:


Review of facility policy titled "Restraint Management", #011, last revised 7/12/23 revealed that restraints were initiated only upon the order of a physician but it did not include any information about orders for seclusion. In an interview on 2/15/24 at 1:30 pm, DQM-Staff #D stated that there were no other polices besides #011 that addressed patients in seclusion.

Record review on 2/15/24 at 11:30 of all orders for Patient #10 was conducted with Staff #D. This included all electronic orders and handwritten seclusion orders.

In addition, record review of the facility forms titled "Patient Observation Form Q15, which documented Patient #10's location inside the seclusion room was compared and contrasted to all orders. It revealed the following:

On 2/4/24, the patient was secluded for 10 hours inside seclusion room per Patient Observation Form Q15. It showed the patient was in seclusion from 7:00 am to 11:45 am, then again at 1:30 pm to 6:30 pm. Review of all orders in the patient's records failed to show any evidence of corresponding seclusion orders.

On 2/9/24, the patient was secluded for 11.5 hours inside seclusion room per Patient Observation Form Q15. It showed the patient was in seclusion from 7:00 pm to 6:30 am the following day. Review of all orders in the patient's records failed to show any evidence of corresponding seclusion orders.

On 2/12/24, the patient was secluded from 7:45 am to 10:15 am per Patient Observation Form Q15. Review of all orders in the patient's records failed to show any evidence of corresponding seclusion orders.

In an interview on 2/15/24 at 12:00 pm, Staff #D stated that all orders reviewed and received were complete.

Based on record review and interview, the facility failed to ensure seclusion orders were not written as PRN for 1 of 2 patients (Patient #10).


Findings included:


Review of facility policy titled "Restraint Management", #011, last revised 7/12/23 showed under the section titled "General Provisions For Restraint And Seclusion", that orders would not be accepted as a standing order or on an as-needed basis -PRN.

Record review on 2/15/24 at 11:30 of all orders for Patient #10 was conducted with DQM-Staff #10, which included all electronic orders.

An order on 2/13/24 at 10:04 pm from Dr-Staff #U showed "Seclusion/Restrain-Adult Every Four Hours PRN, ...".

Another order on 2/14/24 at 2:04 pm from Dr.-Staff #U showed "Seclusion/Restraint-Adult Not to Exceed 4 Hours PRN, ...".

In an interview on 2/16/24 at 5:15 pm, RN-Staff #(Anonymous) stated that all restraint and seclusion orders should never be written as PRN and this was wrong to do.

Based on record review and interview, the facility failed to ensure orders for seclusion were renewed after the 4-hour time limit for adults for 1 of 2 patients (Patient #10).


Findings included:


Review of facility policy titled "Restraint Management", #011, last revised 7/12/23 revealed that it failed to include procedures for duration of seclusion orders per federal and state regulations. In an interview on the morning of 2/15/24, DQM-Staff #D stated that there were no other polices besides #011 that addressed patients in seclusion.

Record review on 2/15/24 at 11:30 of orders for Patient #10 was conducted with Staff #D. This included all electronic restraint/seclusion orders as well as all handwritten restraint/seclusion orders.

In addition, record review of the facility forms titled "Patient Observation Form Q15, which documented Patient #10's location inside the seclusion room was compared and contrasted to all orders. It revealed the following:

On 2/8/24, the patient was secluded for 13 of 24 hours inside seclusion room per Patient Observation Form Q15. However, there was only one order to seclude patient at 6:00 pm.


On 2/13/24, the patient was secluded 15 of 24 hours per Patient Observation Form Q15 with only one order written at 9:45 pm.

On 2/14/24, the patient was secluded 23.4 of 24 hours per Patient Observation Form Q15 with only one corresponding order written at 2:04 pm.

In an interview on 2/15/24 at 12:00 pm, Staff #D stated that all orders reviewed and received were complete.

Based on record review and interview, the facility failed to:

A. Continually monitor and assess a patient in seclusion for 1 of 2 patients (Patient # 10), and;

B. Develop and implement a policy and procedure for the monitoring and assessment of patients in seclusion (cross reference tags A-168, A-169 & A-171).


Findings included:


A. Failed to continually monitor and assess a patient in seclusion:

Review of facility policy titled "Restraint Management", #011, last revised 7/12/23 revealed that seclusion shall be discontinued when the behaviors or situations that prompted the use of restraint are no longer evident. However, the policy failed to include procedures for monitoring and assessing patients who were secluded and determining the criteria for releasing them at the earliest possible time.

In an interview on 2/15/24 at the time policy was obtained, DQM-Staff #D stated that there were no other policies besides #011 that addressed patients in seclusion.

Record review on 2/15/24 at 11:30 am of orders for Patient #10 was conducted with Staff #D, which included all electronic restraint/seclusion orders as well as all handwritten restraint/seclusion orders from date of admission on 1/30/24 up to time of survey, 2/15/24.

Review of videotape footage of seclusion room was also conducted on 2/15/24 at 2:30 pm. Numerous random times for when Patient #10 was secluded inside the room were observed from 1 to 3 hours apart. Each of the reviews of video footage showed that the door was constantly shut.

Direct observation on 2/15/24 at 4:00 pm of the facility's seclusion rooms with Staff #D present showed that when the doors were closed, they locked automatically.

Record review at the time of survey of two types of medical record forms was conducted to determine when and how long Patient #10 was in seclusion and any type of monitoring and assessing that was done during that time:

One form was titled "Restraint Observation Flowsheet". This form was specifically used for patients who were restrained and secluded. The form had entries for monitoring Vital Signs, Fluid Offered, Readiness to Discontinue Restraint, Neurocgnitive status, Cardiac/Circulation status, Respiratory status, Range of Motion and Repositioning, and Physical and Comfort Status.

The other facility form reviewed used to determine when patient was secluded was titled "Patient Observation Form Q15". This form documented the location of the patient and the patient's behavior (This form was also used for every patient to routinely monitor them every 15 minutes-aka Q15 minutes obs'). It only documented the patients' location with a brief description of behavior. It did not include all the other types of monitoring used for patients in seclusion like the Restraint Observation Flowsheet did.


The following are times Patient #10 was in seclusion:


2/6/24 starting at 8:05 pm: Restraint Observation Flowsheet showed the patient was monitored from 7:05 pm to 11:05 pm (4 hours). However, Patient Observation Form Q15 showed the patient was in seclusion for 8 more hours, with no Restraint/Seclusion monitoring/assessing.



2/8/24 starting at 5:41 pm: Restraint Observation Flowsheet showed the patient being monitored from 5:56 pm to 6:44 pm (approximately 45 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 12.5 more hours, with no Restraint/Seclusion monitoring/assessing.


2/9/24 starting at 12:05 pm: Restraint Observation Flowsheet showed the patient being monitored from 12:05 pm to 3:50 pm (approximately 3 hours, 45 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 11.5 more hours, with no Restraint/Seclusion monitoring/assessing.



2/11/24 starting at 10:56 pm: Restraint Observation Flowsheet showed the patient being monitored from 10:30 pm-12:20 am (approximately 1 hour, 50 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 11.5 more hours, with no Restraint/Seclusion monitoring/assessing.



2/12/24 starting at 8:53 pm: Restraint Observation Flowsheet showed the patient being monitored from 9:45 pm to 1:30 am (approximately 3 hours, 45 minutes). However, Patient Observation Form Q15 showed the patient was in seclusion for 6.5 more hours, with no Restraint/Seclusion monitoring/assessing.



2/13/24 starting at 7:00 am: Patient Observation Form Q15 showed the patient was in seclusion from 11:30 pm on 2/13/24 up until 11:00 pm 2/14/24, the following day (23.5 hours in seclusion) with no Restraint/Seclusion monitoring/assessing.



2/14/24 at 11:45 pm: Patient Observation Form Q15 showed the patient was in seclusion from 11:45 pm until 7:00 am 2/14/24, the following day with no Restraint/Seclusion monitoring/assessing.


In an interview on 2/21/24 at 11:15 am, RN Supervisor-Staff #T was asked how a patient was monitored and assessed while in seclusion. She stated that a "1-hour face-to-face" [post restraint assessment] was done. She was further questioned how a patient would be monitored in any other ways as well as being assessed to determine readiness for release after the 1-hour face-to-face assessment. Staff #T stated the patient would be monitored every 15 minutes on the facility's rounding sheets ("Patient Observation Form Q15", aka 'Q15 minute rounds'-the form that is used to routinely monitor all patients in the facility, every 15 minutes). Record review of these forms showed they did not contain documentation of criteria for monitoring and assessing patients in seclusion.

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B. Failed to develop and implement a policy and procedure for the monitoring and assessment of patients in seclusion :


Further review of facility policy titled "Restraint Management", #011, last revised 7/12/23 revealed that it failed to fully address required regulatory requirements for monitoring and assessing patients placed in seclusion.

In an interview on the morning of 2/15/24, DQM-Staff #D stated that there were no other polices besides #011 that addressed patients in seclusion.

Based on interview and record review , the facility failed to initiate an investigation in a timely manner or fully investigate adverse incidents for 2 of 2 patients [Patent ID # 7, 1]

Findings included :

TX00490857

Review of facility policy titled" Incident Reporting," effective date 8/1/2022, showed:

-An incident report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places the Company at an increased risk for liability.

-All hospital employees, contractors and providers are obligated to escalate any concern they have over the safety and well-being of any patient, visitor, or staff through the chain of command.

Guidelines:

1. The Incident Report must be completed by the employee(s) who witnessed or discovered the event as soon as possible following an event which meets the above-mentioned reporting definition. Occurrences must be reported within 24 hours of the occurrence, preferably by end of shift.

2. Escalation of critical concerns should occur immediately ( within 15 minutes )

3. The following categories, not limited to, are reported on the incident form:....patient injury...falls...

B. Incident Investigation:

2. When conducting event investigation, the following steps are to be taken:...c. Interview staff members, patients, and witnesses as applicable.
~~~~~~~~~~~~~~~~~~~~

Patient ID# 7:

Delay in initiating an investigation :

Record review of the medical record of Patient ID # 7 with Staff ID# B, CNO, showed he was transferred to an acute care hospital on 2/5/2024. The CNO said he had fallen. Patient ID # 7 was transported to a local hospital ER and from there to a hospital in the medical center. The CNO said that she heard from the nurses that Patient ID # 7 had fractured ribs and developed a pneumothorax that required chest tubes. CNO said she learned of this two days after the transfer ( on 2/7/24). The CNO said she did not complete an incident report or inform Staff-D, Director of Quality Management (DQM) of the extent of Patient ID #7's injuries.

During an interview on 2/15/2024 at 2:15 PM with Staff -D, DQM, she stated she did not learn of Patient ID #7's fractured ribs, pneumothorax, and death until the Medical Examiner requested the medical records on 2/13/2024.

Incomplete; inaccurate investigation: Patient ID # 7 [fall]

Review of facility fall report and "post-fall huddle," dated 2/4/2024 [2300 hrs] read:

Patient # 7 showed the following:

- "reported or found by: MHT ID-S"

- "witnessed fall"

- "staff assisted to bed, pt. swung at staff, lost balance & fell."

During a telephone interview conducted on 2/20/2024 at 9:08 AM with Staff ID-S, MHT, she stated she was the tech making rounds on 2/5/2024. She said while making rounds, she saw Patient ID # 7 on the floor by the bed; he had taken off his clothes. She wanted to help him back to bed so that he would not get up and fall. He was unsteady. MHT went on to say Patient # 7 attempted to hit her when she tried to help him up. He did not fall then; he was already sitting on the floor with his back to the bed. MHT stated she was certain she did not witness this patient fall. She also said that no one from the facility had talked with her about Patient ID's 7's fall.

Patient ID # 1 [injury of unknown origin]

Observation during unit tour on 2/15/2024 at 9:45 AM showed Patient ID-1 lying in a bed low to the floor. Patient ID # 1 was on 1: 1 monitoring by staff. During an interview at time of observation with Staff-ID-F, Mental Health Tech (MHT), was asked if this patient had any wounds? She said he had a wound to his left great toe.

Observation on 2/15/24 of Patient ID# 1's left great toe showed: the toe appeared very swollen & red. Dried and fresh blood was noted on the nail bed, surface, and in between the great toe and 2nd toe.

Record review of facility policy titled " Wound Care Policy & Procedure," undated, showed:"...As part of the admission process the RN will perform an initial head-to-toe assessment to include wound photographs and documentation of the wound to include the size, depth...and appearance of the wound to include any drainage..."

Review of Patient # 1's admission 'Skin and Wound Assessment', dated 2/11/2024, showed : " bruises on face..unable to do a complete assessment to pt due to his aggressive and violent behavior." Area for notation of wounds showed "none."

Record review of Patient# 1's nursing skin assessments by shift [dates 2/12/2024 though 2/18/2024 ] showed inconsistencies in the nursing skin assessments .

--February 18, 2024 (1108) : was the first nursing skin assessment notation of abnormal findings :" laceration on toe with redness." [surveyor observed this wound on 2/15/2024]

Review of NP progress notes, dated 2-14-2024 showed :" psych NP reported pt's great left toe has new wound noted- bruising and some open skin to the toes." An X-ray performed on 2/14/2023 showed a fracture of acute great toe.

During record review on 2/16/2024 with Staff ID -ED, Quality Director acknowledged the skin assessment findings and that they were not consistent and accurate. She went on to say that because this wound was not documented on admission-it was considered an" injury of unknown origin" and should be investigated. It had not been investigated at time of interview.

Based on record revew and interview, nursing staff failed to provide patient care as ordered for 2 of 2 patients ( Patient IDs # 7, 9)

Diagnostic studies were not perfomed or were not completed in a timely manner.

Fingings included:

TX00490857:

During an interview with Staff -B, Chief Nursing Officer (CNO), on 2/15/2024 at 1:30 PM, she said it is the responsibility of nursing to ensure all lab and x-ray orders are completed and results received in a timely manner. Nursing is also responsible for reporting critical labs or other diagnostic results to the provider as soon as received.

Record review of facility's current "Registered Nurse-Position Description" showed:
i. Patient Care Essential Job Functions:"...Performs all scheduled assessments and physician orders in a timely manner..."

Record review of professional guidelines established by the American Nurses Association (ANA) titled : " Principals of Nursing Documentation: Guidance for Registered Nurses," 2010, showed:

-Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice;

-The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient's health record : assessments; order acknowledgement, implementation, and management [*not all inclusive ].


Record review of the clincial records or Patient ID # 7 and #9 showed the following:

Patient ID # 9:

a. Nurse Practitioner (NP) provider order dated 2/2/2024 ( 1548): "STAT chest x-ray "

- Date chest x-ray exam performed : 2/6/2024 (12:24)

b. NP provider order dated 2/2/2024 ( 1742 ) : "Please do COVID and flu test: please document results."

- These tests were not completed ; no results were located by Staff-V, Health Information Management (HIM) director.

During an interview with Staff -B, Chief Nursing Officer (CNO), on 2/15/2024 at 2:45 PM, she said she was unable to determine the reason these tests were not done.

Patient ID # 7:

c. NP provider order dated 1/31/2024 (1548) : "STAT Urinalysis (UA) with culture and sensitivity C & S) ""

- Lab result showed date urine specimen collected for "UA-no micro" was 2/4/2024 ; results 2/5/2024

During an email exchange on 2/28/2024 at 2:30 PM with Staff -D, Director of Quaity Management, she stated there was no facility policy regarding STAT lab orders. She went on to say the established timeframe expectation for a STAT order was 1 hour.

Based on observation, interview, and record review, the facility failed to ensure an RN accurately evaluated and supervised the care for 8 of 17 sampled patients (IDs 1,2,3,5,7,15,16, 17) . RN nursing staff failed to :

a. Perform & accurately document patient assessments : infection control screening and skin / wound assessments.

b. Accurately document post-fall information.

c. Develop and implement a hydration policy for the high-risk geriatric patients on the 100 hallway.

Findings include:

TX00490857

Record review of professional guidelines established by the American Nurses Association (ANA) titled : " Principals of Nursing Documentation: Guidance for Registered Nurses," 2010, showed:

-Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice;

-The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient's health record : assessments; order acknowledgement, implementation, and management [*not all inclusive ].

a. Inconsistent infection control screening and wound/skin assessments:

Patent ID # 2: inaccurate RN infection control screening assessment :

Observation during 100 hallway tour on 2/15/2024 at 9:30 AM , showed Patient # 2 sitting in her room, maskless. Staff ID-E, RN reported this patient was admitted positive for COVID.

Continued observation on the 100 hallway showed housekeeping staff with a cleaning cart - two doors down from Patient ID # 2's room. Interview at this same time with Staff ID-G, environmental services tech (EST), she stated there were no current patients on the 100 hallway who were positive for COVID. Surveyor informed Staff G that the patient in room 113 was positive for COVID. Surveyor requested that she don a mask prior to entering that room.

Record review of facility admission form titled " Infection Screening" for Patient ID # 2, dated 2/11/24 at 11:20 PM, showed:" Is there a history of MRSA, VRE, E-coli, C-Diff, COVID ? box for "NO" was checked by Staff ID -Q, registered nurse (RN).

Record review of Patient ID #2's admission orders, dated 2/11/24: " contact and droplet isolation, Patient is COVID positive."

Review of Staff ID-J, nurse practitioner (NP), progress note, dated 2/15/24 read : "patient remains on COVID isolation."

Patient ID # 1: inconsistent wound/ skin assessments:

Observation during unit tour on 2/15/2024 at 9:45 AM showed Patient ID-1 lying in a bed low to the floor. Patient ID # 1 was on 1: 1 monitoring by staff. During an interview at time of observation with Staff-ID-F, Mental Health Tech (MHT), she said this patient was on 1:1 monitoring because he was very high risk for falls. Staff ID-F was asked if this patient had any wounds? She said he had a wound to his left great toe.

Observation on 2/15/24 of Patient ID# 1's left great toe showed: the toe appeared very swollen & red. Dried and fresh blood was noted on the nail bed, surface, and in between the great toe and 2nd toe.

Record review of facility policy titled " Wound Care Policy & Procedure," undated, showed:"...As part of the admission process the RN will perform an initial head-to-toe assessment to include wound photographs and documentation of the wound to include the size, depth... and appearance of the wound to include any drainage..."

Review of Patient # 1's admission "Skin and Wound Assessment," dated 2/11/2024, showed "bruises on face..unable to do a complete assessment to pt due to his aggressive and violent behavior." Area for notation of wounds showed "none."

Record review of Patient# 1's nursing skin assessments by shift [dates 2/12/2024 though 2/18/2024 ] showed the following:

- February 12 & 13, 2024: box not checked to indicate normal; section tabled "abnormal findings " left blank.

- February 14, 15, 16, 17 , 2024 : box checked to indicate: "integumentary warm to touch, dry, color good. No new bruises,lacerations or abrasions."

--February 18, 2024 (1108) : first nursing skin assessment notation of abnormal findings :" laceration on toe with redness." [surveyor observed this wound on 2/15/2024]

Review of NP progress notes, dated 2-14-2024 showed : " psych NP reported pt's great left toe has new wound noted- bruising and some open skin to the toes."
An X-ray performed on 2/14/2023 showed a fracture of acute great toe.

During record review on 2/16/2024 with Staff ID -D, Quality Director acknowledged the skin assessment findings and that they were not consistent and accurate. She went on to say that because this wound was not documented on admission, it was considered an" injury of unknown origin" and should be investigated. It had not been investigated at time of interview.

b. Patient ID #7 : Inconsistent documentation of patient fall :

Record review of Patient ID # 7's medical record showed RN progress note & NP progress note regarding a patient fall were not consistent with MHT staff description of her actual observation of finding this patient on the floor.

RN nursing progress note [ Staff ID-R, RN] , "electonically signed " 2/3/2024 (05:51) , read: " staff was trying to assist patient to bed when he tried to physical (sic) hit her. When pt swung his arm at MHT he ended up having a fall. Noted skin tear to left and right arm. No head injury noted.."

NP progress note , dated 2/5/2024 (untimed), read: "nurse report (pt.) had a witnessed fall last night..found right flank area crustaceous emphysema ... sent to ER for further evaluation.."

During a telephone interview conducted on 2/20/2024 at 9:08 AM with Staff ID-S, MHT, she stated she was the tech making rounds on 2/5/2024. She recalled Patient # 7 and said that when she made rounds past his door she saw him on the floor by the bed; he had taken off his clothes. She wanted to help him back to bed so that he would not get up and fall. He was unsteady. MHT went on to say Patient # 7 attempted to hit her when she tried to help him up. He did not fall then; he was already sitting on the floor with his back to the bed. She said she called for some assistance to get him back into bed. MHT re-stated she did not witness this patient fall.

During a telephone interview on 2/20/2024 at 9:45 AM with with Staff ID -D, Quality Director, she stated the nursing progress note (dated 2/3/2024 ) was not consistent with the MHT ID-S account of finding the patient on the floor. Unknown if patient fell ; should have been described as unwitnessed fall.

Patient ID # 7 was was transferred to a local acute care hospital on 2/5/2024 and from there to a hospital in the medical center.

Record review of both acute care hospital records revealed Patient ID # 7 had four (4) fractured ribs and developed a pneumothorax that required chest tubes. He expired on 2/13/2024. Preliminary cause of death: acute pneumothorax; respiratory failure.

c. Failure to develop and implement a hydration policy / process for high-risk geriatric patients on the 100 hallway:

Review of patient census dated 2/15/2024 for the 100 hallway showed 18 patients. Seven (7) of the 18 patients were between the ages of 64- 89 years.

Observations and interview conducted on the 100 hallway on 2/15/2024 and 2/16/2024 showed the following:

- Patient # 3: age 76 years ; observed sitting in wheelchair while speaking with surveyor. She repeatedly tried to get up and walk unsteadily over to her roommate [age 87 years] who was lying in bed. Patent ID # 3 said "she keeps asking for water; she needs water." [ 2/15/24 at 9:45 AM]

- Patient # 17: age 76, observed sitting in his wheelchair in his room. Surveyor was given permission by patient for staff to remove his socks in order to observe his feet. During observation, Patient ID# 17 stated in a raspy voice" I need water!" Staff brought him a small paper cup of water ( approx. 3 ounce size). [ 2/16/24 at 2:40 PM]

- Patient ID # 5 : During an interview on 2/16/2024 at 3:00 PM she stated staff never offers water to patients on the 100 hallway.

- Anonymous Staff RN:-interview 2/15/2024 at 9:15 AM, she stated :"it is common for the geriatric patients to be transferred out due to dehydration."

Record review of January 2024 "Acute Transfer Log" showed:

- Patient ID # 16, 73 years old: :[ transferred to acute hospital on 1/16/24] "not drinking well; altered mental status." NP progress note , dated 1/16/24 read: "sent to ER for higher level of care: altered mental status...possible dehydration"

- Patient ID # 15 , 80 years old :[ transferred to acute hospital on 1/19/24] critical labs ( "critical levels" sodium & blood urea nitrogen)--[suggestive markers of dehydration].

During an interview with Staff -B, Chief Nursing Officer (CNO), on 2/15/2024 at 1:15 PM, she said the facility did not have a hydration policy or process established for the geriatric patients. She stated "patients are offered fluids at meal times and when they tell us they are thirsty."
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Reference :

Nursing Times Magazine : "Hydration in Older People with Mental Health Problems", 17 January 2002, Vol.: 98, Issue: 03, Page no,: 3 Josef Brown, BSc, RMN, RGN ; Glenn Marland, BEd,

Dehydration:

Dehydration is caused by an inadequate intake or excessive loss of fluid. Adults can become dehydrated in as little as 48 hours, depending on the individual and environmental factors. As humans age, the thirst response naturally decreases; the individual becomes accustomed to a lower fluid intake and the body adapts quickly, resulting in a reduced urge to quench the thirst (Watt, 1991).

People with an organic brain disease, such as Alzheimer's, may have damaged osmoreceptors, which are situated in the hypothalamus region of the brain and are thought to regulate the body ' s thirst mechanism (Watson, 1996). They may also have a degree of cognitive impairment which prevents them from satisfying their thirst or letting others know that they are thirsty.

Illness-dehydration cycle:

Mental illnesses such as depression, psychosis, confused states, anxiety, disability and suicidal intent can all diminish fluid intake. The resulting dehydration may, in turn, lead to medical and mental health problems such as hypovolemia, tachycardia, renal failure, disorientation and hallucinations, which can exacerbate the original dehydration. If there is a concurrent increase of fluid output through vomiting, diarrhea, polyuria, excessive perspiration or blood loss, the consequences can be severe and even fatal (Alexander et al, 2000; Sansevero, 1997).