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Based on record review and interview the facility failed to evaluate care initially upon admission and ongoing throughout the hospital stay for 1 out of 5 patients (#3) reviewed, resulting in severe dehydration and deterioration in the patient's condition. Findings include:

According to medical record review it was revealed that the patient was not given IV fluids to replace g-tube output in a 1:1 ratio, as instructed. Refer to findings at A395.

Based on interview and record review the facility failed to allow the patient advocate to participate in the patient's care, resulting in harm to patient #3. Findings include:

On 7/24/2012 at approximately 1500 during an interview with the complainant it was stated that both the patient's son's and wife requested the patient be given intravenous (IV) fluids to replace fluid loss from the gastrostomy tube (g-tube). "We asked the doctor, the PA and the nurses. They all told us "We are on top of that". But, no one ever was until it was too late. He went into kidney failure, and died on Easter Sunday."

On 7/25/2012 at approximately 1130 during medical record review of patient #3 it was revealed in the Interdisciplinary Plan of Care, Discharge and Barrier Update that no family signed or were recorded as present. Staff C confirmed that "It would be documented if the family or patient attends the meetings, but some just do not want to come or cannot come. We usually invite them to the meetings, they are called C3 meetings." No other documentation of family involvement in care was documented. This was confirmed with staff D at approximately 1200 on 7/24/2012.

On 7/25/2012 at approximately 1145 during review of the policy titled Nursing Care Plan it was stated "Each discipline is responsible to review goals and progress with patient and approved significant others."

Based on record review and interview the facility failed to comprehensively evaluate 1 of 5 patients (#3) on admission and ongoing through the patient's stay resulting in severe dehydration. Findings include:

On 7/25/2012 at approximately 1230 during review of the medical record for patient #3 it was revealed in the Discharge Summary Instruction sheet from UofM hospital where the patient was transferred from that "Final Discharge Non-Medications: 1. 1/2 NS +20KCL 1:1 replacement of G-tube output volume every 8 hours in bolus form." Under "Discharge Instructions" on the same form it was stated "2. Continue additional free water flushes of the J tube of 120 ml q 4 hours for maintenance. This does not include additional replacement fluids needed for G tube output. **Continuation of other care during nutrition care: 1. Ensure replacement fluids are continued via IV, as the patients losses cannot be replaced via J-tube due to large GI losses and limitation in volume tolerated via J-tube." This document was faxed on 3/21/2012 to the facility. The patient arrived on 3/20/2012.
Under the section titled Nutrition Assessment on 3/21/12 it was stated by the dietitian "Replace G-tube losses with 0.9% NS 1:1 ration per OSH recommendations."
Under the section of the medical record titled Nursing it was revealed, in the 24 Hour Patient Records & Plan of Cares, that the patient did not receive any IV Fluids until 3/26/2012. On the intake and output records there was a recorded fluid loss from the patient on 3/20 of negative 100 mls, 3/21 positive 245 mls (without fluid loss from the G-tube recorded on the evening shift), 3/22 negative 910 mls, 3/23 negative 1620 mls, 3/24 negative 120 mls and 3/25 positive 280 mls. No evidence of 1:1 fluid replacement for G-tube loss was recorded for 3/20/2012 until 3/26/2012.
Under the section titled Consultation it was revealed that a nephrologist was consulted on 3/26/2012. In the consult it was stated by the nephrologist "...He re-presented to the UofM with high output from his G-tube and nausea and was readmitted for evaluation and then transferred here to Select for further evaluation and treatment. His renal function was normal on presentation with a creatinine of 0.9. Labs today indicate a creatinine of 5.9 and repeat of 6.4, BUN of 124, prompting this consultation... He is complaining of thirst. Extremities show some very dry skin. Mucous membranes do appear slightly dry."
On review of the Discharge Summary from Select Specialty dictated on 4/2/2012 by the PA-C and attending Physician caring for patient #3, it was documented "During his stay at Select Specialty Hospital, he continued to have a fair amount of drainage from his G-tube. He was not receiving IV hydration to match output from his G-tube and developed acute renal failure on 3/26/2012. Aggressive IV hydration was begun. Plan: 1. Transfer the patient back to University of Michigan for continued medical management."

On 7/25/2012 at approximately 1230 staff D stated "It looks like this patient did not receive IV fluids from 3/20/2012 through 3/26/2012."