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Based on interviews and records review, it was determined that the Governing Body was not effective in its oversight of the hospital regarding the care of Patient ID #1.

A) The therapy services staff failed to complete and document a comprehensive evaluation which included patient ID #1 functional ability to self-feed and stipulate what assistance was required.
B) The nutrition services/dietitian staff failed to complete and document a comprehensive evaluation which included Patient ID #1 functional ability to self-feed and stipulate what assistance was required.
C) The nursing services staff failed to document assistance with feeding for Patient ID #1.

Findings included:

Record review of complaint intake for TX 00413775 stated "the complainant states that the staff did not feed him (patient) the first week because staff believed he was supposed to be feeding himself." (Patient ID #1)

Medical record review of Patient ID #1 chart revealed he was an 82 year old male who had been transferred from an acute care hospital after recent acute stroke. He was status post tissue plasminogen activator (tPA) dosing for stroke. His admission history and physical by Staff MD ID #64 stated patient was "mod to max assist." His physical exam stated "Strength: his right upper and right lower extremity strength is limited due to weakness, 3+ out of 5, left upper extremity strength is 3 out of 5, left lower extremity is 2+."

Medical record review of patient's oral intake with Staff ID # 63, patient access coordinator, failed to show any documented feeding assistance by unit-based staff. A scanned copy of "Aspiration Precautions" sign with diet "Mechanical Soft" and Liquids "Thin" was located. The following swallowing strategies were checked: "Oral hygiene 2-3x/day, Sit upright 90 degrees with meals and at least 30 mins after eating, small bites and sips, 1 bite/sip at a time, Crush meds and take with puree, Supervision during meals." It should be noted that the following boxes remain unchecked "Set-Up Assistance with meals, Supervision during meals, 1:1 Feeding assistance."

Medical record review of Dietitian Staff ID #67 assessment which was completed on 3/2/2022 at 10:21 am revealed:
"Diet history" was left blank. Feeding ability "Self" or "Assistance needed" boxes were unchecked (blank). "Social history" was left blank. "Learning needs and barriers reviewed" left blank. The "Progress Note" section stated "Per nursing - patient has a good appetite and po intake of at least 75% or greater. Says he requires feeding assistance. Denies any N/V/C/D. Denies any swallowing or chewing issues. Regular BM."

Medical record review of Occupational Therapy Staff ID # 68 assessment completed on 3/1/2022 at 11:54 a.m. stated "Eating: the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. 1. 'Dependent'" is noted in the field. There is no documentation or discussion with nursing staff and/or how this will be achieved. The "assessment" stated "low 02 sat, lethargic. Needed max A (assist) n up for all ADLs."

Phone Interview 2/8/23 at 1:30 pm with complainant. He stated his family member "could not feeding himself due to weakness from the recent stroke and ICU stay." He stated that the family would find meal trays in the room when they visited that were unopened. He stated that "on more than one occasion, we told staff he needs help eating."

Interview 2/9/23 at 4:45pm with Charge RN Staff ID # 62 revealed there was "no place to specifically chart feeding assistance" in the "ADL Flowsheet" which was utilized for charting nursing and nursing assistant's activities with patient's activities of daily living. She stated, "I guess they could type it under 'other'."

Interview 2/9/23 at 4:15 pm with Physical Therapy Assistant Staff ID # 56, he stated that "OT (Occupational therapy) covers feeding." He stated that functional assessments of patient's abilities to self-feed would be performed by OT "within 24 hours of admission." He stated that the level of assistance that patients needed would be "on the room communication white board" and "should be in the OT note."

Interview 2/9/23 at 4:30 pm with Director of Quality Staff ID # 53, she confirmed that the electronic medical record failed to demonstrate comprehensive dietitian and therapy evaluations and failed to demonstrate exactly when and what type of assistance Patient ID #1 received with Activities of Daily Living related to feeding except when patient was fed as a part of a therapy session.

Based on observation, record review and interview, the facility failed to ensure that medications were administered per orders for four (4) of four (4) sampled patients (Patient ID #5, 13, 14, 15).

Findings included:

Observation on patient care unit on 2/9/2023 at 11:45 am of electronic medical record with Staff RN ID #61 on her computer on wheels, revealed the medication administration record showed that Patient ID #5 had none of her morning medications administered (all reflected medications due at 2/9/2023 08:00 am and 2/9/2023 at 09:00 am (see below for detail).

Review of facility policy titled "Medication Administration Record and Medication Administration," revised 3/28/2022, stated "All medication will be administered within one hour before or after the scheduled time. All administered, refused or omitted medications will be recorded on the patient's MAR."

Medical Record Review:
Patient ID #5 had orders for Buspar 5 mg twice a day by mouth (to be administered at 08:00 am and 5:00 pm); Cymbalta 60 mg by mouth once daily (to be administered at 08:00 am); Furosemide 40 mg by mouth once a day (to be administered once a day at 08:00 am); Glucotrol 2.5 mg by mouth daily with food (to be administered at 08:00 am); Prednisone 60 mg twice a day by mouth with food (to be administered at 08:00 am and 5:00 pm); Metoprolol 25 mg by mouth three times a day (first dose to be administered at 08:00 am). All oral morning medicines were over 3 hours late.

Patient ID #13 had an order for tramadol 25 mg by mouth four times daily scheduled for pain. Per electronic medical record, the doses were scheduled for 08:00 am, 12:00 pm, 4:00 pm and 8:00 pm. The electronic medical record showed a missed dose on 2/9/2023 at 8:00 am. The next dose was provided by RN Charge Staff ID 62 on 2/9/2023 at 11:42 am.

Patient ID #14 had an order for metformin 1000 mg by mouth twice a day with meals (scheduled for blood glucose control). Per electronic medical record, the doses were scheduled to be administered at 8:00 am and 5:00 pm. The electronic medical record showed the metformin dose had been administered 2/9/2023 at 11:04 am by Staff RN #61 (Three hours late).

Patient ID #15 had an order for carvedilol 25 mg twice a day with meals. Instructions to hold if DBP<50. Per electronic medical record, the doses were due at 08:00 am and 5:00 pm. The electronic medical record showed the dose had been administered 2/9/2023 at 1:06pm by Staff RN #61 (four hours late).

Interview on 2/9/2023 at 11:45 a.m. with Patient ID #5, she stated she had not received any of her morning medicines except for insulin. She stated her "agency nurse was new at the facility today and did not have computer access."

Interview on 2/9/2023 at 11:48 a.m. with RN ID #61, she stated she had not administered any of the patient's oral medications because the patient had "been gone to the therapy gym." She was questioned regarding the facility's practice for handling this and she stated "today is my first day here. The charge nurse said I could have gone to the gym to give the medicines but I did not know I could."

Interview on 2/9/2023 at 2:20 p.m. with pharmacist Staff ID # 58, she confirmed patient ID #5, 13, 14 and 15 had medications which had not been given or were given late and there was no description of why they had been omitted or given late.