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Based on observation, interview, and record review, the facility failed to provide Dietary Services that meets the needs of patients in that,


a.) A patient did not receive counseling regarding his caloric intake and protein needs and meal choices possibly attributing to the 4.69% weight loss in less than 30 days. (Patient #7)


b.) The facility's Dietitian did not develop and ensure the proper serving sizes for large portion, double portion diets, and a 750ml fluid restricted diet placing patients at risk for weight loss, fluid overload and delayed wound healing. Patient #1 was receiving 3150cc of fluids for the day; the physician's order was for 1500cc fluids per day.


c.) The facility's dietary service did not provide the physician ordered double portions diet, ordered to promote wound healing. The tray ticket was written as large portions.

cross refer to A621 and A629

Based on observation, interview, and record review, the facility failed to provide nursing services that meet the needs of patient in that,


a.) Patients requiring assistance for repositioning were not repositioned every two hours per the nursing recommended care to prevent skin breakdown. (Patients #1,7, and 2)


b.) A patient was not provided oral care to promote oral hygiene. (Patient #4)


c.) Patients were not provided meal tray set-up and assistance to prevent weight loss. The nursing staffs did not document meals provided or percentages eaten in order to monitor for adequate nutritional intake. (Patients #1 and 7)


d.) The nursing staff failed to communicate the need for a swallowing evaluation for a patient at risk of aspiration and did not weigh a patient at risk for weight loss as the physician had ordered. (Patient #1)


Findings:


a.) Review of Patient #1's Medical Records reflected a 73-year-old female admitted on 7/17/18 with a prior medical history of morbid obesity, and altered mental status. The records reflected total assist for all activities of daily living and requires a two person assist for bed mobility. Patient #1 presented with multiple pressure wounds to the sacrum and heels.


Review of Patient #1's electronic repositioning records reflected there was no documentation to show the patient was repositioned on the following dates and times:

7/20/18 from 8:00 am to 1:11 pm and from 1:12 pm to 5:04 pm.

7/21/18 from 2:00 pm to 6:06 pm and from 10 pm to 1:41 am.

7/22/18 from 2:00 pm to 6:30 pm.

7/23/18 from 5:53 pm to 10:20 pm

7/30/18 from 8:30 am to 12:35 pm and from 12:35 pm to 4:02 pm.


Review of Patient #1's family complaint (undated) reflected, "...they would leave her alone for hours without turning her over."


Review of Patient #7's medical records dated 11/12/18 reflected a 65-year-old-male admitted with hyponatremia with SIADH and a non-healing sacral decubitus ulcer.... Plan: Strict I & O's (intake and outputs) ... Risk for impaired skin/tissue integrity: Reposition: SIDE TO SIDE (KEEP OFF HIS BACK) Start 11/11/18 18:00, q 2 h ...."


During an interview on the morning of 12/10/18, on the inpatient unit, Patient #7 stated, "...I'm supposed to be turned every 2 hours. If my family doesn't call the nurses, they won't turn me. I have a wound that isn't healing because I'm left wet. Most of the times my family has to help them turn me; only one staff will come to turn me and it takes at least two people...."


Review of Patient #7's electronic repositioning records reflected there was no documentation to show the patient was repositioned on the following date and times:

12/9/18 from 3:00 pm to 7:00 pm.

12/10/18 from 8:00 am to 12:30 pm.


Review of Patient #2's medical records reflected a 51-year-old male admitted on 11/27/18 with a chief complaint of Traumatic brain injury and respiratory failure. Review of the Physician's order reflected, "Reposition: Start ASAP (11/28/18) and then, q 2 h (0 2 4 ... 22) ..."


Review of Patient #2's electronic repositioning records reflected there was no documentation to show the patient was repositioned on the following date and times:

On 12/09/18 at 12:00 pm, 2:00 pm and at 6:00 pm.


During an interview on the afternoon of 12/10/18, in an administrative office, Staff 1, RN stated, "...Nursing intervention recommends the patient is to be turned every two hours." When asked about the repositioning records Staff #1 stated, "...not consistently... there's gaps."



b.) An observation on the afternoon of 12/10/18, in Room 527 revealed a male patient (Patient #4), with an naso-gastro tube inserted into the patient's right nares due to dysphagia and aspiration. The patient was sleeping on his back and his mouth was open. Patient #4's mouth was dry and the lips were cracked. There was a brown coating noted on the patient's tongue.


Review of Patient #4's medical records reflected an admission on 12/7/18. Further review revealed no orders had been written for oral care and there was no documentation to reflect the patient was receiving oral care.



c.) During an interview on the afternoon of 12/1018, on the inpatient unit, Patient #7 was visibly upset and stated, "I have to call to have my meal trays set-up. The kitchen staff just deliver it. They say they cant's touch the tray.... I've complained.... When they bring in my meal they don't send me what I've ordered.... They cross off the items I asked for... It's taken up to an hour for someone to answer the call light. They tell me the nurse is at lunch and I have to wait...."


During an interview on the morning of 12/11/18, in the conference room, Staff #7, Chief Clinical Officer stated, ".... The kitchen staff are not supposed to be delivering the meal trays. We recently changed it because we were having trouble with the delivery. The CNAs or the Nurses are supposed to deliver the trays so they can set the patients up or assist with the feeding."


Review of Patient #1's family complaint (undated) reflected, "...The nursing staff did not wake my Aunt to be fed. She is blind and needs total assist ...."


Review of Patient #1's meal percentages reflected meals were not documented as having been given or percentages documented on the following dates:

o dinner 8/27/2018
o breakfast 8/29/2018
o breakfast and lunch on 8/30/2018
o lunch and dinner on 8/31/2018
o dinner 9/1/2018
o breakfast 9/2/2108
o dinner 9/3/2018


During an interview on the afternoon of 12/11/18, in the conference room, Staff #9, Quality Manager confirmed the finding.

d.) Review of Patient #1's Nutritional Assessment dated 7/17/18 reflected,

"Nutrition Diagnosis:

... Providing full liquid diet with nectar thick liquids. Monitor: wt, lab results, I&0's. PO intake.

Recommendations:

Speech Therapy Screening: Swallowing/risk of aspiration

Start today (7/17/2018), x1, not renewable."

Record note:

"Order acknowledged by.... RN at 7/17/2018 15:21..."



Review of the medical record reflected that the swallow screen, and weight monitoring were not carried out during Patient#1's admission from 7/17/2018 to 9/11/2018.


During an interview on the morning of 12/11/2018, in the facility conference room, when asked if Patient #1 had received the Speech Screen, Staff #9, Quality Manager stated, "I can't find anything showing where they got the screen."


During an interview on the afternoon of 12/10/18, in the CEO's office, when asked how the therapist would receive notice of a swallow screen, Staff #8, SP (Speech Therapist) stated, "It would have to be under a physician's order for a speech evaluation.... It can come through nursing; they sometimes will ask us in passing if they think someone needs to be seen. If it's written in a note it won't show up...."


Review of the medical records reflected on 7/17/2018, the day of admission, Patient #1's weight was recorded at 198.90 lbs. (pounds). Subsequent weights on 8/10/2018 and 8/16/2018 reflected the same 198.90lbs. Further review reflected the patient's weight was ordered on 9/3/18, there is no weight recorded for this date and on 9/9/2018 the weight record reflected, "not done".


During an interview on the morning of 12/11/18, in the conference room, when asked about the three weights recorded at 198.90 lbs. Staff #2, Chief Clinical Officer confirmed and stated "... Those were her initial weight, when she was admitted...."

Based on interview and record review, the facility's dietitian failed to provide Therapeutic Diet counseling to patients requiring fluid restrictions and increased protein and caloric needs and approve the patient's menus to ensure the nutritional needs are met.


Findings:


Review of Patient #7's's medical records dated 11/12/18 reflected a 65-year-old-male admitted with hyponatremia with SIADH and a non-healing sacral decubitus ulcer.... Plan: Strict I & O's (intake and outputs)


Review of Patient #7's Nutritional Assessment dated 11/12/18 reflected, "Nutritional Needs:

Energy needs: ...2250 Kcals (kilocalories) at 25 Kcals/kg (kilogram)/bw (body weight)

Daily Protein need: 90-135 gr (grams)...

Increased nutrient needs related to wound healing as evidenced by increased ebergy [sic], protein, vitamin and mineral needs. Monitor: wt, lab results, Po intake, I/os...." The facility provided nutritional anaylis for Week 3's menu reflected weekly averages of 2386 Kcal and 123 grams of Protein. This is dependent on a patient receiving and eating 100% of the meals.


Review of Patient #7's Nutritional Assessment dated 11/30/18 reflected, "... Current diet order: General diet with 1.5L fluid restriction.... Increased nutrient needs related to wound healing as evidenced by increased energy, vitamin, protein and mineral needs. Intervention: Providing a general diet with large portions and zinc sulfate...." On 11/23/18 reflected, "...Providing a general diet with double portions...."


During an interview on the afternoon of 12/1018, on the inpatient unit, Patient #7 was visibly upset and stated, ".... When they bring in my meal they don't send me what I've ordered.... They cross off the items I ask for.... I usually get two glasses of tea, they only sent one. They didn't send me the milk"


An observation of the Patient #7's meal tray contents on afternoon of 12/10/18 revealed a 6-ounce bowl of chicken tortilla soup with tortilla chips and an 8-ounce glass of tea. A staff member was observed being instructed to take milk to Patient#1.


During an interview on the afternoon of 12/10/18, in the facility's dietary department, when asked if the tray tickets reflected the increased portion size of the large portions diet Staff #6, Director of Food Service stated, "The tray ticket only shows portions for a regular diet." When asked if the tortilla soup and chips meets his nutritional needs and does someone counsel the patient on adequate nutritional needs, Staff #6 stated, "There were other items available.... We only send what the patient asks for."


During an interview on the morning of 12/11/2018, in the facility conference room, Staff#10, RD (Registered Dietitian) stated, "... If the patient is asking for more than what the diet is allowed the clerk will contact the Dietitian to talk to the patient...." Staff #10, RD confirmed she had not been notified of Patient #1's subtherapeutic requests and a need for counseling.

Based on observation, interview, and record review, the facility's Menus failed to provide Patient #7's nutritional and physician ordered medical intervention needs when the Dietitian failed to,

- to ensure that portion sizes had been adjusted to accommodate for double portion and large portion diets.

- to ensure a prescribed fluid restriction was being served correctly. Patient #7 was receiving 3150cc of fluids for the day. The physician's order was for 1500cc fluids per day.


Findings:


Review of Patient #7's's medical records dated 11/12/18 reflected a 65-year-old-male admitted with hyponatremia with SIADH (when an excessive amount of antidiuretic hormone is released resulting in water retention and a low sodium level) and a non-healing sacral decubitus ulcer.... Plan: Strict I & O's (intake and outputs)


Review of Patient #7's Nutritional Assessment dated 11/12/18 reflected, "Nutritional Needs:

Energy needs: ...2250 Kcals (kilocalories) at 25 Kcals/kg (kilogram)/bw (body weight)

Daily Protein need: 90-135 gr (grams) ...

Increased nutrient needs related to wound healing as evidenced by increased ebergy [sic], protein, vitamin and mineral needs. Monitor: wt, lab results, Po intake, I/os...."


Review of Patient #7's Nutritional Assessment dated 11/30/18 reflected, "... Current diet order: General diet with 1.5L fluid restriction.... Increased nutrient needs related to wound healing as evidenced by increased energy, vitamin, protein and mineral needs. Intervention: Providing a general diet with large portions and zinc sulfate...." On 11/23/18 reflected, "...Providing a general diet with double portions...."


Review of Patient 's #7's Nutritional Assessment dated 11/2/18 reflected, "...Weight: 198 lb.

Review of Patient #7's Nutritional Assessment dated 12/06/18 reflected, "...Weight: 188.7 lb.

The weight change reflects a 4.69% weight loss in one month.


During an interview on the morning of 12/11/2018, in the facility conference room, Staff #10, RD (Registered Dietitian) stated, "...All of our food and plates and menus, we have standardized portion sizes on our menu recipes. We delineate how much fluids nursing has verses how much the kitchen sends. Dietary will designate how much the nursing staff and how much the dietary provide to the patient. Right now we are in the process of making a fluid restriction policy... If the patient is asking for more than what the diet is allowed the clerk will contact the Dietitian to talk to the patient...."


Review of Patient #7's tray ticket for 12/11/18 reflected whole milk had been handwritten in on the tray ticket for breakfast, lunch and dinner.


Breakfast- Coffee 8oz. X 2, milk (a carton is 8 oz.) and Apple Juice 4 oz.

Lunch- Iced Tea 8 oz. X 2, milk and chicken noodle soup 6 oz.

Dinner- Iced tea 8 oz., milk and chicken noodle soup 6oz.


The total fluids provided by dietary, if provided as written, equals 2400cc fluids/day.

Combined with nursing's allowed 750cc fluids, Patient #7 was receiving 3150cc of fluids for the day. The physician's order was for 1500cc fluids per day.


During an interview on the afternoon of 12/10/18, on the inpatient unit, Staff #12, RD stated, " ...we (dietary) send 750 fluids and nursing uses the other 750 because he (Patient #7) is getting supplements and meds ..."


Staff #10, RD confirmed she had not been notified of Patient #7's request for more fluids and confirmed the diet sheets do not reflect the ordered large portions.