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Based on document review and interview, facility nursing staff failed to report significant change in patient weight to a provider, failed to complete point of care blood glucose checks as order by provider, failed to complete laboratory blood testing as ordered by provider, failed to notify a supervisory practitioner of patient care concerns, and failed to review and update a care plan for 1 of 10 medical records reviewed.

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, facility nursing staff failed to report significant change in weight to a provider, failed to complete point of care blood glucose checks as order by provider, failed to complete laboratory blood testing as ordered by provider, and failed to notify a supervisory practitioner of patient care concerns in 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled, "Vital Signs and Weight", PolicyStat ID 12386461, last revised 09/2022, indicated under PROCEDURE: Staff is to report any significant changes or abnormal findings to the nurse. Nurses will notify the provider of findings outside patient's normal range.

2. Facility policy titled, "Patient Refusal of Food", PolicyStat ID 12522835, last approved 10/2022, indicated under PROCEDURE: 4. If meal refusal or poor food consumption continues to be a problem, weekly weights are to be initiated. If a significant weight loss is incurred, the physician is to be contacted. If an insulin-dependent diabetic continues to eat poorly or refuse meals, the physician will be contacted by the nursing staff.

3. Facility policy titled,"Laboratory Process", PolicyStat ID 12197196, last approved 08/2022, indicated under PROCEDURE: 1. Provider orders lab. 2. Nurse transcribes order onto patient lab sheet, which is with the patient's MAR. 3. Nurses place order for laboratory tests on lab website. 4. Nurses and/or phlebotomist obtains specimen for ordered tests. 8. Nurses/Unit Clerks obtain laboratory results for lab website and print results. 1. Nurse updates provider of abnormal results as needed, including obtaining any new orders. 9. Nurses/Unit Clerks place printed results in the patient's medical record for the provider to review. 10. Lab Refusals shall be documented on the lab sheet in the patient's MAR and/or the Nursing narrative.

4. MR (Medical Record) review for P1 indicated provider orders were placed on 12/25/24 at 6:30 pm for laboratory tests including CBC (Complete Blood Count) with Differential, BMP (Basic Metabolic Panel, CMP (Comprehensive Metabolic Panel), TSH (Thyroid Stimulating Hormone), and Urinalysis with C & S (Culture & Sensitivity). On 12/26/24 at 3:00 pm provider orders for laboratory tests for P1 included BMP, TSH, Vitamin D level, and Accu checks (point of care blood glucose testing) before meals and at bedtime. Rationale for the provider order was P1's decreased appetite. On 12/29/25 at 1:07 pm provider orders for P1 included laboratory tests of CBC and CMP. Rationale for the provider order was P1's refusal of meals, medications, and drinks. Nursing narrative documentation for dates 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/2/25, 1/3/25, 1/4/25 indicated nursing staff notified in-house and/or on-call provider notification of P1's refusal of meals, drinks, and medications. P1's MR indicated his/her admission weight was 137.5 lbs, weekly weight on 1/1/25 was 113 lbs. MR for P1 lacked supervisory provider notification of P1's refusal to eat, drink, or take medications after nursing concerns were not satisfied by either the in-house and/or on-call provider, lacked documentation of completed laboratory orders performed by nursing as ordered on 12/25/24, 12/26/24, and 12/29/24, lacked notification to a provider of a 24 lb weight loss in a seven day period by P1.

5. In interview on 1/23/25 at approximately 12:00 pm with N1 (Registered Nurse) confirmed provider notification of P1 not eating, drinking, and refusal of medications to both medical and psychiatric providers numerous times. Confirmed knowing how to escalate concerns to the supervisory medical doctor if concerns are not being met. Confirmed he/she did not escalate his/her concerns to the attending physician but should have.

6. In interview on 1/23/24 at approximately 12:30 pm, A4 (Director of Quality and Risk) confirmed ordered laboratory studies for P1 were not completed by nursing and should have been.
7. In interview on 1/24/25 at approximately 10:47 am with MD1 (Medical Doctor), confirmed he/she was not notified by nursing staff with concerns of P1 refusing, meals, medications, drinks, or significant weight loss in a seven-day period.

8. In interview on 1/24/25 at approximately 11:30 am with NP2 (Nurse Practitioner) confirmed he/she was the main medical provider for P1, does not remember if he/she followed up on the orders placed for laboratory work and accuchecks, confirmed he/she completes face-to-face assessments with the patients, confirmed he/she doesn't know why or does not have a good answer for the lack of interventions established by him/her despite nursing notification of continued refusal of medications, meals, and drinks by P1.

Based on document review, facility nursing staff failed to review and update a care plan for 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled,"Plan of Care-Protocol for the Use of the Interdisciplinary Format", PolicyStat ID 12197123, last approved 08/2022, indicated under PROCEDURE: Phase II: Formulating the Interdisciplinary Treatment Plan (Initial Session). The Interdisciplinary Treatment Team will meet on a weekly basis to ensure the preparation, review, and update of each patient's individualized problem, goals, and approaches through an interdisciplinary approach. The Interdisciplinary Treatment Team meetings will be attended by at least the Psychiatrist or designee, Director of Nursing or designee, Social Worker, Psychology, Therapy Services, Medical Provider (or designee), Utilization Review, Dietary, and Pharmacy.

2. MR (Medical Record) review for P1 indicated nursing documentation of P1 was refusing meals, medications, and liquids on 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/2/25, 1/3/25, and 1/4/25. Interdisciplinary care plan for refusing meals was created 12/25/24 at 5:10 pm by N1 (Registered Nurse). Short term goals included P1 was to maintain or increase his/her body weight during hospitalization. Nursing interventions initiated on 12/25/24 included weighing the patient weekly, monitoring fluid and food intake/output and assessing daily for signs or symptoms of nutritional issues along with notifying the provider if signs or symptoms worsened. No Provider interventions were documented on this care plan. On 12/27/24 dietary services initiated an intervention for nutritional supplements three times a day. MR for P1 lacked documentation of P1's nutritional care plan being reviewed per policy by nursing, lacked documented nursing interventions to aid P1 in increasing intake of meals, medications, or liquids.