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Based on policy review, medical record review and staff and physician interviews, nursing staff failed to evaluate and supervise patients' nutritional needs as evidenced by failing to assess nutritional needs, failing to monitor food consumption and ability to swallow, follow care plan interventions and/or failing to notify the physician of difficulty swallowing for 6 of 7 sampled records reviewed (#3, #5, #6, #8, #2 and #10).

Review of the hospital policy, "Assessment/Reassessment", revised 04/2009, revealed, "POLICY: An initial screening or assessment of each patient's (neonate to advanced adulthood) physical...will be performed. PURPOSE: To determine the need for care, the type of care to be provided, and the need for any further assessment. SPECIAL INSTRUCTIONS: ...IV. A Registered Nurse will assess the patient's need for nursing care and prioritize these needs in all settings in which nursing care is provided. It is the responsibility of the RN to initiate a plan of care that accurately reflects the patient's condition. ...VI. Patients (age 13 years to advanced adult) admitted for service will be screened for nutritional risks by the nursing staff. Those patients found to be a nutritional risk will need a nutrition consult. The dietician will be notified and an assessment and plan for nutrition therapy will be developed and implemented. A Dietary Consult will be ordered for patients with any of the following: Tube feeding/TPN (total parenteral nutrition), Unintentional Weight Loss > (greater than) 10 lbs (pounds)/ (per) 1 month, Poor Oral Intake/1 week, Difficulty Chewing/Swallowing, Frequent Nausea/Vomiting/Diarrhea > 5 days, NPO (nothing by mouth) > 3 days, Needs Special Diet Information, New Onset Diabetes, Complication of Pregnancy..., Decubitus Ulcer... REASSESSMENT: XXIII. Each unit/department (inpatient/outpatient) will perform patient reassessments to ensure care decisions remain appropriate. These will be done at a minimum: ...D. When a significant change occurs in the patient's condition...".

Hospital administrative staff were asked for a policy that addressed aspiration precautions and presented a "Swallow Screen Evaluation for the Stroke Patient" form dated 05/17/2010. Review of this form revealed "PURPOSE: This evaluation tool is to be completed by the nurse performing the initial Stroke Assessment to assist in determining the patient's risk for aspiration. Note: Keep HOB (head of bed) at 90 degrees for meals and for RN (registered nurse) Swallow Screen Procedure. INSTRUCTIONS: Evaluate the patient's response to each indicator. Circle appropriate responses from Columns A or B. Column A - If all responses are in Column A, feed patient with caution. Column B - If any indicators are circled, keep patient NPO (nothing by mouth). Obtain order for speech evaluation from physician. Re-evaluate with change in patient condition." Review of the form revealed 13 indicators to be evaluated with responses to be circled in Column A and Column B. Review of the indicators included "3. Facial Weakness, 8. Voice Quality, 9. Patient complains of difficulty swallowing, 11. Swallows sips of water (teaspoon of water), 12. Swallows 60 ml (milliliters) of water (4 tablespoons) and 13. Swallows food." Review of Column B responses that would require a patient to be placed on nothing by mouth included: drools, chokes, facial droop, weak or absent cough, change in voice, patient complaint of difficulty swallowing and delayed swallowing of food greater than 3 seconds.

1. Closed medical record review on 06/21/2011 of Patient # 3 revealed a 63 year-old male admitted to the ICU (Intensive Care Unit) on 04/25/2011 with hypertensive crisis with cerebral vascular disease. Review of the physician's history and physical revealed the patient's evaluation was positive for a CVA (stroke). Review of an admission nursing assessment dated 04/25/2011 (not timed) revealed "Reason for Hospitalization: Bad headache. Couldn't move left arm. Last all night - woke up this AM still weak - but not as bad. Difficulty swallowing." Further review of the admission assessment revealed "Nutritional Screen" with items that included "Difficulty chewing/swallowing." Review of this section revealed "If any item(s) in the above section initialed, enter nutritional consult in Meditech (electronic order system)." Review of the Nutritional Screen revealed the section was blank (not completed). Further review of the admission assessment revealed the patient had slurred speech and strong grip on the right and left side. Review of the patient's care plan initiated 04/25/2011 revealed a problem identified as "Swallowing impaired r/t (related to) neuromuscular impairment." Review revealed interventions included "Aspiration Precautions, Suction at bedside, Elevate HOB (head of bed), especially during and immediately after feeding/eating, Place food on unaffected side of mouth." Further review of the care plan revealed "Feed assist." Review of physician's orders revealed an order dated 04/26/2011 at 1230 for "Advance diet as tolerates." Review of the record revealed no documentation of the type of diet ordered or served to the patient. Review of the record revealed a section to record diet percent for breakfast, lunch and dinner. Review of the record for 04/25/2011 revealed the section was blank. Review of this section on 04/26/2011 revealed the section was blank for breakfast, 30% recorded at lunch and 75% at dinner. Review of this section on 04/27/2011 revealed it was blank. Review of neurological assessments recorded on 04/26/2011 at 2000 revealed the patient had left arm weakness and facial drooping, on 04/27/2011 at 0730 the patient had left facial droop and was able to lift his arm, unable to squeeze his hand, and at 1920 the patient had left facial droop, left upper extremity weakness and his left arm was flaccid. Review of nursing notes recorded on 04/27/2011 at 1230 revealed "Patient eating lunch being helped by girlfriend. Food dripping from left side of mouth...." Nursing notes at 1715 revealed "Daughter in room. Patient trying to eat dinner, drank tea and coughed, took spoonful of soup, carrots and meat, pocketing meat on left side. Discussed with daughters and patient that patient should not eat at this time..." Review of the physician's discharge summary dictated on 04/27/2011 at 1840 revealed "...(Patient #3's) stroke has evolved and it is not surprising that he had developed a little more left facial weakness as well as more right upper and lower extremity weakness.... The family was quite concerned that (the patient) may have extended his stroke or that he could not swallow and he may suffer aspiration pneumonia..." Further review of the record revealed the patient was transferred to another acute hospital for continued care on 04/27/2011 at 2040.

Interview on 06/21/2011 at 1500 with the hospital's dietician revealed a nutritional screening assessment is to be completed on all patients at the time of admission by nursing staff. Interview revealed "difficulty chewing/swallowing" was an indicator that would prompt a dietary consult. Interview further revealed the hospital did not have a speech therapist available to do swallow studies. Interview revealed the hospital nursing staff and physicians are responsible for evaluating a patient's ability to swallow.

Telephone interview on 06/22/2011 at 1400 with RN #1 revealed she was a registered nurse (RN) that worked day shift in ICU. Review of Patient #3's record revealed RN #1 was the nurse who was assigned to the patient on 04/27/2011 from 0700 through 1900. Interview with the nurse revealed she would not discuss Patient #3 without the medical record for reference and she was not able to come in for interview. The nurse stated she was willing to discuss general information and practice and procedures followed in ICU. Interview revealed nursing staff complete a nutritional screening assessment on all newly admitted patients. Interview revealed nursing staff do not conduct swallow studies and that she had never seen a "Swallow Screen Evaluation" tool. Interview revealed a patient admitted with a stroke would have potential for aspiration and that she would evaluate the patient's ability to tolerate liquids by giving the patient sips of water. The nurse stated that if the patient tolerated the water, she would request a liquid diet, and if tolerated, advance to a soft diet. The nurse stated this assessment would be documented in the patient's record. The nurse stated "If I saw a patient pocketing food or not able to swallow or drooling, I would notify the physician and make the patient NPO." Further interview with the nurse revealed "Aspiration Precautions" included having the patient sit up and staying with the patient while they eat, making sure the patient only takes small amounts of food at a time."

Interview on 06/22/2011 at 1135 with Patient #3's physician (Physician A) revealed he could not remember what kind of diet the patient was receiving. Interview revealed the physician recalled observing the patient eating solid food at some point and stated that he was not having any trouble eating, just a little coughing. Interview revealed he remembered the patient doing well with his diet and asking the physician for more to eat. Interview revealed the physician was not notified on 04/27/2011 at 1230 when the patient was seen with food dripping from the left side of his mouth. The physician stated, "I should have been (notified). I would have made him NPO (nothing by mouth) until an evaluation was done. I would have gone up and evaluated him myself." Interview revealed that there was not a speech therapist available, but that he could order a modified barium swallow (radiology procedure) that would show if there were aspiration concerns. Interview revealed the physician had not ordered a modified barium study because he was not aware of any concerns with swallowing.

Interview on 06/22/2011 at 1325 with dietary administrative staff revealed diet orders were entered electronically. Review of Patient #3's dietary orders revealed the patient was ordered a full liquid diet on 04/26/2011 at 1323 and would have received this for lunch. Review revealed a diet order on 04/26/2011 at 1422 for a Special CCU Diet (cardiac diet with no added salt and no cholesterol) which the patient would have received for dinner on 04/26/2011. Review and interview revealed there were no diet order changes made and the patient remained on the Special CCU diet until he was transferred on 04/27/2011.

Interview on 06/21/2011 at 1555 with the ICU Nurse Manager revealed the "Swallow Screen Evaluation for the Stoke Patient" form had been implemented in May 2010. The staff member stated she was on leave when this form was initiated and she was not sure what training or education had been done related to the swallow screen assessment. Interview further revealed the ICU nursing staff was not familiar with the swallow screen assessment form and it was not used. Interview revealed nursing staff should have completed a nutritional assessment on Patient #3 and confirmed it was not done. Interview revealed a dietary order for "advance diet as tolerated" would start with water, Sprite or broth, then progress to a soft regular or regular, depending on the patient's ability to tolerate the diet. Interview revealed nursing staff should assess the patient's ability to swallow before advancing a diet. The staff member reviewed the patient's record and was not able to find an assessment of the patient's ability to swallow. Interview confirmed the "Swallow Screen Evaluation for Stroke Patient" form was not completed on Patient #3. Interview further revealed that there was no evidence of the type of diet the patient was served during his hospitalization. Interview revealed nursing staff failed to monitor and document the percent of food consumed for each meal. Interview revealed the nurse manager was not able to determine if the patient was tolerating his diet based on the documentation in the record. Interview revealed the staff manager was not able to find evidence that nursing staff assessed the patient's ability to swallow, monitored the patient's food consumption, provided supervision of meals or feeding assistance according to care plan interventions and notified the physician when the patient had evidence of eating difficulty on 04/27/2011 at 1230. Interview confirmed there was no evidence in the patient's record that a diet change was made after the patient was seen with food dripping from the left side of his mouth on 04/27/2011 at 1230. Interview revealed the patient received a meal on 04/27/2011 at 1715 and was not able to tolerate consumption of the food.

2. Open record review on 06/22/2011 of Patient #5 revealed an 84 year-old male admitted on 06/19/2011 with a gastrointestinal (GI) bleed, dehydration, aspiration pneumonia and history of Parkinson's disease. Record review revealed an "Admission Assessment Form" completed 06/19/2011 (not timed). Review of the Admission Assessment Form revealed a Nutritional Screen that was blank (not completed). Further review of the assessment form revealed no documentation that Patient #5 was assessed for nutritional status. Review of the record revealed a nursing note dated 06/19/2011 at 0015 revealed the patient was admitted to ICU from the emergency department with GI bleeding. Notes recorded the patient was weak with limited movement from Parkinson's disease. Review of Patient #5's plan of care dated 06/22/2011 revealed "...Malnutrition...Complete nutritional assessment on admission, monitor food intake, supplemental diet.... Additional Interventions...Assess feeding tolerance, weight loss, vomiting, diarrhea, poor sucking ability, poor swallowing reflex...." Record review revealed no documentation that a dietary consult was ordered for Patient #5.

Interview on 06/22/2011 at 1030 with RN #2 (assigned to the patient) confirmed there was no documentation of a nutritional assessment for Patient #5. Interview revealed, "nurses should be completing a nutritional assessment on all patients." Interview confirmed the nurse failed to follow hospital policy for assessing a patient's nutritional status on admission.



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3. Open record review on 06/21/2011 of Patient #6 revealed a 57 year old admitted 06/17/2011 with an acute stroke. Record review revealed an "Admission Assessment Form" completed 06/17/2011 (not timed). Review of the Admission Assessment Form revealed a Nutritional Screen, marked out with a large X. Further review of the assessment form revealed no documentation that Patient #6 was assessed for nutritional status. Review of the record revealed a nursing note dated 06/17/2011 at 1130, "Received care of pt (patient) via stretcher from ED (Emergency Department)...Pt speech slurred but understandable. Assessment completed as noted on flowsheet. Pt hand grips unequal, left strong, right weak...". Review of Patient #4's plan of care dated 06/18/2011 revealed "...Swallowing Impaired R/T (related to) Neuromuscular Impairment...". Record review revealed no documentation that a dietary consult was ordered for Patient #6.

Interview on 06/22/2011 at 1020 with the registered nurse (RN #3) who performed the admission assessment for Patient #6 revealed, "a nutritional assessment should have been completed. I don't know why I didn't". Interview further revealed, "I observed him eating and (name of physician) assessed his ability to swallow. He went from NPO to full liquids to a regular diet". Interview confirmed a nutritional assessment was not completed on admission. Interview confirmed the nurse failed to follow hospital policy for assessing a patient's nutritional status on admission.

4. Open record review on 06/22/2011 of Patient #8 revealed a 91 year-old admitted 06/16/2011 with acute brain hemorrhage and stroke. Record review revealed an "Admission Assessment Form" completed 06/16/2011 (not timed). Review of the Admission Assessment Form revealed a Nutritional Screen, marked out with a large X. Further review of the assessment form revealed no documentation that Patient #8 was assessed for nutritional status. Review of the record revealed a nursing note dated 06/16/2011 at 1250, "Received pt from ED via stretcher. Pt unresponsive...Assessment completed, see flow sheet...". Review of Patient #8's plan of care dated 06/16/2011 revealed "...Swallowing Impaired R/T (related to) Neuromuscular Impairment...". Record review revealed no documentation that a dietary consult was ordered for Patient #8.

Interview on 06/22/2011 at 1030 with administrative nursing staff confirmed there was no documentation of a nutritional assessment for Patient #8. Interview revealed, "nurses should be completing a nutritional assessment on all patients, especially elderly patients with a stroke". Interview confirmed the nurse failed to follow hospital policy for assessing a patient's nutritional status on admission.

5. Closed record review on 06/22/2011 of Patient #2 revealed an 87 year-old admitted 04/24/2011 with urinary tract infection, chronic anemia, rule out stroke, nausea, weakness and confusion. Record review revealed an "Admission Assessment Form" completed 04/24/2011 (not timed). Review of the Admission Assessment Form revealed a Nutritional Screen that was blank (not completed). Record review revealed no documentation that a dietary consult was ordered for Patient #2.

Interview on 06/22/2011 at 1030 with administrative nursing staff confirmed there was no documentation of a nutritional assessment for Patient #2. Interview revealed, "nurses should be completing a nutritional assessment on all patients, especially elderly patients with a stroke". Interview confirmed the nurse failed to follow hospital policy for assessing a patient's nutritional status on admission.

6. Open record review on 06/22/2011 of Patient #10 revealed a 71 year-old female admitted on 06/22/2011 with chest pain, possible acute coronary syndrome and history of diabetes and obesity. Record review revealed an "Admission Assessment Form" completed 06/22/2011 (not timed). Review of the Admission Assessment Form revealed a Nutritional Screen that was blank (not completed). Further review of the assessment form revealed no documentation that Patient #10 was assessed for nutritional status. Record review revealed no documentation that a dietary consult was ordered for Patient #10.

Interview on 06/22/2011 at 1030 with RN #2 (nurse assigned to the patient) confirmed there was no documentation of a nutritional assessment for Patient #10. Interview revealed, "nurses should be completing a nutritional assessment on all patients." Interview confirmed the nurse failed to follow hospital policy for assessing a patient's nutritional status on admission.

Based on review of hospital policy, medical records and staff and physician interviews the hospital's nursing staff failed to administer medications as ordered by the physician for 2 of 7 sampled records reviewed (#3 and #4).

Review of the hospital's policy, "Medication Administration Times", revised 10/2010, revealed, "POLICY: Medications will be administered on specified time schedules as defined by the medical staff, nursing , and pharmacy. PURPOSE: To ensure the administration of medications on schedule for therapeutic effect. ...Medications are to be given within 30 minutes of administration time listed on the MAR worksheet. If the medication is given more than 30 minutes before or 30 minutes after the time listed on the MAR Worksheet, write the time it is actually given and initial in the slot on the MAR Worksheet, then explain in Nurse's Notes or if using Intellidot, scan a rationale. ... DESIRED OUTCOME: Medications will be administered to maintain safe, therapeutic levels".

Review of an Intensive Care Unit (ICU) protocol revised April 2011 revealed the purpose of the protocol was "To outline the nursing responsibility in the care of the patient receiving Nitroglycerine (vasodilator) by IV (intravenous) infusion." Review of the protocol revealed "Usual Dose: Usual dose is 5 mcg/min (micrograms per minute) initially (3 cc/hr) (3 cubic centimeters per hour). Increase by 5 mcg/min every 3-5 minutes until BP (blood pressure) response or relief of chest pain is noted. If no response at 20 mcg/min, 10 mcg/min increases can be used. Up to 100 mcg/min may be needed. No fixed optimum dose." Further review revealed "Nursing Management: 1. Maintain adequate systemic blood pressure. 2. Monitor heart rate and blood pressure every five minutes until stabilized, then check every 30 minutes - 1 hour...."

1. Closed medical record review on 06/21/2011 of Patient # 3 revealed a 63 year-old male admitted to the ICU on 04/25/2011 with hypertensive crisis with cerebral vascular disease. Review of the physician's history and physical dictated 04/25/2011 at 1913 revealed "... When the patient first came to the emergency room he was quite hypertensive. He was apparently quite anxious also. His blood pressure was 202/145. He was given some Ativan (medication for anxiety) and IV Vasotec (blood pressure medication). His blood pressure has still remained elevated. However his blood pressure has come down some and his headache has resolved.... We will need to start a Nitroglycerine infusion to try to slowly and carefully bring his blood pressure down. I would like to get his systolic down to below 160, diastolic below 94. He was up to 190/110 during the time I was at the bedside.... We will titrate his medications to maintain good blood pressure control...." Review of physician's admission orders dated 04/25/2011 at 1910 revealed an order for "NTG (Nitroglycerine) infusion 5 mcg/min - titrate to keep his Sys BP(systolic blood pressure) < (less than) 160, Dias BP (diastolic blood pressure) < 94." Review of nursing notes dated 04/25/2011 at 2040 revealed the patient came to ICU at 2040 with a NTG infusion going at 9 cc/hr (15 mcg/min). Review revealed the patient's blood pressure at 2100 was 175/85. Review of the notes revealed the NTG was decreased to 6 cc/hr at 2300 with a blood pressure of 155/76, then 3 cc/hr on 04/26/2011 at 0000 for a BP of 141/77. Review revealed the NTG drip was turned off at 0030 with a BP of 126/79. Further review of nursing notes revealed the NTG infusion was started back at 6 cc/hr on 04/26/2011 at 1600 for a BP of 159/108 and remained at 6 cc/hr through 04/27/2011 at 0200 when it was decreased to 3 cc/hr. Review revealed the patient's blood pressure was monitored every 30 minutes to hourly during this time. Review of the patient's blood pressures and NTG infusion revealed: 04/26/2011 at 1600 BP 159/108 and NTG 6 cc/hr, 1630 BP 159/110 and NTG 6 cc/hr, 1700 BP 154/111 and NTG 6 cc/hr, 1730 BP 146/86 (below ordered parameters) and NTG 6 cc/hr, 1800 BP 152/91 (below ordered parameters) and NTG 6 cc/hr, 1830 BP 156/103 and NTG 6 cc/hr, 1930 BP 158/85 (below ordered parameters) and NTG 6 cc/hr, 2000 BP 147/85 (below ordered parameters) and NTG 6 cc/hr, 2030 BP 133/99 and NTG 6 cc/hr, 2100 BP 144/76 (below ordered parameters) and NTG 6 cc/hr, 2130 BP 158/69 (below ordered parameters) and NTG 6 cc/hr, 2200 BP 147/83 (below ordered parameters) and NTG 6 cc/hr, 2230 BP 153/74 (below ordered parameters) and NTG 6 cc/hr, 2300 BP 122/84 (below ordered parameters) and NTG 6 cc/hr, 2330 BP 129/88 (below ordered parameters) and NTG 6 cc/hr, 04/27/2011 at 0000 BP 147/71 (below ordered parameters) and NTG 6 cc/hr, 0030 BP 152/81 (below ordered parameters) and NTG 6 cc/hr, 0100 BP 152/78 (below ordered parameters) and NTG 6 cc/hr, 0130 BP 103/58 (below ordered parameters) and NTG 6 cc/hr, 0200 BP 119/67 and NTG decreased to 3 cc/hr. Review of nurses notes revealed the patient's blood pressure was below the physician's ordered parameters of less than 160 systolic and less than 94 diastolic for 15 of 20 BP readings (from 1600 on 04/26/2011 through 0200 on 04/27/201, 10 hours) without adjustments made to the NTG infusion. Record review revealed nursing staff failed to titrate the Nitroglycerine drip according to the physician's orders. Further review of the record revealed the patient was transferred to another acute hospital for continued care on 04/27/2011 at 2040.

Interview on 06/22/2011 at 1135 with the patient's physician (Physician A) revealed he ordered the Nitroglycerine infusion to be titrated by nursing staff to maintain the patient's blood pressures below 160 systolic and 94 diastolic. The physician stated he would expect the nursing staff to decrease the Nitroglycerine infusion when the patient's blood pressure dropped below the identified parameters with a goal of trying to discontinue the Nitroglycerine infusion. Interview revealed the Nitroglycerine drip should be restarted when the patient's blood pressure was above the identified parameters. The physician stated that a low blood pressure below 120 systolic in this patient would be concerning due to possible compromise of the patient's stroke. Interview revealed the physician would expect to be notified of low blood pressure readings (below 120 systolic). Interview revealed the physician was not notified about any low blood pressures (below 120 systolic) during the patient's admission. Interview revealed the physician was not aware that the patient's blood pressure was below identified parameters on 04/26/2011 and 04/27/2011 with no decrease in the Nitroglycerine infusion.

Interview on 06/22/2011 at 1000 with an ICU registered nurse (RN #2) revealed a Nitroglycerine infusion was increased or decreased by 5 - 10 mcg/min based on the identified parameters ordered by the physician. Interview revealed the goal was to control the patient's blood pressure using the minimum medication needed to maintain the patient's blood pressure below the identified parameters. Interview revealed consistent blood pressure readings below the physician's ordered parameters without decreasing the Nitroglycerine infusion would not be consistent with the physician's orders.

Interview on 06/22/2011 at 1440 with a nursing administrative staff member revealed a Nitroglycerine infusion should be titrated according to the physician's orders. The staff member reviewed Patient #3's medical record and confirmed the physician's order to titrate the Nitroglycerine to maintain a systolic blood pressure below 160 and diastolic blood pressure below 94. The staff member reviewed the patient's blood pressures and Nitroglycerine infusion administration. The staff member stated nursing staff failed to follow the physician's orders by failing to decrease the Nitroglycerine infusion when the patient's blood pressure was below the identified parameters.



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2. Closed record review of Patient #4 revealed a 66 year-old admitted 06/08/2011 with lung cancer. Record review revealed a physician's order dated 6/08/2011 at 1025 "...Demeclocycline (antibiotic) 300 mg (2) po (by mouth) bid (twice daily)...". Further record review revealed a physician's order dated 06/10/2011 at 1000, "...Be sure to control nausea so he can keep the Demeclocycline down...". Review of Patient #4's Medication Administration Record revealed Demeclocycline 600 mg oral twice a day was scheduled to be given at 1000. Review of the Medication Administration Record dated 06/11/2011 revealed the Demeclocycline was given at 1105 (1 hour, 5 minutes late) and the late reason was documented as "increased unit activity". Review of the Medication Administration Record dated 06/12/2011 revealed the Demeclocyline was given at 1141 (1 hour, 41 minutes late) and the late reason was documented as "increased unit activity".

Interview on 06/21/2011 at 1500 with administrative nursing staff confirmed that Patient #4's Demeclocyline was administered on 06/11/2011 at 1105 and 06/12/2011 at 1141. Interview confirmed the medication should have been administered at 1000. Interview confirmed the nursing staff failed to follow hospital policy for the administration of medications.

Interview on 06/22/2011 at 1030 with the registered staff nurse who administered the Demeclocyline on 06/11/2011 at 1105 and 06/12/2011 at 1141 revealed "sometimes the unit is busy and I can't give the medications on time. If I documented increased unit activity then I was too busy to give it at 1000". Interview further revealed, "I don't complete a medication variance report when it's late, only if it's the wrong dose, wrong drug, wrong patient". Interview further revealed that a variance report should be completed if medication is given late. Interview confirmed the hospital policy for the administration of medications was not followed.

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