HospitalInspections.org

Based on observation, interview, and record review, licensed nursing staff failed to create a care plan ( provides a framework for evaluating and providing patient care needs related to the nursing process) that addressed nutritional needs and/or aspiration (when food or liquid go into the airway instead of the stomach) concerns for patients who are receiving enteral feeding for five of the thirty (30) sampled patients (Patient 1, 17, 25, 28, and Patient 30), in accordance with the facility's policy and procedure.

This deficient practice had the potential to delay the provision of necessary care and services due to the incompleteness or absence of an individualized care plan that contains the information needed to properly care for the affected patient. For Patient 1, the deficient practice resulted in aspiration.

Findings:

1a. A review of Patient 1's "Patient Registration Data," indicated Patient 1 was admitted to the facility on 7/21/2023.

During a review of Patients 1's "History and Physical" (H&P), dated 7/21/2023, the "H&P" indicated Patient 1 was transferred to the facility with chief complaint of acute respiratory failure (when air sacs of the lungs cannot release enough oxygen into the blood).

During a review of Patient 1's "Physician Orders," dated 7/22/2023 at 7:33 a.m., the order indicated Patient 1 was placed on a Diabetic Diet (a healthy-eating plan that ' s rich in nutrients and low in fat and calories), ... Food Consistency: pureed (level 4, food has been ground, pressed or stained to make it easy to swallow, smooth, lump free, not firm and not sticky), liquid consistency: moderately thick (Level 3 ...).

During a review of Patient 1's "Progress Note," dated 7/25/2023 at 2:29 p.m., the "Progress Note" indicated Patient 1 was "in no apparent distress, dry mouth membranes, neck is supple, lungs crackles (a sound that may indicate there is fluid in the lungs) at the bases bilaterally..."

During a review of Patient 1's "Progress Note," dated 7/25/2023 at 12:57 p.m., the "Progress Note" indicated Patient 1 had a history of respiratory failure requiring intubation (a tube is inserted through the mouth or nose, then down into the airway, to allow air to get through). Patient 1 was successfully extubated (removal of the tube from the airway), stabilized and transferred to the facility for continued care. Assessment, Plan and Recommendations: Aspiration precautions (interventions to help prevent food or liquid from going into the airway instead of the stomach).

During a review of Patient 1's "Infectious Diseases Follow up Note," dated 7/25/2023 at 8:49 p.m., the note indicated the following: Impression ... 5. Recurrent aspiration pneumonia (lung infection that occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed). Plan: Aspiration precautions.

During the review of Patient 1's "Gastrointestinal Follow-up" note, dated 7/27/2023 at 11:15 p.m., the note indicated the following: Patient 1 was arousable and cooperative. Impression: malnutrition, history of mild dysphagia, altered mental status ...Recommendations:

Patient is currently on pureed diet and required advancement of the diet.

We will request swallow evaluation to see if the patient is fit for the next diet ...

During a review of Patient 1's "Speech notes," dated 7/28/2023 at 8:56 a.m., the notes indicated Swallow evaluation and treatment: clinical/bedside evaluation: 7/28/2023 at 7:57 a.m., Bedside swallowing assessment completed ...Chest x-ray from 7/22/2023 showed bibasilar patchy opacities (partial lung collapse), small bilateral pleural effusions (buildup of fluid between the tissues that line the lungs and chest) ... Mildly delayed swallow response noted ...Assessment: moderate oral and suspected pharyngeal dysphagia (difficulty swallowing). Plan: Recommend continue puree diet with mildly thick liquid with universal swallow precautions (sitting upright while eating, eating a slow rate, etc).

During a review of Patient 1's "Nutrition note," dated 7/28/2023 at 11:47 a.m., the note indicated "informed son patient's diet order remains pureed / mildly thick liquid and swallowing evaluation and Ensure (a nutritional supplement) pudding had been recommended and ordered due to patient eating poorly due to disliking pureed food. Informed that patient had consumed two Ensure pudding cups yesterday but very little food (only small amount of pureed starch and apple sauce) and that SLP (Speech Language Pathologist, or speech therapist, specialized in speech and swallowing) saw patient this morning and recommended to continue pureed/mildly thick diet.

During a review of Patient 1's "Plan of Care" or "POC" titled "Impaired Swallowing," dated 7/28/2023 at 8:45 a.m., the "POC" indicated Patient 1 had impaired swallowing related to dysphagia (difficulty swallowing). The desired goal: "Patient to tolerate puree diet with mildly thick liquids without signs and symptoms of aspiration ...Intervention: Treat swallowing dysfunction and / or oral function for feeding ..."

During a review of Patient 1's "Progress Note titled: Pulmonary Progress/Critical Care Notes," dated 7/28/2023 at 5:06 p.m., the note indicated "Assessment: Recurrent aspiration pneumonia ...Plan: Aspiration precautions."

During a review of Patient 1's RT (respiratory therapy) Progress Note," dated 7/28/2023 at 5:32 p.m., the note indicated "7/28/2023 at 16:40 (4:40 p.m.): Rapid Response (Rapid response team, a team of health care providers that respond to patient with early signs of deterioration to prevent respiratory or cardiac arrest) was called and Patient was found to be bradycardic (slow heart rate), hypotensive (low blood pressure) with no spontaneous respirations. Patient was orally suctioned for large amount of thin brown fluid ...

During a review of Patient 1's "Resuscitation Record," dated 7/28/2023 at 6:28 p.m., the note indicated, "Respiratory arrest, CPR (cardiopulmonary resuscitation, lifesaving techniques used in emergencies in which someone ' s breathing or heart stopped) started at 16:47 (4:47 p.m.). Patient was intubated at 16:55 (4:55 p.m.) by Respiratory Therapist (RT 1) 1.

During a review of Patient 1's "Change of Condition Note," dated 7/28/2023 at 6:28 p.m., the note indicated treatment initiated: Patient was intubated in a code blue (indicates a patient requires resuscitation or immediate medical attention as a result of a respiratory or cardiac arrest) ... Patient placed on mechanical ventilation (a machine that helps one breathe).

During a review of Patient 1's "RT Progress Note," dated 7/28/2023 at 6:35 p.m., the note indicated on "7/28/2023 at 16:40 (4:40 p.m.): Rapid Response called. Proceeded to bag the patient (Patient 1). 1647 (4:47 pm) Code called on patient, non-responsive. ACLS (advanced cardiac life support, a group of procedures and techniques that treat immediately life-threatening conditions) performed with ROSC (return of spontaneous circulation), restart of a sustained heart rhythm that permeates the body after a cardiac arrest (heart stops beating). Patient intubated ..."

During a review of Patient 1's "Chest, 1 View" radiology report, dated 7/28/2023 at 6:42 p.m., the report indicated the x-ray indicated the following. Indication: Acute dyspnea (difficulty breathing), status post intubation (after intubation). Impression: Moderate right pleural effusion (buildup of fluid between the tissues that line the lungs and chest) with adjacent atelectasis (partial or complete lung collapse).

During a review of Patient 1's plan of care and nurse's notes, from admission on 7/21/2022 through expiration of Patient 1 on 7/28/2022, the documentation indicated the following. There was no documented evidence that a nursing care plan had been developed addressing Patient 1's risk for aspiration. There was no documented evidence that nursing personnel implemented any interventions to reduce the risk for aspiration.

During an interview and record review, on 7/26/2023 at 2:48 p.m., with Registered Nurse (RN) 1, RN 1 stated the following. Patient 1 was admitted to the Telemetry unit (a unit with where patients undergo continuous heart monitoring) on 7/21/2021 for respiratory failure. Patient 1 was on a pureed diet. Patient 1 was at risk for aspiration due to delayed swallowing and should be on aspiration precautions. There was no nursing documentation addressing aspiration precautions.

During a second interview and record review, on 7/27/2023 at 9:02 a.m., with RN 1, RN 1 stated the following. On 7/28/2023 at 4:40 p.m., a Rapid Response was called for Patient 1 due to bradycardia, hypotension, and no respirations. Per RT note, a large amount of thin brown fluid was orally suctioned by the Respiratory Therapist (RT 1). Patient 1 coded, was resuscitated, then intubated and placed on a ventilator (breathing machine). Per radiology report, dated 7/28/2023 at 6:42 p.m., Patient had fluid accumulation in the lungs. Patient 1 coded again at 7/28/2023 at 10:45 p.m. Chest compressions were started. Patient 1's code status was changed from Full Code (if a person ' s heart stopped and / or they stopped breathing, all resuscitation procedures will be provided to keep them alive) to Do Not Resuscitate (DNR, an order that instructs healthcare providers to not provide CPR if a patient stops breathing) and Patient 1 was pronounced dead on 7/28/2023 at 11:35 p.m.

During an interview, on 7/27/2023 at 9:58 a.m., RT 1 stated the following regarding a Rapid Response for Patient 1 on 7/28/2023 at 4:40 p.m.. RT 1 responded to the Rapid Response for Patient 1. RT 1 suctioned a large amount of thin brown fluid from Patient 1's mouth and down the trachea (airway). RT 1 suspected Patient 1 aspirated food while eating. Patient 1 coded (respiratory and/or cardiac arrest). Patient 1 was intubated and placed on a ventilator.

During an interview, on 7/27/2023 at 11:56 a.m., with the Speech Language Pathologist (SLP 1), SLP 1 reviewed Patient 1's medical record and stated the following: The SLP who evaluated Patient 1 on 7/28/2023 was no longer with the facility and unavailable for interview. Patient 1 was referred to speech pathology for a swallow evaluation because of a chest x-ray showing bilateral effusions in the lungs. Patient 1 was on a pureed diet with mildly thickened liquids. A puree diet was a modified diet, and patients on modified diets were at risk for aspiration. Recommendations included "Universal Swallow Precautions," interventions included, eating at a slow rate, taking small bites, not talking while eating. SLP develop their own care plans to treat the swallowing issues, that do not include interventions to be done during patient care. Nurses should develop their own care plans or add to the existing care plan for interventions to be implemented by nursing personnel. Patients who suffered from dysphagia were at risk for aspiration and all staff should take precautions to help prevent aspiration. A care plan addressing impaired swallowing was developed on 7/28/2023 by the SLP. SLP 1 verified there were no other care plans by nursing regarding aspiration precautions in Patient 1's medical record.

During a third interview and record review, on 7/28/2023 at 9:29 a.m., RN 1 stated the following. Speech therapist develop their own care plans and their own interventions. Nurses can add interventions to the speech therapists' care plans. Patients with dysphagia were at risk for aspiration and a nursing care plan should be developed to implement interventions to reduce the risk of aspiration upon admission and when the problem was identified. Patient 1 was at risk for aspiration, a nursing care plan should have been developed. RN 1 verified a nursing care plan addressing Patient 1's risk for aspiration was not developed during Patient 1's hospitalization. RN 1 also reviewed the nurse ' s notes and stated there was not documentation in the nurse ' s notes addressing aspiration precautions for Patient 1.

During a review of a document provided by the facility titled "International Dysphagia (difficulty swallowing) Diet Standardization Initiate: Pureed Level 4," dated 6/2022, the document indicated the International Dysphagia Diet Standardization Initiate, IDDSI, is considered the current "best practice" and is used as the resource for hospital menu planning. The IDDSI Level 4 is designed for individuals who have a moderate to severe dysphagia with poor oral phase abilities and reduced ability to protect their airway.

During a review of the facility' policy and procedure titled, "Core: Interdisciplinary assessment and Re-Assessment," dated 6/2022, the policy indicated the goal of the assessment/reassessment process is to provide an interdisciplinary approach for the assessment and ongoing reassessment of individual patient care needs and for planning and implementing patient specific interventions ...Data analysis to develop a plan of care to meet the patient's care or treatment needs.

1b. A review of Patient 17's Inpatient Admission Face sheet indicated that the patient was admitted to the facility on 7/20/2023 to the intensive care unit (ICU).

During a review of Patient 17's "History and Physical (H&P)," dated 7/20/23, the "H&P" indicated, Patient 17's medical history included cerebrovascular accidents (strokes), hypertension (high blood pressure), metabolic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), being on a ventilator (a machine to support or replace breathing), and sepsis (harmful microorganisms in the blood).

During a concurrent observation and interview on 7/27/23 at 9:12 a.m. with Registered Nurse (RN) 2, who is assigned to care for Patient 17, observed patient was lying at 30 degrees. Enteral tube feeding was infused at 40 mL (milliliter) per hour. RN 2 stated that Patient 17 had multiple wounds, and she was getting Prosource supplements (a nutritional supplement that is used to meet the needs of people who are nutritionally at risk for protein malnutrition). RN 2 stated that patients who are on enteral feeding are also at increased risk for aspiration.

During a review of physician orders, dated 7/24/23 at 4:51 p.m., the physician orders indicated nutrition ordered for Patient 17 was enteral feeding with Nepro (an artificial formula specifically designed for people with chronic or acute kidney failure) to be infused at a rate of 40 mL per hour and to be started on 7/24/23.

During a concurrent interview and record review on 7/28/2023, at 10:12 a.m. with the clinical chief operator (CCO), Patient 17's care plan was reviewed. There was a care plan for risk of aspiration documented by nursing with goals, but there were no interventions documented. The CCO verified that the care plan was incomplete. The CCO stated that nursing was able to add interventions to the electronic system. CCO stated, "Nursing is supposed to review patients ' plans of care every shift and add interventions or revise the care plan as patient conditions change."

During a review of the facility's policy and procedure (P&P) titled, "Core: Interdisciplinary Assessment and Re-Assessment," dated June 2022, the P &P indicated, "that one of the purposes of assessment and reassessment is to determine the appropriate care, treatment, and services to meet the patient ' s needs during hospitalization.

The P&P indicated the nursing department is responsible for the following:

"The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of care is developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient's goals and the nursing care to be provided to meet the patient's specific needs. The admitting RN will screen each patient during the initial assessment process to identify those patients requiring further specialized interventions. Screening for specialized interventions and/or possible referral to other disciplines is completed within 24 hours of admission and includes Functional status, nutritional status..."

1c. During a review of Patient 25's "Inpatient Admission Face sheet," undated, the face sheet indicated that the patient was admitted to the facility on 7/11/2023.

During review of Patient 25's "History and Physical (H&P)," dated 7/21/2023, the "H&P" indicated, Patient 25's medical history included chronic obstructive pulmonary disease (airflow blockage and breathing-related problems), chronic anemia (a long-term condition in which the body does not have enough healthy red blood cells), and a history of GI (gastrointestinal) bleeding.

During a review of Patient 25's "Nutrition Initial Assessment" notes, dated 7/25/23, the note indicated, Patient 25 ' s "Swallowing abilities: speech and language pathologist (SLP) evaluated patent ' s swallowing today and recommended to continue artificial nutrition and hydration."

During a concurrent interview and record review on 7/28/2023 at 10:20 a.m. with the CCO, Patient 25's nursing care plan was reviewed. The CCO said Patient 25 ' s nursing care plan record indicated there was no care plan from nursing related to swallowing difficulty or nutritional needs. There are care plans for swallowing difficulties from dieticians and SLPs, but those care plans are incomplete. The care plan by the dietitian and the SLP does not have interventions. CCO confirmed that care plan input by dieticians is solely for dieticians to perform and is not for nursing. "Nursing must input their own plan of care." The CCO stated that nursing was responsible for reviewing and revising the care plan every shift.

During a review of the facility's policy and procedure (P&P) Titled, "Core: Interdisciplinary Assessment and Re-Assessment," dated June 2022, The P&P indicated, "that one of the purposes of assessment and reassessment is to determine the appropriate care, treatment, and services to meet the patient ' s needs during hospitalization.

The P&P indicated the nursing department is responsible for the following:

"The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of care is developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient's goals and the nursing care to be provided to meet the patient's specific needs. The admitting RN will screen each patient during the initial assessment process to identify those patients requiring further specialized interventions. Screening for specialized interventions and/or possible referral to other disciplines is completed within 24 hours of admission and includes Functional status, nutritional status..."

1d. During a review of Patient 28's "Inpatient Admission Face sheet," undated, indicated that the patient was admitted to the facility on 10/31/2022.

During a review of patient 28's History and Physical (H&P), dated 11/2/2022, the "H&P" indicated, Patient 28's past medical history included diabetes mellitus (a group of diseases that affect how the body uses blood sugar), moderate protein-calorie malnutrition (the state of inadequate intake of food as a source of protein, calories, and other essential nutrients), and encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition). H&P also indicated the plan for concern relating to moderate protein-calorie malnutrition was to continue on tube feeds via PEG (percutaneous enteral gastronomy, feeding tube through the abdominal wall). Plan to consult a clinical nutrition specialist. H&P also indicated Patient 28 had a sacral (area at the bottom of the spine; the tail bone) wound.

During an interview with the Speech and Language Pathologist (SPL)1 on 2/27/23, at 11:56 a.m., SPL 1 stated, "All patients who are on enteral tube feedings are at risk for aspiration (food, secretions, fluids, or other substances enter the airways or lungs)." SPL1 stated that the care plan that speech and language therapists document are the goals and treatment for the SPL to be performed; it is not for Nursing. Nursing staff must input their own care plan.

During a review of Patient 28's dietician's note titled, "Plan of Care," dated 7/26/2023, the "Plan of Care" indicated, Patient 28 had orders for enteral feeding, Jevity 1.2 (a high-protein, fiber-fortified formula that provides complete, balanced nutrition for long- or short-term tube feeding) at a rate of 75 mL per hour, to be started today (7/26/23).

During an interview on 7/28/23 at 9:41 a.m. with registered nurse (RN) 1, RN 1 stated, "It is important that the care plan for patients with aspiration risk or on enteral tube feeding be updated and revised to reflect the patient's condition." RN 1 stated the care plan was important so there were goals and interventions that can help improve patient comfort and health conditions.

During a concurrent interview and record review on 7/28/2023, at 10:12 a.m. with the clinical chief operator (CCO), the nursing care plan for Patient 28's nutritional needs was reviewed. CCO stated, "There is no nursing care plan documented for the patient (Patient 28) relating to nutritional needs." CCO said that there were other nursing care plans, such as risk for infection and impaired mobility, documented. CCO stated, "It looks like all nutritional care plans are inputted by dietary." CCO confirmed that care plan input by dieticians is solely for dieticians to perform and is not for nursing. "Nursing must input their own plan of care." The CCO stated that nursing was responsible for reviewing and revising the care plan every shift.

During a review of the facility's policy and procedure (P&P) Titled, "Core: Interdisciplinary Assessment and Re-Assessment," dated June 2022, The P&P indicated, "that one of the purposes of assessment and reassessment is to determine the appropriate care, treatment, and services to meet the patient ' s needs during hospitalization.

The P&P indicated the nursing department is responsible for the following:

"The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of care is developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient's goals and the nursing care to be provided to meet the patient's specific needs. The admitting RN will screen each patient during the initial assessment process to identify those patients requiring further specialized interventions. Screening for specialized interventions and/or possible referral to other disciplines is completed within 24 hours of admission and includes Functional status, nutritional status..."

1e. A review of Patient 30's "Inpatient Admission Face Sheet (Face sheet)," undated, the "Face Sheet" indicated, Patient 30 was admitted to the facility on 8/16/2022.

During a review of patient 30's "History and Physical (H&P)," dated 11/22/2022, the "H&P" indicated, Patient 28 medical history included type 2 diabetes (a disease that affects the way the body regulates and uses sugar), sepsis (harmful microorganisms in the blood), sacral decubitus (damaged tissue that occurs due to the skin being under constant pressure), and dysphagia (difficulty swallowing).

A review of Patient 30's dietician note titled, "Nutrition," dated 7/2623, the dietician notes indicated, "Swallowing abilities: patient has dysphagia and is NPO." Review of a care plan enter by dietician dated 7/26/23 at 5:18 p.m., indicated for "Swallowing difficulty/biting or chewing difficulty the goal was the patient will tolerate enteral feeding as measured by tolerated enteral feeding without problems." The care plan does not include interventions.

During a concurrent interview and record review, on 7/28/2023, at 10:35 a.m., with the CCO, Patient 30's nursing care plan was reviewed. Patient 30 ' s nursing care plan record indicated there were no care plan from nursing related to swallowing difficulty or nutritional needs. CCO stated, "It is nursing standard of practice for nursing to review care plans and add or revised the care plan every shift."

During an interview on 7/28/23 at 12:00 p.m., with the director nursing clinical services (DNCS), DNCS stated, "it is important that nursing care plan should be review every shift and if condition change as needed."

During a review of the facility's policy and procedure (P&P) Titled, "Core: Interdisciplinary Assessment and Re-Assessment," dated June 2022, The P&P indicated, "that one of the purposes of assessment and reassessment is to determine the appropriate care, treatment, and services to meet the patient ' s needs during hospitalization.

The P&P indicated the nursing department is responsible for the following:

"The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of care is developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient's goals and the nursing care to be provided to meet the patient's specific needs. The admitting RN will screen each patient during the initial assessment process to identify those patients requiring further specialized interventions. Screening for specialized interventions and/or possible referral to other disciplines is completed within 24 hours of admission and includes Functional status, nutritional status..."

Based on observation, interview, and record review, the facility failed to weigh two of two sampled patients (Patient 3 and 9) before and after receiving hemodialysis (HD, the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) treatment and failed to notify the physician of weight changes, in accordance with the facility ' s policy and procedure and physician ' s orders.

This deficient practice had the potential to result in incorrect documentation of patient ' s weight and had the potential for ineffective hemodialysis treatment, which may cause shortness of breath or fluid overload.

Findings:

1a. During an observation on 7/26/2023 at 9:41 a.m., in the Intensive Care Unit (ICU), Patient 3 was observed in bed receiving hemodialysis treatment by the Hemodialysis Registered Nurse (HDRN).

During a concurrent interview, on 7/26/2023 at 9:41 a.m., with Registered Nurse (RN) 4, RN 4 stated the following. All patients, including patients who received hemodialysis (HD) were weighed once a week. RN 4 stated he did not weigh Patient 3 prior to Patient 3 ' s treatment. The dialysis nurse weighs the patients before and after the HD treatment. RN 4 stated the facility documents the patient ' s most recent weekly weight as the patient ' s pre-dialysis treatment weight, then calculates the post-dialysis weight by measuring the amount of fluid removed from the patients. RN 1 stated patients should be weighed before and after receiving hemodialysis treatment, in accordance with the facility ' s policy and procedure.

During a concurrent interview, on 7/26/2023 at 9:43 a.m., with the Hemodialysis Registered Nurse (HDRN), HDRN stated she did not weigh Patient 3 prior to the HD treatment, nor does she weigh the patients after HD treatment.

During a review of Patient 3 ' s "Inpatient Admission Face Sheet," the face sheet indicated Patient 3 was admitted to the facility on 5/16/2023.

During a review of Patient 3 ' s "History and Physical" (H&P), dated 5/16/2023, the H&P indicated Patient 9 had a history of End Stage Renal Disease (ESRD, a condition when the kidneys stop functioning) and on hemodialysis (HD).

During a review of Patient 3 ' s "Hemodialysis Treatment Record," dated 7/19/2023, the record indicated there was no pre-dialysis weight or post-dialysis weight documented in the treatment record.

During a review of Patient 3 ' s "Hemodialysis Treatment Record," dated 7/21/2023, the record indicated the following. Pre-dialysis weight was 122 lbs. (55.4kg). Post-dialysis weight was 119 lbs. (54 kg).

During a review of Patient 3 ' s "Hemodialysis Treatment Record," dated 7/24/2023, the record indicated the following. Pre-dialysis weight was 153 lbs. (69.5 kg). Post-dialysis weight was 150 lbs. (68 kg).

During a review of Patient 3 ' s "Hemodialysis Treatment Record," dated 7/26/2023, the record indicated the following. Pre-dialysis weight was 121 lbs. (55 kg). Post-dialysis weight was 118 lbs. (53.6 kg).

During a review of Patient 3's weekly weights, the weights were documented as follows.

On 7/7/2023, Patient 3 ' s weight was 124.4 lbs. (56.5 kg).

On 7/15/2023, Patient 3 ' s weight was 122.5 lbs. (55.6 kg).

On 7/22/2023 at Patient 3 ' s weight was 121 lbs. (55 kg).

During a concurrent interview and record review, on 7/26/2023 at 2 p.m., with Registered Nurse (RN) 1, RN 1 stated Patient 3 was on HD treatments on Mondays, Wednesdays, and Fridays. Patients on HD treatment should be weight before and after HD treatments, in accordance with the facility ' s policy and procedure.

1b. During a review of Patient 9 ' s "Inpatient Admission Face Sheet", the face sheet indicated Patient 9 was admitted to the facility on 7/15/2023.

During a review of Patient 9 ' s "History and Physical" (H&P), dated 7/15/2023, indicated Patient 9 had a diagnosis of End Stage Renal Disease and on hemodialysis (HD) three times a week. Patient 9 was alert and oriented x 4 (person, place, time, and event).

During a review of Patient 9 ' s "Physician Orders," dated 7/16/2023 at 9:13 a.m., the order indicated the following. "If weight changes 5 pounds (lbs.) or more the patient must be re-weighted with RN (registered nurse) verification. The MD (doctor) must be notified of any weight changes of 5 lbs. or more."

During a review of Patient 9 ' s weekly weights, the weights were documented as follows. 7/16/2023 at 2 a.m., weight 175.5 lbs. (79.77 kilograms [kg)), bed scale. 7/22/2023 at 6:25 p.m., Weight 216 (98.1 kg) standing scale.

During a review of Patient 9 ' s "Hemodialysis Treatment Record," dated 7/17/2023, the record indicated the following. Pre-dialysis weight was 175.5 lbs. Post-dialysis weight was 168 lbs. (76 kg).

During a review of Patient 9 ' s "Hemodialysis Treatment Record," dated 7/19/2023, the record indicated the following. Pre-dialysis weight was 175.5 lbs. Post-dialysis weight was 168 lbs.

During a review of Patient 9 ' s "Hemodialysis Treatment Record," dated 7/21/2023, the record indicated the following. Pre-dialysis weight was 97.5 kg (214 lbs.). Post-dialysis weight was 94.5 kg (207 lbs.)

During a review of Patient 9 ' s "Hemodialysis Treatment Record," dated 7/24/2023, the record indicated the following. Pre-dialysis weight 98.5 kg (216 lbs.). Post-dialysis weight 95.5 kg (210 lbs.).

During a review of Patient 9 ' s "Hemodialysis Treatment Record," dated 7/26/2023, there was no pre-dialysis weight or post-dialysis weight documented in the treatment record.

During a concurrent interview and record review, on 7/28/2023 at 10:10 a.m., RN 1 stated the following. Patient 9 was admitted from a skilled nursing facility (SNF) on 7/15/2023 and had a history of ESRD and was receiving HD treatment on Mondays, Wednesdays, and Fridays. Patient 9 weighed 175.6 pounds (lbs.) on 7/16/2023, and 216 lbs. on 7/22/2023. No other weights were documented in the medical record. The physician ordered for Patient 9 to be weighed on 7/22/2023, if the weight increased by more than 5 lbs., re-weigh the patient and notify the physician. RN 1 verified that Patient 9 gained 41 lbs., and there was no documented evidence that Patient 9 was re-weighed or that the physician was notified of Patient 9 ' s weight increase of over 5 lbs. RN 1 also verified that Patient that pre-dialysis weight and post-dialysis weight was not documented in Patient 9 ' s medical record. RN 1 stated patients should be weighed before and after receiving hemodialysis treatment, in accordance with the facility ' s policy and procedure. RN 1 stated that not weighing patient before and after HD treatments may result in the inability to identify problems such as fluid build-up in the tissues, shortness of breath and cardiac issues.

During an observation and interview, on 7/28/2023 at 11:21 a.m., in the Medical Surgical Unit, Patient 9 was sitting at the edge of the bed, awake and alert. Patient 9 stated he had not been weighed at the facility. Patient 9 stated he was not weighed on a standing scale, otherwise, he (Patient 9) would have remembered. If he (Patient 9) was weighed on the bed, nobody informed him he was being weighed. Patient 9 stated staff does not weigh him before or after dialysis treatment.

During a review of the facility ' s policy and procedure (P&P) titled, "Weight Measurement," dated 6/2021, the P&P indicated the following. "Weight change over time is an important indicator of nutritional status and fluid status. The policy of the hospital is to ensure proper measurement of patient weights ...Weight measurement is scheduled as follows: ... Before and after dialysis treatment. Timing of weight assessment may be individualized based on a physician ' s order ..."