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Based on staff interview and document review, it was determined the hospital failed to ensure a Registered Nurse (RN) appropriately supervised the care of each patient. Specifically, nursing staff failed to ensure assistance was provided to patients who required feeding assistance, failed to ensure meals provided to and consumed by patients were documented in the medical record, and failed to ensure oral care was consistently provided to patients unable to independently perform grooming activities in one (1) of four (4) medical records reviewed in the survey sample. Medical record #3.

Findings:

Four (4) medical records were reviewed 08/15-16/22. The medical record for patient #3 contained documentation that the patient was hospitalized 05/24/22-05/30/22 with a diagnosis of worsening Parkinson's Disease. The medical record indicated the patient was alert and oriented at times and at other times was more confused and "agitated." The record indicated that patient #3 needed assistance with oral care and feeding and the level of assistance required throughout the hospital stay ranged from completely dependent to needing partial/moderate assistance with oral hygiene and eating.

The medical record for patient #3 contained documentation that oral care was provided five (5) times throughout the patient's seven (7) day hospital stay. The medical record for patient #3 contained documentation that the patient was fed breakfast on 05/28/22. The record contained no documentation that the patient was fed lunch or dinner on 05/28/22. The medical record contained no documentation that the patient was fed breakfast or lunch on 05/29/22. The record contained documentation that the patient's appetite was "fair" at 6:00 PM on 05/29/22, but it was unclear from the record whether or not the patient was fed dinner at this time or received any meals for an approximately 48 hour time period from breakfast on 05/28/22 to breakfast on 05/30/22.

The medical record for patient #3 contained documentation that the patient was seen by the physician on 05/30/22 for an "episode of agitation." The medical record contained no documentation from nursing regarding this episode. The patient was ordered IV (intravenous) fluids by the physician on 05/30/22 for dehydration.

An interview was conducted with the facility's Chief Nursing Officer (staff member #3) on 08/16/22 who stated the facility did not have a policy related to documentation of meals or oral care, but did have charting guidelines that were provided to the surveyor. Staff member #3 stated that oral care should be provided or offered at least twice daily.

Interviews were conducted with a Registered Nurse (staff member #8) and a nursing tech (staff member #9) on 08/16/22. Both staff members confirmed that oral care should be performed at least twice per day. Both staff members confirmed that the level assistance required for eating should be documented in the medical record for each meal provided. Both staff members confirmed that if a patient refused to eat a meal, that information should be documented in the medical record.

The facility provided the surveyor with a document, Care Tracker Documentation Checklist that reads as follows: "The below checklist should be used as a reference tool for daily documentation requirements for RNTs (rehab nursing techs)." The checklist indicates that oral care should be documented a minimum of once on day shift and once on night shift. Eating should be documented on a minimum of three (3) times on day shift and one (1) time of night shift. Meals should be documented three (3) times on day shift and PM snack a minimum of one (1) time on night shift.

The above noted findings were discussed with the Chief Nursing Officer, Chief Executive Officer, and the Director of Quality and Risk Management on 08/16/22 during the exit conference.