HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure nursing services provided patients with activities of daily living which included bathing and failed to follow physician orders for intake and output monitoring and calorie count for 2 of 3 (Patients #1 and #2) sampled patients.

The findings included:

1. Review of the facility's "GUIDELINES AND PROTOCOLS, CLINICAL" policy revealed, " ...Hygiene ...Patient bathed ...Daily ..."

Medical record review revealed Patient #1 was admitted to Hospital #1 on 3/20/2020 with diagnoses that included Post Op Bowel Resection and Malnutrition wound. Patient #1 was discharged from the facility on 4/8/2020. There was no documentation Patient #1 received bathing care on 3/21/2020, 3/22/2020, 3/23/2020, 3/26/2020, 3/27/2020, 3/29/2020, 4/1/2020, and 4/4/2020.

Medical record review revealed Patient #2 was admitted to Hospital #1 on 2/27/2021 with diagnoses that included Post Operative Right Nephroureterectomy (removal of right kidney and ureter) for ureteral cancer and Post Operative ileus that required Total Parenteral Nutrition (feeding/fluids given into a vein to provide nutrients). Patient #2 was discharged from the facility on 3/10/2021. There was no documentation Patient #2 received bathing care on 3/1/2021, 3/2/2021, 3/6/2021, 3/7/2021 and 3/8/2021.

In an interview on 8/2/2021 at 10:30 AM in the conference room, the Quality Director verified the missing documentation for Patient #1 and Patient #2.

2. Review of the facility's "GUIDELINES AND PROTOCOLS, CLINICAL" policy revealed, "...A specific physician order will supersede the minimum frequencies noted below...Nutrition and Fluids...Intake and output totaled...Every shift..."

Medical record review for Patient #2 revealed an admission date of 2/27/2021 with diagnoses that included Post Operative right nephroureterectomy (removal of kidney and ureter) for ureteral cancer and Post Operative ileus requiring Total Parenteral Nutrition (TPN- food/fluids through a vein for nutritional support).

Review of a 3/1/2021 physician's order revealed, "Strict intake & [and] output..."

Review of a 3/3/2021 physician's order revealed, "...calorie count"

Review of nursing flowsheet documentation beginning on 3/1/2021 revealed incomplete intake and output documentation on the following days: 3/1/2021, 3/2/2021, 3/3/2021, 3/5/2021, 3/7/2021, 3/8/2021 and 3/9/2021.

Review of a 3/8/2021 Nutrition progress note revealed, "Calorie count completed 3/3/21 to 3/5/21...Day #2 no documentation...Day #3 no documentation...Results of calorie count limited due to inadequate documentation by nsg [nursing] staff..."

In an interview on 8/2/2021 at 11:00 AM in the conference room, the Quality Director verified intake and output monitoring was not completed as ordered.