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Based on record reviews and interview, the facility failed to ensure that patients were free from all forms of abuse and/or neglect for 1 of 1 patients (patient #1). The facility failed to ensure nursing staff provided oral fluids to patient #1 and adequately address his severely low core body temperature (hypothermia).

Refer to A0145 for evidence of findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on record reviews and interview, the facility failed to ensure that patients were free from all forms of abuse and/or neglect for 1 of 1 patients (patient #1). The facility failed to ensure nursing staff provided oral fluids to patient #1 and adequately address his severely low core body temperature (hypothermia).

Findings:

Record review of the medical record for patient #1 revealed that he was a 65-year-old male admitted to the facility on 06/13/2019 with a history of: Oral motor dysphagia, Non-ischemic cardiomyopathy, Coronary Artery Disease (CAD), Severe mitral valve regurgitation, Pulmonary hypertension with pulmonary venous hypertension, Recurrent Atrial Fibrillation, Recurrent Atrial Flutter, Chronic Kidney Disease, Tracheostomy placement, Cardiogenic shock with ECMO, and Status post AICD implantation.


Record review of the bedside clinical record Intake and Output (I&O) sheets for the dates of 06/13/2019 to 06/15/2019 revealed the following information:

06/13/2019:
Intake 24-hour total: 246.4 ml

06/14/2019:
Intake 24-hour total: 587.6 ml

06/15/2019:
12-hour Total: (No Documentation. Form Blank)


Record review of the nurses notes for the dates of 06/13/2019 to 06/15/2019 revealed no evidence that nursing staff had provided additional fluids of any kind to patient #1, except for what had been documented on the Intake and Output sheets for the time period.


Record review of Patient#1's Critical Care Flow Sheet for the date of 06/15/2019 revealed that his core body temperature was documented as 92.9 F (Fahrenheit) at 12:00 PM (hypothermia) and 94.9 F at 4:00 p.m., taken rectally, (hypothermia).


Record review of the Nursing Daily Care Notes dated 06/15/2019 revealed in part the following information:

- 08:30 am- B/P 80/63, HR 89, repeated 85/61, No complaints. Put Head of Bed (HOB) down.

-09:50 am- B/P 83/65, HR 89, cont. to monitor. Family at bedside.

- 10:00 am- B/P 81/62, HR 89, -11:00 am- B/P 85/59, HR 89, - 11:30 am- B/P 80/59, HR 89, - 12:00 PM- B/P 84/56, HR 89, cont. to monitor.

- 12:30 PM- Received Pt. from the floor after speaking with physician about transfer. Spouse continues to insist on transfer to the unit with no specific orders as to what the Pt. needs in the ICU. Physician has now given orders upon transfer to the unit. All orders in progress except levophed order as Pt. is mapping >69. Will continue to monitor.

- 2:40 PM- MAP (Mean Arterial Pressure) Still >69 but SBP in the 90's and family wants the SBP greater than 100. Initiates levophed at 4 mcg/ml at this time. Pt's temp at this time is 93.9 ax .... Stat CBC and renal panel are in, remain stable, with no abnormal data to treat .... No changes from Pt's previous baseline.

- 4:00 PM- Core Temperature is 94.9 F rectally at this time but Pt. is diaphoretic at this time. Blood glucose check reveal as BS (Blood Sugar) 220 mg/dl. No coverage given at this time as is not routine accu-check. Physician has seen Pt and ordered stat blood cultures x 2 and lactic acid and procalcitonin level of which all have been initiated.

- 4:30 PM- Physician has just informed me that family members want Pt. transferred to an acute hospital and I should notify the Primary Physician to initiate the process.

- 5:00 PM- Received orders to transfer Pt. Primary Physician has secured a room for Pt to be transferred. EMS on the way to pick up Pt. Levophed has been discontinued. Primaco still infusing as ordered.


Record review of the facility policy entitled: Basic Clinical Documentation, Revision: 1.0, approved on 07/01/2018, revealed in part the following information:


Record review of the facility policy entitled: Basic Clinical Documentation, Revision: 1.0, approved on 07/01/2018, revealed in part the following information:

Procedure
A. Basic principles of charting fall into three categories: Format, Identification, and Significant Events:
3. Significant Events:
e.) Vital signs, I & O


Record review of the facility policy entitled: Abuse Neglect Assault Alleged or Suspected: undated, revealed in part the following information:

Policy:
Employees will report any suspected abuse or neglect of a patient. All accusations of physical, emotional, or psychological abuse of any patient necessitate immediate action.

Definition:

-Active Neglect: The willful deprivation by a caregiver of goods or services essential to avoid a clear and serious threat to physical or mental health.

Examples: Deliberate abandonment or deliberate denial of food or health related services/poor hygiene/unattended physical/ medical needs. Withholding of medicine, food clothing, heat housing, assistance with ADL's.


-Passive Neglect: The deprivation by a caregiver of goods or services, which are necessary to maintain physical or mental health, without a conscious attempt to inflict physical or emotional distress.

Examples: Denial of service because of inadequate knowledge, infirmity, or disputing the value of prescribed services/ unintentionally ignored or left alone. Evidence of poor care, decubiti, contractures, dehydration, impaction of stool, poor skin hygiene, malnutrition, urine burns/ excoriation and hypothermia.


In an interview conducted on 10/23/2019 at 2:35 PM, the facility Director of Quality Management confirmed the above findings.