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Based on observation, interview and record review the facility failed to provide care in a safe setting when a patient requiring modified techniques for safe eating did not have the information passed onto all staff performing the patient's care, placing the patient at risk for choking or aspiration. (Patient #2)

Findings include:

Review of Patient #2 medical records reflected an 89-year-old male admitted on 12/01/18 Right Femur Fracture status post fall, Dementia with profound cognitive deficits and mild-moderate oral dysphagia.

During an interview on the morning of 12/06/18 Staff #5, CNA (Certified Nursing Assistant), on the first floor patient unit, when asked about her job duties stated, "I answer call lights, deliver the meal trays and help to care for patients.... I record the meal percentages eaten. If the tray was already picked up, I will ask the patient how much they ate. We try to encourage everyone to eat. If the family wants to feed the patient, the therapist has to have trained them first." When asked how does the staff know what kind of assistance a patient requires to eat stated, "...usually the speech therapy leaves a sign on the patient's communication board.... We set their trays up, cut up the meats and get them started.... There isn't anyone needing total assist right now."

During an interview on the afternoon of 12/06/18, in the facility conference room, Staff #6, CCC-SLP (Speech Therapist) when asked how the recommendations get passed onto the staffs providing care stated, "I insert them into the computer.... Preferably the physician will write the order.... I will tell the nurses; they can get the physician's order. When they look in the computer they can see the recommendations. I don't know what access the CNA's have, if they can see the order...."

During an in interview on the morning of 12/06/18, in patient room #100, Staff #2's stated, "The staff come in and set the tray up. If a patient needs to be one to one, the physician has to order it."

Review of Patient #2's swallow evaluation, dated 12/05/18 and completed by the Speech therapist, revealed, "...Compensatory swallowing techniques recommended: Seated upright with all PO intake, Small bites, Small sips, Alternate solids/liquids-liquid wash, Clear oral cavity post PO intake and Oral Care post PO intake.... Level of supervision at meals recommended: 1 to 1 assistance due to cognitive or motor deficits. (Patient requires cues to initiate swallow)... Oral phase impairments: Pocketing on right, Pocketing on left, Prolonged mastication, Reduced bolus control, Suspect piecemeal deglutition, Reduced rotary chewing, Delayed oral transport, Oral holding of liquids and Oral residue...Patient unaware of pocketing unless given verbal cues."

An observation on the morning of 12/06/18, in patient room #100, revealed a pink sign on the patient's communication board stating, "...Oral care post PO intake." The sign did not detail the directions or the need for one to one assistance.

Review of Patient #2's meal tray ticket revealed no instructions for the assistance required or the feeding techniques required.

Review of the facility provided policy Patient Rights (dated 6/18) reflected, "Receive safe, quality care through the services that the hospital provides."

Review of the facility provided policy Clinical Services RH-CL-147L (dated7/01/2018) reflected, "...Patient care services occur through organized and systematic processes which are designed to assure the delivery of safe, effective and timely assessment of needs, treatment management, continuum of care and maximization of the rehabilitation goals and outcomes for each patient...."

Review of the facility provided policy Clinical Services RH-CL-149L (dated7/01/2018) reflected, "Mutual effort between employees and medical staff to coordinate care in a manner is conducive to optimal patient outcomes, quality and safety.
The provision of care includes the following processes:...
- Assessing and reassessing the patient initially upon admission and throughout the hospital stay.
- Planning the patient's care.
- Providing the patient with care, treatment, and services based upon physician order in a safe efficient, and positive manner.
- Coordinating the patients' care, treatment and services incorporating the interdisciplinary team...."

During an interview on the afternoon of 12/06/18, in the facility conference room, Staff #1, CNO (Chief Nursing Officer) confirmed CNA's did not have access to the electronic records.

Based on observation, interview and record review the facility failed to provide nursing services in an organized manner in that:

(A) a patient requiring modified techniques for safe eating did not have the information passed onto all staff performing the patient's care, placing the patient at risk for choking or aspiration. (Patient #2)
(B) patients did not adequately and consistently receive meals, supplements, and/or snacks along with staff assistance with feeding as ordered by the physician, placing the patients at risk for malnutrition. (Patients #1 and 3)
(C) a patient developed a stage 2 pressure ulcer while hospitalized (Patient #4)
(D) facility failed to properly document pressure injuries on admission (Patient #1)

Findings include:

(A) Review of Patient #2's medical records reflected an 89-year-old male admitted on 12/01/18 Right Femur Fracture status post fall, Dementia with profound cognitive deficits and mild-moderate oral dysphagia.

During an interview on the morning of 12/06/18 Staff #5, CNA (Certified Nursing Assistant), on the first floor patient unit, when asked about her job duties she stated, "I answer call lights, deliver the meal trays and help to care for patients .... I record the meal percentages eaten. If the tray was already picked up, I will ask the patient how much they ate. We try to encourage everyone to eat. If the family wants to feed the patient, the therapist has to have trained them first." When asked how does the staff know what kind of assistance a patient requires to eat stated, "...usually the speech therapy leaves a sign on the patient's communication board.... We set their trays up, cut up the meats and get them started.... There isn't anyone needing total assist right now."

During an interview on the afternoon of 12/06/18, in the facility conference room, Staff #6, CCC-SLP (Speech Therapist) when asked how the recommendations get passed onto the staffs providing care stated, "I insert them into the computer.... Preferably the physician will write the order.... I will tell the nurses; they can get the physician's order. When they look in the computer they can see the recommendations. I don't know what access the CNA's have, if they can see the order...."

During an in interview on the morning of 12/06/18, in patient room #100, Staff #2's stated, "The staff come in and set the tray up. If a patient needs to be one to one, the physician has to order it."

Review of Patient #2's swallow evaluation, dated 12/05/18 and completed by the Speech Therapist, revealed, "...Compensatory swallowing techniques recommended: Seated upright with all PO (by mouth) intake, Small bites, Small sips, Alternate solids/liquids-liquid wash, Clear oral cavity post PO intake and Oral Care post PO intake.... Level of supervision at meals recommended: 1 to 1 assistance due to cognitive or motor deficits. (Patient requires cues to initiate swallow)... Oral phase impairments: Pocketing on right, Pocketing on left, Prolonged mastication, Reduced bolus control, Suspect piecemeal deglutition, Reduced rotary chewing, Delayed oral transport, Oral holding of liquids and Oral residue... Patient unaware of pocketing unless given verbal cues."

An observation on the morning of 12/06/18, in patient room #100, revealed a pink sign on the patient's communication board stating, " ...Oral care post PO intake." The sign did not detail the directions or the need for one to one assistance.

Review of Patient #2's meal tray ticket revealed no instructions for the assistance required or the feeding techniques required.

Review of the facility provided policy Patient Rights (dated 6/18) reflected, "Receive safe, quality care through the services that the hospital provides."

Review of the facility provided policy Clinical Services RH-CL-147L (dated7/01/2018) reflected, "...Patient care services occur through organized and systematic processes which are designed to assure the delivery of safe, effective and timely assessment of needs, treatment management, continuum of care and maximization of the rehabilitation goals and outcomes for each patient...."

Review of the facility provided policy Clinical Services RH-CL-149L (dated7/01/2018) reflected, "Mutual effort between employees and medical staff to coordinate care in a manner is conducive to optimal patient outcomes, quality and safety.
The provision of care includes the following processes: ...
- Assessing and reassessing the patient initially upon admission and throughout the hospital stay.
- Planning the patient's care.
- Providing the patient with care, treatment, and services based upon physician order in a safe efficient, and positive manner.
- Coordinating the patients' care, treatment and services incorporating the interdisciplinary team...."

During an interview on the afternoon of 12/06/18, in the facility conference room, Staff #1, CNO (Chief Nursing Officer) confirmed CNA's did not have access to review the electronic records.

(B) Review of Patient #1's medical records reflected a 75-year-old male admitted on 09/17/18 following evaluation in the setting of a spinal cord injury. Diagnoses included incomplete cervical myelopathy, protein-calorie malnutrition. Goals included "mod to max assist for ADLs (Activities of Daily Living)."

Review of Physician Orders revealed the following:
- 9/17/18 Therapeutic Diet: carb controlled, cardiac diet.
- 9/21/18 to 9/26/18: snacks, Nutritional supplement Glucerna Shake; 1-unit pack
- 9/27/18 to 10/3/18: Nutritional supplement Ensure Enlive, 1-unit pack, Nutritional supplement Pro-Stat Sugar Free AWC (advanced wound care), 1-unit
-10/2/18 Therapeutic Diet: regular diet.

Review of Care Plan interventions included "nutrition intake (inadequate or predicted suboptimal energy or oral intake). Interventions included medical nutrition therapy interventions (as needed)."

Review of Physician Progress Notes dated 9/20/18 at 6:26 PM indicated "plan of care for supervision at meals recommended: 1 to 1 assistance due to cognitive or motor deficits."

Review of Patient #1's Daily Meal Intakes under flowsheet revealed the following:
- 9/18 meals: 50% recorded for breakfast, and 33% recorded for lunch.
- 9/19 meals: 0% recorded for lunch, no documentation for dinner.
- 9/20 meals: 50% recorded for breakfast, no documentation for lunch, 10% recorded for dinner.
- 9/21 meals: No documentation for any meals. 590 ml liquid consumed for the day. No evidence of supplement or snack given.
- 9/22 meals: No documentation for any meals or liquids. No evidence of supplement or snack given.
- 9/23 meals: 25% recorded for breakfast, 33% recorded for lunch. No evidence of supplement or snack given.
- 9/24 meals: 25% recorded for lunch, 25% recorded for dinner. No evidence of supplement or snack given.
- 9/25 meals: 25% recorded for breakfast, 10% recorded for lunch, 25% recorded for dinner with 240 ml Ensure given.
- 9/26 meals: 25% recorded for breakfast with 240 ml Ensure. No documentation for lunch, dinner, or additional supplement given during these times.
- 9/27: meals provided and supplements given as ordered. No issues noted.
- 9/28, 9/29: No documentation for lunch, dinner, or additional supplement given during these times.
- 9/30 to 10/3: meals provided and supplements given as ordered. No issues noted.

The above records revealed that for 9 of 16 days, Patient #1 did not receive adequate therapeutic diet, supplement, and/or snacks as ordered by the physician. Additionally, there was no consistent documentation that Patient # 1 was assisted with feeding.

Review of Patient #1's Weights under flowsheet revealed his admission weight was approximately 136 lbs. and discharge weight was 132 lbs. indicating a 2.94% weight loss.

During an interview on the afternoon of 12/06/18, in the facility conference room, Staff #1, CNO confirmed the above findings.

Additional review of sampled medical record for Patient #3 revealed the following regarding dietary intake:
- A Nutrition Initial Assessment Note on 11/02/18 stated in part, "Intake is inconsistent 33-100% with 4 meal average being 66 %...Needs assistance with Food..."
- A dietician note on 11/05/18 stated in part, "Nursing order for feeding assistance already in place."
- On 11/06/18 at 12:04 PM an order was placed "Assist with feeding patient" and included the comments "Please set up tray, open packages. Assist with feeding, as needed." This order was discontinued on 11/12/18.
- Review of intake documentation revealed from 11/06/18 (lunch) through 11/12/17 there was no documentation that the patient was assisted with eating meals per order.

(C) Review of the medical record for Patient #4 revealed the following regarding assessment of her skin integrity:
- Upon admission on 11/01/18 no skin issues were noted on the patient's coccyx.
- On 11/06/18 a "small stage 2 coccyx" was noted.
- A physician note on 11/07/18 stated in part, "15. St 2 coccyx. Add vit C and zinc Offload".
- There was no photo of this change in skin condition, per facility policy when noted on 11/06/18. The only photo of the patient's coccyx was on 11/11/18 to document a rash.

(D) Review of Assessment Note dated 9/17/18 at 5:00 PM (admission date) revealed Patient #1 had a pre-existing wound to coccyx area described as a "non blanching stage 2 to sacrum upon admit." There was no evidence of photo taken of this wound.

During an interview on the afternoon of 12/06/18, in the facility conference room, Staff #1, CNO stated there was no photo taken of Patient #1's wound on admission and the first available photo was taken on 10/4. He further stated photo of wound on admission was not required but it was a best practice to do so.

Review of facility provided policy titled Pressure Injury Prevention and Management with revised date of 1/1/18 and under policy #6 reflected "pressure injuries and wounds will be photographed on admission."