109.21 Principle
Written nursing care and
administrative policies and procedures
shall be developed to provide the
nursing staff with methods of meeting
its responsibilities and achieving
goals.
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Observations:
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure nursing staff followed physician orders for recording patients intake and output for two of two applicable medical records reviewed (MR1 and MR2); the facility failed to ensure nursing staff followed physician orders for recording daily weights for one of two applicable medical records reviewed (MR2) and the facility failed to ensure nursing staff obtained a new weight as recommended by the dietitian for one of one applicable medical records reviewed (MR1).
Findings include:
Review on February 24, 2025, of the facility's "Documentation - Patient Care Services" policy, last reviewed / revised November 2024, revealed "... II. Purpose: The purpose of this document is to provide guidance for documenting clinical data utilizing [name of electronic medical record documentation system] functionality and the Elsevier Care Planning (Trademark) content. Clinical documentation of patient care will be completed in an interprofessional manner using electronic health record tools. The medical record is the legal record of the patient's hospital stay. Documentation in the medical record is specific to the patient's condition, reflects care given and provides information for communication among health care providers. Paper documentation formats will be scanned into the medical record ... VI. Intervention/Guideline ... B. Admission Documentation ... 6. Height/weight are documented within 4 hours of admission unless otherwise indicated in a specialty specific manual ..."
1. Review of MR1 on February 24, 2025, revealed this patient was admitted to the facility on February 14, 2025, with a primary diagnosis of failure to thrive in adult and pain all over the body. MR1 continued to be an inpatient on the day of this survey.
Review on February 24, 2025, of MR1 revealed physician admitting orders dated February 14, 2025, at 2013 instructing nursing staff to monitor this patient's intake and output every shift.
Review on February 24, 2025, revealed there was no documentation in MR1 indicating nursing staff monitored this patient's intake on the following dates and times:
February 16, 2025, at the lunch and dinner meals.
February 17, 2025, at the breakfast, lunch and dinner meals.
February 18, 2025, at the breakfast, lunch and dinner meals.
February 19, 2025, at the breakfast, lunch and dinner meals.
February 20, 2025, at the breakfast, lunch and dinner meals.
Interview with EMP1 and EMP2 on February 24, 2025, confirmed the above findings at the time of the medical record review.
Review of MR2 on February 24, 2025, revealed this patient was admitted to the facility on February 15, 2025, with a primary diagnosis of ambulatory dysfunction. MR1continued to be an inpatient on the day of this survey.
Review on February 24, 2025, of MR2 revealed physician admitting orders dated February 16, 2025, at 0106 instructing nursing staff to monitor this patient's intake and output every shift.
Review on February 24, 2025, revealed there was no documentation in MR2 indicating nursing staff monitored this patient's intake on the following dates and times:
February 16, 2025, at the dinner meal.
February 17, 2025, at the breakfast, lunch and dinner meals.
February 18, 2025, at the breakfast, lunch and dinner meals.
February 19, 2025, at the breakfast, lunch and dinner meals.
February 20, 2025, at the breakfast, lunch and dinner meals.
Interview with EMP1 and EMP2 on February 24, 2025, confirmed the above findings at the time of the medical record review.
2. Review on February 24, 2025, of MR2 revealed a physician order instructing nursing staff to obtain a daily weight on this patient.
There was no documentation in MR2 indicating nursing staff obtained or recorded weights on MR2 on February 17, 18, 19 and 23, 2025.
Interview with EMP1 and EMP2 on February 24, 2025, confirmed the above findings at the time of the medical record review.
3. Review on February 24, 2025, of MR1 revealed a physician order instructing nursing staff to obtain an admission weight on February 14, 2025. Nursing obtained a weight of 117 pounds on admission.
Review of MR1 on February 24, 2025, revealed a nutrition note dated February 17, 2025, indicating this patient met the diagnosis of moderate protein calorie malnutrition; recorded MR1's admission weight as 53.3 kilograms (kg) (117 pounds 8.1 ounces), recorded MR1's current weight as 49.7 kg (109 pounds and 9.6 ounces) ordered protein supplements with meals and dietary snacks in the morning and with meals and recommended obtaining a new weight.
There was no documentation in MR1 indicating nursing staff obtained a new weight on this patient following the dietitian's recommendation.
| | Plan of Correction - To be completed: 04/11/2025
Findings were reviewed by LVH-Dickson City President, CMO, Administrator of Clinical Services, and Regulatory Director.
Education will be provided for inpatient RNs/LPNs to include the following:
-Review of "Documentation – Patient Care Services Policy"
-Monitoring and documentation of intake and output per provider order
-Documentation of admission weight, weights per provider order, and weights per nutrition recommendation.
The Administrator of Clinical Services, or designee, will review 10 charts weekly x 12 weeks for: the presence of intake and output per provider order; documentation of admission weight per "Documentation – Patient Care Services Policy"; documentation of weights per provider order; and documentation of weights per nutrition recommendation (if applicable). Non-compliance will be addressed, and corrective actions documented. After 12 weeks, frequency of chart audits will be reevaluated based on compliance.
The results of these chart audits will be presented to the Vice President of Patient Care Services monthly.
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