Novant Health Rehabilitation Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 41946 Based on medical record review, physician and staff interviews, the nursing staff failed to follow physician orders in applying continuous positive airway pressure (CPAP) in 1 of 5 patients reviewed. (Patient #6). The findings include: Requested policy on 11/06/2024 revealed was not available for review. Closed medical record review on 11/06/2024 revealed Patient #6, a 56-year-old female transferred on 08/31/2024 at 0150 for rehabilitation for acute on chronic respiratory failure with hypoxia (low levels of oxygen), a chronic tracheostomy (surgical airway opening in the trachea), acute pneumonia (infection in the lung) with Obstructive Sleep Apnea (upper airway collapses repeatedly causing low oxygen levels). Review of the History and Physical on 08/31/2024 at 0453 by Rehabilitation (rehab) Medical Doctor (MD) #1 revealed “... She has a primary rehab impairment classification of pulmonary with acute diagnoses including acute on chronic respiratory failure with hypercapnia (carbon dioxide retention) and hypoxia, tracheostomy, pneumonia, diabetes type II (high sugar levels in the blood), hypertension (high blood pressure), hyperglycemia (high blood sugar), intellectual disability (cognitive delay), and severe hiatal hernia (part of the stomach bulges into the chest). ... Abnormalities of gait, ADLs (activities of daily living), and mobility, impaired balance, decreased strength, endurance, activity tolerance, the patient continues to require 24-hour nursing and physician availability....” Review of the admission Physician Orders revealed on 08/30/2024 at 2002, Rehab Doctor of Osteopathic Medicine (DO) #2 ordered CPAP, Respiratory therapy to treat and evaluate, incentive spirometry, and oxygen 2 liters per nasal cannula for Patient #6. The respiratory evaluation was completed 08/31/2024 at 1518 by Respiratory Therapist (RT) #3, “... Patient still has a pinhole stoma. Patient had removed oxygen at some point this morning, SPO2 (oxygen saturation) via ear proe [sic] 70% (normal 95-100%), placed back on 2.0 L/ Nasal Cannula SPO2 96%. Stoma (surgically created opening in the neck) cleaned and dressed with foam dressing. Spoke with mom and explained stoma (sic) and that CPAP will be set up in about four days to allow the stoma to heal. Mom stated she understood. Respiratory will continue to monitor... “ Review of the medical record on 08/31/2024, 09/01/2024, 09/02/2024, 09/03/2024, 09/04/2024 revealed the physician CPAP ordered 08/30/2024 was not implemented or changed. On 09/05/2024 at 0806 RT #3 documented “... CPAP set up and sterile water placed, placed on CPAP while sleeping ...” Review failed to reveal communication to update the physician on the CPAP ordered 08/31/2024 through 09/05/2024. Review of the medical record failed to reveal Patient #6 had CPAP applied at bedtime on 09/05/2024 by nursing staff. Review of the Discharge Summary dated 09/06/2024 at 1144 by Rehab DO #2 revealed “ ... At approximately 5 AM on 09/06/2024 patient was found in room with no pulse at that time CPR (cardiopulmonary resuscitation) was administered for 30 minutes, with no return of spontaneous circulation. ...Condition at the time of discharge: deceased.” Patient #6’s discharge disposition was to the funeral home on 09/06/2024 at 1230. Review of the medical record failed to reveal physician orders for CPAP were followed for Patient #6. Interview on 11/07/2024 at 0803 with Licensed Practical Nurse (LPN) #6 revealed “... the CPAP was not on because the outgoing nurse reported she (Patient #6) was always removing it. ...” The interview revealed LPN #6 did not apply the CPAP on 09/05/2024 - 09/06/204 for Patient #6 during sleep. The interview revealed LPN #6 did not notify the Physician of not applying the CPAP as ordered. The interview revealed Physician orders were not followed for Patient #6. Interview on 11/07/2024 at 1040 with the Chief Medical Officer, (CMO) #4 revealed “... the Physician should be notified when physician orders for CPAP cannot be completed, absolutely. ...” The interview revealed if physician orders for CPAP cannot be implemented when ordered, the physician should be notified to ensure patient care options can be evaluated as needed. The interview revealed physician orders for CPAP for Patient #6 were not followed. Interview on 11/07/2024 at 1300 with the Chief Nursing Officer (CNO) #5 revealed “... this CPAP order was an incomplete order. This order would not generate any work tasks for the nursing staff to address. If an order was not clear, the Nurse should call the Physician for clarification. ...” The interview revealed if the CPAP order for Patient #6 needed clarification of when the CPAP was to be administered, the Nurse should contact the Physician to clarify the order, and/or let the Physician know the CPAP was not applied as ordered. The interview revealed Physician Orders for Patient #6 was not followed by the Nurse. NC00222350”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 41946 Based on medical record review, physician and staff interviews, the nursing staff failed to document nursing notes following a code blue event, physician notification and/or a disposition for Patient #6. And failed to document reports of CPAP (continuous positive airway pressure) treatments ordered in 5 of 5 medical records reviewed. (Patient #5, Patient #6, Patient #9, Patient #10, and Patient #11) The findings include: Requested policy on 11/07/2024 revealed was not available for review. 1. Open medical record review 11/07/2024 revealed Patient #5, an 84-year-old female admitted on 10/28/2024 at 1410 to rehabilitation for impaired immobility status post subdural hematoma (bleeding near the brain). Review of the Admission Physician Orders dated 10/28/2024 at 1515 revealed Patient #5 was ordered “CPAP” by Chief Medical Officer (CMO) #4. Review of the Nursing Assessment and Flowsheet revealed 10/30/2024 - 11/05/2024 (7 days) no reports of CPAP treatment were documented by the nursing staff. Review revealed 7 out of 7 days reviewed, nursing staff failed to document CPAP treatments for Patient #5. Interview on 11/06/2024 at 1637 with Charge Nurse #6 revealed they were assigned to be Patient #5’s nurse 1900-2100 (2 hrs.) on 10/30/2024. The Nurse and Respiratory Therapist completes CPAP ordered. ...Respiratory is not scheduled midnight (0000) to 0600. ...” The interview revealed the nurse assigned completes all respiratory care when the respiratory therapist was not working. The interview revealed Charge Nurse #6 did not apply CPAP for Patient #5 while assigned. Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed “... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP’s are applied by Nursing staff as ordered. ...” The interview revealed CPAP treatment ordered for Patient #5 was not documented by the nurse. 2. Policy review on 11/06/2024 of Resuscitation and Evaluation, last reviewed 09/19/2024 revealed “...Purpose. Define process to follow when resuscitation becomes necessary. Policy ... Nurse assigned to the patient 1. Completes medical record of event and patient transfer/disposition in the medical record. ...” Closed medical record review on 11/06/2024 revealed Patient #6, a 56-year-old female transferred on 08/31/2024 at 0150 for rehabilitation for acute on chronic respiratory failure with hypoxia (low levels of oxygen), tracheostomy (surgical airway opening in the trachea), and pneumonia (infection in the lung) and Obstructive Sleep Apnea (upper airway collapses repeatedly causing low oxygen levels). Review of the Admission Physician Orders revealed on 08/30/2024 at 2002, Rehab Doctor of Osteopathic Medicine (DO) #2 ordered “CPAP” for Patient #6. A Respiratory Evaluation was completed 08/31/2024 at 1518 by Respiratory Therapist (RT) #3, “... Patient still has a pinhole stoma. Patient had removed oxygen at some point this morning, SPO2 (oxygen saturation) via ear proe [sic] 70% (normal 95-100%), placed back on 2.0 L (liters)/ Nasal Cannula SPO2 (oxygen) 96%. Stoma (surgically created opening in the neck) cleaned and dressed with foam dressing. Spoke with mom and explained stoma and that (sic) CPAP will be set up in about four days to allow the stoma to heal. Mom stated she understood. respiratory will continue to monitor...” Review failed to reveal documentation of communication with a physician to update the existing CPAP treatment ordered. Review failed to reveal documentation of reports of CPAP treatment ordered 08/31/2024 through 09/04/2024 by the nurse. On 09/05/2024 at 0806 RT #3 documented “... CPAP set up and sterile water placed, placed on CPAP while sleeping ...” Review failed to reveal nursing documentation on 09/05/2024, Patient #6’s CPAP was applied/not applied as ordered. (7 of 7 days). Review of the Discharge Summary dated 09/06/2024 at 1144 by Rehab DO #2 revealed “ ... At approximately 5AM on 09/06/2024 patient was found in room with no pulse at that time CPR (cardiopulmonary resuscitation) was administered for 30 minutes, with no return of spontaneous circulation. ...Condition at the time of discharge: deceased.” Review of the record failed to reveal nursing notes documented of the event (finding Patient #6 unresponsive) by LPN #6 assigned, notification of a physician, or notification of the family. Patient #6’s discharge disposition was to the funeral home on 09/06/2024 at 1230. Interview on 11/07/2024 at 0803 with Licensed Practical Nurse (LPN) #6 revealed he was the assigned nurse of Patient #6 on 09/05/2024 1900 through 09/06/2024 0700. The interview revealed “... the CPAP was not on because the outgoing nurse reported (Patient #6) was always removing it. ...” The interview revealed LPN #6 did not apply the CPAP on 09/05/2024 - 09/06/204 for Patient #6 during sleep as ordered. The interview revealed LPN #6 did not document applying the CPAP as ordered. The interview revealed LPN #6 did notify a physician of the Code Blue event, with a voice mail once the event was over, and did notify the family by telephone, however, did not document any of the care he provided for Patient #6 in the medical record during the event in which Patient #6 died. Interview on 11/07/2024 at 1040 with the Chief Medical Officer, (CMO) #4 revealed “... the Physician should be notified when physician orders for CPAP cannot be completed, absolutely. ...” The interview revealed if physician orders for CPAP cannot be implemented when ordered, the physician should be notified to ensure patient care options can be evaluated as needed. The interview revealed physician communication should be documented in the medical record. Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed “... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP’s are applied by Nursing staff as ordered. ...” The interview revealed CPAP treatment ordered for Patient #6 was not documented by the nurse. 3. Open medical record review 11/06/2024 revealed Patient #9, a 72-year-old female patient admitted to rehabilitation on 10/25/2024 at 1200 for Septic Arthritis (painful infection in the joint). Review of the Admission Physician Orders dated 10/25/2024 at 1527 revealed Patient #9 was ordered “CPAP” by CMO #4. Review of the Nursing Assessment and Flowsheet revealed 10/25/2024 - 10/28/2024 (4 days), 10/31/2024 - 11/05/2024 (6 days), no reports of CPAP treatment were documented by the nursing staff. Review revealed 10 out of 13 days reviewed, nursing staff failed to document CPAP treatments ordered for Patient #9. Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed “... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP’s are applied by Nursing staff as ordered. ...” The interview revealed CPAP treatment ordered for Patient #9 was not documented by the nurse. 4. Open medical record review 11/07/2024 revealed Patient #10, a 77-year-old female patient admitted to rehabilitation on 11/04/2024 at 1555 for Acute Congestive Heart Failure (the heart can’t pump blood well enough) and Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow, making it difficult to breathe). Review of the Admission Physician Orders dated 11/05/2024 at 1250 revealed Patient #10 was ordered “CPAP” by CMO #4. Review of the Nursing Assessment and Flowsheet revealed 11/04/2024 through 11/05/2024 (2 days), no reports of CPAP treatment were documented by the nursing staff. Review revealed 2 out of 3 days reviewed, nursing staff failed to document CPAP treatments ordered for Patient #10. Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed “... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP’s are applied by Nursing staff as ordered. ...” The interview revealed CPAP treatment ordered for Patient #10 was not documented by the nurse. 5. Open medical record review 11/07/2024 revealed Patient #11, an 80-year-old male patient admitted to rehabilitation on 10/30/2024 at 1915 for Atrial Fibrillation (irregular heart rhythm), chronic indwelling catheter, Diabetes (high blood sugar), and Obstructive Sleep Apnea (upper airway collapses during sleep causing low oxygen levels). Review of the Admission Physician Orders dated 10/31/2024 at 1003 revealed Patient #11 was ordered “CPAP” by Rehab Physician, DO #2. Review of the Nursing Assessment and Flowsheet revealed 10/31/2024 - 11/01/2024 (2 days), and 11/03/2024 - 11/05/2024 (3 days), no reports of CPAP treatment were documented by the nursing staff. Review revealed 5 out of 7 days reviewed, nursing staff failed to document CPAP treatments ordered for Patient #11. Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed “... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP’s are applied by Nursing staff as ordered. ...” The interview revealed CPAP treatment ordered for Patient #11 was not documented by the nurse. NC00222350”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 39307 Based on review of the facility policy, medical record review, and staff interviews the survey revealed the nursing staff failed to maintain a care plan for 10 of 10 patients admitted for impaired ability to perform self care activities of daily living (bathing and monitoring of meal consumption). (Patient #2, #3, #7, #8 ,#10, #1, #4, #5, #6 and #9). The findings included: Review on 01/10/2024 of the facility policy “Care Planning” revised 09/21/2023 revealed “PURPOSE To define a mechanism to document an individualized interdisciplinary Plan of Care (IPOC) for the patient...Definitions Care planning involves planning for patient’s needs from the perspective of the patient...includes but is not limited to physical needs, cognitive needs, functional needs...POLICY...plan of care developed, which will be based on his/her assessed individual needs...IDT (Interdisciplinary Team) members have primary responsibility for the plan including goal setting as per their discipline and area of expertise...Each body system or functional area with identified problems will be followed by specific interventions designed to meet the needs of the patient...” 1. Review on 01/09/2024 of an open medical records revealed Patient #2 was an 83-year-old male admitted on 01/01/2024 at 1220 for abnormalities of gait, ADL’s (Activities of daily living). Review of the History and Physical completed 01/02/2024 at 1212 by the admitting Medical Doctor (MD) revealed “...Impression and Plan:...Risk of complications (and plans to mitigate them):..Nutrition: We will assess the patient’s intake and add nutritional supplements as recommended per dietician...Current Level of Function...Basic ADL’s Moderate Assistance: Bathing...” Review of the Interdisciplinary Plan of Care documented on 01/02/2024 at 1508 revealed “...Functional Status Self Care...Eating, Independent...Shower,Bathe Self: Partial/Moderate assistance...” Record review failed to reveal documentation of percent of meal consumption on 01/02/2024, 01/03/2024, 01/04/2024, 01/06/2024 and 01/08/2024 (5 of 7 days). Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Review revealed OT would provide Nursing staff with a daily list of scheduled baths to be performed by the OT staff. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/03/2024, 01/06/2024, 01/07/2024 (3 of 7 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. 2. Review on 01/09/2024 of a closed medical record revealed Patient #3 was a 70-year-old male admitted on 11/14/2023 at 1540 for abnormalities of gait, ADL’s. Review of the History and Physical completed 11/15/2023 at 1140 by the admitting MD revealed “..Impression and Plan:...Risk of complications (and plans to mitigate them):..Nutrition: We will assess the patient’s intake and add nutritional supplements as recommended per dietician...Current Level of Function...Basic ADL’s: Supervision Comments: grooming/Set up with oral hygiene while sitting up in cardiac chair position. Basic ADL’s: Minimal Assistance Comments: Proximal aspect of LEs (lower extremities) with CGA (contact guard assistance) and min cues for task completion...” Review of the Interdisciplinary Plan of Care documented on 11/15/2023 at 1157 revealed “...Functional Status Self Care...Shower,Bathe Self: Partial/Moderate assistance...Nutrition...Goals-Maintain/achieve nutritional requirements...” Record review of Nutrition Assessment on 11/15/2023 at 1627 documented by the Dietician of the facility revealed “...Nutrition Monitoring and Evaluation Monitor nutritional status, Monitor fluid and PO (oral intake of liquid or solid food) intake...” Record review failed to reveal documentation of percent of meal intake on 11/18/2023, 11/19/2023, 11/20/2023 and 11/21/2023 (4 of 7 days). Record review failed to reveal documentation of bath/shower offer or patient denial on 11/18/2023, 11/19/2023, 11/20/2023 and 11/21/2023 (4 of 7 days). Review revealed Patient #3 was discharged on 11/28/2023 at 1530 home with Home Health Agency supportive services. Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. 3. Review on 01/09/2024 of an open medical record revealed Patient #7 was a 75-year-old male admitted on 12/23/2023 at 1440 for Stroke with right hemiparesis (muscle weakness or partial paralysis on one side of the body). Review of the History and Physical completed by the admitting MD on 12/24/2023 at 1412 revealed “...Risk of complications (and plans to mitigate them):...Nutrition: We will assess the patient’s intake...Current Level of Function...Basic ADL’s: Maximal Assistance Comments: UB (upper body)/LB (lower body) bathing...” Review of the record failed to reveal documentation of a bath/shower offer or patient denial on 01/01/2024, 01/03/2024, 01/05/2024 and 01/06/2024 (4 of 7 days). Review of Nutrition Assessment completed on 12/23/2023 at 1637 revealed “... Nutrition Monitoring and Evaluation Monitor nutritional status, Monitor fluid and PO intake...” Review failed to reveal documentation of percent of meal intake on 01/02/2024, 01/03/2024, 01/04/2024 (3 of 7 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. 4. Review on 01/11/2024 of an open medical record revealed Patient #8 was a 72-year-old female admitted on 12/25/2023 for abnormalities of gait, ADL’s. Review of the History and Physical completed 12/26/2023 at 1032 by the admitting MD revealed “..Impression and Plan...Risk of complications (and plans to mitigate them):..Nutrition Monitoring and Evaluation Monitor nutritional status, Monitor fluid and PO intake...” Review of the Interdisciplinary Plan of Care documented on 12/25/2023 at 1400 revealed “...Eating: Supervision or touching assistance...Shower, Bathe Self: Dependent...Self Care Plan...Therapeutic PO (oral) feeding...” Record review failed to reveal documentation of percent of meal consumption on 12/31/2023, 01/03/2024 (2 of 7) day. Review failed to reveal documentation of bath/shower offer or patient denial on 12/30/2023, 12/31/2023 (2 of 7 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. 5. Review on 01/10/2024 of a closed medical record revealed Patient #10 was 67-year-old male admitted on 11/24/2023 at 1752 for impaired mobility and ADL’s. Review of the History and Physical completed 11/24/2023 at 1750 by the admitting MD revealed “...Current Level of Function...Basic ADL’s: Moderate Assistance UB (upper bathing) Basic ADL’s Maximal Assistance LB (lower body)...” Review of the Interdisciplinary Plan of Care documented on 11/24/2023 at 1825 revealed “...Eating minimal assistance/supervision...Self car...Shower, Bathe supervision or touching assistance...” Review failed to reveal documentation of bath/shower offer or patient denial on 01/02/2024, 01/03/2024, 01/04/2024 and 01/05/2024 (4 of 7 days). Review failed to reveal documentation of percent of meal consumption on 01/05/2024, 01/08/2024, 01/09/2024 (3 of 7 days). Record review revealed Patient #10 was discharged home with Home Health Agency supportive services. Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. 49003 6. Review on 01/10/2024 of an open medical record revealed Patient #1 was a 66-year-old male admitted on 12/30/2023 at 1803 for abnormalities of gait, ADL’s (activities of daily living), and mobility after having a stroke on 12/19/2023. Review of the History and Physical completed 12/31/2023 at 1357 by the admitting Medical Doctor (MD) revealed “... Current level of function ... Basic ACL’s: ... Minimal assistance comments: set up ... Impression and Plan: ... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient’s intake and add nutritional supplements as recommended per dietician.” Review of the Interdisciplinary Plan of Care documented on 12/30/2023 at 1819 revealed “...Functional Status Self Care...Eating, setup and clean-up assistance...Shower, Bathe Self: Substantial/Maximal assistance...” Record review for the week of 01/01/2024 through 01/07/2024 failed to reveal documentation of percent of meal consumption on 01/03/2024 for the evening meal, 01/04/2024 for the evening meal, 01/06/2024 for breakfast and the evening meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/01/2024, 01/04/2024, 01/05/2024, 01/06/2024, and 01/07/2024 (5 of 7 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. 7. Review on 01/09/2024 of a closed medical record revealed Patient #4 was a 64-year-old male admitted on 11/14/2023 as a second chance rehabilitation admission for abnormalities of gait, ADL’s (activities of daily living), and mobility after a motor vehicle collision on June 2023 in which Patient #4 was diagnosed with a cervical spine injury, incomplete quadriparesis (weakness in all four extremities) at cervical vertebrae 5-6. Review of the History and Physical completed 11/15/2023 at 1108 by the admitting Medical Doctor (MD) revealed “ ... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient’s intake and add nutritional supplements as recommended per dietician.” Review of the Interdisciplinary Plan of Care documented on 11/14/2023 at 1516 revealed “...Functional Status Self Care ...Eating: Supervision or touching assistance...Toileting Hygiene: Substantial/Maximal assistance...” Record review for 12/03/2023 through 12/05/2023 failed to reveal documentation of percent of meal consumption on 12/04/2023 for 3 meals. Record review for 12/31/2023 through 01/06/2024 failed to reveal documentation of percent of meal consumption on 12/31/2023 for 3 meals, 01/01/2024 for 3 meals, 01/02/2024 for 3 meals, 01/03/2024 for 3 meals, 01/04/2024 for 3 meals, 01/05/2024 for the evening meal, and 01/06/2024 for the lunch meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 12/11/2023, 12/13/2023, 12/15/2023, 12/31/2023, 01/01/2024, 01/02/2024, 01/03/2024, and 01/05/2024 (8 of 12 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. 8. Review on 01/10/2024 of an open medical record revealed Patient #5 was a 68-year-old male admitted on 01/03/2024 around 1830 for abnormalities of gait, ADL’s (activities of daily living), and mobility after treatment for a stroke on 12/26/2023. Review of the History and Physical completed 01/04/2024 by the admitting Medical Doctor (MD) revealed Patient #5 needed minimal assistance with eating, and “Nutrition: We will assess the patient’s intake and add nutritional supplements as recommended per dietician.” Review of the Interdisciplinary Plan of Care documented on 01/03/2024 at 2225 revealed “...Functional Status Self Care...Eating: Supervision or touching assistance...Shower, Bathe Self: Partial/Moderate assistance...” Nutrition consult dated 01/05/2024 at 1027 revealed Patient #5 stated “I don’t eat hospital food.” The Dietary note revealed a plan to monitor the weight of the patient and for dietary to continue working with food preferences and encourage the patient to order out for food preferences as needed with nursing assistance. The admission weight on 01/03/2024 for Patient #5 was reported as 80.6 kg (kilograms), follow up measurements include: 80.5 kg on 01/04 and 05/2024, 80.4 kg on 01/06/2024, 78.5kg on 01/07/2024, 78.7 kg on 01/08/2024, 78.9 kg on 01/09/2024, and 78.2 kg on 01/10/2024. Record review revealed for the week of 01/04/2024 through 01/10/2024 a % of meal documented for the breakfast meal on 01/04/2024 and for the breakfast and lunch meal on 01/10/2024. While there are amount totals or refusals documented on the majority of the meals, there are 7 meals with no documentation of totals or % eaten. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/05/2024, and 01/08/2024 (2 of 7 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. 9. Review on 01/10/2024 of an open medical record revealed Patient #6 was a 67-year-old male admitted on 01/01/2024 at 1550for abnormalities of gait, ADL’s (activities of daily living), and mobility after having a stroke around 12/27/2023. Review of the History and Physical completed 01/02/2024 at 1220 by the admitting Medical Doctor (MD) revealed “... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient’s intake and add nutritional supplements as recommended per dietician. ... Current level of function ... Basic ACL’s: Dependent ... Comments: Total A (assistance) ADLs.” Review of the Interdisciplinary Plan of Care documented on 01/01/2024 at 1626 revealed “...Functional Status Self Care...Eating: Partial/Moderate assistance...Shower, Bathe Self: Partial/Moderate assistance...” Record review for the week of 01/02/2024 through 01/08/2024 failed to reveal documentation of percent of meal consumption on 01/04/2024 for the evening meal, 01/06/2024 for the evening meal, 01/07/2024 for breakfast and 01/08/2024 for lunch and evening meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/04/2024, 01/06/2024, and 01/08/2024 (3 of 7 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. 10. Review on 01/10/2024 of an open medical record revealed Patient #9 was an 82-year-old male admitted on 12/29/2023 at 1500 for right hip osteoarthritis and Parkinsons Disease. Review of the History and Physical completed 12/29/2023 at 1503 by the admitting Medical Doctor (MD) revealed “... Current level of function ... Basic ADL’s: Moderate assistance ... comments: bathing, toileting ... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient’s intake and add nutritional supplements as recommended per dietician.” Review of the Interdisciplinary Plan of Care documented on 12/29/2023 at 1607 revealed “...Functional Status Self Care...Eating: Independent...Shower, Bathe Self: Substantial/Maximal assistance...” Record review for the week of 01/03/2024 through 01/09/2024 failed to reveal documentation of percent of meal consumption on 01/03/2024 for 3 meals, 01/04/2024 for 3 meals, 01/05/2024 for breakfast and the lunch meal, 01/06/2024 for the lunch and evening meal, 01/07/2024 for 3 meals, 01/08/2024 for the lunch and evening meal, 01/09/2024 for the lunch and evening meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/04/2024, 01/05/2024, 01/08/2024, and 01/09/2024 (3 of 7 days). Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient’s progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital. NC00211068”