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Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the care for each patient. This deficient practice was evidenced by failure of the hospital to ensure the RN referred a new patient, who had scored at high risk for nutritional factors, for a timely nutritional assessment by the Dietician for 1 (#2) of 3 (#1, #2, #3) total sampled patients reviewed for dietary consults from a total patient sample of 5 (#1-#5) and a random sample of 2 (#R1, #R2).

Findings:

Review of the hospital policy titled, "Nutritional Consults Assessment/Reassessment", Policy Number: AS-06, revealed in part: Policy: Nutritional consults are to be ordered for patients at nutritional risk by the attending physician so that the registered dietician (RD) can conduct a nutritional assessment to evaluate the needs of the individual and provide recommendations, counseling and instruction. The assessment is to be provided within 3 days of the physician's order for consult. ..... Nurse: Informs dietician of need for consult. Nursing should document this request in the patient's chart. Registered Dietician: Provide nutritional assessment and/or counseling, education, and instruction to patients in a timely manner, no greater than 3 days.

Review of the hospital policy titled,"Hydration Management", Policy Number: Nsg-48, revealed in part:
Purpose: To ensure timely screening of nutritional and hydration risk factors with determination and implementation of interventions for dietary and hydration risks by Registered Dietician. Procedure: Screening: Nutrition and hydration screening is built into the initial nursing assessment, which is to be completed within 8 hours after a patient is admitted. Dietary is notified, by nursing, of patients requiring nutrition and hydration assessment by the Dietician.

Review of Patient #2's medical record revealed an admission date of 1/4/19 and a discharge date of 1/12/19. Further review revealed the patient's admission diagnosis was Dementia in other diseases. Additional review revealed the patient was admitted on Megace for appetite stimulation due to poor appetite and had a history of failure to thrive.

Review of Patient #2's admit physician's orders, dated 1/4/19, revealed the following, in part: 6. Special Diet: No concentrated sweets, mechanical soft, gravy with meat. 7. Dietary Consult for: Triggers per screening had a box beside it that was checked indicating a dietary consult was needed if triggers were identified.

Review of Patient #2's initial nursing assessment, dated 1/4/19, revealed the following scores on the Nutritional Screen of High Risk Factors (score of 10 or above requires consult) portion of the assessment:
Critical Diagnosis: Diabetes Mellitus: Score: 10
Dysphagia: Score: 5
Chewing/Swallowing Difficulties/Limits: Score: 5
Greater than 68 years old: Score: 5
Therapeutic Diet/Special Diet Needs: Score: 3
Anticoagulant Therapy: 2
Score = 30; RD (registered dietician) consult needed? "Yes" was checked.
Further review of the nutritional screen revealed the following instructions: If yes, please obtain LIP order for Registered Dietician Consult and notify RD immediately. Please note time when RD notified of consult.

Further review of Patient #2's medical record revealed a handwritten progress note by the RD, dated 1/8/19, indicating dietary recommendations (4 days after the initial nutritional screen had triggered the need for a consult with the RD).

Additional review revealed a comprehensive nutritional assessment, by the Dietician, had not been performed until 1/12/19. The patient's recorded meal intake had been decreasing since the initial dietary recommendations had been made.

In an interview on 5/7/19 at 8:50 a.m. with S2DON, she confirmed Patient #2's nutritional screen score of 30 on admit indicated the patient was at high risk for nutritional issues and triggered a need for a consult with the Dietician. S2DON indicated the hospital policy was for nutritional consults to be done, by the Dietician, within 3 days of receipt of the consult. S2DON confirmed Patient #2's dietary consult was not performed until 1/8/19 which was 4 days after the score triggered the need for an assessment by the Dietician.

In an interview on 5/7/19 at 10:05 a.m. with S3Dietary, she reported a request for an assessment by the Dietician should have been faxed to the Dietician, along with the patient's labs, if the patient had triggered a need for a consult. S3Dietary reported the dietician would have then reviewed the referred patient's information and would have made dietary recommendations. S3Dietary indicated the physician would have been notified of the recommendations. S3Dietary reported the hospital's policy was for the dietician to respond within 3 days of receipt of a referral. S3Dietary reported the dietician's narrative note, dated 1/8/19, in Patient #2's medical record, contained recommendations related to the patient's faxed information, reviewed offsite by the Dietician. S3Dietary indicated the full assessment documented on 1/12/19 was probably done when the Dietician was onsite. S3Dietary reported she could not find a confirmation to verify when the consult had been sent.