HospitalInspections.org

Based on quality assurance committee minutes, interview, and governing board committee meeting minutes, the provider failed to ensure:
*A comprehensive Quality Assurance Performance Improvement (QAPI) program that 6 of 15 departments and services (social services, activities, environmental services, nursing services, contracted vendors, and swing bed) had developed and implemented a system/process improvement plan.
*Substantial compliance was maintained with previously cited regulatory deficiencies (C279, C298, C336, C385, C386 and C395).
*Staff were qualified for their position and had required consultation (activities).
*Staff were adequately trained for their roles and responsibilities (activities, social services and dietary manager).
Findings include:

1. The hospital failed to ensure a comprehensive QAPI program that encompassed all hospital departments and services including social services, activities, environmental services, nursing services, contracted vendors, and swing bed in developing and implementing a system/process improvement plan.

Refer to C336, finding 1.

2. The hospital failed to maintain substantial compliance with previously cited regulatory deficiencies including C279, C298, C336, C385, C386 and C395.

Refer to C336, finding 2.

3. The hospital failed to ensure all positions had appropriate training to fulfill their roles and the responsibilities of those positions (social services, activities, and dietary).

Refer to C385, finding 1; C386, finding 1; and C401, finding 1.

4. The hospital failed to ensure seven of seven sampled acute care patients (1, 6, 7, 8, 9, 10, and 27) had comprehensive care plans initiated or completed during their stays.

Refer to C270 and C279.

Based on record review, interview, dietary consultant review, and policy review, the provider failed to ensure:
*Seven of seven sampled acute care patients (1, 6, 7, 8, 9, 10, and 27) had comprehensive care plans initiated or completed during their stays.
*A nutritional screening process was in place to determine a patient's nutritional risk at the time of admission for six of seven sampled acute care patients (6, 7, 8, 9, 10, and 26) and had a nutritional assessment completed by a registered nurse (RN) or a registered dietitian (RD).
*A physician's diet order had been received prior to serving a meal for four of seven acute care patients (8, 9, 10, and 26).
*The dietary menu provided:
-Dietary extensions for diets and textures other than a standard regular diet.
-Specific portion size were listed for each food item.
*The diet manual was reviewed and approved annually by the registered dietitian and the medical director.
*Menu planning had referred only to long-term care residents. It had not referred to hospital patients.

1. Review of patients 1, 6, 7, 8, 9, 10, 26, and 27's electronic medical records revealed:
*Their care plans had either not been initiated or completed during their stays.
*A nutritional screening process was in place to ensure nutritional risks had been identified, physician's ordered diets had been provided, and dietary extensions had been in place for all types of diets.

Refer to C279 and C298.

32332

Based on record review, interview, policy review, and dietary consultant agreement review, the provider failed to
ensure:
*A nutritional screening process was in place to determine a patient's nutritional risk at the time of admission for six of seven sampled acute care patients (6, 7, 8, 9, 10, and 26) and had a nutritional assessment completed by a registered nurse (RN) or a registered dietitian (RD).
*A physician's diet order had been received prior to serving a meal for four of seven acute care patients (8, 9, 10, and 26).
*The dietary menu provided:
-Dietary extensions for diets and textures other than a standard regular diet.
-Specific portion size were listed for each food item.
*The diet manual was reviewed and approved annually by the registered dietitian and the medical director.
*Findings include:

1. Review of patient 6's electronic medical record (EMR) revealed:
*She had been admitted on 3/25/18 for abdominal pain.
*An admission initial nursing assessment revealed the nutritional assessment section:
-Had not been completed.
-Had not indicated her diet order.
*The 3/25/18 at 10:20 p.m. twelve hour nursing assessment indicated:
-She had a wound dressing on her epigastric area.
-The wound had packing in place with some drainage.
-A culture had been sent to the laboratory.
-Factors that might have affected wound healing: "Poor nutritional status."
*There was no documented nutritional assessment by the RN or the RD.

2. Review of patient 26's EMR revealed:
*He had been admitted to the emergency department on 2/3/17 with a diagnosis of convulsions/seizures.
*He remained on observation until 2/4/17 due to weather problems.
*A 2/4/17 observation assessment revealed at 8:00 a.m. he was eating breakfast.
*No diet orders had been located in his medical record.

Surveyor: 26632
3. Review of patient 7's EMR revealed:
*He had been admitted on 2/14/17 for urinary retention and right leg pain.
*His past surgical history revealed the removal of three-quarters of his stomach.
*An admission initial nursing assessment revealed the nutritional assessment section:
-Had not been fully completed.
-Indicated physician's diet order was for a mechanical soft diet.
*There was no documented nutritional assessment by the RN or the RD.

4. Review of patient 8's EMR revealed:
*He had been admitted on 3/11/17 for left leg cellulitis.
*An admission initial nursing assessment revealed in the nutritional assessment section:
-He was overweight.
-His diet order was for a regular diet. That had not been ordered by his physician.
*There was no documented nutritional assessment by the RN or the RD.

5. Review of patient 9's EMR revealed:
*He had been admitted on 11/14/17 for shortness of breath and hypoxia.
*He had other medical conditions that included:
-Anemia.
-Chronic obstruction pulmonary disease.
-Gastric bypass surgery.
*An admission initial nursing assessment revealed in the nutritional assessment section:
-He was overweight.
- His diet order was for a regular diet. That had not been ordered by his physician.
*There was no documented nutritional assessment by the RN or the RD.

6. Review of patient 10's EMR revealed:
*She had been admitted on 12/4/17 for weakness post cervical neck surgery.
*An admission initial nursing assessment revealed in the nutritional assessment section:
-She had upper and lower dentures that were at home.
-Her diet order was for a regular diet. That had not been ordered by her physician.
*There was no documented nutritional assessment by the RN or the RD.

Surveyor: 32332
7. Review of the 3/1/17 through 3/29/18 Nutrition Consultation reports revealed:
*He consulted every month.
*All of his reports referenced the EMR of Point Click Care which was used only in the nursing facility.
-There was no reference to the EMR for the hospital or swing bed patients.
-The above reports did not reflect that acute care nutritional assessments had been completed.

Interview on 3/28/18 at 2:30 p.m. with the information technology director revealed the consulting RD:
*Did not have access to the swing bed/hospital EMR.
*Was not able to document in it without access.

Telephone interview on 3/29/18 at 7:45 a.m. with the consulting RD revealed:
*He was usually informed by the nursing department if there was someone admitted.
*He consulted to the long-term care nursing facility also.
*Most of his contact and consultation was directed to the residents in the attached nursing facility.
*He instructed the nurses to call or email him if they had any questions for him.
*He had never done any documentation specifically for the patients in the acute care, but felt he responded whenever he was contacted by the nursing staff regarding patients.
*He was unfamiliar with the regulations for the acute care patients.
*He was not aware he was to have assessed those residents with nutritional or skin concerns in the hospital.

Review of the provider's 7/1/16 Dietary Consultant agreement revealed:
*"Responsibilities of:
- A. Dietitian:
--3. Assist in nutrition screening, assessment, and care planning."

Review of the provider's 2005 Diet Manual: A Comprehensive Nutrition Care Guide revealed:
*The manual was to have been reviewed and approved annually by the RD, DON, medical director, and the administrator.
*The manual was last signed as having been reviewed and approved:
-By the medical director on 4/17/15.
-By the RD on 4/20/15.

Review of the provider's November 2006 Nutritional assessment policy revealed:
*All patients admitted were to have been assessed (screened) for nutritional problems within twenty-four hours.
*The initial screen was the responsibility of the nurse.
*The admitting nurse was to have notified the dietary manager of risk factors or problems identified.
*The dietary manager was to have notified the RD of a need for further evaluation and/or directions regarding the nutritional plan of care.

Review of the provider's undated Transmission of Diet Orders policy revealed the nursing staff were to send the physician's diet order to the dietary department as soon as possible, preferably within one to two hours using the diet order form.

8. Review of the dietary menus requested on 3/28/18 at 8:30 a.m. from the dietary manager (DM) and the administrator revealed those received menus were for week 4 (the current week) and week 3 (the previous week). The menus:
*Were undated and unsigned.
*Contained breakfast, lunch, and supper menus for one standard (regular) diet.
*Had no:
-Diet extensions for special diets.
-Diet extensions for any special food consistencies.
-Portion sizes listed for any food or drink items.

Interview on 3/29/18 at 11:00 a.m. with the director of nursing (DON) regarding diets confirmed:
*The patients were receiving liberalized regular diets.
*Those patients who were diabetic and receiving insulin were also receiving the liberalized regular diet.

Interview with the DM and the administrator at the above time revealed:*The DM had only been in her job for a few weeks.
-The administrator was overseeing her new role.
*The menus had been used since 9/25/17 and had been signed by the dietitian to indicate this.
*The hospital had used a liberalized diet for all the patients, just as they did at the long-term care nursing facility attached to the hospital.
*The liberalized diet had been added some years ago to allow patients more choices in their diet.
*No other diets were utilized except those diets with texture changes, such as a modified soft, pureed, or thickened liquid diet.
*Currently there were three patients. One patient received mechanical soft foods. Another received a pureed diet.
*They confirmed:
-There were no diet extensions on the menu to direct any alternate food needed on the current menu.
-The menu did not include portion sizes for foods or drinks.
-The portions were listed on the recipes.

Interview on 3/28/18 at 3:15 p.m. with the DM revealed:
*She did not use the recipes at the serving table as a guide for serving portions.
*She just used the serving spoon that looked right when she placed the food on the plate.
*The dietitian:
-Had not visited for a "long time," and normally did his visit in the evening from about 5:00 p.m. until about 9:00 p.m.
-Did visit the building monthly, but she rarely saw him.
-Documented in the long-term care residents charts.
*She had not seen RD documentation regarding the hospital patients.
*If she wanted to discuss a patient she would email the RD.

Interview on 3/29/18 at 11:30 a.m. with certified physician's assistant (PA-C) A regarding diet orders revealed:*All the diets were liberalized.
*He has written orders for specific diets such as controlled carbohydrate diets.
*Those diet orders were changed to the liberalized diet once the patient was in the hospital.
*He was told he could order special diets, but "everyone gets a regular diet."
*When asked if he believed the patients were receiving diets to benefit their health he stated that was not always the case.
*He thought many meals served were heavy in carbohydrates and light in protein that was required for healing.

Telephone interview on 3/29/18 at 7:45 a.m. with the consulting RD confirmed:
*Patients were provided liberalized diets except for those who required special textures.
*The hospital patients just required regular diets. The regular diet provided enough calories for healing.
*Some doctors might have ordered supplements if they wanted more than a regular diet.
*He did not document in the patients' EMRs, because he did not have permission to open those records.
*If the nurses had questions they could call or email him.
*The liberalized diet was something he had developed after the Centers for Medicare and Medicaid had discussed it. It had been placed in the diet manual for staff to follow.

Interview on 3/29/18 at 3:30 p.m. with the administrator regarding the dietary department confirmed:*The DM required more education in her role and more oversight.
*He was aware the RD had done his monthly visits in the evening.

Review of the undated, unsigned Liberalized Diet located in the provider's Diet Manual revealed:*"Liberalized diets should be the norm, restricted diets should be the exception."
*"Research suggests that a liberalized diet can enhance the quality of life and nutritional status of older adults in long-term care facilities."
*The diet had referred to long-term care residents. It had not referred to hospital patients.
*"When a resident is not eating well or is losing weight, the interdisciplinary team may temporarily abate dietary restrictions and liberalize the diet to improve the resident's food intake to stabilize their weight."

Review of the provider's 2005 Diet Orders policy revealed:*Any diets ordered that were not on the menus would be written/approved by the dietetics professional.
*Diets would be offered as ordered by the physician.

Review of the provider's 2005 Diets Available on Menu policy revealed:*The following diets and extensions would be offered:
-Regular/No Added Salt.
-Mechanical Soft.
-Pureed.
-Consistent Carbohydrate.
-Consistent Carbohydrate Pureed.
-Other diets listed in the Combination Diet Order policy.

Review of the provider's 2005 Menu Planning policy revealed:
*Menu planning was to have been completed by the dietetics professional.
*Regular and therapeutic menus were written using an accepted standard meal planning guide, such as the USDA Food Guide Pyramid.
*Menus were written in amounts consistent with each resident's nutritional needs.
*The menu planning had referred only to long-term care residents. It had not referred to hospital patients.

Review of the provider's Portion Control policy revealed:*Residents would receive appropriated portions of food as planned on the menu.
*The Portion Control policy had referred to the long-term care residents. It had not referred to hospital patients.
*"Control at the point of service is necessary to assure that only the standard portion was served."
*The menu should list the specific portion size for each food item.
*Menus were to have been posted at the tray line for staff to refer to for proper portioning of servings for each diet.
*"Serving too small of portions results in the residents not receiving the nutrients needed."

32332

Based on record review, interview, and policy review, the provider failed to ensure seven of seven sampled acute care patients (1, 6, 7, 8, 9, 10, and 27) had comprehensive care plans. Findings include:

1. Review of patients 1, 6, 7, 8, 9, 10, and 27's electronic medical records (EMR) revealed their care plans had either not been initiated or completed during their stays.

Interview on 3/29/18 at 2:30 p.m. with the director of nursing (DON) during the review of the above patients' records revealed:
*Care plans were incomplete or missing entirely.
-A generic nursing problem had been identified for patients 6 and 27, but there were no patient specific interventions and no goals identified.
-Patient 1 had no care plan problems, goals, or interventions.
*The expectation was for a patient to have their care plan started within forty-eight hours of admission.

Interview and record review on 3/29/18 at 3:00 p.m. with the DON revealed patient's 1, 7, 8, 9, and 10 had no comprehensive care plan in their medical record. She had been aware since last fall that care plans had not always been done. She had provided education to all the nurses on the care plan section of the EMR, but had not completed any audits to ensure they had been completed.

Review of the provider's 4/16/17 Nursing Care Plan policy revealed:
*"Care plans must be initiated in EMR. They are to be reviewed daily and updated with any change of status or need. Care plan is to be multidisciplinary, including needs and plan from all department including dietary, social services and activities as indicated.
*A. Winged patients-Care plan is to be implemented within 7 days of admission and to be focused on functionality."
-A handwritten note on the policy said "now 48 hours."

Based on quality assurance committee minutes, interview, and policy review, the provider failed to ensure:
*A comprehensive facility wide Quality Assurance Performance Improvement (QAPI) program ensured 6 of 15 departments and services (social services, activities, environmental services, nursing services, contracted vendors, and swing bed) had developed and implemented a system/process improvement plan.
*Substantial compliance was maintained with previously cited regulatory deficiencies (C279, C298, C336, C385, C386, and C395.)
Findings include:

1. Review of the 3/1/17 through 3/28/18 QAPI meeting minutes revealed a facility wide QAPI program had maintained an effective process for the identification and correction of projects to enhance the quality of care.

Refer to C336.

Based on quality assurance committee minutes, interview, and policy review, the provider failed to ensure:
*A comprehensive facility wide Quality Assurance Performance Improvement (QAPI) program that ensured 6 of 15 departments and services (social services, activities, environmental services, nursing services, contracted vendors, and swing bed) had developed and implemented a system/process improvement plan.
*Substantial compliance was maintained with previously cited regulatory deficiencies (C279, C298, C336, C385, C386, and C395.) Findings include:

1. Review of the 3/1/17 through 3/28/18 QAPI meeting minutes revealed the following departments and services had not been identified as part of their facility wide QAPI program:
*Social Services.
*Activities.
*Environmental services.
*Swing bed.
*Electronic medical record.
*Comprehensive care plan completion.
*Contracted vendors.
*Previously cited regulatory deficiencies

Further random review of the above meeting minutes revealed that up to fifty percent of the anticipated twenty participants had not attended the scheduled QAPI meetings.

Interview on 3/27/18 at 4:00 p.m. with the QAPI coordinator revealed:
*Their committee met monthly.
*All departments were invited and were to have been part of the QAPI committee.
*They invited all disciplines.
-Despite the expectation that all departments attended the meeting, staff had not showed up for the meeting.
--She could not explain why that happened.
*All disciplines were to have a project they were working on for QAPI.
-They knew that.
*She confirmed all components of the hospital were not being incorporated into the QAPI meetings/reviews including those areas listed above.
*She was unsure if their QAPI program focused on high risk, high volume, or problem prone areas of the hospital, and stated "I have never thought about that."

2. Review of the 7/14/16 Statement of Deficiencies conducted by the South Dakota Department of Health revealed the facility had failed to maintain their compliance with the following deficiencies that had been cited that included: C279, C298, C336, C385, C386, and C395.

3. Interview on 3/28/18 at 10:30 a.m. with the chief operating officer confirmed the above findings.

Review of the provider's August 2016 QAPI policy revealed:
*It was a policy that only addressed nursing.
*A further 3/26/15 QAPI policy taken from the QAPI meeting minute book was directed to the nursing facility and did not address the hospital.
-It stated "The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers and other partners to that we may realize our vision to create an environment where residents are loved, valued and at peace."

Based on record review, interview, and policy review, the provider failed to ensure:
*A qualified person was in place to direct the activity program.
*A schedule of activities was available for four of four sampled swing bed patients (3, 4, 11, and 13).
Findings include:

1. Review of patients 3, 4, 11, and 13 swing bed medical records revealed there was no documentation present regarding:
*Individual activity assessments having been completed.
*Activities being provided to individual patients based on their assessment.

Interview on 3/27/18 at 3:30 p.m. with the activity director (AD) revealed:
*She was relatively new in her position and was supervised by the social services designee (SSD).
*She was unsure if she had completed all the requirements to be a qualified AD.
*She usually came and met with the patients and asked about what they liked to do.
-She sometimes jotted that information down on a piece of paper that was not part of the medical record or conveyed to other hospital staff.
*She told the patient about the activities that were available in the adjoining nursing facility.
-They were welcome to attend those activities.
*There was not a planned schedule of activities for the swing bed patients other than the nursing facility activities.
*An activity assessment had never been completed on swing bed patients.
-She was unaware she needed to do that or how to do that in their electronic medical record system.

Interview on 3/28/18 at 10:30 a.m. with the SSD revealed:
*She confirmed she supervised the AD but was not qualified to be the AD consultant.
*She had spoken to the AD in the past about going to the swing bed patients and offering them activities.
-She thought that was being done.
*She was unaware an activity assessment should have been completed.
-She was also not aware how to do that in their electronic medical record system.

Interview on 3/28/18 at 11:30 a.m. with the rehabilitation director revealed there was not a therapist who was responsible for consulting the AD on the activity program. She was unaware who that would have been.

Review of the provider's March 2015 Admission to Swing Bed policy revealed: "Activities Director, Social Services Designee and Dietitian shall write these summaries within seven (7) days of admission."

Based on record review, interview, social work (SW) consultant reports, job description, and policy review, the provider failed to ensure medically related social service needs had been assessed for four of four sampled swing bed patients (3, 4, 11, and 13). Findings include:

1. Review of patients 3, 4, 11, and 13 swing bed medical records revealed there was no documentation of patients being assessed to determine their medically related social service needs.

Interview on 3/28/18 at 10:30 a.m. with the social services designee (SSD)/coordinator revealed:
*She had been in her position for about six months.
-She was also the SSD in the adjoining nursing facility.
*She was not a licensed social worker (LSW).
-Her professional background was in the prison system.
*She had a consulting licensed SW who consulted at least quarterly.
*She met with the patients in the hospital and discussed issues related to their discharge.
-If she uncovered some information she thought the nurses should know she told them.
*She did not feel she had received a lot of training on the requirements for the hospital.
*She had never documented a social service assessment in the electronic medical record (EMR).
-She was unaware she needed to do that.
-She did not know how to do that either.
--No one had shown her how to document in the EMR.

Review of the 3/1/17 through 3/27/18 Social Work Consultant reports revealed:
*The consultant came at least quarterly.
*Each report revealed she made recommendations regarding the responsibility of the SSD including documentation that was required.
*None of the reports addressed requirements for the acute care patients or swing bed patients.

Review of the provider's social services coordinator job description revealed:
*"Social Service assignment element:
-1. Designs a social service program that meets the medically related, social and emotional needs of the resident or swing bed patient.
-4. Obtains a social history pertaining to resident/swing bed patients upon admission or pre admission when possible.
5. Participates in the care planning process of each resident to identify, meet and evaluate the resident's social, emotional and physical needs.
*Others:
-2. Completes resident assessments.
3. Documents social service finding relative to resident care needs, requests and likes, using standard or recommended methods in both the individual resident's medical record as well as computer entry.
4. Participates in the care planning process for the Swing Bed program.
5. Coordinates the care planning process for the Swing Bed program."

Review of the provider's March 2015 Admission to Swing Bed policy revealed: "Activities Director, Social Services Designee and Dietitian shall write these summaries within seven (7) days of admission."

Based on record review, interview, and policy review, the provider failed to ensure five of five sampled swing bed patients (3, 4, 11, 12, and 13) had comprehensive care plans. Findings include:

1. Review of patients 3, 4, 11, 12, and 13's medical records revealed:
*There were no comprehensive care plans documented.
*The care plans only addressed the patient's admission diagnosis.
*There was no care plan contributions from dietary, activities, social services,.
*Discharge planning was not addressed.

Interview on 3/27/18 at 3:00 p.m. with the director of nursing during the review of patients 3, 4, 11, 12 and 13's medical records revealed:
*Care plans were incomplete or missing entirely.
-A generic nursing problem had been identified but was not written specific to the patient.
-There were no patient specific interventions.
-Dietary, social services, and activities were not addressed on the care plan.
-Goals were incomplete.
*When a care plan review of a swing bed patient had been scheduled nursing and physical therapy were the only disciplines who reviewed them.
-She was unaware of why no other disciplines were reviewing it.
--They were missing reviews by dietary, social services, and activities.
*The expectation was for a patient to have the care plan started within forty-eight hours of admission.

Interview on 3/28/18 at 10:30 a.m. with the social services designee (SSD)/coordinator revealed:
*She had been in her position for about six months.
*She did not feel she had received a lot of training on the requirements for the hospital.
*She had never documented a social service assessment or care plan in the electronic medical record (EMR).
-She was unaware she needed to do that.
-She did not know how to do that either.
--No one had shown her how to document in the EMR.
*In the past they had care planning conferences in the nursing facility and reviewed the hospital patients and nursing home patients at the same time.
-They had stopped going into the nursing facility to do the review of the swing bed patients awhile ago.
-She was not aware they were still having the care plan reviews, so she had not attended or participated.

Interview on 3/28/18 at 10:40 a.m. with the activity director (AD) revealed:
*She was relatively new in her position and was supervised by the social services designee (SSD).
*She was unaware of the care plan meetings or reviews.

Telephone interview on 3/29/18 at 7:45 a.m. with the consulting registered dietitian revealed:
*He was usually informed by nursing if there was someone admitted.
*He consulted for the nursing facility also.
*Most of his contact and consultation was directed to the residents in the nursing facility.
*He was unaware of patients 3 and 11.
*He confirmed a nutritional assessment should have been completed on any new patient, a patient with a wound, or with weight loss.
*He had never done any documentation specifically for the patients in the swing bed, but felt he responded whenever he was contacted by the nursing staff regarding patients.
*He was unfamiliar with the regulatory requirements for swing bed patients.

Review of the provider's 7/1/16 dietary consultant agreement revealed:
*"Responsibilities of:
- A. Dietitian:
--3. Assist in nutrition screening, assessment, and care planning."

Review of the September 2003 Swing Bed Nursing Patient Care policy revealed: "There is a written nursing care plan for each patient based on the nature of illness, treatment prescribed, long and short term goals and other pertinent information."

Review of the provider's 4/16/17 Nursing Care Plan policy revealed:
*"Care plans must be initiated in EMR. They are to be reviewed daily and updated with any change of status or need. Care plan is to be multidisciplinary, including needs and plan from all department including dietary, social services and activities as indicated.
*A. Winged patients-Care plan is to be implemented within 7 days of admission and to be focused on functionality."
-A handwritten note on the policy said "now 48 hours".

Based on record review, observation, interview, policy review, and consultant agreement review, the provider failed to ensure four of four sampled swing bed patients (3, 4, 11, and 13) had a nutritional assessment completed by a registered dietitian (RD). Findings include:

1. Review of patient 3's electronic medical record (EMR) revealed:
*She had been admitted to a swing bed on 3/5/18 for a fractured hip.
*Her weight record revealed:
-Her stated weight on 3/6/18 was 111 pounds (lb).
-On 3/12/18 the recorded weight was 130 lb.
-On 3/15/18 the recorded weight was 124.08 lb.
*The physician had ordered a liberal pureed diet with Mighty shakes three times a day.
*There was no documented nutritional assessment by the registered dietitian (RD).

Observation and interview on 3/27/18 at 2:00 p.m. with patient 3 revealed she had no appetite, but she was trying to eat a bowl of tomato soup.

2. Review of patient 4's EMR revealed he:
*Had been admitted on 3/22/18 with a diagnosis of deconditioning, dementia, atrial fibrillation, and Parkinson's disease.
*Had been admitted with an opened wound on his hip.
*Had a physician's order for a pureed regular diet with no special interventions.
*Had not been assessed by the RD.

3. Review of patient 11's EMR revealed he:
*Had been admitted on 5/8/17 and discharged on 6/15/17 with a diagnosis of cerebral vascular accident and status post laminectomy.
*During his admission the RD had not documented a nutritional assessment of him.

4. Review of patient 13's EMR revealed she:
*Had been admitted on 11/24/17 and discharged on 12/13/17.
*During her admission the RD had not completed a nutritional assessment of her.

5. Review of the 3/1/17 through 3/29/18 Nutrition Consultation reports revealed:
*The RD consulted every month.
*All of his reports referenced the EMR of Point Click Care that was used only in the nursing facility.
-There was no reference to the EMR of the hospital or swing bed patients.
*October 2017 was the only report that referenced swing bed patients and it read "10/12/17-In house visit - 2 new resident assessments. 4 hospital swing bed reviews."
-It did not reflect that an assessment had been completed.

Interview on 3/28/18 at 2:30 p.m. with the information technology director revealed the consulting RD did not have access to the swing bed/hospital EMR. Thus he could not do any documentation in it.

Telephone interview on 3/29/18 at 7:45 a.m. with the consulting RD revealed:
*He was usually informed by nursing if there was someone admitted to the hospital.
-They would send him a text on his cell phone.
*He consulted to the nursing facility also.
*Most of his contact and consultation was directed to the residents in the nursing facility.
*He was unaware of patients 3 and 11.
-He confirmed a nutritional assessment should have been completed on any new patient, a patient with a wound, or with weight loss.
*He had never done any documentation specifically for the patients in swing beds, but felt he responded whenever he was contacted by the nursing staff regarding patients.
*He was unfamiliar with the regulatory requirements for swing bed patients.

Review of the provider's 7/1/16 dietary consultant agreement revealed:
*"Responsibilities of:
- A. Dietitian:
--3. Assist in nutrition screening, assessment, and care planning."