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29499


Based on record reviews and staff interviews, the hospital failed to ensure the nutritional needs of the patients were met when the Registered Dietitian (RD) failed to perform nutrition assessments on 6 of 30 sampled patients identified with nutrition related problems but did not have a nutrition assessment. This occurred when:

1. Patient 31 experienced a continuous weight loss with associated poor meal intake and a physician order for a nutritional supplement for the poor meal intake. Patient 31 did not receive a nutrition assessment by the RD.

2. Patient 32 experienced an undesirable significant weight increase and a new physician order for medication due to the weight increase. In addition, Patient 31 had a physician order for a therapeutic diet not consistent with hospital's diet manual and the physician was not notified to resolve the inconsistency. Patient 32 did not receive a nutrition assessment by the RD.

3. Patient 34 experienced a continuous gradual weight gain of more than 20 pounds over the course of the hospital stay. There was no nutrition assessment by the RD of this weight gain.

4. Patient 23 was admitted with a diagnosis of abnormal weight gain of 30 pounds prior to admission. There was no documented nutrition assessment by the RD in the medical record.

5. Patient 1 was admitted to the facility with a diagnosis of diabetes. Patient 1 also had a severe weight increase in the first 5 days of admission. There was no documentation of a nutrition assessment by the RD in the medical record.

6. Patient 8 experienced a 12 pound weight increase in the first 5 days of his admission. There was no documented nutrition assessment by the RD in the medical record.

This failure resulted in these patients experiencing significant weight changes that were not assessed by the RD to determine if the nutrition needs of these patients were met. In addition, there was a failure to implement the hospital's plan of correction for monitoring weights from the Validation Survey that was dated as completed as of 9/6/18, but was not put into place.

Findings:

A review of the hospital's validation survey Plan of Correction (POC) dated 9/10/18, indicated, "RD will create a new log sheet for collecting weekly inpatient weights that will allow for calculation of weekly weight changes. RD will review weekly weight charts on each unit to check for significant weight changes; loss of > 2% for the week or >5% for the month, or gain of same percentages for patients with BMI (Body Mass Index is a measure of body fat based on height and weight that applies to adult men and women) over 30 upon admission will trigger consult by RD." The completion date for this POC was indicated as 9/6/18.

During an interview with the RD on 10/2/18, at 10:00 AM, the RD stated that the new weight logs were not being used yet. She stated that she was not reviewing the logs weekly since the new logs were not in place. She had thought that the new logs were being prepared for "roll-out" and once they were in the log books, she would start reviewing them weekly.

A review of the Weight Log Books for ASU II, ASU III and PICU on 10/2/18 indicated that the new weight logs were not being used.

A review of the hospital's policy titled "Weighing of Patients" (review/revise date 08/18), indicated "it is the policy of [the hospital] that all patients will be weighed at least weekly to be able to assess and monitor homeostasis and for any significant weight loss and/or weight gain." It further stated, "recording of weights will be placed in the patient's record on the Nursing Flow Sheet at the time the weight is obtained. If the patient has a weight loss of greater than 5 lbs (pounds) or a weight gain greater than 10 lbs Behavior Health Specialist will notify the nurse on duty. The nurse will then notify the dietician and the medical physician."

1. A review of the medical record for Patient 31 indicated that the patient was admitted to the facility on 7/31/18 with medical diagnoses which included a urinary tract infection. Patient 31's weight on admission was 254.6 pounds, his height was recorded as 6 feet 4 inches. On 9/9/18, Patient 31 weighed 244 pounds. On 9/29/18, Patient 31's weight was 237.4 pounds. Patient 31 had lost 17.2 pounds since admission.

A review of the meal intake records for Patient 31 indicated that between 9/6/18 and 10/1/18, Patient 31 had eaten 0% of his meal for 32 of 64 recorded meals. Also noted on 9/6/18 was a physician order for a nutritional supplement, "one can if patient eats less than 50% of any meal." Only 2 meals between 9/6/18 and 9/28/18 indicated the patient had consumed the nutritional supplement.

A review of the physician orders indicated that the nutritional supplement order had been changed on 10/1/18 to one can three times a day, routinely.

Further review of the medical record for Patient 31 with the RD on 10/2/18, at 12:00 PM, indicated there was no nutritional assessment by the RD. The RD verified that there was no nutrition assessment. The RD stated that nursing did not call for a dietitian consult for Patient 31. The RD also stated that she did not conduct her own screen of patients in order to determine if there were patients at nutrition risk who were not referred by the physician or nursing. RD stated that she did not have a system in place to catch those patients at nutrition risk who fell through the cracks when nursing and the physician did not order a consult.

During an interview with the RN Supervisor 1 (RNS 1) the same day at 12:15 PM, the RN Supervisor stated, "I thought the RD was following [Patient 31]."

During an interview with Patient 31's medical physician (MD 1) on 10/3/18, at 1 PM, MD 1 stated that Patient 31 should have been seen by the RD for a nutritional assessment due to his weight loss and inadequate meal intake. MD 1 agreed that the RD is the nutrition professional uniquely qualified to determine nutrition risk in the patients.

2. A review of the medical record for Patient 32 indicated the patient was admitted on 8/28/18 with medical diagnoses that included hypertension and history of respiratory failure. Patient 32's weight on admission was 221.8 pounds, her height was 5 feet 6 inches. On 9/2/18, 4 days after Patient 32 was admitted, her weight was 213.6 pounds representing an 8.2 pound weight loss in 4 days.

During an interview with the RD on 10/3/18, at 8:45 AM, the RD verified that there was no documentation in the medical record for Patient 32 that the weight on 9/2/18 was rechecked to verify the accuracy. The RD also verified that she was not informed of this weight loss.

Further record review indicated Patient 32's weight on 9/9/18 was recorded as 224.8 pounds, an 11.2 pound weight gain in one week. On 9/23/18 Patient 32's weight was 231.4 pounds, an additional 6.6 pound increase.

In Patient 32's medical record, a review of the Group Progress notes dated 9/27/18 for the 'Nutrition Group" the RD noted that Patient 32 "reported gaining a lot of weight recently." Further review of the weight record indicated Patient 32's weight was recorded at 233.8 pounds on 9/30/18, a total of 12 pound weight increase since admission. At this point there was no nutrition assessment in the medical record. The RD verified that there was no nutrition assessment prior to 10/2/18 during an interview on 10/3/18, at 8:45 AM.

A review of the physician orders for Patient 32 indicated that on 10/1/18, there was a physician order for a Dietary Consult secondary to weight gain and an order for Metformin (a medication used for diabetes), 500 mg (milligrams) QAM (every morning) for weight gain.

Also noted in a review of the medical record was a physician order for a Regular NAS (no added salt) diet on 8/28/18. During an interview with the RD on 10/3/18, at 9:00 AM, the RD stated that the hospital does not have a NAS diet. She stated that it is the process that when a diet is ordered that the facility does not have, the RD or nursing requests that the order be changed to a diet order that is in the hospital's diet manual. The RD could not explain why the order from 8/28/18 had not been changed, or why she had not addressed the discrepancy between the hospital offered diets and the physician ordered diet.

A review of the hospital's diet manual (undated) indicated for the hospital, "Diets offered include: General, Vegetarian, Low Fat- No Concentrated Sweets, 2 g (gram) sodium. 6 small meals, full liquid and clear liquid". A NAS diet was not offered according to the diet manual. The diet manual also stated, "If there are specific questions regarding any diet or a patient has a need for a diet not listed in this manual, contact the Registered Dietitian."

3. A review of the closed medical record for Patient 34 indicated that Patient 34 was admitted on 3/22/18 and discharged on 9/20/18. Patient 34's weight on admission was recorded at 163.4 pounds, his BMI was 21.6 (normal BMI 18.5-24.9 according to the National Institute of Health or NIH). The last recorded weight for Patient 34 was 186 pounds on 9/9/18, with a BMI of 24.5 (25 or greater is classified as overweight by the NIH). This represented a 22.6 pound or 13.8% weight increase during the patient's hospitalization.

During a review of the medical record and concurrent interview with the RD on 10/3/18, at 3:45 PM, the RD verified that there was no nutrition assessment in the medical record. The RD stated that she looked at Patient 34's weight gain at one point [during his admission] but since it was a "relatively gradual weight gain", she did not think it to be of immediate concern. The RD further stated that Patient 34's weight gain did not meet her criteria for being problematic. The RD verified that there was no documented nutrition assessment to determine if the weight gain was desirable or not. She verified that Patient 34's BMI came close to being overweight by his discharge.

4. Per Patient 23's clinical record, patient was admitted to the facility on 9/24/18 with diagnosis of abnormal weight gain. Per physician's order dated 9/24/18, a dietary consult for 30 lb. weight gain was ordered. There was no documentation to reflect the dietary consult was initiated.

On 10/3/18 at 1:20 P.M. RNS 1 was interviewed. The RNS 1 stated she called dietary services and left a message regarding the referral for dietary consult for Patient 23.

On 10/3/18 at 2:45 P.M. RD was interviewed. The RD stated she was not notified by phone and did not receive phone message regarding dietary consult for Patient 23.

According to the facility policy revised 11/11, entitled, Acknowledgment of Orders, "To acknowledge a physician's orders, transcribe it and implement these orders in a timely manner." And " ...it is the policy ...to provide a process for physician orders to be noted and implemented."

5. Patient 1 was admitted to the facility on 9/25/18, per the Facesheet.

Patient 1's clinical record reflected the patient had a diagnosis of diabetes and was receiving medications for the treatment of his diabetes. There was no documentation to reflect a referral was made for a nutrition consult.

On 10/2/18 at 12:20 P.M. the DON and RNS 1 were jointly interviewed. The DON stated the person who performed the nursing admission assessment was supposed to initiate a nutrition consult referral for a patient admitted with a known diagnoses of diabetes.
RNS 1 stated she did the admission assessment for Patient 1 on 9/25/18, but forgot to initiate the nutrition consult referral.

According to the POC, dated 9/6/18, "The nurse supervisor will audit all new admissions...weekly patient weights with a gain or loss of more than 2%, and patients identified as having: diabetes...for a Nutritional Consult referral..."

Also, according to the Nursing Admission Assessment, dated 9/25/18, Patient 1 weighed 121 pounds on admission.

According to Patient 1's Vitals/O2/ Chart Sheet, on 9/30/18, a BHS staff member documented Patient 1 weighed 139.6 pounds, which was an 18.6 lb increase in 5 days.

Patient 1's clinical record did not reflect the facility RD or Patient 1's physician was notified of the weight increase of 18.6 pounds in 5 days.

RN 1 stated 10/3/18 at 2:35 P.M., he worked on 9/30/18 in the unit Patient 1 was housed. RN 1 said he was not notified by anyone that Patient 1 had an increase of 18.6 pounds in a 5 day period of time.

6. Patient 8 was admitted to the facility on 9/25/18, per the Facesheet.

According to the Nursing Admission Assessment, dated 9/25/18, Patient 8 weighed 165 pounds on admission.

According to Patient 8's Vitals/O2/ Chart Sheet, on 9/30/18, a BHS staff member documented Patient 8 weighed 177 pounds, which was an 12 lb increase in 5 days.

Patient 8's clinical record did not reflect the facility RD or Patient 8's physician was notified of the weight increase of 12 pounds in 5 days.

The BHS staff member who obtained Patient 1 and Patient 8's weight on 9/30/18 was unavailable for interview.

The DON stated in an interview on 10/3/18 at 2 P.M., the BHS staff member who obtained Patient 1's and Patient 8's weight on 9/30/18 should have notified the nurse and the nurse was responsible for notifying the RD and the patients' MD.

The RD stated in an interview on 10/3/18 at 2:20 P.M., she was not notified of Patient 1 or Patient 8's weight gain of over 10 pounds.

According to the facility policy, entitled, Weighing of Patients, last revised, 8/18, "If patient's has a weight loss of greater than 5 pounds or a weight gain greater than 10 pounds Behavior Health Specialist will notify the nurse on duty. The nurse on duty will then notify the dietician and the medical physician."