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Based on review of Critical Access Hospital (CAH) policy, clinical record review, and staff interview, it was determined, that for 1 of 10 clinical records reviewed (Pt. #1), the CAH failed to ensure the patient was adequately evaluated for nutritional needs.

Findings include:

1. CAH policy, dated 4/10, titled, "Nutritional Assessments" required, "... A nutritional assessment is completed within two weeks by Registered, Licensed Dietitian... a full nutritional assessment will also be completed for patients who have had a significant change in condition..." The policy failed to provide guidance for reassessment when patient's nutritional goals were not met.

2. Pt. #1's clinical record was reviewed and included that Pt. #1 was an 85 year old female, admitted to the CAH's swing bed section (room 222) on 12/1/11 from another Hospital, with diagnoses of Spinal Fusion, Right Trochanteric Bursitis, and Chronic Obstructive Pulmonary Disease (COPD), Diastolic Heart Failure, Pleural Effusion, and Pulmonary Hypertension.

Pt. #1's Nursing Admission Database dated 12/1/11 at 1:10 PM included Pt. #1's weight at 150 pounds. Nursing documentation included Pt. #1's weight at 136.4 lbs. By 12/9/11, the day Pt. #1 was discharged to an acute care hospital, Pt. #1 had sustained a 13.6 lb. weight loss in 8 days. On 12/16/11, when Pt. #1 was readmitted from the acute care hospital, Pt. #1's weight was 127.7 lbs., a 11.3 lb. weight loss in 7 days, and was down to 122 lbs. on 1/23/12.

3. A dietary note dated 12/30/11 at 2:42 PM, included a Heart Healthy diet, weight 120 lbs, ideal body weight 100 lbs + or - 10%, and "Inadequate energy intake related to decrease appetite as evidenced by patient stating 'I'm not hungry, I'm nauseated.', recorded intakes of 0 - 25%. Goal: Improved intakes of 50 - 75% most meals. Monitor: Intake record."

4. Pt. #1's intake record from 12/31/11 through 2/1/12 (33 days), included 14 days when the goal of 50 - 75% consumption of most meals was not met. There was no reassessment by the Registered Dietitian.

5. An interview was conducted with the Dietary Director (E #7) on 6/27/12 at 2:55 PM. The Director stated that the Registered Dietician was part time, 16 hours per month, and that the Dietician saw Pt. #1 once on 12/30/11.

6. Pt. #1 was transferred to the Long Term Care Facility within the CAH on 2/2/12 and was transferred to an acute care Hospital on 2/3/12 at 4:00 AM, in a comatose condition. Pt. #1 expired on 2/3/12.

Based on review of Critical Access Hospital (CAH) clinical record review and staff interview, it was determined, that for 1 of 10 clinical records reviewed (Pt. #1), the CAH failed to ensure the patient was weighed according to care plan goals.

Findings include:

1. Pt. #1's clinical record was reviewed and included that Pt. #1 was an 85 year old female, admitted to the CAH's swing bed section (room 222) on 12/1/11 from another Hospital, with diagnoses of Spinal Fusion, Right Trochanteric Bursitis, and Chronic Obstructive Pulmonary Disease (COPD), Diastolic Heart Failure, Pleural Effusion, and Pulmonary Hypertension.

Pt. #1's Weekly Patient Care Conference notes dated 12/21/11, included that Pt. #1 would be weighed twice each week. However, Pt. #1 was weighed 8 times during the following 6 weeks, missing 4 weights.

2. An interview was conducted with the Director of Medical Surgical Unit (E #2) on 6/27/12 at 11:00 AM. E #2 stated that weights are recorded twice per week on all patients.