HospitalInspections.org

Based on medical record review and nursing staff interview the hospital failed to ensure a comprehensive care plan for 2 patients (Patients 1 and 3) and that fully described all elelments of delivered patient care and failed to identify a change in nutritonal status

Findings:

1. Patient 1 was admitted with diagnosis including sepsis (an infection in the blood) and diabetes. Admission diet order dated 8/10/11 was NPO (nothing by mouth. Follow up diet orders dated 8/12 was a clear liquid and 8/12 a consistent carbohydrate diet. An admission nutrition screen dated 8/10/1 noted that the patient had decreased intake. A comprehensive nutrition assessment dated 8/12/11 noted that Patient 1 was eating well; however had decreased mental function. Patient 1 was classified at high nutritional risk.

Review of dietary intake from 8/13-8/18/11 (17 meals) revealed that only 2 of 17 meals were recorded. It was also noted that the average intake of these 2 meals was 20% per meal. It was also noted there was no additional documentation that the RD was notified of Patients' 1 decreased nutritional intake.

Review of hospital document titled "Interdisciplinary Plan of Care/Discharge Plan" dated 8/11/11 revealed that nursing staff identified 4 care areas of concern. They included the sepsis, fall risk, cellulitis and ineffective coping. There was no care plan developed for Patient 1's diagnosis of diabetes or his high risk nutritional status. It was also noted that the patient goal was documented as "as written" for the identified care areas; however there was no documentation of what those goals might be.

In an interview on 8/23/11 at 1:20 pm, with CS D she stated that the RD's were no documenting nutrition related problems, goals and/or outcomes on the comprehensive patient care plan.

In an interview on 8/23/11at approximately 1:30 pm, with AS E she stated the hospital implemented a new care planning system in preparation for the development of an electronic medical record. She stated that upon admission nursing staff identified care areas. Based on the identified care areas nursing staff would implement the pre-printed clinical practice guideline. She also stated that the goals/outcomes were pre-printed on the multi-page practice guideline; however that guideline did not become part of the permanent medical record.

In an interview on 8/24/11 at 11:30 am, with RN F she stated that the hospital was no longer developing measurable outcome statements as part of care planning. She also stated that on a daily basis nursing would document the patients' response to interventions on the "Adult Patient Care Summary." She further stated that there were no clinical practice guidelines for issues surrounding clinical nutrition care such as poor dietary intake.

Based on the standards for acute and critical care nursing practice, which includes standards of professional performance, the American Association of Critical Care Nurses (2009) guides that standards of nursing practice would include assessment, diagnosis and outcome identification among other elements. The standard for outcome identification would ensure that outcomes are measurable and should include a time estimate for attainment, if possible and that outcomes are documented in a retrievable form (American Association of Critical Care Nurses).

2. Patient 3 was admitted with diagnosis including pneumonia and a stage 3 pressure ulcer. Admission height was 6 feet 1 inch and weight was 166 pounds. An admission nutrition screening dated 6/4/11 demonstrated that the patient was at nutritional risk. A comprehensive nutrition assessment dated 6/5/11 noted that the patient had poor dietary intake prior to admission and continued to have poor intake; was at high nutritional risk and had a recommendation for a nutritional and a multi-vitamin/mineral supplement.

Review of hospital document titled "Adult Patient Care Summary" dated 6/7 and 6/8/11. The RD documented a goal of dietary intake of 75-100% however there was no development of a comprehensive plan on how the desired goal would be achieved or the timeframe for the achievement. It was also noted that there was no care plan developed for Patient 3's pressure ulcer.

Based on the standards for acute and critical care nursing practice, which includes standards of professional performance, the American Association of Critical Care Nurses (2009) guides that standards of nursing practice would include assessment, diagnosis and outcome identification among other elements. The standard for outcome identification would ensure that outcomes are measurable and should include a time estimate for attainment, if possible and that outcomes are documented in a retrievable form (American Association of Critical Care Nurses).