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Based on medical record review, pharmacy staff interview, pharmacy and nutrition document review the hospital failed to ensure an effective system to identify 1 of 3 patients (Patient 205), reviewed for nutrition care, for drug nutrient interactions.

Findings:

Patient 205 was admitted on 5/24/14 with diagnosis including congestive heart failure, acute renal insufficiency and fatigue. Medical record review was conducted beginning on 5/28/14. Admission history and physical dated 5/24/14 also noted that the patient had pneumonia (an infection of the lungs) chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breath, National Heart, Lung and Blood Institute (NHLBI), 2014), hypoxia (a low level of oxygen in the blood (NHLBI) and kidney insufficiency. Admission diet order dated 5/24/14 was a regular diet. It was also noted that on 5/27/14 at 1700 the physician ordered Coumadin (a blood thinner).

In an interview on 5/28/14 beginning at 9 am, with the Nutrition Services Manager (NSM) she was asked to describe the process for evaluating drug nutrient interactions for medications such as Coumadin. She stated that prior to every meal dietary staff printed out a list which depicted the patients on Coumadin. It was noted that the list did not contain Patient 205's name.

In an interview on 5/28/14 at 4:15 pm, with Pharmacy Staff Q, who was assigned as the medication safety officer and the Director of Pharmacy provided a document titled "Northern California PHA Warfarin [Coumadin] Patient List" it was noted the list was printed on 5/28/14 at 15:57. Patient 200's name was not on the list despite receiving a dose of Coumadin on 5/27/14 at 17:00 with an order to continue the medication until 6/26/14 at 17:00. In a group telephone interview on 5/28/14 at 5 pm and 5/29/14 at 8 am, with hospital Administrative Staff R and Information Technology Staffs S, T, U, V and W who were responsible for the electronic medical record they were unable to explain the omission of Patient 200's name from both the dietary drug-nutrient interaction list and the pharmacy warfarin patient list.

Hospital policy titled "Medication and Food/Drug Interaction" dated 12/13 revealed that it was the responsibility of the pharmacist "...for entering the patient's prescribed medications into the electronic database."

Based on medical record review, administrative staff interview and nursing document review the hospital failed to ensure effective nutrition admission screening procedures for 1 of 3 patients (Patient 205). The lack of effective admission screening resulted in lack of comprehensive nutrition assessment for Patient 205 who was admitted with multiple nutrition related diagnosis. Failure to develop an effective nutrition screening tool may result in absence or delay of nutrition assessment and may further compromise patient medical status.

Findings:

1. Patient 205 was admitted on 5/24/14 with diagnosis including congestive heart failure, acute renal insufficiency and fatigue. Admission history and physical dated 5/24/14 also noted that the patient had pneumonia (an infection of the lungs) chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breath, National Heart, Lung and Blood Institute (NHLBI), 2014), hypoxia (a low level of oxygen in the blood (NHLBI) and kidney insufficiency. Admission diet order dated 5/24/14 was a regular diet.

A nursing nutrition admission screening dated 5/24/14 failed to note any of Patient 205's chronic diseases. Review of undated hospital electronic medical record screen shot titled "Document Nutritional Screening" noted that minor, chronic and severe disease problems were associated with a nutritional risk factors ranging from a risk factor of 1-3 points depending on patient diagnosis.

In an interview on 5/29/14 at 10:10 am, with Administrative Staff (AS) EE she stated that the hospital reviewed the comprehensive completion of nursing admission screening and found the percent completed to be within acceptable parameters; however had not evaluated the quality of the screening. She also stated that after a recertification survey conducted in March 2014 nursing staff was reminded via a flyer dated 4/15/14 and titled "Staff Education-Nutrition Screening" to "...complete all 5 aspects of the Nutrition screen on admit ..." Nursing staff was also provided the policy titled "Nutritional Screening and Assessment" dated 3/14 which included an attestation that the Registered Nurse understood the policy. Administrative EE also stated that nursing staff was provided 6 hours of training on the electronic medical record update.

Review of hospital document titled "RN Acute Part A and Part B Training Guide" dated 12/10/13 and 1/12/14 respectively revealed that while training was provided on the computer program update, the training in relationship to nutrition services was limited to guidance on how to enter a diet order. There was no training in relationship to nutrition admission screening or the accuracy of the screening. As a result of lack of comprehensive and accurate identification of Patient 205's nutritional risk there was no provision of nutrition care services for a patient with multiple nutritional risk factors after 5 days of hospitalization.

Based on medical record review and nursing staff interview the hospital failed to ensure development of care plans that fully depicted patient medical needs for 1 of 3 patients (Patient 205) reviewed for nutrition care. Failure to develop comprehensive care plans may result in patients receiving inadequate care, further compromising medical condition.

Findings:

Patient 205 was admitted on 5/24/14 with diagnosis including congestive heart failure, acute renal insufficiency and fatigue. Admission history and physical dated 5/24/14 also noted that the patient had pneumonia (an infection of the lungs) chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breath, National Heart, Lung and Blood Institute (NHLBI), 2014), hypoxia (a low level of oxygen in the blood (NHLBI) and kidney insufficiency. Admission diet order dated 5/24/14 was a regular diet.

Review of Patient 205's lab indicators revealed that during the course of hospitalization the blood, urea, nitrogen (BUN) level was elevated ranging from 28-53 mg/dl (normal 8-26 mg/dl). The BUN is a measure of nitrogen in the blood which evaluates kidney function. Elevated BUN levels depict compromised kidney function (National Library of Medicine, 2014). Similarly the patients' creatinine level, also a measure of kidney function, was elevated ranging from 2.04-1.9 mg/dl (normal - .61 to 1.24 mg/dl). Glucose levels, which are indicative of diabetes (American Diabetes Association), were elevated ranging from 154-173 mg/dl (normal 70-130 mg/dl).

Review of Patient 205's interdisciplinary care plan dated 5/24/14 revealed there was no documented plan with respect to abnormal lab values; rather was limited to activity tolerance, fluid imbalance, hypoxia, depression, falls, angina and discharge readiness. Hospital policy titled "Patient Assessment and Interdisciplinary Plan of Care" dated 11/26/12 noted that "Each discipline involved with the care of the patient is responsible for contributing to the plan of care."

Based on medical record review, administrative staff interview and departmental document review the hospital failed to ensure evaluation of the quality of nutrition risk screening and the quality of nutrition care services as evidenced by lack of effective nutrition care of 2 of 3 patients reviewed (Patients 205 and 206). Failure to effectively assess nutrition care services may result in lack of effective nutrition care, may further compromise medical status, lengthen hospitalization stay and may contribute to increased readmission rates.

Findings:

1. During medical record review on 5/28/14 beginning at 9 am, it was noted that the nutrition risk screening completed at the time of admission did not accurately reflect the nutritional risk of 1 of 3 patients reviewed for nutrition care (Cross Reference C296). In an interview on 5/29/14 at 10:10 am, with Administrative Staff (AS) EE she stated that the hospital reviewed the comprehensive completion of nursing admission screening and found the percent completed to be within acceptable parameters; however had not evaluated the accuracy of the screening.

2. During medical record review on 5/28/14 beginning at 9 am, it was noted that Patients 205 and 206 did not receive comprehensive nutrition care planning. Patient 205 did not receive a nutrition assessment despite nutrition related chronic diseases. While Patient 206 received a comprehensive nutrition screening he did not receive nutrition interventions for identified nutritional problems (Cross Reference C279).

Review on 5/29/14 at 9 am of the departments' performance improvement parameters noted that while there was a system for assessment of registered dietitian consultation with respect to timeliness in relationship to hospital policy; however there was no system to evaluate the quality of the assessment in relationship to patient nutritional needs or defined standards of practice. In an interview and concurrent document review with Administrative Staff CC she acknowledged that in neither of the instances the quality of the process was evaluated.

Nutrition Department policy dated 1/14 and titled "Quality Control and Performance Improvement" noted that the department "assures quality through gathering data...and planning of improvement efforts..." It was also noted that all of the performance improvement procedures were related to food services. There were no defined procedures for evaluation of nutrition care services. Hospital policy dated 8/13 and titled "Plan for Improving Organizational Performance" noted that "at a minimum, the organization will collect data in the following areas...other aspects of performance that assesses processes of care, hospital service and operations..."