HospitalInspections.org

Based on interview, record review, and policy review, the facility failed to document consumption of a nutritional supplement (a drink added to the diet, usually to increase calories and/or protein to increase weight) for four patients (#6, #14, #19 and #20) of four current patients and for one patient (#1) of one discharged patient reviewed for consumption of a nutritional supplement. The facility also failed to document weights for two patients (#19 and #20) of four current Geriatric Psychiatric Unit (GPU) patients and for one patient (#1) of one discharged GPU patient reviewed. These failures had the potential to affect all patients receiving nutritional care in the facility. The facility census was 49.

Findings included:

1. During an interview on 12/04/13 at 10:00 AM, Staff E, Corporate Compliance Officer, stated that the facility had no policy to show facility staff direction for the documentation of patient consumption of a nutritional supplement.

2. Record review of the facility policy titled, "Weight and Height Measurement-Adult Inpatient," revised on 06/11/12, showed accurate weight was essential for monitoring the course of treatment. It was the responsibility of the primary nurse assigned to the patient to ensure that a patient weight was obtained.

3. During an interview on 12/04/13 at 11:34 AM, Staff E stated that the facility had no policy to show facility staff direction for the GPU's practice of obtaining weekly weights.

4. Record review of Patient #14's History and Physical (H & P) dated 11/27/13, showed she was admitted on 11/27/13, that she was at risk for a pressure sore, and had a diagnosis of weight loss.

5. Record review of Patient #14's nutritional note dated 12/02/13, showed inadequate oral food/beverage intake related to decreased appetite as evidenced by intake of 53% of meals.

6. Record review of Patient #14's physician order dated 11/27/13, showed a regular diet with a supplemental shake.

7. Record review of Patient #14's intake record (documentation of food and fluid intake by mouth) showed no documentation of the consumption of the supplemental shake.

8. Record review of Patient #19's H & P dated 10/30/13, showed she was admitted on 10/29/13 with diagnoses of an impaired fasting glucose (sugar), vitamin B-12 deficiency, and multiple lacerations (cuts) on her forearm. Her albumin (a level of protein in the blood) was 3.4 g/dl (grams per deciliter-normal 3.5-4.8). A low albumin level can be an indicator of a poor nutritional status and decreased ability to heal wounds.

9. Record review of Patient #19's nutritional note dated 11/06/13, showed inadequate oral intake evidenced by less than 75% intake at meals.

10. Record review of Patient #19's physician order dated 10/29/13, showed a regular diet with a supplemental shake.

11. Record review of Patient #19's intake record showed no documentation of the consumption of the supplemental shake.

12. Record review of Patient #20's H & P dated 10/20/13, showed she was admitted on 10/19/13 and had obesity and a diagnosis of type 2 diabetes (life long disease in which there are high levels of sugar in the blood).

13. Record review of Patient #20's nutritional note dated 10/24/13, showed the current intake was not meeting her estimated needs. The dietitian documented that nursing was unclear if the patient was receiving or drinking the supplement.

14. Record review of Patient #20's physician order dated 10/14/13, showed vegan (no animal products) diet with a supplemental shake.

15. Record review of Patient #20's intake record showed no documentation of the consumption of supplemental shakes.

16. During an interview on 12/03/13 at 11:20 AM, Staff G, Registered Nurse (RN), stated that staff failed to document patient consumption of supplements in the medical record.

17. During an interview on 12/03/13 at 2:35 PM, Staff AA, Food Service Supervisor, stated that dietary staff provided supplements with meals when the physician ordered supplements for a patient.

18. During an interview on 12/03/13 at 3:55 PM, Staff JJ, Clinical Dietitian, stated that staff failed to document in the medical record patient consumption of supplements on the GPU and that she would have to ask staff if patients consumed the supplements that were ordered. Staff JJ was unable to trend the patient consumption of supplements.

19. Record review of Rehabilitation Unit Patient #6's nutritional assessment dated 11/17/13, showed that she had weight loss over the last 30 days. The dietitian recommended a nutritional supplement, three times daily, to address her increased nutrient needs.

20. Record review of Patient #6's physician order dated 11/20/13, showed an order for a supplement three times daily.

21. Record review of Patient #6's intake record showed staff failed to document her supplement intake 11 out of 15 days.

22. During an interview on 12/03/13 at 12:30 PM, Staff P, Rehabilitation Unit Director, stated that the supplements were not correctly documented on Patient #6's record.

23. Record review of Patient #1's physician order dated 08/29/13, showed an order to offer patient whole milk and Mighty Shakes (a brand name for a nutritional supplement) at meals.

24. Record review of Patient #1's intake record showed staff failed to document that the patient was received whole milk or mighty shakes during meals.

25. Record review of Patient #1's nutritional notes showed recommendations to offer whole milk and mighty shakes at meals. The notes showed no intake amounts of the supplements consumed throughout her hospital stay.

26. During an interview on 12/03/13 at 3:55 PM, Staff G, RN, stated that the Mental Health Technicians (MHTs) weighed the patients every week on Wednesdays. The MHTs were responsible to document the weights in the computer.

27. Record review of Patient #19's medical record showed she was admitted on 10/30/13 with a weight of 67.8 kilograms (kg) (149.16 pounds). Staff obtained the next weight of 62.5 kg (137.5 pounds) on 11/27/13, a weight loss of 5.3 kg (11.66 pounds).

28. Record review of Patient #19's nutritional notes dated from 11/06/13 through 11/25/13, showed the GPU staff failed to obtain weekly weights for the dietitian to provide an accurate nutritional assessment.

29. Record review of Patient #20's medical record showed she was admitted on 10/19/13 with a weight of 72 kg (158.4 pounds). Staff obtained the next weight of 77.2 kg (169.84 pounds) on 11/12/13, a weight gain of 5.2 kg (11.44 pounds).

30. Record review of Patient #20's nutritional notes dated from 10/24/13 through 11/06/13, showed the GPU staff failed to obtain weekly weights for the dietitian to provide an accurate nutritional assessment.

31. During an interview on 12/03/13 at 4:00 PM, Staff X, RN, stated that there was no process for the RN to ensure the weight was obtained weekly.

32. During an interview on 12/03/13 at 9:30 AM, Staff JJ stated that when nursing staff failed to obtain patient weights, the dietitians completed their assessment and calculations using a previous weight.

33. Record review of Patient #1's H & P dated 08/30/13, showed the patient was admitted to the GPU on 08/28/13 and was at risk of weight loss.

34. Record review of Patient #1's physician order dated 08/30/13, showed an order to weigh the patient on Wednesdays.

35. Record review of Patient #1's recorded weights showed the patient was weighed twice during hospitalization, at admission (08/28/13) and on 09/15/13, and failed to show documentation of weights every week.

36. Record review of Patient #1's nutritional note dated 09/19/13 showed the patient had a 6.8% weight loss from 08/28/13 to 09/15/13. There was no further documentation of her weight through discharge on 10/08/13 for the dietitian to evaluate for additional weight change.

37. During an interview on 12/04/13 at 9:25 AM, Staff KK, GPU RN Clinical Team Leader, stated that she teaches nursing staff to routinely weigh patients upon admission, weekly on Wednesdays, and upon discharge.

38. During an interview on 12/04/13 at 2:30 PM, Staff X, GPU RN, stated that patient weights were taken weekly on Wednesdays.


31891




15697