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Based on review of facility policy, medical record review, and staff interviews, the facility failed to ensure that nutritional comprehensive assessments were completed per facility policies and procedures and to ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and the requirement is met with respect to inpatients receiving post hospital SNF care.

Findings:

Review of medical records revealed that four(4) (patient #5, patient #9, patient #18, patient #20) of twenty (20) medical records did not have a nutritional assessment completed per policy or physician order.

Review of the medical record for Patient # 5 revealed that the patient was admitted on 03/21/18 with Multilobar Pneumonia (infection in more than one section of a lung), Hypertension(high blood pressure), Newly Diagnosed Diabetes Mellitus Type 2 (new diagnosis of elevated blood sugar in an adult). The patient was discharged on 03/28/18. The discharge summary documents that the patient was diagnosed with diabetes during the his/her stay with an elevated A1C(a blood test that measures the amount of sugar in the blood for the past two(2)to three(3)months)of 9(normal range is 4 to 5.6). The patient was started on basal insulin(medication that keeps blood sugar levels at a consistent level) and discharged home on the insulin and an oral medication for diabetes. The medical record documents that the patient received sliding scale insulin during the course of the patient's stay. The initial interview documented by the registered nurse records that the patient had a 120 pound weight loss in 2015. On 03/21/18 it is documented that the patient was educated on diabetes. On 03/22/18 it is documented that the patient ate 40 per cent (out of eating 100 per cent)of his/her breakfast; 30 percent(out of 100 percent) of his/her lunch; and 50 percent(out of 100 percent) of his/her dinner. On 03/22/18 it is documented that the patient was a newly diagnosed diabetic and that blood glucose monitoring tests(way to test the amount of sugar in the blood)and sliding scale insulin(medication given on an as needed basis in accordance with physician orders)was ordered. Documentation in the medical record indicates that the patient received sliding scale insulin on 03/22/18, 03/23/18, 03/24/18, 03/25/18, and 03/26/18. There was no documentation that the patient had a nutritional(diet) assessment completed by the registered dietician during the patient's stay.

Review of the medical record for Patient #9 revealed that the elderly patient was admitted to observation(a place to continue to provide care or continued evaluation of a patient)on on 05/06/18 with Leukocytosis(a high level of white blood cells in the blood), Hypotension(low blood pressure), Bronchitis(inflammation of the bronchial tubes), and Weight Loss. The patient was transferred as an inpatient(was admitted) to the facility on 05/08/18. The patient was discharged on 5/11/18. Documentation on the history and physical revealed that the patient had not been eating due to no appetite, and that the patient had a 25 pound weight loss in the last two(2)months. The patient when in observation status had an elevated white blood count and a low total protein(a blood test that may indicate malnutrition). The physical therapy initial interview documents that the patient has a history of diverticulitis( inflammation of the lower bowel). The patient progress note on 05/08/18 documents that the patient ate 30 per cent of lunch and 50 per cent of dinner. The patient progress note on 05/06/18 documents per the Braden Scale(an assessment tool to measure the chance that a patient may develop a bedsore) that the patient had a score of less than two (2) which flagged that a dietary consult was needed. There was no documentation that the patient had a nutritional assessment completed by the registered dietician during the patient's stay.

Review of the medical record for Patient # 18 revealed that the patient was admitted on 07/26/18 to the facility with Gait Instability Status/Post Total Knee Arthroplasty(walking was not stable after a knee replacement); Type 2 Diabetes, and Gastrointestinal Prophylaxis(medication used to prevent a problem with the stomach and intestines). The physician ordered a dietary consult on 07/26/18. Review of the medical record revealed that as of 07/31/18, there was no documentation that the patient had a nutritional assessment completed by the registered dietician.

Review of the medical record for Patient # 20 revealed that the elderly patient was admitted on 07/19/18 to the facility with Debility(physical weakness), Gait Instability(walking is not steady), Recent Pneumonia, and Gastroesophageal Reflux(disorder that affects the esophagus and stomach). The initial nursing interview on 07/19/18 documents that the patient drinks Ensure(diet supplement with increased protein, vitamins, and minerals) with all meals. The progress note on 07/19/18 and 07/20/18 documents that the patient eats only about half(1/2) of any food offered. The physician ordered on 07/19/18 that a laxative to be given every day. The policy and procedure states that dietary assessments will be completed within four (4) days of admission. Review of the medical record revealed that as of 07/31/18, there was no documentation that the patient had a nutritional assessment completed by the registered dietician.

A review of the facility policy, 250, "Dietary Assessments," revised 08/2015, revealed that a dietary assessment would be completed for all residents in the Swing Bed Program. A further review revealed that all staff would be involved in the Swing Bed Program, and the enforcement would fall under the Swing Bed Coordinator. A continued review revealed that dietary assessments would be completed within four (4) days of admission. Dietary progress notes would be made as needed by the Dietary Supervisor. Diet reports would be included in the resident ' s clinical record, and the amount the resident eats would be recorded in the Patient Care Flowsheet.
A review of the facility policy, DTY.023, "Nutritional Assessment," revised 04/2017, revealed that all nutritional assessments would be documented on a nutrition assessment form to include subjective and objective data. A continued evaluation revealed that patient diet instruction and pain would be included on the form. A Registered Dietician will assess high-risk patients within forty-eight (48) hours, or as soon as possible after the initial nursing assessment had been completed and notice was given to the dietary department/dietary manager. A further review revealed that Nutrition Consults received by the Dietary Department/Dietary Manager would be completed as soon as possible or within twenty-four (24) hours. All information on consuls/ high-risk patients would be entered onto a Nutritional Assessment Data form and faxed to the Registered Dietician by the Nursing or Dietary Manager.
A review of the facility policy, DTY.022, "Scope of Services," revised 04/2017, revealed that the patient ' s diet needs would be assessed at the time of admission. The assessment would be provided by Nursing, the dietician, and the physician.
A review of the facility policy, DTY.025, "Nutrition Intervention," revised 04/2017, revealed that an initial nutritional screening would be performed by nursing. Those patients found to be at nutritional risk will be referred to the Dietary Department/Dietary Manager for additional screening and nutrition intervention recommendations from the Registered Dietitian. Patients considered to be at Nutritional Risk have the following criteria:
1. Tube Feedings/TPN
2. Albumin below 2.5
3. Nausea/Vomiting, and unable to eat >4 days
4. A weight loss of more than ten (10) pounds in three (3) months
5. Swallowing impairment
6. Decubitus of stage II or greater
7. NPO/CL - 3 days
8. Teenage/ High-Risk Pregnancy
A continued review revealed that all high-risk patients would be visited during mealtime periodically to observe food intake and tolerance by Nursing Services/Registered Dietician. Lab data would be reviewed and evaluated as needed.

During an interview with staff #9 on 7/31/18 at 3:30 p.m. in his/her office staff #9 confirmed that there was a problem with getting the dietician to complete the nutritional assessments in a timely manner.

During an interview with staff # 12 on 08/01/18 at 10:00 a.m. in the administrative office, the dietician confirmed that he/she is not full time, but comes to the facility one(1) to two(2)days per week for three(3) hours per week. Staff #12 stated that a dietary consult could be flagged by an order from the physician or a nurse practitioner. He/she confirmed that he/she has 4 days to complete a nutritional assessment, but due to time sometimes will make notes on sticky notes to give to the staff to implement. Staff # stated that there is a "back-up" dietician that covers for him/her while he/she is on vacation. However, when he/she was at a conference or training session that there is not a "back-up" dietician to assess the patients in the facility.

During an interview with staff #2 on 8/1/18 at 11:00 a.m. in the administrative office he/she explained that the following measures were currently being undertaken to improve the process for triggering and obtaining nutritional assessments:
Update the nursing assessment documentation in the electronic medical record to include ' triggers ' for nutrition consults or assessments.
Develop an automated system to alert the registered dietician when a consult is needed.
Ensure that a registered dietician is available for consult seven (7) days per week.
Update the policies to include definitive expectations on performing nutritional assessments.

During the exit conference with facility staff #2 presented the team with a "Corrective Action Plan" with a date for implementation of the corrective action by September 4, 2018.