HospitalInspections.org

Based on interview and record review, the hospital failed to ensure:

1. The Registered Dietitian's (RD) input on the interdisciplinary plan of care was documented for one Patient, (Patient 300) who was at nutritional risk;

2. The RD comprehensively addressed the nutritional status of one patient, (Patient 302) in accordance with facility policy and standards of practice; and,

3. The nutritional needs of one sampled patient (Patient 301) were met as the patient sustained a significant weight loss of approximately 35 pounds in three weeks.
The failure to use current community standards in assessing or following up on these patients could potentially impact their nutritional and medical stability.

Findings:

1. A review of the record for Patient 300, indicated he was admitted to the main campus on October 3, 2012. The patient was admitted with a DTI (deep tissue injury) on the right heel and redness of the coccyx.

On October 4, 2012, the RD completed a nutritional assessment and documented the patient had a healed Stage II pressure sore on the sacrum, but did not reference the presence of a DTI to the right heel. The RD documented the patient had inadequate oral intake and was not meeting more than 75% of his estimated nutritional needs. The RD recommended an appetite stimulant.

On October 11, 2012, the RD completed a nutrition re-assessment and documented the patient was receiving Boost (a nutritional supplement) and had inadequate oral intake, and "only drinks juice". The RD made no reference to the patient's DTI. The RD again recommended an appetite stimulant, and made a recommendation for a tube feeding (feeding via a tube inserted directly into the stomach) should the patient continue with a poor oral intake. The same recommendations were made on October 18, 2012.

On October 25, 2012, the RD documented the patient had increased protein needs to promote wound healing as evidenced by a low prealbumin (a measure of protein stores. The RD reassessed the patient's protein needs from 68-99 grams per day (as initially assessed) to 68-102 grams per day. No new recommendations were established.

A review of the patient's plan of care, indicated no entry by the RD referring to Patient 300's compromised nutritional status, the provision of a nutritional supplement, or an appetite stimulant.

On November 7, 2012, at 3:45 p.m., in an interview with RD 2, she stated Patient 300 was at a high nutritional risk, and confirmed the absence of an entry on the active care plan in the patient's record. She acknowledged the availability of juice based nutritional supplements that could have been recommended for the patient since she documented the patient liked juice. She could not explain why she did not reference the DTI on her initial nutrition assessment, and why she did not identify the patient's increased protein needs for wound healing until October 25, 2012, even though the DTI was present on admission.

A review of the facility policy titled, "Assessing & Meeting Patient care Needs - Revised 2/6/12", indicated: "The Registered Dietitian will complete the interdisciplinary patient care plan for all patients at high nutrition risk."

2. A review of the medical record for Patient 302, indicated he was admitted to the Arlington Campus on September 11, 2012. The patient's admission height was documented as six feet two inches, his weight was 180 pounds. The RD completed an initial nutrition assessment on September 13, 2012, and documented the patient's ideal body weight (IBW) as 190 pounds. The patient was prescribed a low sodium, high fiber diet due to problems with constipation. The RD documented a recommendation to, "Monitor I/Os (intake and output), lab (laboratory), wt (weight), continue Diet RX (recommendation)."

A further review of the medical record indicated the patient's measured weekly weights, as documented on the nursing graphics flowsheet as follows:

October 7, 2012, - 193 pounds
October 14, 2012, - Refused
October 21, 2012, - 194.5 pounds
October 28, 2012, - 200 pounds
November 4, 2012, - 204 pounds.

Patient 302 gained 24 pounds from September 11, 2012, to November 4, 2012.

A review of the RD re-assessment dated, October 12, 2012, indicated that no new weight was available. The RD re-assessment dated, October 20, 2012, referenced the patient's refusal of weight on October 14, 2012, but did not address the patient's documented 13 pound weight gain as of October 7, 2012. On the RD re-assessments dated, October 27, 2012, and November 3, 2012, the RD documented "No new weight" was available. On each re-assessment, the RD documented "Monitor wt" as a recommendation.

On November 7, 2012, at 1:55 p.m., in an interview with RD 1, she stated she was familiar with Patient 302, but could not explain why she had not addressed the significant weight gain experienced by Patient 302, when the weekly weights were available on the nursing flowsheets on October 7, 21, and 28, 2012. The RD stated she did not attend team meetings at the Arlington campus, where the care of each patient was discussed with the multidisciplinary team.

A review of the facility policy titled, "Assessing & Meeting Patient Care Needs - Revised 2/6/12", indicated: "The Registered Dietitian will participate in multidisciplinary conferences on their assigned units.

3. Patient 301 was admitted to the hospital on August 13, 2012, with diagnoses including left sided weakness, and high blood pressure. Patient 301 was 6 feet 3 inches tall and weighed 180 pounds on admission. He was on NPO (nothing by mouth) pending a speech evaluation. In addition, the physician ordered a nutritional consult.

On August 14, 2012, a nutritional assessment was conducted by a registered dietitian. The recommendations included a low sodium diet with Boost three times a day (a nutritional supplement), after a swallow evaluation was completed. Additional recommendations included monitoring tolerance, laboratory values and consulting RD as needed.

On August 21, 2012, Patient 301 weighed 158.4 pounds, and had lost 21.6 pounds within a week. There was no documented evidence by nursing, nutrition, or medical staff to indicate Patient 301 had been reweighed to validate that this was not an error.

On September 3, 2012, Patient 301 weighed 144.8 pounds. Patient 301 loss an additional 13.86 pounds for a total of 34 pounds in three weeks. On September 4, 2012, a nutrition consult was ordered by the physician.

Patient 301 was reassessed on September 4, 2012, by another registered dietitian who recommended Patient 301 remain on a mechanical soft, chopped 2 gram sodium diet and to add Boost Plus three times a day. Boost Plus, a nutritional supplement has 100 more calories per can than regular Boost.

A review of the physician progress notes from August 17 through September 17, 2012, did not include documentation of problems with eating, chewing or swallowing. Nutrition notes indicated Patient 301 was eating between 50 to 100% of his meals or "po (oral) good."

On October 30, 2012, the RD recalculated the patient's caloric needs. She again recommended "Boost Plus three times a day to increase weight." No acknowledgement was observed in the record and Patient 301 remained on the less caloric supplement.

In an earlier interview on November 7, 2012, at 10:25 am, the Nurse Manager reviewed Patient 301's record and indicated there was no physician order for Boost Plus. She stated the RDs wrote their recommendations and posted the recommendations on the cover of the Patient's medical record.

In an interview with the Chief of Staff at 11 a.m., on November 07, 2012, he stated the RDs communicated their recommendations to physicians via a Post it note on the cover of the medical record. He stated the current system worked, but could be improved on. There was not an effective system to validate that the physician had seen the recommendation or concurred with the RDs.

In an interview with the Supervising Dietitian on November 7, 2012, at 3:20 p.m., she stated Boost Plus was carried by the hospital and was available with a physician's order.

A review of Patient 301's record indicated three different dietitians used different calculations to determine Patient 301's caloric needs.

The Supervising Dietitian did not provide information on why the three different dietitians used a different calculation when the Patient 301 was experiencing weight loss to determine the patient's caloric needs.

The Supervising Dietitian did not provide the rationale as to why the RDs followed a high risk patient once a week instead of increased frequency when recommendations had been made and indicated it was the hospital's policy to do so.

Patient 301 subsequently experienced a 16 % weight loss in less than a month. Patient 301's weight of 152 pounds on October 26, 2012, was less than his admission weight of 180 pounds.

A review of the hospital's policy, "Assessing & Meeting Patient Care Needs, (Revised Date: 2/6/12)," indicated ,"Follow-up nutrition re-assessments are completed every seven days or less for high risk patients."

The RDs failed to follow up on recommendations that they made or that had been made by their colleagues for this high risk patient. This failure resulted in the continued use of a supplement that provided less calories than had been recommended by the RDs. The RDs used incorrect nutritional calculations to determine his nutritional needs.

The recommendation to change Patient 301's supplement to a higher caloric one was not acknowledged by the physician and, as of November 7, 2012, over two months later, Patient 301 remained on the lower calorie supplement.

Further record review failed to indicate Patient 301's weights were accurate, and that interdisciplinary coordination of the patient's nutritional care needs were addressed according to current standards of practice.

3. Patient 105's record was reviewed on November 5, 2012, at 2 p.m. Patient 105 was a 47 year old male with history of hypertension, asthma, and Human Immunodeficiency Virus (HIV). Patient 105 was admitted to the hospital on October 9, 2012. On October 10, 2012, Patient 105's health status declined and he was transferred to the Intensive Care Unit (ICU). An initial nutritional assessment was completed in the ICU on, October 11, 2012. On October 23, 2012, Patient 105 was transferred to the Progressive Care Unit, after being treated for pneumonia in the ICU.

On November 1, 2012, a Nutrition Re-assessment was completed by the Registered Dietitian. The RD recommended to add a Boost (a nutritional drink that provides extra supplements) drink three times a day. There was no documentation to indicate the recommendation had been reviewed and addressed by the physician.

On November 5, 2012, at 2:10 p.m., an interview was conducted with the Registered Dietitian (RD) 4. RD 4 stated she usually called the physicians to let them know she had made a nutritional recommendation, but did not call Patient 105's physician on November 1, 2012. RD 4 stated the recommendation was not acted on because it was done over the weekend, but that the, "physician should come today" (November 5, 2012), to address the recommendation. The RD stated she flagged the recommendation for the physician.

On November 7, 2012, at 2:45 p.m., a concurrent review of Patient 105's record and interview with Registered Dietitian 4 was conducted. There was no written documentation to indicate the physician had reviewed the RD's recommendation. There were no new orders for the boost supplement. RD 4 stated she had made the recommendation to aide in improving Patient 105's immune system, since he had been in the ICU with pneumonia, and did not want his health to deteriorate. The RD stated she did not know why the physician had not addressed her recommendation, six days later.

On November 7, 2012, at 11:05 a.m., in an interview with the Chief of Medical Staff, he stated the expectation was for physicians to respond to RD recommendations within 24 hours. The physician sees each patient daily. If the recommendation was completed after the physicians made their rounds, they would then address the recommendation the next day.





22384

Based on observation, interview and record review, the facility failed to ensure the recommendations of the Registered Dietitian (RD) were addressed for Patients 200, 202, and 105. These failures could negatively impact patients' nutritional status and overall medical stability.

Findings:

A review of the facility policy, "Assessing & Meeting Patient Care Needs (Revised Date: 2012)," was conducted. The policy indicated, "Patients requiring nutritional care and follow-up beyond the basic care level are seen by the Registered Dietitian within 48 hours after referral. The dietitian will communicate the recommendation to the physician, and documentation will be done in the Medical Record."

1. An interview was conducted with Patient 200 on November 5, 2012, at 10:15 a.m. Patient 200 stated the RD had spoken with her several times, and told her they were trying to control her cholesterol levels (an indicator of potential heart disease).

A review of Patient 200's record was conducted. Patient 200 was admitted to the facility on October 16, 2012, with diagnoses of a left foot diabetic ulcer, kidney disease, morbid obesity and hypoalbuminemia (low blood albumin-a type of protein).

Patient 200's "Adult Initial Nutrition Assessment," dated, October 17, 2012, at 1:43 p.m. was reviewed. The assessment indicated Patient 200 was receiving was a 2,200 Kilocalorie (Kcal) consistent carbohydrate diet.

The RD interventions/recommendations indicated to change the diet to a 1,800 Kcal, renal (kidney), consistent carbohydrate diet, with 65 grams protein with multivitamins. In addition, the recommendation indicated to add one can glytrol (liquid supplement) daily. Recommendations also indicated to add a multivitamin daily along with Vitamin C 500 milligrams (mg) twice a day and Zinc 220 mg daily.

The nutrition diagnosis indicated Patient 200 had an excessively high cholesterol intake related to her current diet order.

On October 24, 2012, at 10:40 a.m., a nutrition re-assessment indicated Patient 200 remained on a 2,200 Kcal, consistent carbohydrate diet. The recommendations suggested to change the patient's diet to a 1,800 Kcal, renal consistent carbohydrate diet with 70 gm protein, and to add an appetite stimulant to increase oral intake as appropriate.

The documentation did not indicate if the RD recommendations documented on October 17 and 24, 2012, were addressed by the physician.

On October 31, 2012, at 2 p.m., a third nutrition re-assessment was conducted. The re-assessment indicated Patient 200 was now receiving a 1,800 Kcal, consistent carbohydrate, cardiac diet. RD recommendations continued to suggest modifying the patients diet to a renal diet with 100 gm of protein and to include nephro (liquid supplement) three times a day if the patient was eating less than 50% of her diet.

Further record review on November 5, 2012, failed to show the RD recommendations to modify Patient 200's diet to a renal diet with 100 gm of protein, and to include nephro were addressed by the physician.

An interview was conducted with RD 4 on November 5, 2012, at 12:10 p.m. RD 4 stated she would expect the physician to address the RD recommendations and indicate if they should or should not be implemented.


2. On November 6, 2012, at 8:30 a.m., an interview with, and an observation of Patient 202 were conducted. The patient was observed walking about in the facility day room. The patient was alert, her speech was clear as she stated she was on a low salt diet.

A review of Patient 202's record was conducted. Patient 202 was admitted to the facility on November 3, 2012, with a diagnosis of mood disorder and a history of high blood pressure. An, "Adult Initial Nutrition Assessment" was completed on November 4, 2012, at 10:30 a.m., by the RD. The assessment indicated the patient was on a lowfat, low salt diet. The medical/nutrition issues indicated obesity, with the nutrition diagnosis as an excessive kilocalorie (Kcal) intake. The interventions and/or recommendations by the RD recommended to change Patient 202's diet to a 1,600 Kcal, lowfat, low salt diet.

The document did not indicate the RD recommendations for Patient 202 were brought to the attention of the patient's physician nor were they addressed and/or implemented by the physician.

An interview was conducted with the Registered Nurse (RN) 20, on November 6, 2012, at 9:45 a.m. RN 20 stated if a dietary recommendation was written, the recommendation must be brought to the attention of the physician and the information communicated with the next nursing shift.

Based on interview and record review, the hospital failed to have an ongoing quality assessment and performance improvement program that addressed and monitored the complexity and scope of Food and Nutrition Services. This resulted in the facility failing to identify issues in safe food handling practices which could result in food borne illness, and clinical nutrition indicators impacting patients' nutritional needs.

Findings:

During the survey from November 5 to November 7, 2012, deficient practices related to safe and sanitary food services operations (A749 and A620) and ensuring patient nutritional needs were met (A628) were identified.

On November 7, 2012, at 12:23 p.m., in an interview with the Director of Food and Nutrition Services and the Quality Assurance (QA) Director, they confirmed the food and nutrition department submitted data to the Performance Improvement committee (PIC) on a quarterly basis.

The DFNS stated the foodservice indicators were based on HACCP (Hazard Analysis Critical Control Point - a systematic preventive approach to food safety), and included areas such as: Temperature of food items upon receipt from vendors, temperature of food items during cold storage, and cool down temperatures. The same indicators had been monitored for approximately a year and reported data showed compliance at or above the established thresholds. The QA Director described the focus area as Quality Control measures and not necessarily Quality Improvement measures.

The identified survey findings included deficient practice in areas such as manual warewashing, sanitation and cleanliness. There was no established QA/QI monitoring for these areas.

A review of the identified clinical nutrition indicators noted a focus on whether nutrition assessments/reassessments and follow-ups were completed in a timely manner. There was no qualitative review of the assessments to see if they accurately reflected patient status and captured nutritional concerns for follow-up purposes.

Two of the five nutritional indicators: Correct transcription of physician diet order on diet list, and timeliness of Patient Tray Delivery were interdisciplinary in nature. However, there was no established monitoring of other interdisciplinary systems such as follow-up on registered dietitian (RD) recommendations by the physician, and the availability of weekly weights in the medical record for RD follow-up.

The lack of monitoring of these concerns would hinder the opportunity for corrective action that may impact the quality of care provided to the patients.

3. Patient 105's record was reviewed on November 5, 2012, at 2 p.m. Patient 105 was a 47 year old male with history of hypertension, asthma, and Human Immunodeficiency Virus (HIV). Patient 105 was admitted to the hospital on October 9, 2012. On October 10, 2012, Patient 105's health status declined and he was transferred to the Intensive Care Unit (ICU). An initial nutritional assessment was completed in the ICU on, October 11, 2012. On October 23, 2012, Patient 105 was transferred to the Progressive Care Unit, after being treated for pneumonia in the ICU.

On November 1, 2012, a Nutrition Re-assessment was completed by the Registered Dietitian. The RD recommended to add a Boost (a nutritional drink that provides extra supplements) drink three times a day. There was no documentation to indicate the recommendation had been reviewed and addressed by the physician.

On November 5, 2012, at 2:10 p.m., an interview was conducted with the Registered Dietitian (RD) 4. RD 4 stated she usually called the physicians to let them know she had made a nutritional recommendation, but did not call Patient 105's physician on November 1, 2012. RD 4 stated the recommendation was not acted on because it was done over the weekend, but that the, "physician should come today" (November 5, 2012), to address the recommendation. The RD stated she flagged the recommendation for the physician.

On November 7, 2012, at 2:45 p.m., a concurrent review of Patient 105's record and interview with Registered Dietitian 4 was conducted. There was no written documentation to indicate the physician had reviewed the RD's recommendation. There were no new orders for the boost supplement. RD 4 stated she had made the recommendation to aide in improving Patient 105's immune system, since he had been in the ICU with pneumonia, and did not want his health to deteriorate. The RD stated she did not know why the physician had not addressed her recommendation, six days later.

On November 7, 2012, at 11:05 a.m., in an interview with the Chief of Medical Staff, he stated the expectation was for physicians to respond to RD recommendations within 24 hours. The physician sees each patient daily. If the recommendation was completed after the physicians made their rounds, they would then address the recommendation the next day.





22384

Based on observation, interview and record review, the facility failed to ensure the recommendations of the Registered Dietitian (RD) were addressed for Patients 200, 202, and 105. These failures could negatively impact patients' nutritional status and overall medical stability.

Findings:

A review of the facility policy, "Assessing & Meeting Patient Care Needs (Revised Date: 2012)," was conducted. The policy indicated, "Patients requiring nutritional care and follow-up beyond the basic care level are seen by the Registered Dietitian within 48 hours after referral. The dietitian will communicate the recommendation to the physician, and documentation will be done in the Medical Record."

1. An interview was conducted with Patient 200 on November 5, 2012, at 10:15 a.m. Patient 200 stated the RD had spoken with her several times, and told her they were trying to control her cholesterol levels (an indicator of potential heart disease).

A review of Patient 200's record was conducted. Patient 200 was admitted to the facility on October 16, 2012, with diagnoses of a left foot diabetic ulcer, kidney disease, morbid obesity and hypoalbuminemia (low blood albumin-a type of protein).

Patient 200's "Adult Initial Nutrition Assessment," dated, October 17, 2012, at 1:43 p.m. was reviewed. The assessment indicated Patient 200 was receiving was a 2,200 Kilocalorie (Kcal) consistent carbohydrate diet.

The RD interventions/recommendations indicated to change the diet to a 1,800 Kcal, renal (kidney), consistent carbohydrate diet, with 65 grams protein with multivitamins. In addition, the recommendation indicated to add one can glytrol (liquid supplement) daily. Recommendations also indicated to add a multivitamin daily along with Vitamin C 500 milligrams (mg) twice a day and Zinc 220 mg daily.

The nutrition diagnosis indicated Patient 200 had an excessively high cholesterol intake related to her current diet order.

On October 24, 2012, at 10:40 a.m., a nutrition re-assessment indicated Patient 200 remained on a 2,200 Kcal, consistent carbohydrate diet. The recommendations suggested to change the patient's diet to a 1,800 Kcal, renal consistent carbohydrate diet with 70 gm protein, and to add an appetite stimulant to increase oral intake as appropriate.

The documentation did not indicate if the RD recommendations documented on October 17 and 24, 2012, were addressed by the physician.

On October 31, 2012, at 2 p.m., a third nutrition re-assessment was conducted. The re-assessment indicated Patient 200 was now receiving a 1,800 Kcal, consistent carbohydrate, cardiac diet. RD recommendations continued to suggest modifying the patients diet to a renal diet with 100 gm of protein and to include nephro (liquid supplement) three times a day if the patient was eating less than 50% of her diet.

Further record review on November 5, 2012, failed to show the RD recommendations to modify Patient 200's diet to a renal diet with 100 gm of protein, and to include nephro were addressed by the physician.

An interview was conducted with RD 4 on November 5, 2012, at 12:10 p.m. RD 4 stated she would expect the physician to address the RD recommendations and indicate if they should or should not be implemented.


2. On November 6, 2012, at 8:30 a.m., an interview with, and an observation of Patient 202 were conducted. The patient was observed walking about in the facility day room. The patient was alert, her speech was clear as she stated she was on a low salt diet.

A review of Patient 202's record was conducted. Patient 202 was admitted to the facility on November 3, 2012, with a diagnosis of mood disorder and a history of high blood pressure. An, "Adult Initial Nutrition Assessment" was completed on November 4, 2012, at 10:30 a.m., by the RD. The assessment indicated the patient was on a lowfat, low salt diet. The medical/nutrition issues indicated obesity, with the nutrition diagnosis as an excessive kilocalorie (Kcal) intake. The interventions and/or recommendations by the RD recommended to change Patient 202's diet to a 1,600 Kcal, lowfat, low salt diet.

The document did not indicate the RD recommendations for Patient 202 were brought to the attention of the patient's physician nor were they addressed and/or implemented by the physician.

An interview was conducted with the Registered Nurse (RN) 20, on November 6, 2012, at 9:45 a.m. RN 20 stated if a dietary recommendation was written, the recommendation must be brought to the attention of the physician and the information communicated with the next nursing shift.