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Based on medical record review, quality and nutrition management staff interview, and hospital document review, the facility failed to ensure accurate assessment for two of four patients (Patient 6 and Patient 1) reviewed for nutrition care, as evidenced by inaccurate admission and ongoing nursing assessment of nutritional status. Failure to accurately identify Patient 6 and 1's nutritional risk, resulted in lack of nutrition assessment and/or interventions that met patient nutritional needs. Failure to provide comprehensive nutrition care may result in further compromising patient medical status.

Findings:

1) Patient 6 was admitted with diagnoses including diabetes and cardiomyopathy (weakness of the heart muscle, National Heart, Lung and Blood Institute, January 2011). A nursing admission nutrition risk screening, dated 5/16/14, noted that Patient 6 had shortness of breath, complained of nausea for the previous four days and poor dietary intake for greater than two weeks. The results of the screening scored Patient 6 at a nutrition risk of three which, per hospital policy, was classified as adequate nutritional status. It was also noted that the nursing admission assessment failed to identify Patient 6 as having a surgical wound, which was classified as a minor disease problem, with an associated nutrition risk score of one. There was also no identification of diabetes and heart failure, which were classified by the admission assessment as a chronic disease problem. Accurate identification of Patient 6's admission history would have increased his nutritional risk score to seven which, per hospital policy, was classified as at risk for potential malnutrition.

The admission diet order, dated 5/16/14, was a cardiac diet. Review of dietary intake revealed that, with the exception of the breakfast meal on 5/17/14, Patient 6's nutritional intake ranged from 0-40%, with an average intake of less than 20% per day. Review of the daily nursing assessment from 5/17-5/19/14, failed to note the poor dietary intake. It was also noted that while on 5/17/14, the physician ordered protein shakes with meals, there was no indication that there was a referral to the Registered Dietitian for a nutritional assessment. Review of Patient 6's care plan, dated 5/16/14, failed to identify and/or develop interventions for the poor dietary intake or evaluate the acceptance of the physician-ordered protein shakes.

In an interview on 5/20/14 beginning at 11:30 a.m., with the Quality Staff 2, she acknowledged that Patient 6 would have benefited from a nutrition assessment. In an interview on 5/20/14 beginning at 1:30 p.m., with the Director of Nutrition Services, she stated that the nutrition risk screening tool was developed at the corporate level of the hospital and was intended to be used in multiple campuses. She also stated that the dietitians' had expressed concerns of the screening tool's ability to fully identify patients who were at moderate nutrition risk and the ability to capture those at moderate risk to ensure comprehensive nutritional care. She also stated that since the electronic medical record was a system-wide function, any alterations to the screening tool would need to be a consensus of all hospitals within the system.


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2. On 5/21/14 at 10:45 a.m., Patient 1's clinical record was reviewed. Patient 1 had been admitted to the facility on 5/12/14. The 69-year-old patient was admitted with diagnoses to include bilateral cerebrovascular accident (CVA), adenocarcinoma of the lung with adrenal gland metastasis, weight loss, poor appetite, and she was dependent on total assistance with feeding. Her initial food intake documentation was 0 to 20%. Although Patient 1 was at risk for malnutrition, the initial nutritional assessment was not done until 5/16/13, four days after her admission date.

On 5/21/14 at 3:20 p.m., the Nutritional Manager acknowledged that the nutritional assessment could have been completed sooner.

Hospital policy title, "Care Plan: Documentation Guidelines," dated 5/11, noted that, "RN's are responsible for developing, reviewing and updating the care plans of those Patients assigned to their care." Hospital policy title, "Assessment of Patients," dated 5/11, indicated, "The RN is responsible for initial assessment and ongoing reassessments of the patient."

Based on medical record review, quality and nutrition management staff interview, and hospital document review, the facility failed to ensure accurate assessment for two of four patients (Patient 6 and Patient 1) reviewed for nutrition care, as evidenced by inaccurate admission and ongoing nursing assessment of nutritional status. Failure to accurately identify Patient 6 and 1's nutritional risk, resulted in lack of nutrition assessment and/or interventions that met patient nutritional needs. Failure to provide comprehensive nutrition care may result in further compromising patient medical status.

Findings:

1) Patient 6 was admitted with diagnoses including diabetes and cardiomyopathy (weakness of the heart muscle, National Heart, Lung and Blood Institute, January 2011). A nursing admission nutrition risk screening, dated 5/16/14, noted that Patient 6 had shortness of breath, complained of nausea for the previous four days and poor dietary intake for greater than two weeks. The results of the screening scored Patient 6 at a nutrition risk of three which, per hospital policy, was classified as adequate nutritional status. It was also noted that the nursing admission assessment failed to identify Patient 6 as having a surgical wound, which was classified as a minor disease problem, with an associated nutrition risk score of one. There was also no identification of diabetes and heart failure, which were classified by the admission assessment as a chronic disease problem. Accurate identification of Patient 6's admission history would have increased his nutritional risk score to seven which, per hospital policy, was classified as at risk for potential malnutrition.

The admission diet order, dated 5/16/14, was a cardiac diet. Review of dietary intake revealed that, with the exception of the breakfast meal on 5/17/14, Patient 6's nutritional intake ranged from 0-40%, with an average intake of less than 20% per day. Review of the daily nursing assessment from 5/17-5/19/14, failed to note the poor dietary intake. It was also noted that while on 5/17/14, the physician ordered protein shakes with meals, there was no indication that there was a referral to the Registered Dietitian for a nutritional assessment. Review of Patient 6's care plan, dated 5/16/14, failed to identify and/or develop interventions for the poor dietary intake or evaluate the acceptance of the physician-ordered protein shakes.

In an interview on 5/20/14 beginning at 11:30 a.m., with the Quality Staff 2, she acknowledged that Patient 6 would have benefited from a nutrition assessment. In an interview on 5/20/14 beginning at 1:30 p.m., with the Director of Nutrition Services, she stated that the nutrition risk screening tool was developed at the corporate level of the hospital and was intended to be used in multiple campuses. She also stated that the dietitians' had expressed concerns of the screening tool's ability to fully identify patients who were at moderate nutrition risk and the ability to capture those at moderate risk to ensure comprehensive nutritional care. She also stated that since the electronic medical record was a system-wide function, any alterations to the screening tool would need to be a consensus of all hospitals within the system.


21156

2. On 5/21/14 at 10:45 a.m., Patient 1's clinical record was reviewed. Patient 1 had been admitted to the facility on 5/12/14. The 69-year-old patient was admitted with diagnoses to include bilateral cerebrovascular accident (CVA), adenocarcinoma of the lung with adrenal gland metastasis, weight loss, poor appetite, and she was dependent on total assistance with feeding. Her initial food intake documentation was 0 to 20%. Although Patient 1 was at risk for malnutrition, the initial nutritional assessment was not done until 5/16/13, four days after her admission date.

On 5/21/14 at 3:20 p.m., the Nutritional Manager acknowledged that the nutritional assessment could have been completed sooner.

Hospital policy title, "Care Plan: Documentation Guidelines," dated 5/11, noted that, "RN's are responsible for developing, reviewing and updating the care plans of those Patients assigned to their care." Hospital policy title, "Assessment of Patients," dated 5/11, indicated, "The RN is responsible for initial assessment and ongoing reassessments of the patient."