HospitalInspections.org

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Based on document review and interview the hospital failed to ensure that staff appropriately completed an admission nutritional screening/risk assessment according to hospital policy for 1 of 1 patients with nutritional deficiencies reviewed (Patient #502).

Failure to ensure that patients receive appropriate nutritional risk assessments on admission risks improper nutrition that could lead to unanticipated patient outcomes.

Reference:

"Malnutrition Screening Tool (MST)," Abbott Nutrition Laboratories, 2013, abbottnutrition.com. states that for a patient who has lost more that 34 pounds without trying would receive an MST score of 4. An MST score of 4 shows that the patient is at nutritional risk.

Findings included:

1. Document review of the hospitals policy and procedure titled, "Nutritional Risk Referral," no policy number, reviewed 11/21, showed the following:

a. New patients or patients with potential nutritional status change will be referred to the Registered Dietician (RD).

b. A dietary consult is triggered by the Licensed Nurse admitting assessment upon all admits and is automatically sent to dietary.

c. A dietary consult may be requested for any change in nutritional status or needs throughout the patients stay at the facility.

d. The Physician or Allied health Provider (AHP) will be notified by the Licensed Nurse, is nutritional risk is due to acute status change in condition. Some of the risk factors include an unexpected weight gain or loss of 5 pounds in one month.

Document review of the hospitals policy and procedure titled, "Nutritional Risk Referral," no policy number, reviewed 09/20, showed the following:

a. Upon admission for care, a patient will be assessed by the Registered Nurse (RN) to determine nutritional risk.

b. Following the risk assessment, the patient may then be referred to the registered dietitian (RD) for nutritional assessment.

c. Nursing Services will transmit an electronic request for RD consult for nutritional risk.

2. On 07/12/22 at 10:15 AM, Surveyor #5, a Registered Nurse (RN) (Staff #501) and the Social Services Director (Staff #502) reviewed the medical record for Patient #502 who was admitted to "Observation Status" on 07/11/22 for the treatment of chest pain and Hypotension. The medical record review showed the following:

a. The provider History and Physical completed on 07/12/22 at 1:00 AM, showed that the patient had a 35-pound weight loss since 05/22 with persistent diarrhea and occasional nausea and vomiting. The patient was ordered a Heart Healthy Diet.

b. On 07/12/22 at 1:45 AM, an updated MST (Malnutrition Screening Tool) Screen competed by an RN on the "Adult Patient History" form showed the following:

i. Unintentional weight change: No change

ii. Decreased appetite: No

iii. MST (Malnutrition Screening Tool) score: 0 (not at risk)

Surveyor #5 found no evidence a nutritional assessment was ordered.

3. At the time of the review, Surveyor #5 and Staff #503 reviewed the MST online as it was not defined in the hospital's nutrition risk assessment policies. Staff #503 stated that every patient should received a nutritional consult and that the facility had developed an order set that included an automatic nutritional consult. She stated she would need to investigate, but it appeared that the provider had unchecked the box and therefore the consult was not ordered. Staff #503 verified that the nutritional risk assessment (MST) completed by the Licensed Nurse did not reflect the patient actual nutritional risk as the patients 35 weight loss was not reflected in the assessment. Staff #503 verified that a nutritional consult was not ordered.

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