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Based on interview, clinical record and administrative document review, the hospital failed to ensure nutrition needs of inpatients were met by recognized dietary practices when:

1. One of four patients (Patient 8) reviewed for nutrition services did not have documentation of measurable follow up of moderate nutrition status.

2. One of four patients (Patient 9) was assessed at risk for inadequate fluid intake and poor oral intake. RD made nutrition recommendations, but there was no documentation of a system to review with physician and no implementation of a plan of care.

3. One of four patients (Patient 10) had a recommendation from the RD for a change in fluid restriction but there was no documentation or a system to review with physician and implement the recommendation. Patient 10 had a 4 pound weight loss which was not addressed. Nutrition assessment did not have a measurable follow-up schedule of nutrition status.

This failure had the potential to compromise patients nutritional status and overall recovery.

Findings:

1. According to Patient 8's clinical record, Patient 8 was admitted 8/18/15 with septic (infected) right knee. Patient 8 had an order for a vegetarian diet. Patient 8's albumin level was 1.7 g/dl (normal 3.5 to 5.0 g/dl).

The nutrition assessment dated 8/18/15 indicated Patient 8 was at increased nutrition risk related to low weight: height status with BMI 16.4 (body mass index indicator of nutrition status), poor intake, swallowing difficulty and infection. Nutrition assessment recommendations included a vegetarian diet with 3 small meals and 3 snacks per day, adding high protein, and pureed texture pending swallow evaluation. There was no follow up scheduled to reassess recommendations and nutrition status.

On 8/25/15 at 9:30 a.m., during an interview, the ANM confirmed there was no documentation in the medical record of the physician being notified of RD's recommendations or that Patient 8 was provided with increased protein and small meals with snacks. The ANM confirmed there was no system in place to notify the physician of RD's recommendations.

2. According to Patient 9's clinical record, Patient 9 was admitted 8/19/15 with syncope (short loss of consciousness and muscle weakness). Patient 9 was ordered a Regular diet on 8/25/15. The admission nursing nutrition screen indicated moderate nutrition risk based on nausea, and low albumin level.

The RD's nutrition assessment dated 8/20/15 indicated Patient 9 was at increased nutrition risk related to poor intake, fracture and infection. Fluid intake was inadequate. The assessment indicated fluid requirements were 1600 ml day. Recommendations included Mechanical soft diet with finely chopped meats, small frequent meals, and snacks with nutritional health shakes if meal intake was less than 50 percent. The follow-up on nutrition recommendations were not measurable. The RD indicated he would "remain available" for follow up.

On 8/27/15 at 10 a.m., during an Interview, the Director of Nurses (DON) acknowledged the admission nutrition screening tool used to evaluate patient nutrition status had not been evaluated and validated to ensure patients who were at nutritional risk were identified. The DON acknowledged there was no system in place to notify the physician of RD's recommendation and no system for nursing and RD follow-up of recommendations and hydration (body fluid balance) requirements.

3. According to Patient 10's clinical record, Patient 10 was admitted 8/3/15 with compression fractures. The physician ordered a regular diet with two liter fluid restriction per day. Patient 10's admission weight was 140 pounds and height was 5 feet 5 inches. Patient 10's weight on 8/20/15 was 136 pounds. Patient 10's albumin level on 8/4/15 and 8/25/15 was 2.2 g/dl (normal value 3.5 -5.0 g/dl).

Patient 10's nutrition assessment dated 8/4/15, indicated Patient 10 was at increased nutrition risk related to poor intake, altered electrolytes, and fractures. Patient 10 had compromised visceral (indicator of nutrition status) protein stores related to low albumin level. The recommendations were to consider a 1500 ml fluid restriction, and to offer ensure or other nutritional supplements.

On 8/25/15 at 10:30 a.m., during an interview, the ANM acknowledged she had reviewed the overall plan of nutrition care on 8/24/15. The ANM acknowledged there was no system to ensure the physician was notified of the RD recommendations and implementation of recommendations. There was no ongoing assessment of nutrition status, weight loss, continuing low albumen levels, or assessment of the effectiveness of the nutritional care.