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Based on record review, staff interview and review of the policy and procedure, the facility failed to ensure patients' nutritional intake was received and monitored as ordered for one of ten sampled patients (Patient #9). The active census was 257.

Findings include:

Review of the policy titled Calorie Counts, revised on 4/15, revealed the clinical nutritional staff was to determine the daily nutritional intake of a patient when ordered by the physician based on intake recorded by nursing staff.

Review of the medical record for Patient #9 revealed the patient was admitted on 12/16/16 for replacement of a PEG (percutaneous endoscopic gastrostomy) or J tube (jejunostomy) for nutritional intake. Review of a Surgery Progress Note, dated 12/18/16, revealed the plan was for Patient #9 to have a diet ordered after a swallow evaluation was completed. The plan also included a replacement PEG pending the calorie counts.

Review of the physician's orders revealed on 12/18/16 at 9:47 AM a dental soft diet and calorie count was ordered for Patient #9. A standard high calorie nutritional supplement, two times daily was also ordered on 12/18/16 and increased to three times daily on 12/19/16 at 5:21 PM.

Review of the Nutrition Assessment dated 12/19/16 at 5:15 PM revealed the calorie count was started and was to be assessed daily. Review of the Daily Calorie Count from 12/19/16 revealed Patient #9's nutritional intake was 146 calories and 3 grams of protein for breakfast and 120 calories and 3 grams of protein for lunch. Review of the Daily Calorie Count from 12/20/16 at 10:37 AM revealed no intake data was recorded, but intake was estimated by conversation with the registered nurse and call center order history. The estimated calorie count for 12/20/16 was 381 calories (kcal) and 15 grams of protein for breakfast. The comments revealed half of the kcal were provided by ensure (nutritional supplement). There were no calorie counts or meal intake in the record for the three meals on 12/18/16, the dinner meal on 12/19/16, or for the lunch and dinner meals on 12/20/16 by nursing services.

Patient #9 was transferred to another acute care facility on 12/21/16 for replacement of the feeding tube. The calorie counts were discontinued on 12/21/16.

Interview with Staff B on 01/18/17 at 10:00 AM revealed the calorie count was ordered on 12/18/16 but dietary did not receive the order until 12/19/16. Staff B confirmed there was no way of knowing if the patient received the meal, refused the meal or the meal slip was discarded when there was nothing recorded about the patient's meal intake.

This deficiency substantiates Substantial Allegation OH00088595.

Based on record review, staff interview and review of the policy and procedure, the facility failed to ensure patients' nutritional intake was received and monitored as ordered for one of ten sampled patients (Patient #9). The active census was 257.

Findings include:

Review of the policy titled Calorie Counts, revised on 4/15, revealed the clinical nutritional staff was to determine the daily nutritional intake of a patient when ordered by the physician based on intake recorded by nursing staff.

Review of the medical record for Patient #9 revealed the patient was admitted on 12/16/16 for replacement of a PEG (percutaneous endoscopic gastrostomy) or J tube (jejunostomy) for nutritional intake. Review of a Surgery Progress Note, dated 12/18/16, revealed the plan was for Patient #9 to have a diet ordered after a swallow evaluation was completed. The plan also included a replacement PEG pending the calorie counts.

Review of the physician's orders revealed on 12/18/16 at 9:47 AM a dental soft diet and calorie count was ordered for Patient #9. A standard high calorie nutritional supplement, two times daily was also ordered on 12/18/16 and increased to three times daily on 12/19/16 at 5:21 PM.

Review of the Nutrition Assessment dated 12/19/16 at 5:15 PM revealed the calorie count was started and was to be assessed daily. Review of the Daily Calorie Count from 12/19/16 revealed Patient #9's nutritional intake was 146 calories and 3 grams of protein for breakfast and 120 calories and 3 grams of protein for lunch. Review of the Daily Calorie Count from 12/20/16 at 10:37 AM revealed no intake data was recorded, but intake was estimated by conversation with the registered nurse and call center order history. The estimated calorie count for 12/20/16 was 381 calories (kcal) and 15 grams of protein for breakfast. The comments revealed half of the kcal were provided by ensure (nutritional supplement). There were no calorie counts or meal intake in the record for the three meals on 12/18/16, the dinner meal on 12/19/16, or for the lunch and dinner meals on 12/20/16 by dietary services.

Patient #9 was transferred to another acute care facility on 12/21/16 for replacement of the feeding tube. The calorie counts were discontinued on 12/21/16.

Interview with the nurse manager of the unit on 01/18/17 at 9:30 AM revealed the SP was in isolation. The dietary hostess would take meals trays into patient rooms, except for patients in isolation. If a patient was in isolation, the dietary hostess was to notify the nurse the tray was outside the room. The nurse manager confirmed the SP was unable to order his/her own tray. The dietary hostess was to notify the nurse when a patient did not have a tray.

Interview with Staff B on 01/18/17 at 10:00 AM revealed the calorie count was ordered on 12/18/16 but dietary did not receive the order until 12/19/16. Staff B confirmed there was no way of knowing if the patient received the meal, refused the meal or the meal slip was discarded when there was nothing recorded about the patient's meal intake.

This deficiency substantiates Substantial Allegation OH00088595.