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Record reviews, staff interviews and review of Quality Assurance pertaining to nutritional services, revealed the Critical Access Hospital (CAH) failed to provide nutritional assessments or evaluations of the degree to which the needs of patients requiring specific nutritional interventions are met for 3 of 3 acute care patients (Patients 1, 2 and 4), as directed in the Quality Assurance Unit policies for nutritional assessments. The CAH is licensed for 25 beds. Findings are:

A. Review of the Quality Assurance policies, revision date of 11/09/09, pertaining to dietary services and assessments on 3/3/10 at 11:00 AM reads: The Dietary Department at Cherry County Hospital provides for the nutritional needs of all patients cared for in the institution. Personnel in the Department, as directed by the Quality Assurance program, will evaluate the food service program provided by Cherry County Hospital with the express purpose of assuring that each patient receives the highest quality of nutritional care possible within the confines of available resources. Incorporated in this task will be the monitoring of meals served with regard to menu compliance with nutritional and caloric requirements, sensitivities and preferences, monitoring inpatient and outpatient diet instruction, assuring compliance with infection control and safety requirements and evaluating the degree to which the needs of patients requiring specific nutritional intervention are met. Accountability: The consulting Dietitian and Dietary Manager (DM) are mutually responsible for quality, safety, and appropriateness of service within the Dietary Department. However, all employees within the Department will be documented and reported to the DM, to the Quality Assurance Committee per protocol described in the Hospital Quality Assurance Plan:
1. As soon as practical after admission, the DM or cook on duty will obtain a list of food preferences.
2. A general diet history will be initiated as soon after admission as reasonable on all acute patients. (Patient condition may not lend itself to completion or may not serve any real purpose at the time).
3. A nutrition assessment will be initiated on special needs patients (i.e. recent weight loss of 10% or more (unplanned), cancer, failure to comply with therapeutic diet, GI (Gastrointestinal) disorders, cardiovascular disease, decubiti, malnutrition etc.)
4. The diet will be individualized to meet the nutritionally compromised patients.
5. Patients who are NPO (nothing by mouth) or on unsupplemented clear liquid diets for more that 72 hours will receive some type nutritional support or have documentation in the medical records addressing this.

B. Interview with the DM on 3/3/10 at 2:00 PM revealed the CAH contracts the services of a Registered Dietitian (RD) who is in the hospital once a month for 3-5 hours, but can be called if necessary. The DM acknowledged the RD is supposed to also provide the dietary staff with inservices, but does not do it. Review of the RD dietary consultant agreement dated, 1/13/06 reads:
1. Services of the Dietitian: The Dietitian is duly registered and licensed to practice in the state of Nebraska and agrees to serve as the Dietary Consultant for Cherry County Hospital of Valentine, Nebraska. The Dietitian agrees to provide monthly consultation services at the hospital to the Administrator, DM, Director of Nursing (DON) and other medical staff at a mutually acceptable time. Additionally, the Dietitian shall assist and offer consultation services in the day to day organization and operation of the Dietary Department. Beyond monthly visits to the facility the Dietitian will be available for telephone consultations at reasonable hours.

C. Record review for Patient 1 on 3/3/10 at 11:30 AM revealed Patient 1 presented to the Emergency Department (ED) per ambulance on 2/26/10 with vomiting, cirrhosis, alcohol intoxication and thrombocytopenia. ED history indicates Patient 1 to have a past history of alcohol problems, cirrhosis, low platelets, anemia and has presented to the ED on several occasions with the same medical issues. Patient 1 was admitted to an outpatient observation status on 2/27/10 at 0345 (3:45 AM). Physician orders indicate clear liquid diet tonight and regular diet in AM, may dismiss when sober. At 0630 (6:30 AM) on 2/27/10 a CBC was ordered for "this afternoon," resulting in a RBC of 3.3 indicating Patient 1 to be in an anemic state. On 2/27/10 at 0900 Patient 1 is admitted to an acute inpatient status. At 1320 (1:20 PM) physician order changed Patient 1 diet to "diet as tolerated." On 2/27/10 at 2130 (9:30 PM) 2 units of PRBC were ordered and administered due to low RBCs. Review of the physician progress notes indicated Patient 1 was consistently monitored for "vomiting of blood and diagnosed with GI bleed (Gastrointestinal bleed). Estimated count of loose stools from 2/28/10 through 3/1/10 are 23. Further review of Patient 1's medical record noted a lack of documentation from the DM or the RD acknowledging intervention with the care or dietary assessments for Patient 1. Interview with the DM on 3/3/10 at 2:00 PM stated, "I did not get to see this one."

D. Record review for Patient 2 on 3/3/10 at 12:15 PM revealed Patient 2 was admitted to an acute care status and dismissed on 2/17/10. Review of the Physician History and Physical revealed Patient 2 had under gone a significant work up and during chemotherapy treatment a PEG tube was recommended. Discussion with Patient 2's oncologist regarding the possibilities of a jejunal tube or TPN (Taber's Cyclopedic Medical Dictionary, Edition 16, Page 1881, describes TPN as: Provisions of the total caloric needs by intravenous route for a patient who is unable to take food orally.) The final decision was to close the gastrostomy and see how Patient 2 did on oral intake, and if necessary, TPN could be used. The physical exam acknowledged Patient 2 has lost approximately 10 pounds since last seen, partially due to appetite loss and also problems with surgery, both with teeth and tonsils which have caused Patient 2 to have lost appetite and food intake to be poor. Oropharynx shows Patient 2's to be edentulous. During hospital stay Patient 2 required 2 units of PRBCs. Review of the TPN Compound Worksheet, dated 2/17/10 and submitted by the Registered Pharmacist (RP) indicated the total daily electrolytes, nutrients per day, TPN evaluation, estimated nutritional deficit, estimated nutritional requirements, current parenteral nutritional prescription, and summary. Interview with the DM revealed the RP "did this to start the TPN."

Record review of the nutritional progress notes dated 2/18/10 and submitted by the DM reads: "visited with pt briefly about likes and dislikes. Patient 2 denies any food dislikes, prefers milk and coffee to drink. NKFA [no known food allergies]. At this time pt is having TPN. RD was contacted to analyze the TPN." Interview with the DM on 3/3/10 at 2:00 PM acknowledged, "I did call the RD and was told "I could do it myself." The medical record lacks documentation from the RD or DM pertaining to a nutritional followup assessment or evaluation of Patient 2's identified nutritional issues.

E. Record review of Patient 4 on 3/3/10 at 1:45 PM revealed Patient 4 had been receiving Physical Therapy (PT) services on an outpatient basis for an ulcer to the right heel. The ulcer was quite deep and required debridement by PT. Review of the discharge summary reads: "PT felt that Patient 4 required antibiotic therapy and was admitted to an acute care status on 2/15/10 and discharged on 2/19/10. Patient 4 was placed on a wound vac to the right heel and IV antibiotics were ordered. Cultures showed enterococcus sensitive to penicillin products. Review of systems revealed Patient 4 also had issues with fatigue, weakness and recent weight loss, and diabetes mellitus. The patient is to start on a regular diet and activity as tolerated." Review of the physician orders from 2/15/10 through 2/19/10 do not indicate what diet or supplement Patient 4 is to receive. Weight on graphic flow sheet on 2/15/10 was 157.01, no further weights were documented. Meal consumption ranges from bites, 1/3, 1/4, and 1/2, with no meal consumption documentation on 2/17/10. Review of the Nutritional Progress Notes dated 2/17/10 reads: "Pt resting in bed after lunch. Voices that doesn't really have any foods doesn't like, but says doesn't like beef or pork much. Verbalizes that [gender] loves tomato soup and oyster stew. Unable to determine much from pt about likes and dislikes. Voices that [gender] has no food intolerances and NKFA (no known food allergies). Prefers milk to drink with meals. Contact dietary manager at (former residence) she voiced that Patient 4 really doesn't have anything [gender] won't eat but often requests tomato soup or oyster stew. Pt has been losing wt (weight) since admitted to nursing home despite fortified food and between meal snacks. We will continue with fortified foods and provide Ensure shakes TID (3 times a day). Encourage dietary intake, offer foods pt likes on a regular basis." The nutritional assessment fails to identify what foods are to be fortified with or how often. Patient weight loss along with additional protein needs to assist with wound healing is not calculated into the daily caloric needs. And the nutritional progress notes lack documentation or assessment of the nutritional progress of the patient. Interview with the DM acknowledged "I did not see the patient again after the assessment on 2/17/10."