HospitalInspections.org

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Based on document review and interview, the hospital failed to ensure that patients received nutritional risk assessments/screening on admission and failed to ensure that patients needing nutritional consults received a nutritional assessment by a dietician as directed by hospital policy.

Failure to ensure that patients receive nutritional risk assessments and consults by a dietician risks patient harm from improper or inadequate diets.

Findings included:

Failure to ensure that patients received nutritional risk assessments on admission and failure to ensure that patients requiring dietary consults received nutritional assessments by a dietician.

Cross Reference: A0629

Due to the scope and severity of the deficiencies detailed under 42 CFR 482.28, the Condition for Participation for Food and Dietetic Services was NOT MET.

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Based on document review and interview, the hospital failed to ensure admission nutritional screening and risk assessments were completed according to hospital policy for 8 of 13 patients reviewed (Patient #501, #503, #801, #804, #806, #807, #808, and #810) (Item #1) and failed to implement its policy for nutritional assessment by a dietician for 8 of 13 patients reviewed (Patient #501, #502, #503, #801, #804, #806, #807, and #810) (Item #2).

Failure to ensure that patients receive accurate nutritional risk assessments on admission and failure to ensure that patients needing dietary consults receive nutritional assessments risks improper nutrition that could lead to unanticipated patient outcomes.

Findings included:

Item #1 Risk Assessments

1. Document review of the hospitals policy and procedure titled, "Provision of Care: Assessment and Reassessment," policy number PC130, reviewed on 09/18/19, showed that nursing staff will complete a nutritional screening as part of the initial assessment and the nutritional assessment by the dietician and resulting nutritional plan are completed within 72 hours of physician order.

2. On 02/18/20 at 9:45 AM, Surveyor #5 and a Clinical Manager (Staff #501) reviewed the medical record for Patient #501 who was admitted on 02/13/20 post hip replacement with a wound. The record showed that on 02/13/20, staff completed the admission nutritional risk assessment. The documentation on the assessment form showed the patient had no risk factors and a low nutritional risk. The criteria applicable to this patient listed on the form but not marked by staff as an existing problem included presence of a wound and weight loss. The documentation of these problems would have placed the patient at moderate to high nutritional risk and triggered a nutritional consult from the Registered Dietician (RD).

3. At the time of the review, the Clinical Manager (Staff #501) stated that the documentation system was new and that there could be a "glitch" in the system. She stated that the patient should have been assessed as a high nutritional risk.

4. On 02/19/20 at 11:30 AM, Surveyor #5 and a Clinical Manager (Staff #501) reviewed the medical record for Patient #503 who was admitted on 02/12/20 for a Multiple Sclerosis exacerbation with swallowing difficulty. The initial nursing nutritional risk assessment completed on 02/12/20 showed the patient as low nutritional risk. The documentation on the nutritional risk form showed that the patient had a poor appetite which was a criterion listed on the risk assessment form that would place the patient as moderate to high nutritional risk and would trigger a nutritional consult from the Registered Dietician (RD). Surveyor #5 observed that the form was saved in "draft" form.

5. At the time of the finding, Staff #501 verified the patient should have been assessed as a high nutritional risk based on diagnosis and stated that because the form was saved in draft form it might not have been sent to the Dietician and that she would need to investigate.

6. On 02/20/20, Surveyor #8 reviewed the medical record for Patient #801 who was admitted on 02/03/20 with a history of ataxia metastatic cancer to spine, increased fall risk, suprapubic catheter.

Surveyor #8 found no evidence that the patient received a nutrition risk assessment on admission.

7. On 02/20/20, Surveyor #8 reviewed the medical record for Patient #804 who was admitted on 02/07/20 with a history of left below the knee amputation, kidney disease, Diabetes and Hypertension.

Surveyor #8 found no evidence that the patient received a nutrition risk assessment on admission.

8. On 02/20/20, Surveyor #8 reviewed the medical record for Patient #806 who was admitted on 02/12/20 with a history of brain cancer, hypertension, and seizures.

Surveyor #8 found no evidence that the patient received a nutrition risk assessment on admission.

9. On 02/20/20, Surveyor #5 reviewed the medical record for Patient #810 who was admitted 02/07/20 with a history of a stroke with aphasia, impaired swallow, and risk for aspiration.

Surveyor #8 found no evidence that the patient received a nutrition risk assessment on admission.

10. On 02/20/20, Surveyor #8 reviewed the discharged record for Patient #807 who was admitted 02/04/20 to 02/17/20 for a Cerebral Vascular Accident (CVA) with a history of pneumonia, obesity, and diabetes.

Surveyor #8 found no evidence the patient received a nutrition risk assessment on admission.

11. On 02/20/20, Surveyor #8 reviewed of the discharged medical record for Patient #808 who was admitted 12/17/20 to 12/21/19 post-right knee placement with a wound. The patient had a history of hypertension, Parkinson's disease, obesity, peripheral vascular disease, myocardial infarction, and diabetes. Staff completed the Nutrition risk assessment on 12/17/19 and determined the patient was a low risk. The criteria listed on the form applicable to this patient (presence of a wound) would place the patient at moderate to high nutritional risk and would trigger a nutritional consult.

12. On 02/20/20 at 4:15 PM, the Chief Nursing Officer (Staff #801) and the Clinical Educator (Staff #806) confirmed the missing admission nutritional risk assessments for Patient #801, #804, #806, #807, #808, and #810.

Item #2 Dietician Nutritional Assessments/Consults

1. Document review of the hospital's policy and procedure titled, "Nutrition Services: Inpatient Nutrition Screening and Assessment," policy number FDS 6.2, reviewed 09/18/19, showed that:

-If nutritional concerns are identified by nursing, the Registered Dietician (RD), will complete a nutritional assessment within 72 hours of admission.

-The RD will provide a nutritional assessment on all other hospitalized patients within seven days after admission.

-The RD will attend weekly team conferences as needed in order to gain additional patient information that can be incorporated into the nutritional assessment.

-The RD will provide a reassesment within one week of the initial assessment and weekly thereafter.

-The nutritional care plan is modified. Documentation of these modifications is found in the Nutrition Care Plan.

Document review of the hospitals policy and procedure titled, "Provision of Care: Assessment and Reassessment," policy number PC130, reviewed on 09/18/19, showed that nursing staff will complete a nutritional screening as part of the initial assessment, and the nutritional assessment by the dietician and resulting nutritional plan are completed within 72 hours of physician order.

2. On 02/18/20 at 9:45 AM, Surveyor #5 and a Clinical Manager (Staff #501) reviewed the medical record for Patient #501 who was admitted on 02/13/20 post hip replacement with a wound. The record showed that on 02/13/20, a Physician ordered a nutritional consult for a diagnosis of Protein-Calorie Malnutrition and a 20 pound plus weight loss.

At the time of the review, Surveyor #5 found no evidence that the RD completed a nutritional consult (a period of 4 days).

3. At the time of the review, Staff #501 stated that the hospital policy for patients assessed at high nutritional risk is to receive a nutritional consult within 72 hours and provided the Surveyor with a copy of the hospital policy.

4. On 02/18/20 at 11:30 AM, Surveyor #5 and a Clinical Manager (Staff #501) reviewed the medical record for Patient #502, who was admitted on 02/05/19, for poly trauma from crush injury that resulted in multiple fractures and a Moral LavaLee degloving (a closed degloving soft tissue injury, as a result of abrupt separation of skin and subcutaneous tissue from the underlying fascia) of the side chest, peritoneum, and genitals. The review showed that on 02/06/20, a Physician ordered a nutritional consult for a diagnosis of severe Protein-Calorie Malnutrition.

At the time of the review, Surveyor #5 found no evidence that the RD completed a nutritional consult (a period of 12 days).

5. At the time of the review, Staff #501 confirmed the missing nutritional assessment and stated she did not know why and that the Surveyor would need to talk with the Dietician.

6. On 02/19/20 at 11:30 AM, Surveyor #5 and a Clinical Manager (Staff #501) reviewed the medical record for Patient #503 who was admitted on 02/12/20, for a Multiple Sclerosis exacerbation with swallowing difficulty. The initial nursing nutritional risk assessment showed the patient at low nutritional risk, however staff documented on the form that the patient had a poor appetite (which was a criteria listed on the form assessing the patient as moderate to high risk and would trigger a nutritional consult.) On 02/13/20, a Physician ordered a swallowing evaluation. On 02/13/20, the patient received a swallowing evaluation by speech therapy. The patient failed the swallow evaluation and was placed on aspiration precautions.

Surveyor #5 found no evidence the patient's diet was modified and the patient continued on a regular diet with thin liquids. On 02/15/20, the patient experienced a choking episode while eating, and staff performed an abdominal thrust. On 02/18/20 post incident, the patient was evaluated by speech pathologist. No changes to the diet were noted. Surveyor #5 found no evidence the patient received a dietary evaluation.

7. On 02/19/20 at 1:35 PM, during interview with Surveyor #5, the Registered Dietician (RD) (Staff #502) verified the delayed assessments for Patients #501 and #502, and stated that she was behind in the assessments and when she gets behind it "snowballs," but that it was not common for her to be this far behind. She stated she was unaware of the aspiration precautions for Patient #503 and that she had not received a consult for this patient.

8. On 02/20/20, Surveyor #8 reviewed the medical record for Patient #801 who was admitted on 02/03/20 with a history of ataxia metastatic cancer to spine, increased fall risk, suprapubic catheter.

Surveyor #8 found no evidence the RD assessed the patient during the current admission (a period of 17 days).

9. On 02/20/20, Surveyor #8 reviewed the medical record for Patient #804 who was admitted on 02/07/20 with a history of left below the knee amputation, kidney disease, Diabetes and Hypertension.

Surveyor #8 found no evidence the RD assessed the patient during the current admission (a period of 13 days).

10. On 02/20/20, Surveyor #8 reviewed the medical record for Patient #806 who was admitted on 02/12/20 with a history of brain cancer, hypertension, and seizures.

Surveyor #5 found no evidence the RD assessed the patient during the current admission (a period of 8 days).

11. On 02/20/20, Surveyor #8 reviewed the medical record for Patient #810 who was admitted 02/07/20 with a history of a stroke with aphasia (inability to comprehend or formulate language because of damage to specific brain regions), impaired swallow, and risk for aspiration.

Surveyor #8 found no evidence that the RD assessed the patient (a period of 13 days).

12. On 02/20/20, Surveyor #8 reviewed the discharged record for Patient #807 who was admitted 02/04/20 to 02/17/20 for a Cerebral Vascular Accident (CVA) with a history of pneumonia, obesity, and Diabetes.

Surveyor #8 found no evidence the RD assessed the patient during the patient's admission (a period of 13 days).

13. On 02/20/20 at 4:15 PM, the Chief Nursing Officer (Staff #801) and the Clinical Educator (Staff #806) confirmed the missing admission nutritional risk assessments and nutritional assessments by the RD for patients #801, #804, #806, #807, and #810.

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