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Based on documentation review, it was determined Hospital Medical Staff failed to order a diet or nutritional supplementation to meet the nutritional needs of Patient #1 during the time period of 1/1 - 1/7/10.

Findings included:

Medical record documentation indicated Patient #1 was admitted to the hospital on 12/15/09 following a 3-day acute care hospitalization for left hip cellulitis, upper and lower extremity swelling, and inability to ambulate, and her medical history is significant for: ileostomy secondary to Crohn's disease; morbid obesity (BMI = 80) with pulmonary hypertension, congestive heart failure, diabetes mellitus, osteoarthritis, and obstructive sleep apnea requiring the use of BiPAP; asthma; depression and; anxiety with panic attacks.

Admission Physician Orders included orders for: physical and occupational therapy consultations and treatment; activity per the recommendations of the physical and occupational therapists; a 1200 calorie high complex carbohydrate, low fat, low cholesterol, 2 gram sodium diet; a dietitian consultation and; the Patient's usual medications including Megace, ferrous sulfate and vitamins C and D.

The Registered Dietitian assessed Patient #1 on 12/17/09 and indicated she was at 365% of her ideal body weight and had a poor nutritional status secondary to her morbid obesity. The 1200 calorie high complex carbohydrate, low fat, low cholesterol, 2 gram sodium diet was continued.

Patient #1's ileostomy drainage appliance began leaking on 12/16 and despite multiple interventions, the leaking continued, and by 12/18/09; her peristomal area including her right groin and the underside of her pannus was noted to be reddened and excoriated. Over the next several days, multiple ileostomy drainage appliances and skin care products were utilized in attempt to manage the Patient's ileostomy drainage and contact irritant dermatitis, but they were ineffective and her peristomal area remained red and excoriated. The challenging drainage appliance issues and continued/worsening dermatitis were continually followed and evaluated by her Attending Physician and the ET Nurse and multiple potential interventions including a bowel rest with the implementation of TPN were discussed. Patient #1 was adamantly opposed to TPN.

On the evening of 12/31/09, the Attending Physician ordered a clear liquid diet for Patient #1 in attempt to decrease her ileostomy output for implementation of wall-suction drainage. The Order did not include orders for additional dietary supplements, TPN/PPN or a dietitian consultation.

Patient #1 was started on the clear liquid diet.

On the evening of 1/5/10, the ET Nurse ordered a dietitian consultation for Patient #1 for supplementation while on the clear liquid diet.

The Dietitian evaluated Patient #1 on 1/6/10; noted she was on a clear liquid diet to decrease her ileostomy output, had excoriated tissue around the ileostomy that required adequate nutrition to heal, and that the clear liquid diet did not provide adequate calories, protein, minerals and/or vitamins and; recommended TPN.

On the morning of 1/7, the Attending Physician ordered a 1200 calorie, high complex carbohydrate, low fat, low cholesterol, no added salt diet for Patient #1 to begin on 1/8/10.

Patient #1 was on a clear liquid diet that did not provide adequate calories, protein, minerals and/or vitamins for 7+ days.

Based on documentation review, it was determined Hospital Nursing Staff failed to identify and/or communicate that the nutritional needs of Patient #1 were not being met in accordance with recognized dietary practices during the time period of 1/1 - 1/7/10.

Findings included:

Please see Tag A 347 for information regarding Patient #1, her medical condition(s) and her 12/31/09 - 1/8/10 diet orders.

Nursing Staff did not identify and/or communicate that Patient #1 was on a clear liquid diet that did not provide adequate calories, protein, minerals and/or vitamins for 7+ days.

Based on interview and documentation review, it was determined the nutritional aspects of Patient #1's care were not thoroughly supervised by the Dietitian.

Findings included:

Please see Tag A 347 for information regarding Patient #1, her medical condition(s), her 12/17/09 Nutrition Assessment, her 12/31/09 - 1/8/10 diet orders, and her 1/6/10 Nutrition Assessment.

The Dietitian said she works 5 days/week. She also said she was not aware of Patient #1's 12/31/09 clear liquid diet order until 1/6/10.

Assessments completed on Patient #1 by the Dietitian on 1/7 and 1/20/10 noted the Patient was on Megace (an antineoplastic medication that alters hormone balance and increases appetite [indication for Patient #1 = unknown) and indicated possible discontinuation would be discussed with her Attending Physician. The Dietitian said she had not yet discussed the possible discontinuation of the Megace with the Attending Physician.

Based on interview and documentation review, it was determined the nutritional needs of Patient #1 were not met in accordance with recognized dietary practices during the time period of 1/1 - 1/7/10.

Findings included:

Please see Tag A 347 for information regarding Patient #1, her medical condition(s), her 12/17/09 Nutrition Assessment, her 12/31/09 - 1/8/10 diet orders, and her 1/6/10 Nutrition Assessment.

The Dietitian said she was not aware of Patient #1's clear liquid diet order until 1/6/10. She also said clear liquid diets are generally only ordered for Hospital patients: short-term prior; to diagnostic testing.

The Dietitian evaluated Patient #1 on 1/6/10, noted she was on a clear liquid diet to decrease her ileostomy output, had excoriated tissue around the ileostomy that required adequate nutrition to heal, and that the diet did not provide adequate calories, protein, minerals and/or vitamins and; recommended TPN.

On the morning of 1/7, the Attending Physician ordered a 1200 calorie, high complex carbohydrate, low fat, low cholesterol, no added salt diet for Patient #1 to begin on 1/8/10.

The Dietitian discussed TPN and wound healing with Patient #1 on 1/7/10, the Patient was adamantly opposed to having TPN, and the Dietitian recommended a low residue diet with 3 cans of Ensure Plus/day, a daily multivitamin with minerals, and daily vitamin C and zinc supplements.

On the afternoon of 1/8/10, the Attending Physician ordered a low residue diet with 4 ounces of Ensure Plus 3 times/day; between meals for Patient #1. He also ordered a daily multivitamin with minerals and daily vitamin C and zinc supplements. (The Patient was already on a vitamin C supplement [since admission]).

Patient #1 was on a clear liquid diet that did not provide adequate calories, protein, minerals and/or vitamins for 7+ days.