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THIS DEFICIENT PRACTICE REMAINS UNCORRECTED. FOR ADDITIONAL EXAMPLES PLEASE REFER TO THE STATEMENT OF DEFICIENCIES (SOD) DATED 11/06/09.

Based on interview and record review the facility Consultant Dietitians failed to meet special nutritional needs of patients with diet related medical problems by failing to provide comprehensive nutrition assessment, intervention and diet education to three (Patient #10, #48, #33) of three patient's medical records reviewed for provision of nutritional care. The facility census was 45 patients.

Findings included:

1. Record review of the facility policy and procedure titled Consultant Dietitian; Role and Responsibility, dated 07/28/09 directed, in part, the following:
-The Consultant Dietitian provides nutritional care and education to patients and/or families, and is a decision making member of the Health Care Team. The Consultant Dietitian reports to the CEO {Chief Executive Officer}, and works under contract for services provided.
-The Consultant Dietitian Responsibilities included maintains effective, documented communication with the medical staff, nursing staff and administration of the hospital concerning the nutritional care of patients; and provides assessment, development, implementation and evaluation of nutritional care.

Record review of the facility policy and procedure titled Scope of Services and Objectives, dated 07/28/09 directed in part, the following:
-Objectives of the Dietary department include to evaluate and assess inpatients to assure the diet ordered meets the nutritional needs and to develop a plan for providing appropriate nutritional care.
-Objectives of the Dietary department also include to review modified diet orders with all inpatients on modified diets, so that they understand the diet guidelines, and are educated to make appropriate food selections in the cafeteria.

Record review of the facility policy and procedure titled Standards of Nutritional Care, Documentation if Nutritional Care in the Medical Record, Food/Drug Interactions/Nutrition Consults, dated 07/29/09 directed, in part, the following;
-Each patient's nutritional status is determined and adequate nutrition will be provided.
-Within twenty-four hours of admission each patient will receive a nutritional screening by the Nursing Department. If the initial screening indicates the need for Dietitian consult or if need for consult is identified at any other time of hospitalization, nursing will notify the dietitian.
-The dietitian will meet with the patient within seventy-two hours of consult to assess nutritional status.
-Assessment will include but not limited to information including weight and height upon admission and monitor weekly thereafter, need for monitoring food and fluid intake, presence of factors that affect appetite or ability to eat, nutritional goals.
-Document identified nutritional problems, appropriate goals, and interventions in the Multidisciplinary Care Plan. Review and revise on a weekly basis.
-Document ongoing assessment of the patient's nutritional status and response to medical and nursing interventions in the progress notes and care plan a minimum of once weekly.

2. Record review of current Patient #10's face sheet revealed staff admitted the patient on 01/05/10 with depression and post traumatic stress disorder.

Record review of the patient's Nursing Assessment dated 01/05/10 revealed nursing staff assessed the patient with spastic colon and IBS (irritable bowel syndrome) {IBS, a gastrointestinal disorder in which food and gas moving through the colon causes pain, intestinal spasms and irregular bowel patterns. The symptoms of abdominal pain, diarrhea and/or constipation, bloating, gas and cramping vary with each person. IBS is also called irritable colon, spastic colon and mucous colitis.}

Further review of the patient's Nursing Assessment, Nursing Nutritional Screening Form dated 01/05/10 revealed nursing staff assessed the following:
-The patient had a history of eating disorder.
-The history of eating disorder triggered a nutrition consult.
-The problem was added to the MTP (Master Treatment Plan).
-Left a telephone message for the Consultant Dietitian to provide nutrition assessment for the patient.

Further review of the patient's Nursing Assessment, Comprehensive Assessment Tool, Pain dated 01/05/10 revealed staff assessed the following:
-The patient had chronic stomach pain.
-The patient described the pain as dull, shooting, intermittent pain.
-The patient reports pain occurrence depends on foods eaten or if not had a BM (bowel movement).
-The pain was relieved by proper diet and exercise.
-The cause or increase in pain was related to food.
-The pain caused decreased appetite.
-The staff recorded under comments section, "has IBS".

Record review of the patient's Master Treatment Plan (MTP) dated 01/05/10 revealed staff identified a problem with IBS with symptoms of constipation and abdominal cramping, set a goal of patient to report increased symptoms and established interventions including dietary consult to increase the patient's understanding of the condition and nursing to provide a stool softener twice a day.

Record review of the patient's Nutritional Assessment /Consultation dated 01/07/10 revealed the dietitian assessed the following:
-Identified a nutritional risk factor of IBS.
-Identified the patient was on a stool softener.
-Inaccurately recorded the patient did not have diarrhea or constipation.
-Noted the patient denied nutritional issues and problems (even though the nurse admission assessment described problems with food and pain).
-Noted the patient had not had any eating disorders behaviors since high school.
-Noted the patient would be followed at a distance for eating disorders
-Failed to make any recommendations.
-Failed to make any attempts at diet education for problems with IBS and constipation.

Record review of the patient's Nursing Progress notes revealed the following:
-On 01/15/10 the Dietitian assessed the patient had a weight gain of three pounds since admission, there were no nutritional concerns and would monitor at a distance regarding eating disorder behaviors (Eating disorders was not recorded on the MTP as a problem).
-On 01/17/10 Nursing staff assessed the patient was drinking fluids, Magnesium Citrate and had a stool softener without a bowel movement.
-On 01/18/10 patient had loose stools after the Magnesium Citrate, laxative and stool softener.

During an interview on 1/20/10 at 10:05 A.M. the Consultant Dietitian, Staff C said that irritable bowel syndrome (IBS, a gastrointestinal disorder in which food and gas moving through the colon causes pain, intestinal spasms and irregular bowel patterns) is not something he/she instructs patients on. Staff C said he/she does not participate in the care planning process for patients. Staff C said he/she is only in the facility three days a week and doesn't have time to review the entire medical record for nutritional issues. Staff C said that he/she depends on the log the nursing staff keeps at the nursing station and assesses the patients based on what the nursing staff document on the log.

During an interview on 01/20/10 at 12:30 P.M. the Consultant Dietitian, Staff C stated the following:
-The dietitians assisted in establishing the nutritional screening criteria used by nurses to refer patients to the dietitian.
-She responds to voice mail consultations from the nursing staff based on the nutritional screening performed on admission
-She also responds to written messages for consult on the clip board at the nurses' station.
-She does not have time to review medical records of new admissions for possible nutrition problems.
-She stated if the nutrition screening did not indicate a "yes" with an "*" next to the yes on the form then, the dietitians would not provide nutrition assessment for that patient.
-The referral for Patient #10 was due to past history of eating disorders.
-If a patient has IBS and no other nutritional issues then, she felt the patient did not need to be routinely referred to the dietitian.
-She recorded Patient #10 was administered a stool softener and did have IBS however did not feel those factors required nutritional interventions or diet education.
-She did not review the rest of the Nursing Assessment regarding the patient's reports of pain associated with food/diet.
-She did not read any of the MTPs of the patients.
-She was only in the facility three days a week.
-She did not know what was on the MTP for Patient #10.
-She did not see the need to provide diet education to patients on any special diet.
-She did not receive notification of the MTP note for dietary consult to increase the patient's understanding of IBS.

Record review of the Nursing Nutrition Screening form revealed positive responses to five of thirteen screening criteria would trigger a nutrition consult to the dietitians.

3. Record review of current Patient #48's admission history and physical revealed staff admitted the patient on 01/17/10 with chief complaint of suicidal ideation and acute mania.

Further review of the patient's admission history and physical revealed the physician assessed the patient had nightmares and felt those could be either due to psychiatric disorder or low blood sugars. The physician further assessed diagnoses including insulin dependent diabetes, high blood pressure and high blood cholesterol.

Record review of the patient's Nursing Assessment, Nursing Nutritional Screening form
Revealed nursing staff assessed the patient was on a diabetic diet and medication for diabetes however these factors did not trigger a referral to the dietitian for diet counseling or diet interventions.

4. Record review of closed Patient #33 revealed staff admitted the patient on 12/26/09 for suicidal ideations and diagnoses including bipolar mood disorders, personality disorder, Crohn's disease (body's own immune system attacks the gastrointestinal tract, causing inflammation), insulin dependent diabetes and obesity.

Record review of the patient's Nursing Nutritional Screening Form dated 12/26/09 revealed a positive response to diabetes/special diet, current medications for diabetes and medical condition that affects the way you eat however these factors did not trigger a referral to the dietitian for diet counseling or diet instruction.















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