Desert Valley Hospital-Malnutrition

8/4/2019 Desert Valley Hospital-Malnutrition

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(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

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California Department of Public Health

CA240001330 04/29/2011

C

VICTORVILLE, CA 92395

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

DESERT VALLEY HOSPITAL16850 BEAR VALLEY RD

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

E 000 Initial Comments E 000

The following reflects the findings of the California

Department of Public Health during the

investigation of a complaint.

Complaint Number: CA00265152.

Representing the California Department of Public

Health:

26674

28135

The inspection was limited to the specific

complaint incident investigated and does not

represent the findings of a full inspection of the

facility.

2 deficiencies were issued for the complaint

incident number CA00200660.

E 547 T22 DIV5 CH1 ART3-70273(i)(2) Dietetic Service

General Requirements

(2) Observations and information pertinent to

dietetic treatment shall be recorded in patient's

medical records by the dietitian.

This Statute is not met as evidenced by:

E 547

Based on record reviews and staff interviews, the

hospital failed to ensure that the nutrition needs

of the patients that the hospital identified as

having a diagnosis of malnutrition and/or protein

deficiency , in 14 of 14 records reviewed:

1. In 7 of 14 records reviewed with a diagnosis of

malnutrition and/or protein deficiency, there was

no dietitian assessment.

censing and Certification Division

ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE (X6) DATE

If continuation sheet 16899TATE FORM LY6111


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E 547Continued From page 1E 547

2. In 14 of 14 records reviewed with a diagnosis

of malnutrition and/or protein deficiency, the

energy needs of the patient were either not

evaluated or underestimated according to the

hospital's policy and procedures

3. In 9 of 14 records reviewed with a diagnosis of

malnutrition and/or protein deficiency, the nutrition

risk level was determined to be low or moderate,

not consistent with the hospital's policy4. In 10 of 14 records reviewed with a diagnosis

of malnutrition and/or protein deficiency, the initial

nutrition assessment and/or follow-up

assessments were not completed in a timely

manner according to the hospital's policy.

5. In 14 of 14 records reviewed with a diagnosis

of malnutrition and/or protein deficiency, there

were no recent intake or weight histories

evaluated to determine if depleted visceral protein

were a result of malnutrition or some other

metabolic processes. According to the hospital's

policy this is part of the nutrition assessment

process.

The lack of comprehensive and timely

assessments and nutrition interventions may

have resulted in the further compromise of the

clinical nutrition status of these patients.

Findings:

The following is the findings from a complaint

investigation conducted from 4/28/11 to 4/29/11.

Review of the hospital's policy titled, "Nutritional

Assessment" dated 3/09, indicated that the

purpose of the policy was to evaluate thenutritional status of a patient, enabling the

identification of a patient who is malnourished or

at risk of developing malnutrition, and providing

goals for medical nutrition therapy." It further




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stated that, "Timely assessments will be made by

the dietitian, prioritized according to nutrition risk."

It also indicates that, "Nutrition assessments shall

include the following components....:" Adequacy

of nutrient intake: current, previous and

required.....Anthropocentric measurements and

evaluations including weight and weight

history...and BMI measurements." It indicated

that assessments are completed on patientsaccording to the Prioritization Guidelines policy

(see below). The dietitian shall assess the need

for further evaluation/intervention. The policy

indicated that if the dietitian assessed the patient

and determines that the patient may be at risk for

malnutrition, severe malnutrition, protein

deficiency or morbid obesity, the dietitian shall

note appropriate medical nutrition therapy in the

assessment or progress note. And that the

Nutrition Screening format/Nutrition Interventions

form can be used for patient under Priority 2 and

3 at lower nutrition risk.

The flow diagram included in the policy indicated

that Nutrition Services screen patients who are

admitted to the hospital using lists: Albumin List,

Patient Census List and Tube Feeding/TPN List.

Review of the hospital's policy titled, Prioriting

Guidelines" dated 3/09, indicated that the policy

was to ensure that the nutrition needs of the

patients were being met and to establish

guidelines for prioritizing patients that need to be

assessed. It states that High Priority, or Priority 1

patients would be seen and assessed within 1 -2

days of identification. It further indicated that

patients with a diagnosis of malnutrition were inthis category. It also indicated that patients with

an Albumin level less than or equal to 2.2 were in

this category.




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Further review of the "Procedures for

Assessment" portion of the Nutrition Assessment

policy instructed the dietitian to evaluate energy

needs based on weight where, the method based

on kilograms (kg) in actual weight, in evaluating

the energy needs for malnutrition was to use 40 -

50 calories per kg.

Review of the hospital's policy titled, "NutritionTherapy Reassessment" dated 3/09, indicated

that High Nutritional Outcome Risk patients

(Priority 1) were to be reassessed in 2 - 3 days

unless otherwise specified by the dietitian or a

change in condition warrants.

1. Review of the medical record for Patient 1

indicated that the patient was admitted to the

hospital 12/8/09 with diagnoses that included a

heel ulcer, probable acute renal failure (a rapid

loss of kidney function), protein deficiency

malnutrition, hypoalbuminemia (hypo indicates

low and albuminemia refers to a protein level in

the blood sometimes used to indicate nutritional

status, normal values are 3.2 - 5.5 mg/dl) and

anemia (a decreased number of red blood cells).

A nutrition assessment was completed but was

not signed or dated. The nutrition assessment

indicated that the patient's current weight was

109.7 pounds and the weight status was

appropriate. The skin integrity section indicated

that the patient had open bed sores on the upper

buttock area and both ankles. The sections on

the form for Body Mass Index or BMI (a number

calculated from a person's weight and height and

provides a reliable indicator of body fatness),

usual weight and recent weight change were leftblank. The sections on the form for usual diet at

home and usual appetite were also left blank. In

the section where the nutrition goals were

estimated, it indicated that 25 - 30 calories per kg




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were used to estimate energy need, instead of 40

- 50 for patients with malnutrition according to the

policy. A sticker was placed in the Progress

Notes indicating that the registered dietitian (RD)

was alerting the physician of the evidence of

protein deficiency as evidenced by an albumin

level less than 2.8 grams/dl and skin breakdown.

The sticker was signed by the RD and dated

12/11/09. The patient was discharged from thehospital on 12/11/09 with diagnoses that included

severe malnutrition.

During an interview with the Clinical Nutrition

Manager (CNM) and Corporate Director of Food

and Nutrition Services (CDFNS) on 4/29/11 at

3:30 PM, both the CNM and CDFNS confirmed

that the policy to determine the calorie needs for

patients with a diagnosis of malnutrition was 40 -

50 calories per kg. They were unable to explain

why the nutrition assessment form was not

signed or dated and why the calorie needs were

assessed at 25 - 30 calories/kg when a patient

had a diagnosis of malnutrition.


indicated that the patient was admitted on

11/11/09 with diagnoses that included

exacerbation of a pulmonary disease, chest pain

and Parkinson's disease (a disorder of the brain

that leads to shaking/tremors and difficulty with

walking, movement, and coordination). A sticker

dated 11/12/09 was placed in the Progress Notes

indicating that the RD was alerting the physician

of the evidence of malnutrition as evidenced by

an albumin level of 2.5 - 3.4 grams/dl and

inadequate nutritional intake. The sticker wasco-signed by the physician but was not dated.

Review of the Progress Notes indicated a

diagnosis of protein malnutrition on 11/13/09 and

a diagnosis of severe malnutrition on 11/14/09. A




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review of the medical record revealed that there

was no nutrition assessment form in the record,

but instead was a Nutrition Services Intervention

form completed by the RD on 11/13/09.

According to the Nutrition Assessment policy, the

Nutrition Screening format/Nutrition Interventions

form can be used for patient under Priority 2 and

3. There was no documentation on this form to

indicate the patient's nutritional intake history, anyrecent weight changes or history. In addition, the

RD estimated the energy needs for this patient at

25 - 30 calories per kg, instead of the 40 - 50 for

patients with malnutrition according to the policy.

The nutrition risk level indicated was moderate,

despite the diagnosis of malnutrition. The patient

was discharged on 11/14/09.

During an interview with the CNM and CDFNS on

4/29/11 at 3:30 PM, both the CNM and CDFNS

confirmed that the policy to determine the calorie

needs for patients with a diagnosis of malnutrition

was 40 - 50 calories per kg. They were unable to

explain why the Nutrition Services Intervention

form was used instead of the Nutrition

Assessment form and why the risk level was

determined to be moderate despite the diagnosis

of malnutrition and why the calorie needs were

assessed at 25 - 30 calories/kg.


indicated that the patient was admitted from a

nursing home on 10/10/09 with diagnoses that

included malnutrition. A nutrition assessment

was documented on 10/11/09. The sections on

the form for usual weight and recent weight

change were left blank. The sections on the formfor usual diet at home and usual appetite were

also left blank. In the section where the nutrition

goals were estimated, it indicated that 25 - 30

calories per kg were used to estimate energy




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need, instead of 40 - 50 for patients with

malnutrition according to the policy. The

nutrition problem section indicated moderate

protein malnutrition. A sticker dated 1/11/09 was

placed in the Progress Notes indicating that the

RD was alerting the physician of the evidence of

malnutrition as evidenced by an albumin level of

2.5 - 3.4 grams/dl and inadequate nutritional

intake. The sticker was co-signed by thephysician. The physician further documented

severe malnutrition on 10/11/09. The patient was

discharged on 10/14/09.






explain why the calorie needs were assessed at

25 - 30 calories/kg.


indicated that the patient was admitted on 10/3/09

with diagnoses that included hypoalbuminemia,

possible protein deficiency and malnutrition. A

nutrition assessment was documented on

10/6/09, 3 days after admission instead of 1 - 2

days according to the policy. The sections on the

form for usual weight and recent weight change

were left blank. The sections on the form for

usual diet at home and usual appetite were also

left blank. In the section where the nutrition goals

were estimated, it indicated that 25 - 30 calories

per kg were used to estimate energy need,

instead of 40 - 50 for patients with malnutrition

according to the policy.


4/29/11 at 2:00 PM, both the RD and CDFNS





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25 - 30 calories/kg. They further stated that the

diagnosis of malnutrition was not communicated

to Nutrition Services, or a consult ordered to

ensure that nutrition needs were evaluated and

met in a timely manner.



with diagnoses that included intractable nausea

and vomiting, sepsis (a severe illness in which

the bloodstream is overwhelmed by bacteria), an

open bed sore and severe malnutrition. A dietary

consult was ordered on 9/24/09. A nutrition

assessment and consult was completed but was

documented on 9/26/09, 3 days after admission

instead of 1 - 2 days according to the policy, and

2 days after the dietary consult was ordered. The

sections on the form for usual weight and recent

weight change were left blank. The sections on

the form for usual appetite were also left blank.

In the section where the nutrition goals were

estimated, it indicated that 25 - 30 calories per kg

were used to estimate energy need, instead of 40

- 50 for patients with malnutrition according to the

policy. The nutrition problem was listed as

severe protein malnutrition. A sticker dated

9/26/09 was placed in the Progress Notes

indicating that the RD was alerting the physician

of the evidence of severe malnutrition as

evidenced by an albumin level less than 2.4

grams/dl or pre-albumin less than 10 mg/dl and

inadequate nutritional intake and protein

deficiency as evidenced by an albumin level lessthan 2.8 grams/dl and skin breakdown or edema.

The sticker was co-signed by the physician but

was not dated. The patient was discharged on

9/29/09 without further intervention by the RD.




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25 - 30 calories/kg. They further were unable to

state why the dietary consult was not completedin a timely manner.



with diagnoses that included cellulitis (a bacterial

infection of the skin and soft t issues that causes

swelling, redness, tenderness and warmth) to the

left upper arm, diabetes, uncontrolled,

hypoabluminemia, malnutrition and renal failure.

Admitting laboratory values included albumin

level 2.6. There was no dietary consult ordered

during the hospitalization. A Nutrition Services

Intervention form was completed on 6/29/09 by

the Registered Diet Technician (DTR) which

indicated that the patient was at low nutrition risk

despite an albumin level on 6/29/09 of 2.2, a

glucose level of 324 and a diagnosis of

malnutrition. There was no nutrition assessment

documented in the medical record by the RD

when the patient was discharged on 7/2/09.



confirmed that the DTR should have referred the

patient to the RD for nutrition assessment and

follow-up and this did not happen. They also

confirmed that a diagnosis of malnutrition wouldindicate that the patient was at High nutrition risk

per the hospital's policy.




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with diagnoses that included liver cirrhosis (poor

liver function as a result of chronic liver disease),

diabetes, low sodium level, low potassium level

and thrombocytopenia (a disorder in which there

is an abnormally low amount of platelets). On

6/1/09, the physician progress notes indicated

that the patient had protein malnutrition. Therewas no dietary consult ordered during the

hospitalization. A Nutrition Services Intervention

form was completed on 6/2/09 by the DTR which

indicated that the patient was at low nutrition risk

despite a albumin level on admission of 2.6, an

ammonia level of 362 and a diagnosis of

malnutrition. There was no nutrition assessment

documented in the medical record by the RD

when the patient was discharged on 6/2/09.



confirmed that there was no nutrition assessment

and that the DTR should have referred the patient

to the RD for nutrition assessment and follow-up.

They also confirmed that a diagnosis of

malnutrition would indicate that the patient was at

High nutrition risk per the hospital's policy.



with diagnoses that included lower extremity

cellulitis, diabetes, anemia and severe

malnutrition. A dietary consult was ordered on

3/23/09. A nutrition assessment and consult was

completed by the RD on 3/24/09. The sections

on the form for usual weight and weight loss wereleft blank. There was no assessment of the

patient's intake history prior to admission to the

hospital. Pertinent laboratory values listed

albumin level of 1.7. In the section where the




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nutrition goals were estimated, it indicated that 20

- 25 calories per kg (based on the patients ideal

body weight range) were used to estimate energy



assessment further estimated the protein needs

of the patient to be 129 - 172 grams of protein.

According to the assessment the diet the patient's

diet was 2000 calorie diabetic diet and providedapproximately 100 grams of protein. Therefore

the plan was to provide 2 ounces of extra protein

per meal which would provide approximately 42

extra grams of protein for a total of 142 grams

per day to meet the patient's needs. A sticker

was placed in the Progress Notes indicating that

the RD was alerting the physician of the evidence

of severe malnutrition as evidenced by a

decreased albumin level and inadequate nutrition

intake and malnutrition related to morbid obesity

as evidenced by BMI > 40. The sticker was

signed by the RD and dated 3/24/09. On 3/27/09

and Nutrition Follow-up note by the RD indicated

that the patient was now on an 1800 calorie

diabetic diet, the patient's albumin level was now

1.9. No further interventions were recommended.

The patient received the 1800 calorie diabetic diet

without the additional protein from 3/25/09 until

the day of discharge, 6 days. A final nutrition

follow-up note by the RD dated 3/31/09 indicated

a recommendation for 2000 calorie diabetic diet

with double protein at lunch and dinner and a

diabetic nutritional supplement drink three times a

day. The patient was discharged from the

hospital the same day on 3/31/09.

During an interview with the CNM and CDFNS on4/29/11 at 3:00 PM, the CNM confirmed that the

1800 calorie diabetic diet provided approximately

90 grams of protein per day. She was unable to

state why there was no recommendation in the




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follow-up note dated 3/27/09 to change the diet to

a 2000 calorie diabetic diet with the extra protein

as was recommended on the initial Nutrition

Assessment. The CNM was also unable to to


20 - 25 calories/kg based on the patient's ideal

body weight range when the policy to determine

the calorie needs for patients with a diagnosis of

malnutrition was 40 - 50 calories per kg. Thepolicy did not indicate how to determine the

calorie needs for a patient with morbid obesity.



with diagnoses that included renal failure,

anemia, and malnutrition. A review of the

physician's progress notes indicated diagnosis of

malnutrition on 3/2/09, severe malnutrition on

3/5/09, 3/7/09 and 3/8/09. There was no dietary

consult order until 3/9/09. Review of the Nutrition

Assessment dated 3/5/09 (3 days after

admission, not within the 1 - 2 days required by

the hospital's policy) revealed that the sections on

the form for usual weight and weight loss were

left blank. There was no assessment of the

patient's intake history prior to admission to the

hospital. Pertinent laboratory values listed

albumin level of 1.6. In the section where the

nutrition goals were estimated, it indicated that 20

- 25 calories per kg were used to estimate energy



assessment indicated that the patient had severe

protein depletion.

During an interview with the CNM and CDFN on4/29/11 at 2:05 PM, both the CNM and CDFNS







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20 - 25 calories/kg. They further were unable to

state why the nutrition assessment was not

completed in a timely manner.



with diagnoses that included diabetes and

malnutrition. There was no order for a dietaryconsult noted in the medical record. On 2/19/09

a Nutrition Services Intervention form was

completed by the DTR indicating that the patient

was at moderate nutrition risk due to abnormal

lab values with an albumin level of 2.7 and poor

oral intake. There was no Nutrition Assessment

by the RD. However, a sticker was placed in the

Progress Notes indicating that the RD was

alerting the physician of the evidence of

malnutrition as evidenced by an albumin level 2.5

- 3.4 grams/dl and inadequate nutritional intake.

The sticker was signed by the RD and dated

2/19/09, despite not having done a nutrition

assessment. The patient was discharged from

the hospital on 2/20/09 with diagnoses that

included protein malnutrition.




and that the RD should have completed a

nutrition assessment when the RD determined

that the patient had evidence of malnutrition.



12/30/08 with diagnoses that includedappendicitis. There was no order for a dietary

consult noted in the medical record. A physician

progress note dated 12/31/08 stated protein

malnutrition. There was no Nutrition Assessment




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by the RD. However, a sticker was placed in the

Progress Notes indicating that the RD was

alerting the physician of the evidence of severe

malnutrition as evidenced by an albumin level

less than or equal to 2.4 grams/dl and inadequate

nutritional intake. The sticker was not signed by

the RD but was dated 1/1/09. The patient was

discharged from the hospital on 1/2/09.


4/29/11 at 3:10 PM, the CNM confirmed that

there was no nutrition assessment and that the

RD should have completed a nutrition

assessment. They also confirmed that the sticker

was placed in the chart by the DTR and that was

out of the DTR's scope of practice.



with diagnoses that included severe malnutrition,

decreased albumin and protein deficiency. A

dietary consult was ordered on 9/16/09. Review

of the nutrition progress notes indicated that the

RD completed a Nutrition Services Intervention

form used for patient under Priority 2 and 3, lower

nutrition risk on 9/17/09. There was no estimated

nutrition needs as is required by the assessment

policy. Abnormal laboratory values were listed

with an albumin level of 2.3. Problems included

poor oral intake and low serum protein. The risk

level was listed as moderate even though the

note indicates that the patient is malnourished. A

sticker dated 9/17/09 was placed in the Progress

Notes indicating that the RD was alerting the

physician of the evidence of severe malnutrition

as evidenced by an albumin level less than 2.4grams/dl or pre-albumin less than 10 mg/dl and

inadequate nutritional intake. The sticker was

co-signed by the physician but was not dated.

The patient was discharged on 9/18/09 without




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further intervention by the RD.





nutrition assessment.

13. Review of the medical record for Patient 14indicated that the patient was admitted on 11/5/09

with diagnoses that included a pulmonary disease

and morbid obesity. Review of the nutrition

progress notes indicated that the RD completed a

Nutrition Services Intervention form (used for

patient under Priority 2 and 3, lower nutrition risk

per the hospital's policy) on 11/7/09. There was

no estimated nutrition needs as is required by the

assessment policy. Abnormal laboratory values

were listed with an albumin level of 2.4 and a

glucose level of 580. Problems included poor

oral intake and low serum protein. The risk level

was listed as moderate. A sticker dated 11/7/09

was placed in the Progress Notes indicating that

the RD was alerting the physician of the evidence

of severe malnutrition as evidenced by an

albumin level less than or equal to 2.4 grams/dl or

pre-albumin less than 10 mg/dl and inadequate

nutritional intake. The sticker also indicated that

the patient had protein deficiency as evidenced

by an albumin less than 2.8 g/dl and skin

breakdown and malnutrition related to morbid

obesity as evidenced by a BMI greater than or

equal to 40. The sticker was co-signed by the

physician but was not dated. There was no

follow-up note or intervention by the RD before

the patient was discharged on 11/11/09.







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nutrition assessment and follow-up when the RD

determined that the patient had evidence of

severe malnutrition.



10/10/09 with diagnoses that included below the

knee amputation wound necrosis (death of bodytissue), diabetes. There was no order for a

dietary consult noted in the medical record.

There was no Nutrition Assessment by the RD.

However, a sticker was placed in the Progress

Notes indicating that the RD was alerting the

physician of the evidence of protein deficiency as

evidenced by an albumin less than 2.8 g/dl and

skin breakdown . The sticker was signed by the

RD and was dated 10/26/09, even though the

patient was discharged from the facility on

10/15/09. The sticker was cosigned by the

physician but was not dated. On 10/13/09 a

Nutrition Services Intervention form was

completed by the DTR indicating that the patient

was at moderate nutrition risk due to low serum

protein with an albumin level of 2.7 and impaired

skin integrity.





nutrition assessment when the RD determined

that the patient had evidence of protein

deficiency. They also confirmed that a diagnosis

of malnutrition would indicate that the patient was

at High nutrition risk per the hospital's policy.



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