Sherman Oaks Malnutrition

8/4/2019 Sherman Oaks Malnutrition

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IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

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California Department of Public Health

CA93000140 04/08/2011

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SHERMAN OAKS, CA 91403

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

SHERMAN OAKS HOSPITAL4929 VAN NUYS BLVD

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 reflect the findings of the

Department of Public Health during a Complaint

Investigation.

Complaint Intake Number: CA00265099

The inspection was limited to the specific

complaint investigated and does not represent

the findings of a full inspection of the facility

Representing the Department of Public Health:

Evaluator State ID # 2037, Medical Consultant

Evaluator State ID # 2404, Dietary Consultant

E 545 T22 DIV5 CH1 ART3-70273(i) Dietetic Service

General Requirements

(i) Nutritional Care.

This Statute is not met as evidenced by:

E 545

Based on interview, review of clinical records and

review of the hospital's policies and procedures,

the facility failed to ensure nutritional care was

provided to 11 of 15 sampled patients (Patient 1,

2, 3, 4, 5, 6, 7, 9, 10, 11 and 15) according to the

hospital's policy and procedures. Lack of timely

and comprehensive nutrition assessment and

intervention may have resulted in further

compromise of clinical and nutritional status.

Findings:

Review of the hospital's policy and procedure

titled Prioritizing Guidelines, dated 8/2008,

showed high priority patients will be seen and

censing and Certification Division

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

TITLE (X6) DATE

If continuation sheet 16899TATE FORM X4DG11


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E 545Continued From page 1E 545

assessed within one to two days of identification.

High priorities are:

Any nursing triggered consult (based on the

Nursing nutrition screen on the Initial Nursing

Assessment);

Diagnosis of Malnutrition, burn injury with

greater than 25% total body surface burn,

pancreatitis, multiple trauma, multi organ failure,

newly onset renal (kidney) failure, newly onsetdiabetes;

Albumin (protein made by the liver) less than

or equal to 2.2 grams (g) per deciliters (dL) or

Pre-Albumin (has a half-life in blood of about 2

days, much shorter than that of albumin.

Pre-albumin is therefore more sensitive to

changes in protein-energy status than albumin,

and its concentration closely reflects recent

dietary intake rather than overall nutritional

status) less than or equal to 10 milligrams (mg)

per dL - obtained though laboratory data;

Wounds: full thickness skin loss and full

thickness tissue loss and Braden scale (a tool

that was developed to help health professionals,

especially nurses, assess a patient's risk of

developing a pressure ulcer) score of 12 or lower

(the lower the score indicates the higher the risk

for developing a pressure ulcer);

Stage three or four pressure ulcer (stage

three is a full thickness tissue loss, subcutaneous

fat may be visible but bone, tendon or muscle are

not exposed and stage four is full thickness tissue

loss with exposed bone, tendon or muscle);

Nutrition consult;

Tube Feeding (alternate nutrition feeding

through gut) or Total Parental Nutrition (alternate

nutrition feeding through vein) orders.Review of the hospital's policy and procedure

titled Nutrition Therapy Reassessments, dated

8/08, stipulated that high nutritional outcome risk

patients are reassessed in 2-3 days.




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Review of the hospital's policy and procedure,

titled Nutritional Assessment, dated 5/2008,

stipulated procedures for assessment include: 1.

evaluate energy needs. A. Based on weight;

method based on kilogram (kg) in actual weight

when patients are hemodynamically stable. It

showed for the type of therapy:

malnutrition/sepsis/trauma to provide 40-50

kilocalories (kcal) per kg in 24 hours. 2. Evaluateprotein needs. A. Based on weight; method

based on actual weight or ideal body weight in kg

if obese. It showed for the type of therapy

catabolic (energy releasing process that breaks

down large molecules into smaller ones) to

provide 1.2-1.5 grams (g) of protein per kg in 24

hours. It shows to evaluate laboratory data and if

albumin is less than 2.4 g per dL (normal level is

3.4-5.0 g per dL) then to recommend obtaining a

Pre-albumin level.

Review of a sticker that was placed in some

clinical records, showed severe malnutrition is

defined as with any two criteria being met:

[ ] Albumin less than or equal to 2.4 g/dL or

Pre-Albumin less than 5 mg/dL

[ ] Weight: less than 80% of ideal Body

Weight

[ ] Weight decrease: greater than 5% in 1

month

or greater than 7.5% in 3 months or

greater than 10% in 6 months

[ ] Inadequate nutritional intake.

1. Review of the clinical record for Patient 1 was

conducted. Patient 1 was admitted to the hospital

on 7/2/09 with diagnoses that included sepsis,

infected sacral (sacrum, bone at the lower end ofthe spinal column) decubitus ulcer (a bed sore, a

pressure ulcer that comes from lying in one

position too long so that the circulation in the skin

is compromised by the pressure, particularly over




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a bony area), and severe malnutrition. Review of

the laboratory data, dated 7/2/09, revealed that

the albumin was 1.3 mg per dL. Review of the

physician's orders dated 7/2/09, shows the diet

order was Fibersource HN running at 40 milliliters

(ml) per hour through a nasogastric tube feeding

(a tube placed from the nose to the stomach

which is used to provide nutrition to patients who

cannot obtain nutrition by swallowing). Review ofthe Nutrition Assessment dated 7/4/09, showed

Patient 1 was 5' 0" and 94 pounds with a Body

Mass Index ((BMI) is a number calculated from a

person's weight and height. BMI provides a

reliable indicator of body fatness for most people

and is used to screen for weight categories that

may lead to health problems) was 18. A BMI of

18 indicates Patient 1 was underweight. It

showed the estimated nutrition goals were 1100 -

1250 calories (kcals) per day which is 27-30

kcal/kg; and 55-70 g Protein per day which is

1.3-1.6 g per kg. There is no mention of how

much the tube feeding is providing or how much

of Patient 1's needs are being met by it. The

Registered Dietitian (RD) recommended adding a

protein supplement (prosource) once daily. The

RD failed to follow the hospital policy and

procedure for calculating the estimated needs for

malnutrition. The RD failed to recommend a

Pre-albumin level to be obtained as stated in the

policy and procedure. An interview was

conducted with the RD on 4/11/11 at

approximately 2:30 PM. The RD stated an

assessment should include how much the tube

feeding is providing and how much of the

estimated needs are being met.



on 5/25/09 with diagnoses that included sepsis

and severe malnutrition. Review of the laboratory




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data dated 5/26/09, shows the albumin level was

2.1 g per dL. Review of the physician's orders

dated 5/29/09, shows an order for a protein

supplement one pack daily and a pureed diet with

thickened liquids. Review of the nutrition

assessment dated 5/26/09; showed Patient 2 was

5' 4" and 160 pounds with a BMI of 27. A BMI of

27 indicates Patient 2 was overweight (BMI of

25-29). The medical record showed the estimatednutrition goals were for 1800-2150 kcal per day

which was 25-30 kcal per kg. It showed there was

no current diet order but it shows the pertinent

medications are resource 2.0 (nutrition

supplement) and protein powder. The nutritional

problem stated was altered nutrition related labs

related to (etiology) may be secondary to oral

intake prior to admission as evidenced by (signs

and symptoms) an albumin of 2.1 g per dL. The

interventions and recommendations showed to

discontinue resource 2.0 and protein powder;

begin nutrition by 5/29/09; and nutrition support if

no oral intake indicated. The RD failed to mention

a specific intervention regarding what type of diet

or nutrition support would be beneficial to meet

Patient 2's nutritional needs. The RD failed to

follow the hospital policy and procedure for

estimated needs or to recommend obtaining a

Pre-albumin level.



on 8/5/09 with diagnoses including right leg

wound, acute encephalopathy (nonspecific term

describing a syndrome affecting the brain), and

severe malnutrition. Review of the laboratory data

dated 8/5/09 and 8/7/09, showed albumin was 2.5g per dL and 2.2 g per dL, respectively. Review of

the physician's orders dated 8/6/09, showed a

diet order for a regular diet. Review of the

nutrition assessment dated 8/6/09; showed




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Patient 3 was 5'7" and 140 pounds with a BMI of

21. Normal weight indicates a BMI of 18.5-24.9.

The nutrition problem shows low serum protein

(albumin), and impaired skin with a right foot

scab. The RD indicates Patient 3 was at

moderate risk and the nutrition plan states the RD

was "unable to interview the patient at this t ime."

The RD stated the current diet was adequate for

now and to consider an oral supplement if intakewas poor. The RD failed to follow the hospital

policy and procedure to estimate nutrition needs

for malnutrition. The RD failed to show what

Patient 3's current appetite or meal percentages

of food eaten were. Lack of these criteria makes

it unclear what the RD based the assessment and

recommendations upon. An interview was

conducted with the RD on 4/11/11 at

approximately 2:30 PM. The RD stated

malnutrition was considered high nutrition risk

and estimated needs should be written in the

nutrition assessment.



on 4/4/09 with diagnosis that included metastatic

(the spread of cancer to other parts) colon

cancer, cachexia (physical wasting with loss of

weight and muscle mass caused by disease), and

severe malnutrition. Review of the physician's

orders dated 4/4/09, showed a diet order for a

regular diet. Review of the laboratory data dated

4/409, showed the albumin level was 2.0 g per

dL. Review of the nutrition assessment dated

4/5/09; showed Patient 4 was 5'0" and 120

pounds with a BMI of 23. Normal weight indicates

a BMI 18.5-24.9. It showed the estimatednutrition goals were 1350-1600 kcal per day

which was 25-30 kcal per kg; and 65-70 g Protein

per day which was 1.2-1.3 g Protein per kg. The

percentage of oral intakes shows it is poor




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(25-50%). The nutritional problem was stated as

altered nutrition related labs related to may be

secondary to oral intake prior to admission as

evidenced by albumin is 2.0 g per dL. The

interventions and recommendations show the

patient needs further education regarding the

importance of protein, and give cottage cheese

with meals. The RD failed to follow the hospital

policy and procedure for estimating nutritionneeds with malnutrition. The RD failed to follow

the hospital policy and procedure for

recommending obtaining the pre-albumin level

when the albumin is less than 2.4 g per dL.



on 6/29/09 with diagnoses that included right leg

wound, probable sepsis (blood poisoning), and

severe malnutrition. Review of the laboratory

data dated 6/29/09, showed the albumin level

was 1.6 g per dL. Review of the nursing wound

assessment dated 7/2/09, showed a stage two

pressure ulcer (partial thickness loss of dermis

(inner layer of the two main layers of cells that

make up the skin)) on the left buttock. Review of

the physician's orders dated 6/29/09, 7/1/09, and

7/3/09, showed diet orders of NPO (nothing by

mouth), clear liquid diet, and 2,000 mg Sodium

diet, respectively. Review of the nutrition

assessment dated 6/30/09; showed Patient 5 was

5'9" and 170 pounds and had a BMI of 25.

Normal weight indicates a BMI 18.5-24.9. The

assessment showed, the estimated nutrition

goals were 1900-2300 kcal per day which is

25-30 kcal per kg and 90-100 g Protein per day

which is 1.2-1.3 g per kg. The nutritional problemshows altered nutrition related labs related to may

be secondary to underlying condition verses oral

intake prior to admission as evidenced by

albumin of 1.6 g per dL. The interventions and




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recommendations were to begin nutrition by

7/3/09, if no oral intake indicated will benefit from

nutrition support, and question a multivitamin.

There was no specific nutrition intervention or

recommendation to state what oral diet or

nutrition support would be beneficial to meet

Patient 5's nutritional needs. The RD failed to

follow the hospital policy and procedure for the

estimated nutrition needs for malnutrition. TheRD failed to follow the hospital's policy and

procedures regarding recommending obtaining a

pre-albumin level.



on 4/26/09 with diagnoses that included sepsis,

gastrostomy tube (GT) (placement of a feeding

tube through the skin and the stomach wall,

directly into the stomach when unable to take

nutrition through the mouth), chronic ventilator

dependency, severe malnutrition, and

dehydration. Review of the laboratory data dated

4/26/09, showed the albumin level was at 2.1 g

per dL. Review of the physician's orders dated

4/30/09, showed an order for GT feeding with

Fibersource (tube feeding formula) at 85 ml per

hour. Review of the nutrition assessment dated

4/27/09; showed Patient 6 was 6'0" and 220

pounds with a BMI of 30. A BMI of 30 indicates

Patient 6 is obese (BMI of 30 or greater). It

showed the estimated nutrition goals was for

2100-2550 kcals per day which is 25-30 kcal per

kg of adjusted body weight; and 110-130 g

Protein per day which is 1.3-1.5 g Protein per kg

of adjusted body weight. The RD failed to follow

the hospital's policy and procedures for theestimated nutrition goals. The hospital policy

does not state to base estimated needs on

adjusted weight. Review of the nutrition

reassessment dated 7/3/09, showed Patient 6's




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nutrition needs. The RD failed to document

Patient 7's height or weight. The RD failed to

document the albumin level. Lack of these

indicators make it unclear what the RD based the

assessment and recommendations on. Review

of the initial nursing assessment dated 12/16/08

at 5:45 AM, showed Patient 7's height was 6'0"

and 133.8 pounds. The BMI for Patient 7 would

be 18 based on the height on weight from thenursing initial assessment. A BMI of 18 indicates

underweight. Review of the triage assessment

dated 12/16/08 at 1:16-1:30 AM, shows Patient

7's height is 6'0" and 115 pounds. This height

and weight would indicate a BMI of 15.6. All of

these parameters would make the patient a high

risk and would need to have estimated nutrition

needs calculated according to the hospital policy

and procedure and standards of practice. The

only other nutrition entry was a sticker placed in

the progress section on 12/20/08 at 5:00 PM,

showing the patient had been on NPO or clear

liquids for five days which may place him at

nutritional risk and to please consider an advance

in diet or nutrition support if possible. Patient 7

was discharged on 12/24/08. The RD failed to

follow the hospital's policy and procedures on

prioritizing and reassessing patients in the

hospital. An interview was conducted with the RD

on 4/11/11 at approximately 2:30 PM. The RD

stated malnutrition is considered high nutrition

risk and estimated needs should be written in the

nutrition assessment. The RD stated high risk

patients will be assessed in one to two days and

be reassessed in two to three days.

8. Review of the clinical record for Patient 9 wasconducted. Patient 9 was admitted to the hospital

on 1/7/09 with diagnoses that include bilateral

lower extremity cellulitis and a past medical

history of colon cancer. Review of the history and




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physical dated 1/7/09, showed Patient 9 was with

a slow decline in weight and is cachectic (having

cachexia, physical wasting with loss of weight and

muscle mass due to disease) appearing. Review

of the laboratory data dated 1/7/09, showed the

albumin level was at 2.6 g per dL. Review of the

progress notes dated 1/8/09, showed a

malnutrition sticker indicating malnutrition with a

check marked next to the word malnutrition.Review of the physician's orders dated 1/7/09,

showed a diet order for regular diet. Review of

the nutrition assessment dated 1/8/09, showed

Patient 9 was 5'6" and 115 pounds and with a

BMI of 18. A BMI of 18 indicates Patient 9 is

underweight. It showed the current appetite of

Patient 9 was fair with no percentages

documented on how the patient had been eating.

It showed there was a problem with low serum

protein (albumin). It showed the patient was at

moderate nutrition risk. The RD failed to follow

the hospital's policy and procedures to estimate

Patient 9's nutrition needs to indicate how many

calories or protein the patient needs to improve

her nutritional status. Lack of these indicators

make it unclear what the RD based the

assessment, priority and recommendation on.

No nutrition reassessment was provided. Patient

9 was discharged on 1/15/09. The RD failed to

follow the hospital's policy and procedures. An

interview was conducted with the RD on 4/11/11

at approximately 2:30 PM. The RD stated

malnutrition is considered high nutrition risk and

estimated needs should be written in the nutrition

assessment. The RD stated high risk patients will

be assessed in one to two days and be

reassessed in two to three days.


conducted. Patient 10 was admitted on 12/8/08

with diagnoses including sepsis and severe




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malnutrition. Review of the laboratory data dated

12/8/08, showed the albumin level was 1.5 g per

dL. Review of the physician's orders dated

12/8/08, 12/9/08, and 12/10/08, showed a diet

order for soft diet, puree diet and NPO until video

swallow evaluation done, respectively. Review of

the progress notes dated 12/9/08, shows a

sticker indicating the patient was severely

malnourished and the criteria met were albuminless than or equal to 2.4 g/dL and inadequate

nutritional intake. Review of the nutritional

assessment dated 12/9/08, showed Patient 10 ' s

height was 5'0" and 134 pounds with a BMI of

26. It showed the estimated nutrition goals as

1500-1800 kcal per day which was 25-30 kcal per

kg and 70-90 g Protein per day which was 1.2-1.3

g Protein per kg. The nutritional problems were:

1. difficulty chewing and swallowing related to

(etiology) may be due to the underlying condition

as evidenced by (signs and symptoms) the

patient required modified texture; 2. altered

nutrition related labs related to may be secondary

to poor oral intake prior to admission as

evidenced by albumin of 1.5 g per dL. The

interventions were for a multivitamin and the

recommendations were to check the pre-albumin

and to change the diet to puree. The RD failed to

have specific interventions and how in increase

the protein in the diet for Patient 10 or to refer to

the speech therapist for a swallow evaluation.

The RD failed to follow the hospital's policy and

procedures to estimate the nutrition needs for

malnutrition.

10. Review of the clinical record for Patient 11

was conducted. Patient 11 was admitted to thehospital on 12/30/08 with diagnoses including

liver cirrhosis, ascites (excess fluid in the space

between the tissues lining the abdomen and the

abdominal organs (the peritoneal cavity), and




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severe malnutrition. Review of the Initial Nursing

Assessment dated 12/30/08 at 10:00 PM, showed

the nutrition screen was positive for

vomiting/nausea/diarrhea for greater than three

days, weight loss, unintentional greater than 10

pounds in one month, and newly diagnosed

diabetic; and patient 11 was 5'8" and 205

pounds. Review of the laboratory data dated

12/30/08 at 4:00 PM, showed an albumin level at2.3 g per dL. There was no nutrition assessment

located in Patient 11's chart. The RD failed to

follow the hospital's policy and procedure. An

interview was conducted with the RD on 4/11/11

at approximately 2:30 PM. The RD stated

malnutrition is considered high nutrition risk.

11. Review of the clinical record for Patient 15

was conducted. Patient 15 was admitted to the

hospital on 11/19/09 with diagnoses including

acute pancreatitis, and severe malnutrition.

Review of the history and physical dated

11/20/09, showed Patient 15 was a "cachectic

appearing" gentleman. Review of the laboratory

data dated 11/19/09 and 11/20/09, showed an

albumin level at 2.6 g per dL and 2.4 g per dL,

respectively. Review of the physician's orders

dated 11/19/09 and 11/20/09, showed a diet order

for full liquids and mechanical soft, respectively.

Review of the nutrition assessment dated

11/20/09; showed Patient 15's height was 5'11"

and 125 pounds with a BMI of 17.4 and 73% Ideal

body weight. A BMI under 18.5 indicated

underweight. The nutrition problems checked on

the assessment were for low serum protein

(albumin), impaired skin (the RD wrote multiple

scabs on both chins), and other for history ofalcoholism and low ideal body weight. The

nutritional risk level was blank. The nutritional

plans indicate to advance diet by goal of 11/23/09

or when medically appropriate and will follow up




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in 3-5 days to check nutritional status. Review of

the progress notes dated 11/20/09, showed a

sticker indicating malnutrition was placed by the

RD. The sticker indicated by check marks that

Patient 15 was severely malnourished with the

criteria being met was an albumin less than or

equal to 2.4 g/dL and his weight was less than

80% of ideal body weight. The RD failed to follow

the hospital's policy and procedures to estimatenutrition needs. An interview was conducted with

the RD on 4/11/11 at approximately 2:30 PM.

The RD stated when the patient meets the criteria

in the malnutrition sticker, the RD can place the

sticker in the progress notes and then the

physician would have to sign it. The RD stated

malnutrition was considered a high nutrition risk

and estimated needs should be written in the

nutritional assessment.



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Sherman Oaks Malnutrition