Physician Did Not Sign Complete TPN Orders
Summary
The facility failed to ensure the physician properly assigned and delegated therapeutic diet tasks to a qualified dietitian or other qualified nutrition professional for a resident receiving total parenteral nutrition (TPN). Resident #10 was admitted with diagnoses including peritoneal abscess, enterocutaneous fistula, and short gut syndrome, and the MDS indicated moderate cognitive impairment with a BIMS score of 10 and that the resident received parenteral/IV feeding. The resident stated he/she had been on TPN for over a year. Review of the medical record showed a physician's order for TPN that did not include the individual ingredients, nutrients, and additives. The Pharmacy TPN Order Form contained the full TPN formula, including amino acids, dextrose, lipids, electrolytes, zinc, multivitamins, and insulin, but the physician signature line on that form was signed by an RD and not by a physician. During interviews, the Medical Director stated the RD wrote the TPN recommendations on the pharmacy form and the physician co-signed them, while the RD stated writing TPN orders was beyond her scope of practice. The CNO stated the RD reviewed hospital orders and the attending physician was supposed to confirm them, and also acknowledged that the physician did not sign the TPN Pharmacy Order Form containing all ingredients and additives.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident experienced significant weight loss due to swallowing difficulties and dehydration, but was not referred to a dietitian for nutritional support. Despite regular assessments by a CRNP, the resident's poor oral intake was not communicated by nursing staff, leading to the deficiency being identified during a complaint survey.
The facility did not have a policy for physician delegation of tasks to the dietitian, as revealed during a policy review. The administrator confirmed the absence of such documentation, potentially affecting all 69 residents.
Failure to Refer Resident for Nutritional Support
Penalty
Summary
A facility provider failed to refer a resident's case to a dietitian when the resident required additional nutritional supplementation. The resident, who had a history of swallowing difficulties and dehydration, experienced significant weight loss from 124 lbs to 104 lbs between June and July 2022. Despite being assessed by a Certified Registered Nurse Practitioner (CRNP) twice a week during June 2022, there was no evidence of a referral to a dietitian for increased nutritional support. The resident was eventually given a PEG tube after a hospital readmission, but the initial weight loss and lack of referral were not addressed in a timely manner. The CRNP confirmed that the resident was being treated for multiple conditions, including COVID-19 and a urinary tract infection, during the month of June 2022. The CRNP also stated that the facility's nursing staff failed to inform him/her of the resident's poor oral intake, which contributed to the resident's weight loss. The deficiency was identified during a complaint survey, and the facility's administrator and Director of Nursing were informed of the deficient practice.
Lack of Policy for Physician Delegation to Dietitian
Penalty
Summary
The facility failed to develop a policy and procedure for the delegation of tasks by physicians to the dietitian. This deficiency was identified during a review of facility policies, which revealed the absence of a procedure for physician delegation of tasks to the dietitian. The administrator confirmed the lack of such a policy or procedure when interviewed, indicating that no documentation could be found to address this delegation process. This oversight had the potential to impact all 69 residents residing at the facility.
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