PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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 E 547

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: 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.
Licensing and Certification Division
TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
(X6) DATE

STATE FORM

6899

LY6111

If continuation sheet 1 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 1

E 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 policy 4. 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 the nutritional 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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 2 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 2

E 547

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 patients according 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 in this category. It also indicated that patients with an Albumin level less than or equal to 2.2 were in this category.
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 3 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 3

E 547

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, "Nutrition Therapy 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 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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 4 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 4

E 547

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 the hospital 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. 2. Review of the medical record for Patient 2 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 was co-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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 5 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 5

E 547

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, any recent 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. 3. Review of the medical record for Patient 4 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 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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 6 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 6

E 547

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 the physician. The physician further documented severe malnutrition on 10/11/09. The patient was discharged on 10/14/09. 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 calorie needs were assessed at 25 - 30 calories/kg. 4. Review of the medical record for Patient 5 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. During an interview with the CNM and CDFNS on 4/29/11 at 2:00 PM, both the RD and CDFNS confirmed that the policy to determine the calorie
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 7 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 7

E 547

needs for patients with a diagnosis of malnutrition was 40 - 50 calories per kg. They were unable to explain why the calorie needs were assessed at 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. 5. Review of the medical record for Patient 6 indicated that the patient was admitted on 9/23/09 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 less than 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.
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 8 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 8

E 547

During an interview with the CNM and CDFNS on 4/29/11 at 2:00 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 calorie needs were assessed at 25 - 30 calories/kg. They further were unable to state why the dietary consult was not completed in a timely manner. 6. Review of the medical record for Patient 7 indicated that the patient was admitted on 6/27/09 with diagnoses that included cellulitis (a bacterial infection of the skin and soft tissues 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. During an interview with the CNM and CDFNS on 4/29/11 at 2:50 PM, both the CNM and CDFNS 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 would indicate that the patient was at High nutrition risk per the hospital's policy.

Licensing and Certification Division STATE FORM

6899

LY6111

If continuation sheet 9 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 9

E 547

7. Review of the medical record for Patient 8 indicated that the patient was admitted on 5/30/09 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. There was 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. During an interview with the CNM and CDFNS on 4/29/11 at 1:55 PM, both the RD and CDFNS 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. 8. Review of the medical record for Patient 9 indicated that the patient was admitted on 3/22/09 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 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 1.7. In the section where the
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 10 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 10

E 547

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 need, instead of 40 - 50 for patients with malnutrition according to the policy. The 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 provided approximately 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 on 4/29/11 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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 11 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 11

E 547

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 explain why the calorie needs were assessed at 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. The policy did not indicate how to determine the calorie needs for a patient with morbid obesity. 9. Review of the medical record for Patient 10 indicated that the patient was admitted on 3/2/09 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 need, instead of 40 - 50 for patients with malnutrition according to the policy. The assessment indicated that the patient had severe protein depletion. During an interview with the CNM and CDFN on 4/29/11 at 2:05 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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 12 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 12

E 547

explain why the calorie needs were assessed at 20 - 25 calories/kg. They further were unable to state why the nutrition assessment was not completed in a timely manner. 10. Review of the medical record for Patient 11 indicated that the patient was admitted on 2/16/09 with diagnoses that included diabetes and malnutrition. There was no order for a dietary consult 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. During an interview with the CNM and CDFNS on 4/29/11 at 2:15 PM, both the RD and CDFNS confirmed that there was no nutrition assessment and that the RD should have completed a nutrition assessment when the RD determined that the patient had evidence of malnutrition. 11. Review of the medical record for Patient 12 indicated that the patient was admitted on 12/30/08 with diagnoses that included appendicitis. 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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 13 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 13

E 547

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. During an interview with the CNM and CDFNS on 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. 12. Review of the medical record for Patient 13 indicated that the patient was admitted on 9/15/09 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 2.4 grams/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
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 14 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 14

E 547

further intervention by the RD. During an interview with the CNM and CDFNS on 4/29/11 at 3:05 PM, both the CNM and CDFNS confirmed that there was no nutrition assessment and that the RD should have completed a nutrition assessment. 13. Review of the medical record for Patient 14 indicated 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. During an interview with the CNM and CDFNS on 4/29/11 at 3:20 PM, both the RD and CDFNS confirmed that there was no nutrition assessment
Licensing and Certification Division STATE FORM
6899

LY6111

If continuation sheet 15 of 16

PRINTED: 07/28/2011 FORM APPROVED

California Department of Public Health

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED

______________________

CA240001330
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C 04/29/2011

DESERT VALLEY HOSPITAL

(X4) ID PREFIX TAG

16850 BEAR VALLEY RD VICTORVILLE, CA 92395

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

E 547 Continued From page 15

E 547

and that the RD should have completed a nutrition assessment and follow-up when the RD determined that the patient had evidence of severe malnutrition. 14. Review of the medical record for Patient 15 indicated that the patient was admitted on 10/10/09 with diagnoses that included below the knee amputation wound necrosis (death of body tissue), 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. During an interview with the CNM and CDFNS on 4/29/11 at 3:25 PM, both the RD and CDFNS confirmed that there was no nutrition assessment and that the RD should have completed a 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.

Licensing and Certification Division STATE FORM

6899

LY6111

If continuation sheet 16 of 16