Vanderbilt Tullahoma-Harton Hospital

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 51389 Based on review of medical record, review of the Clinical Dietician Job Description, review of the Clinical Nutrition Services Policy and interviews, the facility failed to provide appropriate nutritional needs in 1 patient (Pt #1) out of 4 patients reviewed. The findings include: Review of the Job Description for Clinical Dietician showed “...responsible for providing clinical nutrition services, including nutrition assessment, diet modification, self-management training, and nutrition intervention to patients...develops, revises, and individualizes nutrition care plans based on information from the patient, medical record, family, and health care team members...incorporates current evidence-based research into practice...complies with regulatory standards, including federal, state, and accrediting agencies...” Review of the Clinical Nutrition Services: Initial Screening, Prioritization, and Assessment Policy showed “An initial screening assessment and prioritization process is implemented to identify patients who may require medical nutrition therapy. Patients identified at nutrition risk during the initial screening will be further evaluated with a comprehensive assessment and receive nutrition intervention[s] when applicable...evaluates information from the following sources that include nutrition intervention: Nursing nutrition related protocol reports...information technology - diet orders and changes, admission diagnosis[es]...laboratory - nutrition related values...” Medical record review of Pt. #1’s hospital History and Physical dated 10/22/2022, showed an admission on 10/21/2022 with complaints of possible aspiration (accidental inhalation of fluids or liquids into the airway and lungs). Pt #1 had a history of Hypertension, Diabetes, Chronic Kidney Disease, Sepsis (a body’s overwhelming reaction to an infection), Heart Disease, GERD (Gastroesophageal Reflux Disease - stomach acid goes into the esophagus causing heart burn), Stroke, Dysphagia (difficulty swallowing), MI (myocardial infarction - heart attack) and previous Aspiration. The patient had a GJ tube (tube inserted into the stomach and goes into the first part of the intestine) and was on tube feeding at home. She was normally nonverbal prior to this admission. When Pt #1 arrived at the ED (Emergency Department) her blood pressure was 210/95 mm/Hg (millimeter of mercury - normal range less than 120/80 mm/Hg). She also had an elevated WBC (White Blood Cell - indicates infection) of 26.5/L (normal 4-12/Liter). Pt #1 also tested positive for COVID. Medical record review of the Medication Administration Record dated 10/21/2022, showed an order for sliding scale SA Insulin (short acting insulin to give based on the blood glucose level). Review of the order showed “...if >400 = 12u (units) of insulin and draw lab. Call the MD for 2 consecutive out of range, despite insulin coverage.” Medical record review of Bedside Glucose Checks and Medication Administration Record dated 10/22/2022 at 1:51 AM through 10/26/2022 at 11:35 AM, showed the following blood glucose levels and insulin doses: Date/Time Glucose Level Insulin/ Time 10/22/2022 at 1:51 AM 288 SA Insulin 4u at 1:50 AM 10/22/2022 at 7:31 AM 290 SA Insulin 4u at 8:20 AM and LA Insulin (Long-Acting Insulin) 10u at 9:59 AM 10/22/2022 at 10:16 AM 394 10/22/2022 at 12:35 PM 424 SA Insulin 12u at 12:15 PM 10/22/2022 at 2:48 PM 284 10/22/2022 at 4:41 PM 158 SA Insulin 4u at 5:19 PM 10/22/2022 at 10:22 PM 212 SA Insulin 6u at 10:40 PM 10/23/2022 at 7:57 AM 269 SA Insulin 6u at 6:26 AM and LA Insulin 10u at 8:18 AM 10/23/2022 at 11:54 AM 252 SA Insulin 8u at 12:49 PM 10/23/2022 at 4:31 PM 88 10/23/2022 at 9:39 PM 112 10/24/2022 at 7:49 AM 136 10/24/2022 at 4:44 PM 117 10/24/2022 at 11:14 PM 297 SA Insulin 8u at 12:00 AM 10/25/2022 at 7:58 AM 471 SA Insulin 12u at 8:31 AM and LA Insulin 10u at 10:01 AM 10/25/2022 at 8:57 AM 553 LABORATORY RESULT 10/25/2022 at 11:02 AM 492 SA Insulin 12u at 11:17 AM 10/25/2022 at 12:30 PM 442 10/25/2022 at 3:17 PM 361 10/25/2022 at 5:39 PM 282 SA Insulin 8u at 5:48 PM 10/25/2022 at 10:14 PM 213 SA Insulin 6u at 10:17 PM 10/26/2022 at 7:47 PM 364 SA Insulin 12u at 7:59 AM and LA Insulin 20u at 9:09 AM 10/26/2022 at 11:35 AM 290 SA Insulin 8u at 11:19 AM Medical record review of Nurses Notes dated 10/22/2022 at 11:00 AM, showed Pt #1 had approximately 300 ml (milliliter) of coffee ground material (indicates possible gastrointestinal bleeding) aspirated from her GJ tube. Medical record review of Physician Progress Notes dated 10/22/2022 at 1:44 PM, showed “... with 300 ml residual in stomach...coffee ground appearing...question if GJ port working...will consult surgery...” Medical record review of Physician Progress Notes dated 10/23/2022 at 7:24 AM, showed the physician noted “...awake and lucid...no further bleeding noted...hope to start tube feeding soon...” Medical record review of a Registered Dietician (RD) Progress Notes dated 10/23/2022 at 12:41 PM, showed the RD visited Pt #1 to review for tube feeding, but Pt #1 was NPO (nothing by mouth). The note stated would follow [Pt#1] when able to start tube feeding. Medical record review of Surgery Consultation Note dated 10/23/2022 at 8:32 PM, showed “...patient is stable and don’t think there was a need for an invasive procedure since the bleeding was probably related to mechanical trauma from the GJ tube...can resume tube feeding in the AM...” Medical record review of a RD Note dated 10/24/2022 at 12:15 PM, showed the RD saw Pt #1 to review the need for tube feeding, “...history reviewed...no pertinent past medical history...no past surgical history on file...previous diet...tube feedings...unknown formula or amounts...” An assessment of height, weight, estimated energy needs, estimated protein needs, and fluid needs wa completed. A review of Pt #1’s lab work and intake and output done. “Recommendations...to start tube feedings with [high carbohydrate tube feeding formula]...at 30 ml [milliliter]/hr. [hour] x 8 hours; then increase to goal rate of 60 ml/hr. as tolerated...add flushes [water] 130 ml every 4 hours...” Medical record review of Physician Orders dated 10/24/2022 at 12:17 PM, showed an order was placed for (high carbohydrate tube feeding formula) at 60 ml/hr. with 130 ml water bolus. Medical record review of Physician Progress Notes dated 10/24/2022 at 2:21 PM, showed “...no further bleeding...general surgery doesn’t want to scope...tube feeding restarted today...” Medical record review of a RD Progress Note dated 10/25/2022 at 11:39 AM, showed “...surgery has signed off on patient and GJ tube will now be used. This is a better option for tube feeds since the [high carbohydrate tube feeding formula] running through the tube has more carbohydrates in it and has caused blood sugar levels to spike...patient’s spouse has requested tube feeding to be stopped currently due to blood sugars...will now recommend...change to [lower carbohydrate tube feeding formula]...this should help with GI viability and blood sugar management...” Medical record review of Physician Orders dated 10/25/2022 at 11:46 AM, showed the tube feeding was changed to (lower carbohydrate tube feeding formula) at 40 ml/hr. Medical record review of Physicians Progress Notes dated 10/25/2022 at 4:15 PM, showed “...patient hyperglycemic [high blood glucose level] with [high carbohydrate tube feeding formula] now...will change to different...” Medical record review of the Physician’s Discharge Summary dated 10/26/2022 at 12:30 PM, showed “...patient...got very hyperglycemic [high blood glucose] from the use of [high carbohydrate tube feeding formula]...due to carb load but this was treated with insulin and improving after changing the formulation to something with fewer carbs...is stable for discharge home today with husband...” Home Health was also consulted to see Pt #1 after discharge. During an interview on 5/12/2025 at 1:30 PM, with a hospital Registered Dietician, the RD stated if a patient is on tube feeding at home and they do not know what the formula is they “...do an assessment to determine what they need. We look at the patient medical history, labs, fluid restrictions, are they diabetic, renal failure, etc...” She stated there is a specific formula they can use for diabetics if needed. She stated “if the patient had high glucose levels, I would make a recommendation and would generally speak 1:1 with the doctor, especially if the patient is in ICU...” She reviewed the initial tube feeding Pt #1 was ordered and did confirm it is higher in carbohydrates.”