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1/14
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
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
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
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.
censing and Certification Division
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 2E 545
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
censing and Certification Division
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 3E 545
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.
2. Review of the clinical record for Patient 2 was
conducted. Patient 2 was admitted to the hospital
on 5/25/09 with diagnoses that included sepsis
and severe malnutrition. Review of the laboratory
censing and Certification Division
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 4E 545
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.
3. Review of the clinical record for Patient 3 was
conducted. Patient 3 was admitted to the hospital
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
censing and Certification Division
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 5E 545
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.
4. Review of the clinical record for Patient 4 was
conducted. Patient 4 was admitted to the hospital
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
censing and Certification Division
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 6E 545
(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.
5. Review of the clinical record for Patient 5 was
conducted. Patient 5 was admitted to the hospital
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
censing and Certification Division
If continuation sheet 76899TATE FORM X4DG11
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A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 7E 545
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.
6. Review of the clinical record for Patient 6 was
conducted. Patient 6 was admitted to the hospital
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
censing and Certification Division
If continuation sheet 86899TATE FORM X4DG11
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9/14
8/4/2019 Sherman Oaks Malnutrition
10/14
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 9E 545
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
censing and Certification Division
If continuation sheet 106899TATE FORM X4DG11
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11/14
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 10E 545
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.
9. Review of the clinical record for Patient 10 was
conducted. Patient 10 was admitted on 12/8/08
with diagnoses including sepsis and severe
censing and Certification Division
If continuation sheet 116899TATE FORM X4DG11
8/4/2019 Sherman Oaks Malnutrition
12/14
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 11E 545
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
censing and Certification Division
If continuation sheet 126899TATE FORM X4DG11
8/4/2019 Sherman Oaks Malnutrition
13/14
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 12E 545
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
censing and Certification Division
If continuation sheet 136899TATE FORM X4DG11
8/4/2019 Sherman Oaks Malnutrition
14/14
A. BUILDING
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 09/26/20
FORM APPROV
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
______________________
California Department of Public Health
CA93000140 04/08/2011
C
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)
(X5)
COMPLET
DATE
IDPREFIX
TAG
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 545Continued From page 13E 545
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.
censing and Certification Division
If continuation sheet 146899TATE FORM X4DG11