HospitalInspections.org

1. Based on policy and procedure review, record review, and staff interview, the hospital failed to ensure staff notified the patient's guardian of a change in medical condition and to receive consent for administration of medication for 1 of 2 patient (Patient #9) records reviewed of patients who experienced an allergic reaction to food. Failure to notify patients' guardians of changes in medical conditions and to obtain consent for medication limits the patients' and guardians' right to be informed and make decisions regarding the patients' care.

Findings include:

Review of the procedure titled "Procedure Sheet for Medication Administration" occurred on 01/25/12. This procedure, revised 10/11, stated, ". . . Consent must be obtained for all patients with a guardian or under age prior to giving the first dose unless a specific 'May give without consent' order is received as in an emergency when withholding a medication may have a significant detrimental effect on the current status of the patient. . . ."

Review of Patient #9's medical record occurred on 01/24/12. The hospital admitted Patient #9 on 08/16/11 and discharged Patient #9 on 08/30/11. Patient #9's medical record included a form titled "Prairie St. John's Patient's Bill of Rights." This form, signed by the patient's guardian on 08/16/11, stated, "Subject to certain limitations authorized by a parent . . . each patient has the: . . . 5. Right to obtain current information concerning care in terms the patient can reasonably be expected to understand and to participate in planning of his/her services. . . ."

Patient #9's medical record included the following forms indicating the patient had an allergy to red/cayenne pepper:
- "Comprehensive Assessment Tool - Nursing Assessment," dated 08/16/11
- "Psychiatric Evaluation," dated 08/17/11

Patient #9's "Nursing Assessment Note," dated 08/27/11, stated, ". . . This afternoon while the pt [patient] was at lunch pt reports that he ate a breakfast burrito that contained peppers. Pt told staff that he was allergic to peppers and that he was starting to have an allergic reaction. Pt was turning slightly red in the face and on call doctor was notified and [name of contracted medical service] MD [medical doctor] was here who was able to examine pt right away. Benadryl [an antihistamine] 50 mg [milligrams] IM [intramuscular] was ordered and pt received this injection immediately. . . ."

Patient's #9's "Authorized Prescriber Orders," dated 08/27/11 at 12:00 [p.m.], indicated a physician ordered Benadryl 50 mg IM x1 [times one] due to an allergic reaction to food.

Patient #9's medical record lacked evidence staff received consent from the patient's guardian before administration of the Benadryl. The record indicated the physician did not order the medication as "May give without consent." Patient #9's medical record lacked evidence the hospital notified the patient's guardian after the patient experienced an allergic reaction to food.

During interviews at 2:30 p.m. and 3:00 p.m. on 01/25/12, a nursing management staff member (#3) and a management staff member (#1) confirmed Patient #9's record lacked evidence the physician ordered the Benadryl as "give without consent" and staff failed to contact the patient's guardian to obtain consent for the Benadryl. The staff members (#3) and (#1) confirmed staff failed to notify Patient #9's guardian of the allergic reaction and the treatment provided.


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2. Based on policy and procedure review, record review, and staff interview, the hospital failed to ensure staff notified the patient's family/parent/guardian following a restraint/seclusion procedure which occurred to 2 of 2 children (less than age 12) (Patient #1 and #2) reviewed on the child inpatient treatment unit and 1 of 1 child (Patient #3) reviewed on the child/adolescent inpatient treatment unit. Failure to notify patients' family/parent/guardian of restraint/seclusion procedures limits the family/parent/guardian's right to be informed and make decisions regarding the patients' care.

Findings include:

Review of the policy/procedure titled "Seclusion Guidelines-Hospital Based Services" occurred on 01/25/12. This procedure, revised 05/09, stated, "Policy: To use seclusion as an emergency management intervention when less restrictive alternatives have failed. . . . 8.0 The RN [Registered Nurse] documents the following information in the patient's medical record and seclusion/restraint justification form when seclusion occurs. . . .
8.1. Observed threat of harm to self or others. . . .
8.3. The rationale for the seclusion. . . .
8.5. Communication to the patient and as appropriate, the family, of need for seclusion and criteria for discontinuation of seclusion. . . .
8.6. Patient's response during the process of placement in seclusion.
8.7 The patient's understanding about their need for seclusion. . . ."

Review of a hospital form, titled "Philosophy and Practice for Seclusion & Restraint Use" occurred on 01/25/12. The form, signed by each patient's parent/guardian upon admission and completed by an RN, stated, "The parent/guardian will be notified when seclusion/restraint is used and the reason for this intervention in all cases with minors (patient younger than 18 years of age)."

Review of a hospital form, titled "RN Seclusion & Restraint Note" occurred during record reviews on January 24-25, 2012. The form included specific questions regarding each restraint/seclusion procedure including, "Was patient's family/parent/guardian/other notified? (Always notify the parent or guardian of minors)"

- Review of Patient #1's medical record occurred on 01/24/12. The record identified Patient #1 experienced four restraint and/or seclusion episodes between January 15 and January 22, 2012. The January 22 episode included 15 minutes of seclusion which included eight minutes of restraint due to the patient "head banging." The January 22 "RN Seclusion & Restraint Note" stated in the section for family/parent/guardian notification "Unable to get ahold of". Further review of the record lacked evidence the nurse/nursing staff contacted the family/parent/guardian.

- Review of Patient #2's medical record occurred on 01/24/12. The record identified Patient #2 experienced two restraint/seclusion procedures between January 16 and January 20, 2012. The January 16 "RN Seclusion & Restraint Note" lacked evidence the nurse/nursing staff contacted the guardian. Further review of the record lacked evidence of family/parent/guardian notification.

- Review of Patient #3's medical record occurred on 01/24/12. The record identified Patient #3 experienced four restraint/seclusion procedures between January 17 and January 23, 2012. The January 17 "RN Seclusion & Restraint Note" identified the patient in seclusion for 15 minutes. The note lacked evidence the nurse/nursing staff contacted the guardian. Further review of the record lacked evidence of family/parent/guardian notification.

During interview on the afternoon of 01/25/12, an administrative staff member (#1) stated the hospital requires nursing staff to notify the patient's family/parent/guardian with each restraint/seclusion episode. The staff member stated occasionally the family/parent/guardian is not available. The staff member did not state how follow-up would occur in those situations.

Based on observation, policy and procedure review, record review, and staff interview, the hospital failed to ensure the provision of care in a safe setting for 1 of 2 closed patient (Patient #9) records reviewed of patients who experienced severe allergic reactions to food while hospitalized and for 2 of 2 sampled active patients (Patient #4 and #6) identified with food allergies. Failure to ensure patients do not receive foods they are allergic to limits the hospital's ability to provide care in a safe setting to their patients.

Findings include:

Review of the policy titled "Meal Service/Ordering Diets" occurred on 01/26/12. This policy, revised 02/09, stated, "Policy: to ensure an orderly and efficient means of notifying the food service department of patient diets. Procedure: . . .
4.0 Unit staff provides a meal ticket for the patient to take to the cafeteria to identify the proper diet of the patient. The meal tickets are kept on the Psych [psychiatric] Tech [technicians] clip board for use at meal times. . . .
4.1 The meal tickets are color coded as follows: . . .
4.1.3 Tan: Food Allergy Diets . . .
8.0 Unit staff escorts patients with off unit privileges to the cafeteria for noon and evening meal at the times specified for each population. . . .
8.1 Staff hands out meal tickets to patients in the cafeteria.
8.2 Patient presents color-coded meal ticket to the food server. . . ."

Review of the "Comprehensive Assessment Tool - Nursing Assessment: All Ages" occurred on January 24-26, 2012. The form, revised 11/11, completed by nursing staff upon each patient's admission, included a section for "Nutritional/Dietary Screen" with a "Points Rating" scale from 1-3. Food allergies received one point. This section identified "Report to Psychiatrist score of 3 or more . . . Consult required on all diabetic patients, no physician's order needed." The form did not identify any other situations staff would order a dietary consult.

- Review of Patient #9's medical record occurred on 01/24/12. The hospital admitted Patient #9 on 08/16/11 and discharged Patient #9 on 08/30/11. Patient #9's medical record included a form titled "Prairie St. John's Patient's Bill of Rights." This form, signed by the patient's guardian on 08/16/11, stated, "Subject to certain limitations authorized by a parent . . . each patient has the: . . . 3. Right to personal safety and security insofar as the hospital practices are concerned. . . ."

Patient #9's medical record included the following forms indicating the patient had an allergy to cayenne pepper:
- "Comprehensive Assessment Tool - Nursing Assessment," dated 08/16/11, under Allergies listed "1) cayenne pepper Reaction: anaphylactic"
- "Psychiatric Evaluation," dated 08/17/11, under Environmental Allergies listed "cayenne pepper"

Patient #9's "Nursing Assessment Note," dated 08/27/11, stated, ". . . This afternoon while the pt [patient] was at lunch pt reports that he ate a breakfast burrito that contained peppers. Pt told staff that he was allergic to peppers and that he was starting to have an allergic reaction. Pt was turning slightly red in the face and on call doctor was notified and [name of contracted medical service] MD [medical doctor] was here who was able to examine pt right away. Benadryl [an antihistamine] 50 mg [milligrams] IM [intramuscular] was ordered and pt received this injection immediately. Pt stated that he did start to feel relief short [sic] after receiving this injection. Pt's vitals were also ordered q [every] 15 minutes for 1 hour, then q 30 minutes for 2 hours . . ."

Patient's #9's "Authorized Prescriber Orders," dated 08/27/11 at 12:00 [p.m.], indicated a physician ordered Benadryl 50 mg IM x1 [times one] due to an allergic reaction to food.

During interview at 2:30 p.m. on 01/25/12, a nursing management staff member (#3) stated he did not know if staff had provided Patient #9 with a tan (food allergy) color coded meal ticket to present to the food server in the cafeteria for the noon meal on 08/27/12.

During interview at 3:00 p.m. on 01/25/12, a management staff member (#1) confirmed Patient #9 had off-unit privileges to obtain meals in the hospital cafeteria on 08/27/11. The staff member (#1) confirmed hospital staff knew of Patient #9's allergy to cayenne pepper upon admission and failed to ensure Patient #9 did not receive red/cayenne pepper while hospitalized.


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- On 01/24/12 at 11:15 a.m., observation occurred of psych techs ambulating with a group of children from the children's treatment unit to the cafeteria. Observation did not show the psych techs provided a meal ticket to each patient prior to each patient obtaining their main entree from dietary staff and continued to make their own individual choices through the remainder of the serving line.

During interview on 01/24/12 at 12:30 p.m., a staff nurse (#5) stated the facility identified patient dietary food allergies by using color coded sheets to identify diets different than regular diets. The patients take the colored coded sheets down to the lunch room when they go to eat. The nurse also stated staff remove those foods patients are allergic to from the nursing unit.

- On the afternoon of 01/24/12, review of Patient #4's medical record occurred. Patient #4 resided on a child/adolescent unit. The record identified the patient with a food allergy to squash. A nursing staff member (#9) stated staff identified patient allergies to food on a colored diet sheet which the adolescent carries with them to the dining room, gives to the server, and gives back to a staff member from the unit. The staff member provided copies of all the diet sheets for all the current patients residing on the unit, including those for patients on regular diets. The staff member (#9) stated staff also document allergies on the Kardex, and front of each patient's chart.

- On the afternoon of 01/24/12, review of Patient #6's medical record occurred. Patient #6's record identified the patient with the following food allergies: eggs, dairy and broccoli, and the affect on him/her as "vomiting." Between 5:00 and 5:15 p.m., observation occurred of a psych tech (#7) ambulating with Patient #6 and several other adults from an adult unit to the cafeteria. Observation did not show the psych tech (#7) provided a meal ticket to each patient prior to each patient obtaining their main entree from dietary staff, and continuing to make their own individual choices through the remainder of the serving line. Observation showed Patient #6 visited with the food service worker to obtain their main entree, and then continued to make his/her own food selections. Patient #6 chose mashed potatoes (possibly mashed with milk and/or butter) from the hot food service line, chocolate milk (carton), and tomato soup from the soup and salad bar.

At 5:30 p.m. on 01/24/12, an interview occurred with a random dietary staff member restocking the soup & salad bar regarding the tomato soup contents. The staff member did not know if the soup contained milk (dairy).

During interview on 01/25/12 at 9:00 a.m., a ward clerk/direct care staff member (#6) on an adult nursing unit identified the process of identifying dietary allergies. The staff member (#6) stated staff document allergies on the Kardex and on a sticker on the front of the patient's chart. The staff member (#6) also identified patients present a color coded sheet to the cafeteria staff for selection of the main entree which psych techs then collect. The staff member (#6) also stated the psych techs carry a "staffing sheet" to the dining room with the patients which identify allergies.

During interview on 01/25/12 at 9:10 a.m., a direct care staff member (#7) provided a copy of the "staffing sheet" described by the staff member (#6). The "staffing sheet" included all patients on the 4th floor (all adults); and identified all the special diets. The sheet included Patient #6 with the allergies and stated "No Dairy/Eggs/Broccoli." The sheet also included three patients on a diabetic diet, a patient identified as lactose intolerant, and a patient on a low sodium diet.

During interview on 01/25/12 at 10:00 a.m., a nursing staff member (#8) stated adult patients ask dietary staff regarding the ingredients in food as patients make their own food choices as "we encourage them to be responsible and make the right food choices as they have the right to eat what they want; we educate but can't force them." The nurse stated no dietary consult occurred for Patient #6 as the patient did not score greater than a 3 on her Nutritional/Dietary Screen on the "Comprehensive Assessment Tool-Nursing Assessment" as she scored in food allergies only.

During interview on 01/25/12 at 3:40 p.m., an administrative staff member (#1) stated dietary should provide patients meals based on their meal/diet restrictions and/or dietary allergies.

Based on policy and procedure review, record review, and staff interview, the hospital failed to investigate an allergic reaction to food for 1 of 2 patient (Patient #9) records reviewed of patients who experienced an allergic reaction to food while hospitalized. Failure to investigate this occurrence limited the hospital's ability to ensure patients do not experience an allergic reaction to food provided by the hospital while hospitalized.

Findings include:

Review of the policy titled "Risk Management" occurred on 01/26/12. This policy, revised 07/11, stated, "Scope: This policy applies to all of the Prairie St. John's levels of care and departments.
Purpose: A. To improve patient care, ensure safe practices through . . . evaluation of patient care, and intervention to reduce occurrences. . . .
Policy: . . . Definitions:
A. Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required (near miss) unexpected medical intervention . . .
Procedure: A. Any Prairie St. John's employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer Review (HPR) form. . . .
E. Record keeping and trending
1. The Risk Manager shall see that all necessary parties are informed of the incident regardless of severity classification and document this notification.
2. The Risk Manager shall also insure that the communication of unanticipated outcome process is properly functioning in the facility. . . ."

Review of Patient #9's medical record occurred on 01/24/12. The hospital admitted Patient #9 on 08/16/11 and discharged Patient #9 on 08/30/11. Patient #9's medical record included information obtained upon admission indicating the patient had an allergy to cayenne pepper with anaphylactic reactions. Patient #9's "Nursing Assessment Note," dated 08/27/11, indicated the patient experienced an allergic reaction to peppers requiring treatment by medical staff. Refer to A0144.

Review of the hospital's incident/occurrence reports occurred on 01/24/12. The records from August-December 2011 did not include a report for Patient #9's allergic reaction to peppers experienced on 08/27/11.

Review of the hospital's grievance records occurred on 01/25/12. The hospital responded to a grievance submitted by Patient #9's parent regarding the allergic reaction indicating nursing management staff had "retrained/educated staff involved in incident."

Review of the hospital's Quality Management Workgroup meeting minutes occurred on 01/25/12. The reports from July 25, 2011 through January 10, 2012 did not include evidence of an investigation regarding Patient #9's allergic reaction, implementation of corrective action to help prevent allergic reactions to food for the hospital's patients, or monitoring for compliance with the hospital's food allergy policies and procedures.

During interview at 10:45 a.m. on 01/25/12, an administrative staff member (#4) stated he did not have evidence in the grievance records of the training/education provided to staff regarding Patient #9's allergic reaction. The staff member (#4) stated he did not know if Patient #9 did not present a meal ticket to food servers or if the food servers did not check the ingredients of the food before serving Patient #9 on 08/27/11.

During interview at 2:30 p.m. on 01/25/12, a nursing management staff member (#3) stated he did not document training provided to staff involved in Patient #9's allergic reaction. The staff member (#3) stated he did not document or report to the quality assessment committee monitoring performed to ensure staff gives patients meal tickets regarding food allergies to present to food servers in the cafeteria. The staff member (#3) stated he did not know if Patient #9 did not present a meal ticket to food servers or if the food servers did not check the ingredients of the food before serving Patient #9 on 08/27/11.

During interview the morning of 01/26/12, an administrative staff member (#1) confirmed staff did not complete an occurrence report for Patient #9's allergic reaction on 08/27/11. A staff member (#1) stated the hospital did not investigate the incident to determine whether staff gave a meal ticket with food allergies listed to Patient #9 to present to the food servers or if the food servers knew the allergies and did not check the ingredients of the food before serving Patient #9 on 08/27/11. A staff member (#1) stated the hospital did not perform quality monitoring to ensure compliance with their food allergy policies and procedures as a result of Patient #9's allergic reaction.

1. Based on policy and procedure review, record review, and staff interview, the hospital failed to ensure staff notified the patient's guardian of a change in medical condition and to receive consent for administration of medication for 1 of 2 patient (Patient #9) records reviewed of patients who experienced an allergic reaction to food. Failure to notify patients' guardians of changes in medical conditions and to obtain consent for medication limits the patients' and guardians' right to be informed and make decisions regarding the patients' care.

Findings include:

Review of the procedure titled "Procedure Sheet for Medication Administration" occurred on 01/25/12. This procedure, revised 10/11, stated, ". . . Consent must be obtained for all patients with a guardian or under age prior to giving the first dose unless a specific 'May give without consent' order is received as in an emergency when withholding a medication may have a significant detrimental effect on the current status of the patient. . . ."

Review of Patient #9's medical record occurred on 01/24/12. The hospital admitted Patient #9 on 08/16/11 and discharged Patient #9 on 08/30/11. Patient #9's medical record included a form titled "Prairie St. John's Patient's Bill of Rights." This form, signed by the patient's guardian on 08/16/11, stated, "Subject to certain limitations authorized by a parent . . . each patient has the: . . . 5. Right to obtain current information concerning care in terms the patient can reasonably be expected to understand and to participate in planning of his/her services. . . ."

Patient #9's medical record included the following forms indicating the patient had an allergy to red/cayenne pepper:
- "Comprehensive Assessment Tool - Nursing Assessment," dated 08/16/11
- "Psychiatric Evaluation," dated 08/17/11

Patient #9's "Nursing Assessment Note," dated 08/27/11, stated, ". . . This afternoon while the pt [patient] was at lunch pt reports that he ate a breakfast burrito that contained peppers. Pt told staff that he was allergic to peppers and that he was starting to have an allergic reaction. Pt was turning slightly red in the face and on call doctor was notified and [name of contracted medical service] MD [medical doctor] was here who was able to examine pt right away. Benadryl [an antihistamine] 50 mg [milligrams] IM [intramuscular] was ordered and pt received this injection immediately. . . ."

Patient's #9's "Authorized Prescriber Orders," dated 08/27/11 at 12:00 [p.m.], indicated a physician ordered Benadryl 50 mg IM x1 [times one] due to an allergic reaction to food.

Patient #9's medical record lacked evidence staff received consent from the patient's guardian before administration of the Benadryl. The record indicated the physician did not order the medication as "May give without consent." Patient #9's medical record lacked evidence the hospital notified the patient's guardian after the patient experienced an allergic reaction to food.

During interviews at 2:30 p.m. and 3:00 p.m. on 01/25/12, a nursing management staff member (#3) and a management staff member (#1) confirmed Patient #9's record lacked evidence the physician ordered the Benadryl as "give without consent" and staff failed to contact the patient's guardian to obtain consent for the Benadryl. The staff members (#3) and (#1) confirmed staff failed to notify Patient #9's guardian of the allergic reaction and the treatment provided.


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2. Based on policy and procedure review, record review, and staff interview, the hospital failed to ensure staff notified the patient's family/parent/guardian following a restraint/seclusion procedure which occurred to 2 of 2 children (less than age 12) (Patient #1 and #2) reviewed on the child inpatient treatment unit and 1 of 1 child (Patient #3) reviewed on the child/adolescent inpatient treatment unit. Failure to notify patients' family/parent/guardian of restraint/seclusion procedures limits the family/parent/guardian's right to be informed and make decisions regarding the patients' care.

Findings include:

Review of the policy/procedure titled "Seclusion Guidelines-Hospital Based Services" occurred on 01/25/12. This procedure, revised 05/09, stated, "Policy: To use seclusion as an emergency management intervention when less restrictive alternatives have failed. . . . 8.0 The RN [Registered Nurse] documents the following information in the patient's medical record and seclusion/restraint justification form when seclusion occurs. . . .
8.1. Observed threat of harm to self or others. . . .
8.3. The rationale for the seclusion. . . .
8.5. Communication to the patient and as appropriate, the family, of need for seclusion and criteria for discontinuation of seclusion. . . .
8.6. Patient's response during the process of placement in seclusion.
8.7 The patient's understanding about their need for seclusion. . . ."

Review of a hospital form, titled "Philosophy and Practice for Seclusion & Restraint Use" occurred on 01/25/12. The form, signed by each patient's parent/guardian upon admission and completed by an RN, stated, "The parent/guardian will be notified when seclusion/restraint is used and the reason for this intervention in all cases with minors (patient younger than 18 years of age)."

Review of a hospital form, titled "RN Seclusion & Restraint Note" occurred during record reviews on January 24-25, 2012. The form included specific questions regarding each restraint/seclusion procedure including, "Was patient's family/parent/guardian/other notified? (Always notify the parent or guardian of minors)"

- Review of Patient #1's medical record occurred on 01/24/12. The record identified Patient #1 experienced four restraint and/or seclusion episodes between January 15 and January 22, 2012. The January 22 episode included 15 minutes of seclusion which included eight minutes of restraint due to the patient "head banging." The January 22 "RN Seclusion & Restraint Note" stated in the section for family/parent/guardian notification "Unable to get ahold of". Further review of the record lacked evidence the nurse/nursing staff contacted the family/parent/guardian.

- Review of Patient #2's medical record occurred on 01/24/12. The record identified Patient #2 experienced two restraint/seclusion procedures between January 16 and January 20, 2012. The January 16 "RN Seclusion & Restraint Note" lacked evidence the nurse/nursing staff contacted the guardian. Further review of the record lacked evidence of family/parent/guardian notification.

- Review of Patient #3's medical record occurred on 01/24/12. The record identified Patient #3 experienced four restraint/seclusion procedures between January 17 and January 23, 2012. The January 17 "RN Seclusion & Restraint Note" identified the patient in seclusion for 15 minutes. The note lacked evidence the nurse/nursing staff contacted the guardian. Further review of the record lacked evidence of family/parent/guardian notification.

During interview on the afternoon of 01/25/12, an administrative staff member (#1) stated the hospital requires nursing staff to notify the patient's family/parent/guardian with each restraint/seclusion episode. The staff member stated occasionally the family/parent/guardian is not available. The staff member did not state how follow-up would occur in those situations.

Based on observation, policy and procedure review, record review, and staff interview, the hospital failed to ensure the provision of care in a safe setting for 1 of 2 closed patient (Patient #9) records reviewed of patients who experienced severe allergic reactions to food while hospitalized and for 2 of 2 sampled active patients (Patient #4 and #6) identified with food allergies. Failure to ensure patients do not receive foods they are allergic to limits the hospital's ability to provide care in a safe setting to their patients.

Findings include:

Review of the policy titled "Meal Service/Ordering Diets" occurred on 01/26/12. This policy, revised 02/09, stated, "Policy: to ensure an orderly and efficient means of notifying the food service department of patient diets. Procedure: . . .
4.0 Unit staff provides a meal ticket for the patient to take to the cafeteria to identify the proper diet of the patient. The meal tickets are kept on the Psych [psychiatric] Tech [technicians] clip board for use at meal times. . . .
4.1 The meal tickets are color coded as follows: . . .
4.1.3 Tan: Food Allergy Diets . . .
8.0 Unit staff escorts patients with off unit privileges to the cafeteria for noon and evening meal at the times specified for each population. . . .
8.1 Staff hands out meal tickets to patients in the cafeteria.
8.2 Patient presents color-coded meal ticket to the food server. . . ."

Review of the "Comprehensive Assessment Tool - Nursing Assessment: All Ages" occurred on January 24-26, 2012. The form, revised 11/11, completed by nursing staff upon each patient's admission, included a section for "Nutritional/Dietary Screen" with a "Points Rating" scale from 1-3. Food allergies received one point. This section identified "Report to Psychiatrist score of 3 or more . . . Consult required on all diabetic patients, no physician's order needed." The form did not identify any other situations staff would order a dietary consult.

- Review of Patient #9's medical record occurred on 01/24/12. The hospital admitted Patient #9 on 08/16/11 and discharged Patient #9 on 08/30/11. Patient #9's medical record included a form titled "Prairie St. John's Patient's Bill of Rights." This form, signed by the patient's guardian on 08/16/11, stated, "Subject to certain limitations authorized by a parent . . . each patient has the: . . . 3. Right to personal safety and security insofar as the hospital practices are concerned. . . ."

Patient #9's medical record included the following forms indicating the patient had an allergy to cayenne pepper:
- "Comprehensive Assessment Tool - Nursing Assessment," dated 08/16/11, under Allergies listed "1) cayenne pepper Reaction: anaphylactic"
- "Psychiatric Evaluation," dated 08/17/11, under Environmental Allergies listed "cayenne pepper"

Patient #9's "Nursing Assessment Note," dated 08/27/11, stated, ". . . This afternoon while the pt [patient] was at lunch pt reports that he ate a breakfast burrito that contained peppers. Pt told staff that he was allergic to peppers and that he was starting to have an allergic reaction. Pt was turning slightly red in the face and on call doctor was notified and [name of contracted medical service] MD [medical doctor] was here who was able to examine pt right away. Benadryl [an antihistamine] 50 mg [milligrams] IM [intramuscular] was ordered and pt received this injection immediately. Pt stated that he did start to feel relief short [sic] after receiving this injection. Pt's vitals were also ordered q [every] 15 minutes for 1 hour, then q 30 minutes for 2 hours . . ."

Patient's #9's "Authorized Prescriber Orders," dated 08/27/11 at 12:00 [p.m.], indicated a physician ordered Benadryl 50 mg IM x1 [times one] due to an allergic reaction to food.

During interview at 2:30 p.m. on 01/25/12, a nursing management staff member (#3) stated he did not know if staff had provided Patient #9 with a tan (food allergy) color coded meal ticket to present to the food server in the cafeteria for the noon meal on 08/27/12.

During interview at 3:00 p.m. on 01/25/12, a management staff member (#1) confirmed Patient #9 had off-unit privileges to obtain meals in the hospital cafeteria on 08/27/11. The staff member (#1) confirmed hospital staff knew of Patient #9's allergy to cayenne pepper upon admission and failed to ensure Patient #9 did not receive red/cayenne pepper while hospitalized.


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- On 01/24/12 at 11:15 a.m., observation occurred of psych techs ambulating with a group of children from the children's treatment unit to the cafeteria. Observation did not show the psych techs provided a meal ticket to each patient prior to each patient obtaining their main entree from dietary staff and continued to make their own individual choices through the remainder of the serving line.

During interview on 01/24/12 at 12:30 p.m., a staff nurse (#5) stated the facility identified patient dietary food allergies by using color coded sheets to identify diets different than regular diets. The patients take the colored coded sheets down to the lunch room when they go to eat. The nurse also stated staff remove those foods patients are allergic to from the nursing unit.

- On the afternoon of 01/24/12, review of Patient #4's medical record occurred. Patient #4 resided on a child/adolescent unit. The record identified the patient with a food allergy to squash. A nursing staff member (#9) stated staff identified patient allergies to food on a colored diet sheet which the adolescent carries with them to the dining room, gives to the server, and gives back to a staff member from the unit. The staff member provided copies of all the diet sheets for all the current patients residing on the unit, including those for patients on regular diets. The staff member (#9) stated staff also document allergies on the Kardex, and front of each patient's chart.

- On the afternoon of 01/24/12, review of Patient #6's medical record occurred. Patient #6's record identified the patient with the following food allergies: eggs, dairy and broccoli, and the affect on him/her as "vomiting." Between 5:00 and 5:15 p.m., observation occurred of a psych tech (#7) ambulating with Patient #6 and several other adults from an adult unit to the cafeteria. Observation did not show the psych tech (#7) provided a meal ticket to each patient prior to each patient obtaining their main entree from dietary staff, and continuing to make their own individual choices through the remainder of the serving line. Observation showed Patient #6 visited with the food service worker to obtain their main entree, and then continued to make his/her own food selections. Patient #6 chose mashed potatoes (possibly mashed with milk and/or butter) from the hot food service line, chocolate milk (carton), and tomato soup from the soup and salad bar.

At 5:30 p.m. on 01/24/12, an interview occurred with a random dietary staff member restocking the soup & salad bar regarding the tomato soup contents. The staff member did not know if the soup contained milk (dairy).

During interview on 01/25/12 at 9:00 a.m., a ward clerk/direct care staff member (#6) on an adult nursing unit identified the process of identifying dietary allergies. The staff member (#6) stated staff document allergies on the Kardex and on a sticker on the front of the patient's chart. The staff member (#6) also identified patients present a color coded sheet to the cafeteria staff for selection of the main entree which psych techs then collect. The staff member (#6) also stated the psych techs carry a "staffing sheet" to the dining room with the patients which identify allergies.

During interview on 01/25/12 at 9:10 a.m., a direct care staff member (#7) provided a copy of the "staffing sheet" described by the staff member (#6). The "staffing sheet" included all patients on the 4th floor (all adults); and identified all the special diets. The sheet included Patient #6 with the allergies and stated "No Dairy/Eggs/Broccoli." The sheet also included three patients on a diabetic diet, a patient identified as lactose intolerant, and a patient on a low sodium die

Based on policy and procedure review, record review, and staff interview, the hospital failed to investigate an allergic reaction to food for 1 of 2 patient (Patient #9) records reviewed of patients who experienced an allergic reaction to food while hospitalized. Failure to investigate this occurrence limited the hospital's ability to ensure patients do not experience an allergic reaction to food provided by the hospital while hospitalized.

Findings include:

Review of the policy titled "Risk Management" occurred on 01/26/12. This policy, revised 07/11, stated, "Scope: This policy applies to all of the Prairie St. John's levels of care and departments.
Purpose: A. To improve patient care, ensure safe practices through . . . evaluation of patient care, and intervention to reduce occurrences. . . .
Policy: . . . Definitions:
A. Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required (near miss) unexpected medical intervention . . .
Procedure: A. Any Prairie St. John's employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer Review (HPR) form. . . .
E. Record keeping and trending
1. The Risk Manager shall see that all necessary parties are informed of the incident regardless of severity classification and document this notification.
2. The Risk Manager shall also insure that the communication of unanticipated outcome process is properly functioning in the facility. . . ."

Review of Patient #9's medical record occurred on 01/24/12. The hospital admitted Patient #9 on 08/16/11 and discharged Patient #9 on 08/30/11. Patient #9's medical record included information obtained upon admission indicating the patient had an allergy to cayenne pepper with anaphylactic reactions. Patient #9's "Nursing Assessment Note," dated 08/27/11, indicated the patient experienced an allergic reaction to peppers requiring treatment by medical staff. Refer to A0144.

Review of the hospital's incident/occurrence reports occurred on 01/24/12. The records from August-December 2011 did not include a report for Patient #9's allergic reaction to peppers experienced on 08/27/11.

Review of the hospital's grievance records occurred on 01/25/12. The hospital responded to a grievance submitted by Patient #9's parent regarding the allergic reaction indicating nursing management staff had "retrained/educated staff involved in incident."

Review of the hospital's Quality Management Workgroup meeting minutes occurred on 01/25/12. The reports from July 25, 2011 through January 10, 2012 did not include evidence of an investigation regarding Patient #9's allergic reaction, implementation of corrective action to help prevent allergic reactions to food for the hospital's patients, or monitoring for compliance with the hospital's food allergy policies and procedures.

During interview at 10:45 a.m. on 01/25/12, an administrative staff member (#4) stated he did not have evidence in the grievance records of the training/education provided to staff regarding Patient #9's allergic reaction. The staff member (#4) stated he did not know if Patient #9 did not present a meal ticket to food servers or if the food servers did not check the ingredients of the food before serving Patient #9 on 08/27/11.

During interview at 2:30 p.m. on 01/25/12, a nursing management staff member (#3) stated he did not document training provided to staff involved in Patient #9's allergic reaction. The staff member (#3) stated he did not document or report to the quality assessment committee monitoring performed to ensure staff gives patients meal tickets regarding food allergies to present to food servers in the cafeteria. The staff member (#3) stated he did not know if Patient #9 did not present a meal ticket to food servers or if the food servers did not check the ingredients of the food before serving Patient #9 on 08/27/11.

During interview the morning of 01/26/12, an administrative staff member (#1) confirmed staff did not complete an occurrence report for Patient #9's allergic reaction on 08/27/11. A staff member (#1) stated the hospital did not investigate the incident to determine whether staff gave a meal ticket with food allergies listed to Patient #9 to present to the food servers or if the food servers knew the allergies and did not check the ingredients of the food before serving Patient #9 on 08/27/11. A staff member (#1) stated the hospital did not perform quality monitoring to ensure compliance with their food allergy policies and procedures as a result of Patient #9's allergic reaction.