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Based on document review and interview, the hospital failed to provide written notification to complainants in response to grievances.

Failure of the hospital to provide written notice of the outcome of their grievance investigation, and steps taken on behalf of the patient or the patient's family to investigate the grievance violates their right to be informed of how the hospital investigated and resolved the grievance.

Findings included:

1. Document review of the hospital's policy titled, "Grievances and the Patient Advocate," effective date 5/17, showed that that each patient and others making a complaint will receive a response from the facility staff that addresses the complaint within 1 week and written responses to grievances are to be provided within 30 days of the filed grievance.

2. On 04/04/19, Surveyor #5 reviewed the discharge medical record for Patient #506 who was admitted on 02/03/19 for the treatment of Schizophrenia, suicidal ideation, and medication non-compliance. The record review showed:

-On 02/19/19 at 2:24 PM, an Inpatient Progress note completed by a Program Manager (Staff #509) showed that the complainant had contacted the hospital via phone related to concerns about the patient's discharge plan. Staff #509 documented that she provided the complainant with her fax number and documented that she told the complainant she would forward the fax to the patient's treatment team.

-An undated typed document from the complainant titled, "Postscript after speaking with Staff #509 stated, "We do not think this discharge plan is safe," and asked the facility to assist them to create a good discharge plan together.

On 02/19/19 at 4:48 PM, the Program Manager (Staff #509) documented that she had received the fax from the complainant and would send to the patient's treatment team.

Surveyor #5 found no evidence in the record the complainant received a response from the facility staff that addressed the complaint or a written response to the grievance within 30 days of the filed grievance.

3. On 04/04/19, Surveyor #5 reviewed the hospital's grievance log. Surveyor #5 found no evidence the grievance coordinator documented the written complaint or resolution on the hospital's grievance log.

4. On 04/04/19 at 2:00 PM, the Director of Clinical Services (Staff #508) stated that the patient was discharged on a court release; and the treatment team only met once a week and did not meet again prior to the patient's discharge. She stated that she was unsure of the complaint resolution and verified it was not logged onto the hospital's grievance log.
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Based on observation, document review, and interview, the hospital failed to ensure dietary modifications related to disease, food allergy, or lifestyle were communicated, implemented, and provided to its patients, and failed to provide oversight of non-dietary staff performing dietary functions.

Failure to provide for the nutritional needs of patients, including dietary modifications resulting from diagnosis, disease, or lifestyle choice, and providing effective oversight of dietary department functions risks patients receiving inadequate nutrition, patient harm, and patient death and resulted in an unsafe environment for patients.

Findings included:

Cross Reference A0620:

Failure to provide supervision of personnel providing dietary services, and implementing policies and procedures that ensure that patients with food allergies or other special dietary needs are implemented, risks patients receiving improper nutrition that could lead to unanticipated patient outcomes, harm, and death.

Cross Reference A0629:

Failure to ensure that patients requiring dietary modifications receive the appropriate diet risks improper nutrition that could lead to unanticipated patient outcomes, harm, and death

Due to the scope and severity of the deficiencies detailed under 42 CFR 482.28, the Condition for Participation for Food and Dietetic Services was NOT MET.
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Based on observation, document review, and interview, the hospital failed to ensure that a dietician responsible for the daily management of dietary services, implemented training programs for non-dietary staff performing dietary functions. Additionally, the hospital failed to ensure that established policies and procedures were implemented that addressed supervision of work by non-dietary personnel performing dietary functions.

Failure to provide supervision of personnel providing dietary services, and implementing policies and procedures that ensure that patients with food allergies or other special dietary needs are implemented, risks patients receiving improper nutrition that could lead to unanticipated patient outcomes, harm, and death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Food Allergies," no policy number, effective 05/17, showed that a Registered Nurse (RN) needs to ensure that the foods the patient is allergic to are not available to the patient either on the tray or for snacks. The Food Service Manager will check all foods for the patient (including snacks) to ensure the patient is not given food they are allergic to.

Document review of the hospital's policy and procedure titled, Nourishment between Meals," no policy number, effective date 05/17, showed that special snacks will be written by the dietician and recorded on the special snack list. The dietary aide will prepare the snacks, label them, and place them in the bin with the general snacks for each unit. The dietician oversees food items used for snacks and plans special snacks when appropriate for clients following a modified diet. The dietician is responsible for updating the special snack list. The dietician instructs dietary aides about special dietary restrictions.

2. On 04/02/19 at 10:30 AM, Surveyor #5 observed a dietary staff bring a gray bin filled with snacks, and place it on the front nurse's station desk and then leave. A Mental Health Technician (Staff #504) gave the patient's their snacks after the patients looked in the bin and requested their snack.

3. On 04/02/19 at 10:40 AM, during the mid-morning snack period, Surveyor #5 observed a Mental Health Technician (Staff #504) give Patient #501 a snack that was labeled as "100% Whole Wheat." Surveyor #5 observed the patient open and then ingest the 100% Whole Wheat snack.

At this time, Surveyor #5 immediately asked Staff #504 if she was aware of the patient's food allergies. Staff #504 stated she was not sure what all the allergies were and that she would need to review the medical record. Surveyor #5 showed Staff #504 the allergy documentation in the medical record which showed an allergy to wheat. At that time, Staff #504 took the remaining snack away from the patient. Staff #504 did not review the dietary card prior to providing the wheat-containing snack. Surveyor #5 did not observe any labeled snacks inside the bin for patients with diet modifications or allergies. Surveyor #5 did not observe any RN or dietary oversight from the dietary manager during the snack process.

4. On 04/02/19 at 10:49 AM, Patient #502 presented to the nurse's station and asked for "Sun Chips" for his midmorning snack. Staff #501 and a Mental Health Technician (Staff #502), paused and told the patient they did not know if he could have them, and they would need to review the diet order for carbohydrate restriction. At the time, the patient appeared confused that he was no longer allowed "Sun Chips" and stated that he could have them, but if not he would have popcorn. Surveyor #5, Staff #501, and Staff #502 were unable to locate a carbohydrate range in the medical record. Staff #501 confirmed the provider ordered the patient to receive low sugar, high protein snacks related to elevated blood sugars.

On 04/03/19 at 10:30 AM, Surveyor # 5 and a Program Manager (Staff #503), reviewed the dietary card for Patient #502. The dietary card did not show that the patient had to receive low sugar, high protein snacks. Staff #503 verified the finding and stated that the staff should have updated the dietary card to reflect the dietary modification.

5. On 04/02/19 at 2:00 PM, Surveyor #5 interviewed the Dietician (Staff #505) and the Food Service Manager (Staff #506) about the food allergy findings for Patient #501 and the dietary modifications for Patient #502. Staff #505 stated that it is the nurse's responsibility to review the dietary card for allergies and any diet modifications when providing the appropriate snack. He stated the Food Service Manager did not check the snacks to ensure the patient is not given a food that the patient has an allergy to.

Staff #506 stated that the nurses fax the provider diet orders to the food service department and the nurses are responsible for checking the diet card and ensuring the patient does not receive a food they are allergic to. She stated that nursing staff did not receive oversight supervision from Dietary.
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Based on record review, interview and review of hospital policy and procedure, the hospital failed to ensure that the discharge and transfer plans and post discharge prescriptions were included in the transfer of Patient #906 to an Inpatient Drug Treatment Facility.

Failure to ensure the patient and receiving facility receive a copy of the discharge/transfer documents to include any post discharge prescriptions puts the patient at risk for missed doses of medication and possible harm.

Findings included:

1. Document review of the hospital's policy titled, "Discharge Planning," no policy number, effective 05/17, showed that the discharge plan is to prepare the patient and family for the transition of care and it should address the Patient's instructions for continued treatment. Additionally, the discharge plan is to include timely and direct communication with transfer of information to programs that are continuing care.

2. During closed record review, Surveyor #9 reviewed the discharge planning and supporting documents of Patient #906. The review showed that only pages 1-3 of a 10 page "Discharge and Transition Plan" appeared to have been faxed; there was no cover page in the record to confirm where the documents had been faxed to. The hospital was not able to locate the remaining seven pages of the discharge and transition plan. Also missing from the discharge documents were copies of the medication prescriptions to be filled after discharge.

3. On 04/05/19 at 11:00 AM, Surveyor #9 discussed her review of Patient #906's discharge and transition documents with the discharge-planning supervisor (Staff #907). Staff #907 confirmed that copies of the complete discharge transition plan and medication prescriptions should be part of the medical record. She attempted to locate the missing information; however, it was not located by the end of the survey. The surveyor noted that the patient was to have had several prescriptions for psychiatric medications as well as prescriptions for Lantus (long acting insulin) and Lispro (short acting) insulin.

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