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During an onsite Federal survey, it was revealed that, (1) patient #25 of 30 patients reviewed, was not released from restraint at the earliest possible time, (2) patients #26, and 27 were restrained/secluded without criteria of dangerousness, (3) Quiet Room is mandated by staff, making Quiet Room tantamount to seclusion, and (4) The Restraint/Seclusion Order sheet reveals inappropriate behavioral criteria for release from restraint/seclusion.

Patient #25 is a 47-year-old male admitted on 3/1/2010 for depression, anxiety, hallucinations, and delusions. Patient #25 had recently discharged from another facility, and was now hearing voices and thinking that he had to sell brushes as a Fuller Brush man (a job he once had). Patient #25 was given a diagnosis of Bipolar Disorder, most recent episode, Depressed.

On 3/8/2010 at 11:30 pm, patient #25 was placed in 4-point after attempting to cut his wrist with light switch cover. Documentation indicates that by 3/9/2010 at 2 am, patient #25 was awake, quiet, and continued to be so until 2:30 am when he is documented as sleeping. At 9 am, an RN note states, " Spoke with pt. (patient). Has no insight and blames staff for his behavior. Was calm, verbal and agrees to have a limb released for meds and meals. Informed pt. Dr. ___ will evaluate in AM. " Patient #25 was kept in 4-point restraint until 3/9 at 9:15 am. The RN writes, " Seen by ___ 4 pt D/C (discontinued). In QR (quiet room). "

The hospital failed to offer other observational intervention options after patient #25 became calm, yet was still awake at 1:45 am. Though the psychiatrist intervened and discontinued restraint, the RN indicated she would have removed the restraints limb by limb, even tough patient #25 had met criteria for release. The hospital failed to end restraint at the earliest possible time.

Patient #26 is a 26-year-old male, admitted voluntarily on 4/8/2010 due to suicidal ideation, with a plan to overdose on lortab and coricidin. Patient #26 had been abusing vicodin for some weeks, and was depressed and irritable. Diagnosis for patient #26 were Bipolar Disorder, type 1, most recent episode, depressed, and polysubstance abuse.

On 4/9/2010 at 6:53 pm, nursing documented that patient #26 was on constant visual observation due to him being " Irritable and intense. " At 6:53 pm, patient #26 denied homicidal/suicidal ideation. At 11:59 pm, patient #26 became, " Increasingly agitated after being told he would have to remain in constant observation and sleep in the quiet room. " The patient stated, " You have really made me mad now, " and went to his room to get a sheet, which he placed around his head on return. Nursing writes, " When told the sheet would have to be taken, and his jeans were being taken out of the quiet room, patient grabbed his jeans and slammed the quiet room door and threatened staff. " Patient #26 was placed in 4-point restraint.

At 12:45 am, patient #26 is documented as being, quiet. At 3:40 am, staff notes patient #26 to be " Polite and cooperative, " and " LUE (left upper extremity) restraint removed. " At 6:15 am, nursing removed the Right lower extremity restraint. At 7:48 am after seen by the psychiatrist, both remaining restraints were removed.

Staff believed patient #26 required close observation. Staff mandated the voluntary process of quiet room, and that patient #26 give up his clothing. No documentation reveals what patient #26 had done to warrant this decision; no observational options were offered such as 1:1, and no information was given to patient #26 that quiet room is a voluntary process, and that he had a choice. Consequently, patient #26 escalated, and was placed in 4-point restraint.

After patient #26 met criteria to come out of restraint, staff delayed discontinuation by 4 hours while taking his limbs out one-at-a-time, when by regulation, staff should have released him immediately. The hospital failed to honor patient #26 ' s right to be free of restraint or seclusion.

Patient # 27 is a 19-year-old male admitted on a voluntary basis from another hospital after maternal reports that he had not slept for days, and had been acting in an erratic manner, with impulsivity, and euphoria. Patient #27 ' s toxicology screen was positive for marijuana. On admission, patient #27 was very uncooperative, paranoid, and agitated.

On 3/27/2010 patient #27 was manic and psychotic on admission. An RN note states in part, " Pt. (patient) very uncooperative during admission process stating ' Everything is negative. ' Anything you ask, the answer is no. He refused to sign all forms, " and, " Pt. placed in open door quiet room. " It is unclear what staff means by Open door quiet room, " as quiet room is a voluntary process, and no order for seclusion appears in the record at that time, but patient #1 was put in the quiet room from 10:15 pm until midnight. No indication of patient #27 ' s agreement to use the quiet room (QR) is documented. No discussion of desired behaviors is found. Patient #27 was monitored every 15 minutes, but no nursing note of when patient #27 came out of QR is found. This mandating of quiet room in order to provide constant observation, is in actuality, seclusion.

On 3/28/2010, at 7:30 pm, patient #27 picked up a chair as though he might throw it. At staff request, he put the chair down, and was asked to go to the QR. He refused. An RN note states in part, " Pt became severely agitated, and security was called. " Patient #27 was " Taken down to the mat in QR ....and was instructed to remain in QR. " Patient #27 initially exhibited imminent dangerousness. Staff had cause to seclude. Instead, staff mandated QR which is tantamount to seclusion, though no order for seclusion is found.

On 3/29/2010 at 1:24 am, an RN writes in part, " Pt. woke and came out of the QR, and into DR (day room) Remains confused, and defiant. Refused to go back into QR initially until security came onto unit. Patient attempted to walk back to room and had to be redirected several times back into QR, "and, " Came out of QR again asking for the apple and PB (peanut butter) he refused earlier. After giving the snack, to Pt. he started jogging down the hallway and said, " You have to catch me. " Patient #27 was mandated to the QR. He attempted to go to his own room, which might have been an interventional option, but was stopped and again mandated back to the QR, and again was essentially, secluded.

On 3/29/2010 at 8:30 am, staff secluded patient #27 for, " Escalating, testing limits, refused to stay in QR, coming out, continued to open door. " Criteria for exit from seclusion is documented as " Able to follow direction. " Renewals of seclusion for 3/29 at 4:30 pm, and 8:30 pm and on 3/30 at 12:30 am, and 4:30 am, list no behavioral criteria for release. The 8:30 pm order was obtained as a telephone order. The RN documents in part, " Dr. ____ was notified in regards to renewing locked door seclusion order. Dr.___ stated, " Keep patient in LDS (locked door seclusion) until the morning." The physician statement pre-empts assessments for dangerousness, and violates patient # 27 ' s right to have seclusion discontinued at the earliest possible time.

Patient #27 was kept in seclusion for 27 hours due to assessment findings such as, " Unable to follow polite directions, " and " Pt. continues to test limits. " This is in addition to the mandated hours he spent in the mandated Quiet Room.

Following seclusion, patient #27 was asked to remain in the quiet room. Documentation reveals his agreement. At 11:45 am, RN documentation states, " Pt. came out of quiet room to say goodbye to pt leaving. He was redirected back to quiet room. He continued to come out ignoring staff and security. Pt. Became aggressive and combative, when directed back into quiet room. Code green called. " Patient #27 was again secluded for 3 ½ hours. Seclusion was discontinued at 3:30 pm.

According to documentation, staff once had criteria of imminent dangerousness when patient #27 raised a chair to throw. However, no other documented behaviors indicated imminent dangerousness, or criteria to seclude patient #27 during those 27 and 3 ½ hours. Documentation on 15-minute observations largely show patient #27 restless, asleep, and quiet. Patient #27 was secluded due to difficult-to-manage manic behaviors, for the convenience of staff, and not for immediacy of dangerousness to self or others. In doing so, the hospital violated patient #27 ' s right to be right to be free of seclusion.

The Seclusion/Restraint order sheet lists 3 " Behavioral Criteria For to Regain Control and Release of Restraints (seclusion is not mentioned in this part). The three criteria are described as (1) Contracts for safety, (2) Other ___, (where staff can write in criteria), and (3) Ceases verbal Threats For ____ minutes, or hours. Staff write in the time period in which the patient must cease verbal threats. Documentation indicates that " 4 hours " is the time staff uses in this section.

While it is desirable to gain verbal compliance with patients, contracting for safety is not a valid criterion for release from restraint/seclusion. Likewise, putting a time on how long a patient must be without verbal threats, does not adequately address all behavioral issues, and may be confusing to staff who are charged with discontinuing restraint and seclusion at the earliest possible time.

Patient #26, and 27 of 30 patients reviewed were mandated to, and confined in the Quiet Room, which constitutes seclusion.

The Code of Maryland Regulations (COMAR) 10.21.12.11Use of Quiet Room states that:
(1) A patient may request the use of a quiet room and, unless clinically contraindicated, may be granted use of a quiet room.
(2) Unless staff terminates use of the quiet room for clinical reasons, the patient may terminate self-initiated use of the quiet room at any time.
B. Staff Request.
(1) When staff, permitted by the facility to initiate and terminate use of a quiet room, determine that the use of the quiet room is clinically indicated, staff may request that a patient voluntarily enter into the quiet room.
(2) Staff may not coerce a patient into entering the quiet room.
(3) When the patient enters the quiet room, staff shall discuss with the patient:
(a) The recommended length of stay in the quiet room;
(b) The behaviors expected of the patient before and upon return to the milieu; and
(c) The primary interventions to be initiated if the use of the quiet room is terminated by the patient before the time recommended by staff or is determined to be ineffective.
C. Staff shall determine the need for removal of any harmful objects in the room or from the patient.
D. If staff determine a need for objects to be removed pursuant to § C of this regulation, staff shall ask the patient, in a nonthreatening manner, to surrender the objects.
E. While a quiet room is in use, the staff shall assure that the quiet room door is not locked or in a position that prevents a patient from exiting the room voluntarily.
F. Observation and Documentation. Staff shall:
(1) Be assigned to monitor the patient and the safety of the environment while a patient is in the quiet room;
(2) When the quiet room is used as a clinical intervention, observe the patient at least once every 30 minutes and document the observation in the patient's medical record; and
(3) At least every 2 hours, evaluate the effectiveness of the outcome and document the clinical rationale for continued use of the quiet room.
G. A physician shall review the use of the quiet room after 6 hours and, if use of the quiet room is continued, at least every 24 hours after that.
H. Use of a quiet room may be terminated at any time:
(1) Upon the decision of the patient; or
(2) As clinically determined by staff.

Patient #26 is a 26-year-old male, admitted voluntarily on 4/8/2010 due to suicidal ideation, with a plan to overdose on Lortab and coricidin. Patient #26 had been abusing vicodin for some weeks, and was depressed and irritable. Diagnosis for patient #26 were Bipolar Disorder, type 1, most recent episode, depressed, and polysubstance abuse.

On 4/9/2010 at 6:53 pm, nursing documented that patient #26 was on constant visual observation due to being " Irritable and intense. " At 6:53 pm, patient #26 denied homicidal/suicidal ideation. At 11:59 pm, patient #26 became, " Increasingly agitated after being told he would have to remain in constant observation and sleep in the quiet room. " The patient stated, " You have really made me mad now, " and went to his room to get a sheet, which he placed around his head on return. Nursing writes, " When told the sheet would have to be taken, and his jeans were being taken out of the quiet room, patient grabbed his jeans and slammed the quiet room door and threatened staff. " Patient #26 was placed in 4-point restraint.

Staff believed patient #26 required constant observation. To accomplish constant observation, staff mandated the voluntary process of quiet room, and had patient #26 give up his clothing. No documentation reveals what patient #26 had done to warrant the decision to seclude him in quiet room; no other observational options were offered such as 1:1, and no information was given to patient #26 that quiet room is a voluntary process, and that he had a choice. Consequently, patient #26 escalated, and was placed in 4-point restraint.

The hospital failed to honor the rights of patient #26 by mandating quiet room as a constant observation process, not in compliance with regulatory standards.

Patient # 27 is a 19-year-old male admitted on a voluntary basis from another hospital after maternal reports that he had not slept for days, and had been acting in an erratic manner, with impulsivity, and euphoria. Patient #27 ' s toxicology screen was positive for marijuana. On admission, patient #27 was very uncooperative, paranoid, and agitated.

On 3/27/2010 patient #27 was manic and psychotic on admission. An RN note states in part, " Pt. (patient) very uncooperative during admission process stating ' Everything is negative. ' Anything you ask, the answer is no. He refused to sign all forms, " and, " Pt. placed in open door quiet room. " It is unclear what staff means by Open door quiet room. " No indication of patient #27 ' s agreement to use the quiet room (QR) is documented. No discussion of desired behaviors is found.

On 3/28/2010, at 7:30 pm, patient #27 picked up a chair as though he might throw it. At staff request, he put the chair down, and was asked to go to the QR. He refused. An RN note states in part, " Pt became severely agitated, and security was called. " Patient #27 was " Taken down to the mat in QR ....and was instructed to remain in QR. " Patient #27 showed imminent dangerousness. Staff had cause to seclude. Instead, staff mandated QR.

Though the hospital Seclusion/Restraint policy comprehensively lists interventions other than seclusion/restraint, in practice, the hospital demonstrates a narrow range of observational options, which revolve around the quiet room, i.e. " constant observation. " Consequently, the hospital uses the voluntary process of the quiet room as a mandatory process for those needing constant observation. Mandated quiet room is tantamount to seclusion, and violates the rights of patients who prefer other options, who are not informed of the voluntary aspects of quiet room, and who may not tolerate the observational confines of one room. As demonstrated in the documentation of patients #26 and 27, mandating quiet room can lead to unnecessary patient escalation and an actual need for seclusion and restraint.

An order for restraint of patient #26 of 30 patients reviewed, was written prior to evaluation for release, and errored when the order was not needed.

Patient #26 is a 26-year-old male, admitted voluntarily on 4/8/2010 due to suicidal ideation, with a plan to overdose on Lortab and coricidin. Patient #26 had been abusing vicodin for some weeks, and was depressed and irritable. Diagnosis for patient #26 were Bipolar Disorder, type 1, most recent episode, depressed, and polysubstance abuse.

On 4/9/2010 at 6:53 pm, nursing documented that patient #26 was on constant visual observation due to being " Irritable and intense. " At 6:53 pm, patient #26 denied homicidal/suicidal ideation. At 11:59 pm, patient #26 became, " Increasingly agitated after being told he would have to remain in constant observation and sleep in the quiet room. " The patient stated, " You have really made me mad now, " and went to his room to get a sheet, which he placed around his head on return. Nursing writes, " When told the sheet would have to be taken, and his jeans were being taken out of the quiet room, patient grabbed his jeans and slammed the quiet room door and threatened staff. " Patient #26 was placed in 4-point restraint.

Documentation indicates that patient #26 was placed in 4-point restraint at 11:40 pm, with a renewal of restraint on 4/10/2010 at 3:40 am. Patient #26 was taken out of restraint at 7:30 am. However, a restraint order written as a telephone order sometime prior to his evaluation appears in the record with a time of 7:40 am. Since patient #26 was taken out of restraint at 7:30 am, the order appears to have been was written as a prn order, and is inconsistent with regulatory directives.

Hospital policy states, " PRN (as needed) or standing orders for restraint/seclusion are not permitted and will not be accepted or transcribed.

The hospital failed to act in accordance with regulation and hospital policy when this order was written prior to the patient evaluation.

Based on record review, staff interview and observation, it was determined that the facility staff failed to obtain and evaluate a patient's weights when he was experiencing fluid overload. The findings include:

Patient # 1 is an 87 year old male with diagnoses that include but are not limited to severe lung disease, pulmonary hypertension, lower extremity cellulitis, respiratory failure, anemia of chronic disease with low iron levels, acute kidney failure on chronic kidney failure, fluid overload, heart failure and diabetes.

Review of the patient's medical record on 04/28/10 revealed that his serum albumin (a common indicator of protein malnutrition) was found to be severely depleted (between 1.9-2.0) on 04/16/10, 04/21/10, 04/25/10, and 04/26/10. He was also noted to be on Lasix (a diuretic) due to edema and fluid overload.

Additional record review revealed that on 04/15/10, the patient was admitted weighing 267 pounds. From the time of admission until 04/28/10, no further weights had been obtained. This was confirmed upon interview with facility staff.

Due to the patient's numerous medical conditions and acuity level, frequent weight monitoring would be warranted to assist caregivers in monitoring his overall health and nutritional status.

A review of medical records revealed (1) that three of 30 records reviewed contained unsigned telephone orders in violation of section VI of the hospital ' s " Medical Record Documentation and Completion Requirements " policy which calls for telephone orders to be signed within 48 hours, or, in the case of restraint/seclusion orders, 24 hours, (2) Quiet room notes for patient #25, 26, and 27 are incomplete (3) Missing behavioral criteria on continuation of seclusion order (4) debriefings are noted per hospital policy, (5) QR notes and termination, (6) restraint/seclusion docs

Patient #8 ' s record revealed the following telephone orders which were not signed within 48 hours by the practitioner who gave the order:
1) 4/13/10 at 10:40 pm with parameters for giving/changing Tylenol doses
2) 4/14/10 at 1:35 am for giving a normal saline bolus and blood pressure monitoring parameters
3) 4/14/10 at 5:50 pm to cancel sputum and obtain pulmonary consult
4) 4/17/10 at 8:00 am to draw a vancomycin trough
5) 4/17/10 at 3:45 pm to discontinue airborne isolation and sputum AFB smear

Patient #9's medical record revealed the following telephone orders which were not signed within 48 hours by the practitioner who gave the order:
1) 4/23/10 at 6:30 pm to discontinue Fragmin
2) 4/23/10 at 9:55 pm to access patient ' s port

Patient #27 ' s record revealed two telephone seclusion orders which were not signed within 24 hours by the practitioner who gave the order:
1) 3/29/2010 8:30 pm for continuation of seclusion
2) 3/30/2010 12:30 am for continuation of seclusion

Patient # 25, 26 and 27 ' s records revealed no quiet room notes consistent with COMAR 10.21.12.11.

1) 3/3/2010 4:30 pm until 3/4 at 10 pm, Patient #25
2) 3/7/2010 12 noon until 2:15 pm, Patient #25
3) 3/7/2010 11:15 pm until 3/8/2010 8 am, Patient #25
4) 3/8/2010 2:15 pm until 11:30 pm, Patient #25
5) 3/9/2010 3:45 am until 11:45 am, Patient #25
6) 3/27/2010 10:15 pm until midnight, Patient #27
7) 3/28/2010 1 pm until 4:30 pm Patient #27
8) 3/28/2010 7:15 pm to 3/29 at 8:30 am, Patient #27
9) 4/9/2010 from 3:30 pm until 11:59 pm, Patient #26
10) 4/10/2010 from 7:30 am until 10:45 am, Patient #26
11) 4/10/2010 from 2 pm until 4/11/2010 at 7:30 am, Patient #26

Patient #26 ' s record reveals no behavioral criteria for release of 4-point restraint on 3/29/2010 at 4:30 pm.

During a tour of the Emergency Department, a high alert medication vial was found in a bin with other medication vials.

On April 27, 2010 during a tour of the Emergency Department, a surveyor noted various open bins holding vials labeled by medication . The surveyor noted a vial of the high alert medication, succinylcholine in an inappropriately marked box. It appeared that succinylcholine box was too full to hold all the succinylcholine and a vial was inadvertently moved to the another bin.

The storage of this high alert medication did not follow standards for the safe distribution, and storage of medications.

Based on kitchen and meal service observations, in addition to record review and staff interview, it was determined that the facility staff failed to follow safe food handling practices to minimize the risk of foodborne illness outbreaks. The findings include:

On 04/27/10 at 10:10AM, an unannounced kitchen inspection was conducted. During this time, the surveyor observed an open gallon container of milk with a sell by date of 04/04/10. Upon opening the container, a rancid odor was noted. The item was immediately discarded.

At 11:00AM, a lunch trayline observation was conducted. The surveyor observed the foodservice worker verifying food temperatures prior to meal service. The thermometer was properly calibrated upon observation by the surveyor. The worker proceeded to verify food holding temperatures of all food items with the exception of the pureed foods. When the surveyor intervened, the temperature of the pureed broccoli was found to be 128 dF (degrees Fahrenheit). The foodservice worker then continued to prepare for the meal service, without reheating the pureed item. When the surveyor pointed out the temperature concern, the employee stated that reheating the pureed items would cause them to lose their form, and then asked, "You want me to reheat it?" After surveyor intervention, the product was reheated to an internal temperature of 182 dF.

All hot foods must be maintained at or above 135 dF to maintain food safety and palatability. When hot foods fall below 135 dF, they must be reheated to an internal temperature of 165 dF.

Based on record review, staff interview and observation, it was determined that the facility staff failed to: 1) provide timely nutritional interventions and monitoring to a patient at risk of compromised nutritional status; 2) provide diet-appropriate meals to 2 diabetic patients; and 3) ensure that patients on a pureed diet received varied, nutritionally-balanced menus. The findings include:

1) The facility staff failed to provide timely nutritional interventions and monitoring to a patient at risk of compromised nutritional status.

Patient # 1 is an 87 year old male with diagnoses that include but are not limited to severe lung disease, respiratory failure and shortness of breath, anemia of chronic disease with low iron levels, acute kidney failure on chronic kidney failure, and diabetes. He is identified as being at high risk of aspiration (when food or fluid enters the lungs, often due to a swallowing impairment), and has a diagnosis of aspiration pneumonia.

Review of the patient's medical record on 04/28/10 revealed that he was admitted to the hospital on 04/15/10. On this date, a nutrition referral was made due to the presence of wounds. At this time, the patient was noted to be at "mild nutrition risk". No further documentation, such as an evaluation to include the rationale for this decision, was in place. Interview with the Registered Dietitian confirmed this.

On 04/20/10, the patient was again screened by the dietitian and noted to be at "mild nutrition risk". No further documentation, such as an evaluation to include the rationale for this decision, was in place.

On 04/26/10, the patient was screened by the dietitian and again noted to be at "mild nutrition risk". No further documentation was in place.

On 04/26/10, a nutrition consult was ordered. As a result, a full nutritional evaluation was completed and documented on 04/27/10.

The surveyor requested the guidelines that the dietitians follow to determine a patient's nutritional risk level. The assigned risk level determines when and how often a patient's nutritional status will be followed. Multiple risk factors were present, such as acute kidney failure, unstable lung disease, dysphagia (difficulty swallowing), nutritional anemia (patient had low iron stores), the presence of a stage 1 or 2 pressure ulcer, and a serum albumin of less than 2.4 (patient's albumin was between 1.9 and 2.0). Although these risk factors were present, the patient was still being assigned a low nutritional risk category. As a result, he remained without the benefit of a comprehensive nutritional assessment until 12 days after admission, when a consult was ordered by the physician. At that time, it was determined that he was not meeting his estimated energy needs, and a 2200 calorie diet was recommended. He was also noted to have elevated protein needs, and additional protein supplementation was recommended.

Nutrition protocols are typically put in place to ensure that patients at nutritional risk are properly identified and evaluated to enable appropriate and timely nutritional intervention. When these protocols are not followed, it would be expected that there would be documentation in the patient's medical record including the screening criteria used, and the rationale for level of nutritional risk being assigned.

2) The facility staff failed to provide diet-appropriate meals to 2 diabetic patients.

a) Patient # 1 is an 87 year old male with a physician's order for a 2 gram sodium, 1800 calorie carbohydrate-controlled diet.

On 04/27/10, a lunch tray passing observation was conducted on 3T/PCU. At this time, the patient's meal tray was observed to contain the following food items:

2 cinnamon raisin cookies
5 packets of sugar
1 roll
turkey with gravy
stuffing with gravy
mixed vegetables

This would equate to approximately 6.5 carbohydrate servings. Upon interview with the dietitians, it was determined that the patient should have received 4 carbohydrate servings at lunch, and that the sugar and cookies should not have been provided. It was observed that the food server preparing the trays did not have a specific listing of what the patient should receive at each meal, and was preparing the tray based on her own understanding of what the patient should receive on a 2 gram sodium, 1800 calorie carbohydrate-controlled diet.

b) Patient # 2 is a 64 year old female with a physician's order for a 1800 calorie carbohydrate-controlled diet.

On 04/27/10, a lunch tray passing observation was conducted on 3T/PCU. At this time, the patient's meal tray was observed to contain the following food items:

2 reduced sugar cookies
1 roast beef and cheese sandwich on submarine roll
3 packs of crackers
Hearty Vegetable soup
8 oz. milk
2 packs of mayonnaise

This would equate to approximately 6.5 carbohydrate servings, which is over the 4 carbohydrate serving limit. It was again observed that the food server preparing the trays did not have a specific listing of what the patient should receive, and was preparing the tray based on her own understanding of what a patient on an 1800 calorie consistent carbohydrate meal should receive.

3) The facility staff failed to ensure that patients on a pureed diet received varied, nutritionally-balanced menus.

On 04/27/10, the surveyor reviewed the menus for patients receiving pureed diets. During this time, multiple menu repetitions were noted, including the following:

Sunday dinner - pureed carrots
Monday dinner - pureed peas (alternate pureed carrots)
Tuesday lunch - pureed peas (alternate pureed carrots)
Wednesday lunch - pureed carrots
Thursday lunch - pureed carrots
Friday dinner - pureed peas (alternate pureed carrots)
Saturday dinner - pureed peas (alternate pureed carrots)

Sunday lunch - pureed green beans
Monday lunch - pureed corn (alternate pureed green beans)
Tuesday dinner - pureed green beans
Wednesday dinner - pureed corn (alternate pureed green beans)
Saturday lunch - pureed green beans

Thursday dinner - pureed broccoli
Friday lunch - pureed broccoli

Similar repetitions such as these were seen with the pureed meat entrees, including but not limited to:

Sunday dinner - main entree pureed beef
Monday lunch - main entree pureed beef
Monday dinner - alternate entree pureed beef
Tuesday lunch - alternate entree pureed beef
Tuesday dinner - main entree pureed beef
Wednesday lunch - main entree pureed beef
Thursday lunch - alternate entree pureed beef
Thursday dinner - main entree pureed beef
Friday lunch - main entree pureed beef
Saturday lunch - main entree pureed beef

Repetitions were also noted with the starch side dishes, which consisted of either pureed bread or whipped potatoes.

During the menu review, it was observed that the pureed menus were entirely different from the regular menu. Mechanically-altered diets should replicate the regular menu to the best extent possible. The exception to this would be when a food item is not easily pureed. This duplication of the regular menu is to ensure that all patients receive varied, nutritionally-balanced meals that are based on the same menus one would expect on a regular diet.