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Based on interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure adequate nursing evaluation by providing a patient with an incorrect therapeutic diet for one (1) of ten (10) sampled patients, Patient #3.

The findings include:

Review of the facility's policy titled, "Nursing Guidelines & Directions, Subject: Nursing Documentation," Sec: II (E14), effective date 11/04/15, revealed its purpose was to provide a guide for consistent assessment parameters which would provide consistency in the assessment process. It further revealed patient condition upon handoff/transport was communicated between the giving and receiving caregivers.

Interview with the Executive Director, Quality and Accreditation, on 04/27/18 at 11:00 AM, revealed there was not a policy on nursing assessment or ordering a patient diet related to his/her history, alleriges, or clinical condition.

Review of Patient #3's medical record revealed he/she was admitted through the Emergency Department (ED), on 02/28/18 at 8:46 PM, with a diagnosis of Suicide Attempt. Patient #3 was placed on a seventy-two (72) hour emergency hold due to danger to self. On 03/01/18 at 10:30 AM, he/she was transferred to a medical unit for stabilization. Patient #3 experienced nausea and was not placed on a diet until 03/01/18 at 5:37 PM. The diet ordered was full liquid, gluten-free (no foods with the protein gluten found in grains such as wheat, barley, rye, oat, and all their species and hybrids), and he/she remained on this until transfer to the Behavioral Health Unit (BHU) on 03/02/18 at 5:06 PM. On 03/02/18 at 6:20 PM, Patient #3 was ordered a carbohydrate controlled (CHO) or diabetic diet which was not gluten-free by Licensed Practical Nurse (LPN) #1. On 03/03/18 at 8:26 AM, Patient #3 was ordered a special tray of orange juice, fruit, and yogurt. Also, on 03/03/18 at 12:20 PM, Patient #3 was ordered a gluten-free lunch tray of meat, vegetables, banana, and salad. On 03/03/18 at 12:41 PM, Patient #1 was ordered a gluten-free regular, low CHO diet. The diet order did not change until 03/05/18 at 8:41 AM, when RD #2 consulted with the patient and ordered him/her a regular, gluten-free diet. Patient #3 was discharged on 03/05/18 at 5:33 PM. Further review of Patient #3's medical record revealed there was no mention of the patient being allergic to gluten or that the patient was on a gluten-free diet at home.

Further review of Patient #3's medical record, specifically the "Nutrition Evaluation/Planning,"
completed by RD #2, on 03/05/18 at 8:37 AM, revealed Patient #3 stated his/her appetite was fair, had no history of diabetes mellitus (elevated blood sugar levels), and would like for the CHO diet to be discontinued. Patient #3 also stated she was allergic to gluten and needed to continue with gluten-free restrictions.

Interview with Patient #3, on 04/26/18 at 9:48 AM, revealed he/she was on liquids because of nausea until he/she arrived on the BHU. Once he/she arrived on the BHU, he/she was hungry and wanted solid food. Patient #3 stated he/she did not know why a nurse placed him/her on a diabetic diet, but there should not have been anything in the medical record indicating a history of diabetes mellitus. Further interview revealed at times Patient #3 did get some gluten-free food on the BHU, but only after a special request was made. He/she revealed he/she was served food that he/she could not eat. Patient #3 then stated the last day he/she was in the facility, a dietician did an evaluation, and the right diet was finally ordered. Further interview revealed Patient #3 did not have Celiac Disease (auto-immune where the inner lining of the small intestine would be attacked by the immune system in response to gluten exposure which could lead to anemia, diarrhea, and nutritional deficiencies) but had a gluten sensitivity where he/she experienced unpleasant side-effects (diarrhea, migraines) from eating gluten. Patient #3 revealed he/she told all the nursing staff he/she was on a regular gluten-free diet at home because of the side-effects.

Interview with Registered Nurse (RN) #5, on 04/26/18 at 3:05 PM, revealed she worked on the medical unit on 03/02/18 from 7:00 AM to 7:00 PM. She stated she remembered Patient #3's transfer to the BHU with a security guard and a patient care technician (PCT). RN #5 revealed the charge nurse communicated with the BHU, but RN #5 did not recall any diet issues with Patient #3.

Interview with the Physician, on 04/26/17 at 3:15 PM, revealed he did electronically sign the CHO order entered on 03/02/18 at 6:20 PM by LPN #1. However, he stated he did not recall Patient #3. He stated he would typically sign diet orders entered by nursing unless the order raised a red flag. He also revealed patients on the BHU usually did not have a problem with diet or eating.

Interview with Registered Nurse (RN) #4, on 04/26/18 at 4:07 PM, revealed she was the charge nurse on the medical unit from 7:00 AM to 7:00 PM on 03/02/18. She stated she did not recall anything about Patient #3's diet.

Interview with LPN #1, on 04/26/18 at 4:12 PM, revealed she did not recall anything about Patient #3. She stated for a diet order she would ask the charge nurse or physician before entering it into the computer as a verbal order.

Interview with the Nurse Manager for the BHU, on 04/27/18 at 9:21 AM, revealed she expected all the patients on the BHU to receive their correct diets. She stated she did not know why LPN #1 ordered a CHO diet on 03/02/18 which was not gluten-free or why the CHO, gluten-free diet was given to the patient until the dietary consult on 03/05/18 indicated the patient needed to be on a regular, gluten-free diet. The Nurse Manager revealed it was important for patients to eat a healthy diet and be given the correct diet because it aided in the healing process.