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Based on a review of the patients' diet orders, the patients' medical records and facility policy and interview with the Registered Dietitian and Director of Food and Nutrition Services, the facility failed to ensure that four (#8, #9, #10, #11) of four patients sampled for a review of their physician ordered diets, received nutritional interventions based on their needs.

Findings included:

1. Review of the planned lunch menu for 12/16/2019 revealed the patients at the Recovery Center would be served a choice of milk, a choice of juice, vegetable soup, a chicken salad sandwich , lettuce leaves, sliced tomato, spinach souffle, two slices of wheat bread and peaches. In an interview with the cook on 12/16/2019 beginning at 11:15 a.m., it was reported that patients who had orders for double protein would receive a chicken breast in addition to the scoop of chicken salad. The Cook reported, at that time, that since diet orders changed frequently, it was easier to cook chicken breasts to serve as the double protein, rather than making more chicken salad to provide the double protein.

2. Review of Patient # 8's medical record revealed he had been admitted to the facility with the diagnosis of depression on 12/10/2019. The nutrition screen, completed on admission, did not trigger the need for the patient to be seen by a Registered Dietitian.
The physician ordered diet was noted on 12/13/2019 to be a Regular diet with Double Portions. Review of the Diet Order Roster Report revealed the patient's diet order was Double Protein (not double portions) . Further review of the medical record did not reveal a reason for the double portions, or the double protein. The patient's medical record documented his height at 71" and his weight at 91 kg (200 lbs) which indicated he was 116 % of his ideal body weight for height. The physician's note dated 12/13/2019 included lab values which showed his albumin (an indicator of protein status) was within normal limits.

Review of the chart did not reveal why the diet order included the additional double portions. There was no note by Food and Nutrition Services (FNS) or by the Registered Dietitian indicating why the double portions had been ordered or why the physician ordered double portions was changed to double protein by the FNS department.



3. Review of Patient # 10's medical record revealed he had been admitted to the facility with the diagnosis of depression on 12/06/2019. The physician ordered diet was noted on 12/10/2019 to be Regular Diet, Double Portions. Review of the Diet Order Roster Report revealed the patient's diet order was Regular, Double Protein (not double portions).
The nutrition screen, completed on admission, did not trigger the need for the patient to be seen by a Registered Dietitian. The patient's medical record revealed he had non-insulin diabetes mellitus, was 70 " tall and weighed 202 lbs, which indicated he was 120 % of his ideal body weight for his height. A doctor's note dated 12/06/2019 included lab values which showed his albumin to be within normal limits.


4. Patient # 9 was admitted to the facility on 12/12/19 with unspecified depressive disorder. Review of physician orders revealed a diet order dated 12/13/2019 for Consistent Carbohydrate 60 grams. Review of the Diet Order Roster Request revealed that the patient's diet order was listed as CHO60 with a staff note of Double Protein, Diabetic Snack-Turkey.

Review of the Nutrition Screen completed at admission revealed that a nutrition consult had not been triggered. The patient was 73 inches tall and weighed 175 lbs, which indicated he was 95% of his ideal body weight for height.
A review of an Advanced Practice Registered Nurse's assessment, dated 12/13/2019, revealed the patient had Type 1 diabetes mellitus, fatty liver and hepatitis C. The note included a description of the patient's blood glucose control: "patient arrived to facility, his blood sugars extremely elevated. he is noncompliant with his medications and diet , constantly taking snacks ... eating extra food, patient ended up with blood sugar greater than 500 last night, but resolved with his insulin. His hemoglobin A1C was 12. discussed importance of diabetic diet due to extremely labile blood sugars." The note included several diabetic medications that the patient was receiving including accu checks before meals and bedtime. The Impression and Plan included: Uncontrolled IDDM (insulin dependent diabetes mellitus) accuchecks AC/HA ... CCD (consistent carbohydrate diet) with extra protein only and diabetic snacks.

Further review of the electronic medical record did not reveal the Registered Dietitian (RD) had provided an assessment or ensured that the facility menu provided 60 grams of consistent carbohydrate at every meal, per the diet order. There was no documentation confirming what the patient was receiving for diabetic snacks and how the ordered snacks had been determined to fit with the Physician's ordered diet.

In an interview with the Director of Food and Nutrition Services (FNS) on 12/17/2019 beginning at 10:45 a.m., it was confirmed that the menu for the facility did not provide 60 grams of consistent carbohydrates at each meal, unless it was adjusted by the RD. The RD confirmed she would provide consultation at the facility reported she was not familiar with this patient.

5. Patient #11 was admitted to the pediatric wing of the facility on 12/13/19 with the diagnosis of depressive disorder. Review of the Physician's Diet order at admission revealed the patient had been ordered a Regular Diet.
In a review of a Psychiatric Evaluation dated 12/14/2019, the patient was documented as reporting to the doctor that his medication caused him to gain 20 lbs in 2 months. The doctor included in the note an interview with the patient's mother who also reported the 20 pound weight gain in the last two months. Further review of the Evaluation revealed the patient had an allergy to yeast.

In the interview with the RD and the Director of the FNS, on 12/17/2019 beginning at 10:45 a.m., a review of the electronic medical record for Patient #11 was made. The RD confirmed, after reviewing the medical record, that the nutrition screen completed by the nurses at admission did not pick up the report of the weight gain as it wasn't one of the indicators. It was confirmed that the RD was not consulted to assess the patient's nutritional status for either the weight gain or the allergy to yeast. The Director reported that the consult did not have to come through the screening procedure . She reported that a nurse could have noted the weight gain and the yeast allergy and consulted the RD for an assessment. The allergy to yeast did not trigger a referral to the RD to assist in adjusting the diet.


6. An interview was conducted with the Registered Dietitian (RD) who was identified as the RD who would provide consultation to the Recovery Unit, on 12/17/2019 beginning at 10:45 a.m. She confirmed that the Physician ordered double portions was served as double protein, and reported that they wouldn't want double portions. When asked how she knew that - that patients wouldn't want double portions - she responded that double portions would be two servings of vegetables, two servings of the starch. She reported that they always gave double protein when the order was double portion. When asked for documentation that either someone had confirmed with the patient what the patient wanted, or if there was policy that 'double portions' meant 'double protein', she was not able to provide that documentation.


Further interview on 12/17/2019 beginning at 10:45 a.m., with the Director of Food and Nutrition Services confirmed that the diet order should be provided as the Physician order indicated and she confirmed there was no policy on providing something different from the Physician order. She confirmed that it was not in the cook's scope of practice to make the decision to provide what was assumed the diet meant, rather than what the diet read. She confirmed that foods to include and to exclude in the diet for an allergy to yeast should have been directed by the Registered Dietitian, not the cook.

7. Policies were reviewed that related to diet orders and nutrition assessments .

Policy BC-FN-127 titled Food service to psychiatric care unit patients revealed the Policy had been developed to provide nutritionally balanced meals and snacks compliant with diets as ordered. Under Procedure, point V. read Patients select their meals according to diet order. As per diet order, patients can request double portions of a particular item or two choices for entree, vegetable, starch and beverage. The additional servings are approved by Behavioral Health Staff.


Policy BC-FN106, entitled Diet Orders & Therapeutic Diets included the Policy statement: Therapeutic diets meet guidelines set forth in the approved diet manual. Patients receive a diet as ordered by a provider. The policy listed the diets that were provided by the facility and included the Consistent Carbohydrate diet of 60 gm CHO/meal (carbohydrate), 4 CHO servings/meal.


Policy BC-FN-145 entitled Patient Food Allergies indicated the Policy as The Food and Nutrition Department will monitor for patients with food allergies and adjust their diets accordingly.