HospitalInspections.org

Based on review of patient charts and confirmed in interview, the facility failed to ensure patients with allergies were not exposed to the allergen resulting in anaphylaxis reaction for one of ten patients (Patient #B) reviewed.

Findings included:

Patient #B admitted involuntarily on 03/16/2024 "after reportedly experiencing suicidal thoughts per collateral with a plan to cut with razor due to experiencing stressors consisting of the following: 'loss of my job, loss my boyfriend of 5 years, moved back home with my parents'."

In review of the initial psychiatric evaluation on 3/16/2024, allergies were assessed for "peanuts, reaction: swelling."

Review of nursing notes on 05/17/2024 "At 0825 pm patient approaches the nurse's station stating that she has a peanut allergy which she claimed was due to having inhaled the peanut while other peers were eating peanut [butter] sandwich, patient complained of tight throat and difficulty breathing, vital signs were taken, BP 142/86, HR 104, 02 Sat at 90%, T 98.1, RR 16, oxygen 2 L started, [Staff #6] notified, ordered 50 mg of Benadryl IM now, code was called, due to patient's complaints of tight throat, and bilateral wheezing, 911 was called at 0827, and arrived at 0830 pm, administered Epipen, and Albuterol via face mask, at 0841 patient was transferred to ...hospital awake and oriented."

In an interview with Staff #1 and Staff #3 on 5/24/2024 at 11:10 AM, they stated that the facility had no process in place to ensure there were no cross contamination for food allergens in the unit and/or the kitchen. Staff #1 did provide an email dated 3/20/2024 that stated that peanut butter would no longer be served, but no approved changes to the menu or facility processes had been established.

Based on record review and interview the facility failed to ensure a qualified dietician approved patient menus.

Findings included:

A review of the patient menus provided to this surveyor revealed the facility used a 3-week rotating patient menu plan. The menus provided included the following hand written substitutions for protein and sides with no documentation of approval.

Week 1
Sunday Breakfast 'sausage'
Tuesday Breakfast 'grits'
Tuesday Lunch 'chicken fried steak'
Wednesday Breakfast 'oatmeal' 'egg patty'
Wednesday Dinner 'turkey tetrazzine'

Week 2
Sunday Lunch 'bbq pork'
Tuesday Lunch 'ice cream'

Week 3
Sunday Lunch 'veggie rice'
Monday Lunch 'scallop potato'
Friday dinner 'chicken etoufee'

An interview with Staff #3 on 05/24/2024 at 11:00 AM in the kitchen confirmed the above findings.

Based on record review and interview the facility failed to have a therapeutic diet manual approved by the dietician readily available to medical, nursing, and food service personnel.

Findings:

After multiple requests on 05/24/2024 for the approved therapeutic diet manual, one was not provided for review by the survey exit date of 05/29/2024.

During an interview on 05/24/2024 with Staff #3, she stated she was unaware of any approved diets. She stated that they can offer chicken breast or fish as requested but that substitutions are not in writing and/or approved.