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Based on interview and record review, the facility failed to ensure that nutritional assessments and nutritional needs were consistently documented and communicated between the nursing and dietary staff for one (#1) of three patients reviewed for nutritional needs out of a total sample of 10, resulting in the potential for unmet nutritional outcomes. Findings include:

On 9/16/2020 at 1020 an interview was conducted with Charge Nurse Staff (K).
She said she recalled the patient (#1). She said she recalled the patient had complained to her on at least one occassion about being allergic to poultry and requesting a different meal. She said she just called the cafeteria and got it changed.

On 9/16/2020 at 1050 a review of the medical record for patient #1 was conducted with Day Shift Registered Nurse Manager (Staff A) and Registered Dietitian (Staff M) and the following was revealed:

Review of the admission face sheet revealed patient #1 was a 41 year-old male admitted to the facility on 3/23/2020. An allergy to poultry was documented on the face sheet.
Review of the nursing admission assessment dated 3/23/2020 at 1150 revealed the patient was also allergic to poultry.
Further review of the nursing admission assessment included a nutritional risk screen assessment that scored the patient at "0" for nutritional screening.

On 9/16/2020 at 1100 Staff M was queried regarding the patient's (#1) food allergy. She stated, "I did not see this patient." She said I looked at his chart, there is no consultation/evaluation. She stated, "I review all nursing admission nutritional risk screen assessments for all new admissions." She said, this patient was not seen because nursing scored him at "0". She explained a food allergy would have triggered a score of "3". She stated, "I should have seen him (#1)."

On 9/16/2020 at 1110 Staff A explained the nurse should have documented the patient's "poultry" allergy on the nutritional risk screen assessment. She confirmed the nurse did not.

A review of the facility's "Dietary Services" policy number DS-H-003 dated September 2019 documented:
III. Procedure
A. During the first 24 hours after admission nursing services will complete a nutrition screen on the facility approved form.
B. If a patient's screen score is 3 or above, a consult MUST be written to assess the patient.
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