HospitalInspections.org

21898




28135




17065




22384




22764

Based on observation, interview, and record review, the facility failed to ensure two of seven patients at the Arlington Campus (Patients 107 and 206) received diets in accordance with their physician' orders, when the orders were inaccurately transcribed and entered, by the nursing staff, into an excel spread sheet that was used by the kitchen staff to determine the current diet that should be prepared and delivered for the patients. These failed practices resulted in the potential for failure to meet the nutritional needs of Patients 107 and 206.

Findings:

1. The record for Patient 107 was reviewed on May 13, 2014. Patient 107, a 30 year old male, was admitted to the Arlington Campus on March 10, 2014, for stabilization and treatment of an existing illness.

According to the record, the RD (Registered Dietician) evaluated Patient 107, on Unit A, on March 17, 2014, and recommended a two gram sodium (low salt) diet with a can of ensure (a nutritional drink with additional calories) three times daily. According to the evaluation, the reason for the supplemental can of ensure (in addition to the diet) was the diet only met 81% of the patient's estimated nutrition needs, and the additional calories from the ensure would result in meeting 100% of his needs. The physician ordered the diet as recommended on March 18, 2014.

The record indicated Patient 107 was transferred from Unit A to Unit C on May 1, 2014. The transfer orders included a regular diet with no ensure.

During a meal observation on May 13, 2014, at 12:10 p.m., Patient 107 was served a regular meal with ensure, not consistent with the physician's order. The patient ate all of his meal, including the ensure.

A review of the diet list (an excel spread sheet completed by nursing) indicated Patient 107 should receive a regular diet with ensure three times daily, not consistent with the physician's order.

During an interview with the Arlington Campus RN (Registered Nurse) Care Coordinator on May 13, 2014, at 2:40 p.m., the RN stated when physician's orders were written that included a diet order, the nursing staff transcribed the diet orders into the computer on an excel spread sheet. She stated the excel spread was used as the diet list for the patients at the Arlington Campus. The RN stated when the diet for Patient 107 was changed from a two gram sodium diet with ensure three times a day to a regular diet (with no order for ensure), the nurses did not realize the ensure should have been discontinued. The RN stated the diet list was on a shared computer drive (shared between the Arlington Campus and the kitchen), and the kitchen accessed it before each meal to determine the correct diet to be sent for each patient. She stated the nursing staff entered the diet as regular with ensure, and that was why the meal was delivered that way. The RN stated the nursing staff should have verified the diet list matched the current diet order each night when they did their 24 hour chart checks (a process to verify the correct orders were being carried out for the patient).

During an interview with the Arlington Campus RD on May 13, 2014, at 3 p.m., the RD stated she was aware the transfer orders included a physician's order for a regular diet with no ensure. She stated when the nurses entered the new diet order onto the diet list, they did not remove the ensure. The RD stated the nursing staff did not understand the ensure should have been removed from the diet list with the change of orders.

During an interview with the Director of Food and Nutrition Services on May 14, 2014, at 11 a.m., the director stated she reviewed the record for Patient 107, and the current physician's order was for a regular diet with no ensure. The director stated she reviewed the meals that were sent to Patient 107 the previous night (May 13, 2014) for dinner, and on the date of the interview (May 14, 2014) for breakfast, and the patient continued to receive ensure with his meal. The director stated the error had continued throughout the night and morning. She stated Patient 107 should not have been receiving the nutritional drink since May 2, 2014.

Patient 107 received the incorrect meal for 13 days (37 meals) without the error being recognized.

2. A review of the medical record for Patient 206 indicated the physician's diet order dated May 7, 2014, was for a soft diet.

A review of the facility diet list dated May 13, 2014, indicated the diet order for Patient 206 was listed as a soft advanced diet.

During an interview with the Supervising Registered Dietician (SRD) on May 13, 2014, at 1:30 p.m., the SRD stated Patient 206 was seen by Registered Dietician 1 (RD) on May 9, 2014. She stated RD 1 determined the physician's order for a soft diet was interpreted and transcribed by the nursing staff as a soft advanced diet. She stated the facility had the following soft diets;

a. GI Soft - for gastrointestinal problems;

b. Mechanical Soft (chopped) - for chewing and swallowing problems;

c. Mechanical Soft (ground) - for chewing and swallowing problems; and,

d. Soft Advanced - for patients with oral problems such a painful chewing.

The SRD further stated the physician should have been contacted to clarify which soft diet he wanted his patient to receive. She verified there was no evidence that this occurred.