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Based on record review and interview the facility failed to meet the nutritional needs of 1 of 3 sampled patients (#1), in accordance with dietary assessment and appropriate orders of the practitioners responsible for the care of the patient as evidenced by failure of the Dietician who performed the patient's initial dietary assessment to consult with and notify the physician of expertise dietary recommendations, failure to prescribe the correct therapeutic diet for the patient and failure of dietary, nursing staff and speech therapy to promptly and accurately assess and intervene to ensure the patient received the appropriate dietary order and diet.

The Findings Include:

Review of the clinical record for Patient #1 revealed the patient was admitted to the facility on 04/23/10 at 8:45 PM, for in-patient rehabilitation as a result of his/her decline in function. The patient has a pertinent history of Stroke, Coronary Artery Disease, Status Post Stent, Coronary Artery Bypass Graft (CABG), Diabetes, Hypertension, and Alzheimers.

Review of the physician admitting orders dated 04/23/10 revealed a diet order for the patient as follows: "Mechanical Soft. Thick Liquid. Therapeutic Dining." An order was also documented for a dietary and speech therapy initial evaluation.

Clinical record review revealed that an initial nursing nutrition screen was completed on 04/23/10 at 4:30 PM. The Registered Nurse (RN) completing the initial screen documented the patient swallowing, chewing, dental, mouth and gums were normal. A nutritional risk screening assessment performed by the RN revealed the patient scored zero (no nutritional risk). The patient's diet was documented as: "Mechanical soft.Thick Liquid."

Review of the Nutrition Addendum dated 04/24/10 revealed a nutritional assessment was performed by the Dietician on 04/24/10 at 11:45 AM.
The diet prescribed was noted as: "Mechanical soft.Thick Liquids."

Interdisciplinary Progress Notes dated 04/24/10 at 12:30 PM, document that a speech therapy evaluation was performed by the speech therapist. The therapist recommended therapeutic dining for the patient 3 times a day. The patient's diet order was documented as: "Mechanical Soft. Nectar Thick Liquids."

Nursing's Daily Flow Sheet Treatment Record document the patient's diet as: "Mechanical soft" from 04/23/10 through 04/24/10.The record document the patient consumed 50% of breakfast and 25% of lunch. The Daily Flow Sheet documented the patient's diet as Mechanical Soft through 04/27/10.

A physician order dated 04/24/10 at 6:00 PM document a change in the patient's diet order. The order specified a diabetic diet documented as: "1800 calorie ADA (American Dietetic Association), Mechanical Soft, Nectar Thick Liquid."

Interdisciplinary Progress Notes dated 04/24/10 at 5:00 PM document the patient's spouse was very upset that a diabetic diet was not ordered for the patient and was yelling loudly in the hallway that he/she could take better care of the patient. The notes document the kitchen was called and a message was left requesting a diabetic diet for the patient in the supervised dining room.

Review of the Diabetic Record dated 04/23/10 revealed that accuchecks were being performed before meals by nursing staff, to monitor the patient's blood sugar as ordered, and the prescribed dose of Insulin was administered. The results of the blood sugar tests was noted to be much higher than the normal range (70 to 110 mgs/dl) as follows:
04/23/10 at 9:30 PM Blood Sugar (BS)-252mgs/dl. 6 units of Novolin R Insulin was administered to the patient.
04/24/10 at 7:30 AM BS-158mgs/dl. 2units Insulin was given to the patient.
04/24/10 at 12:30 PM BS-267mgs/dl. 6 units of Insulin was given to the patient.
04/24/10 at 6:30 PM BS-273mgs/dl. 6 units of Insulin was given.
04/24/10 at 10:00PM BS 122mgs/dl. The patient's blood sugar improved and he/she did not require Insulin. By this time the patient had received the correct diabetic diet.

Review of the Interdisciplinary Progress Notes dated 04/25/10 at 8:06 PM, revealed the patient's spouse spoke with the dietician and requested that the patient be placed on a "Heart Health (HH) diet, "meaning a Low Sodium, Low Fat diet, in addition to the prescribed diabetic diet. The notes document that the dietician agreed with the patient's spouse request, wrote orders and notified kitchen staff to change the patient's diet to include a Heart Healthy diet. Although the reason for the spouses request for an "HH" diet was not documented in the clinical record, it is to be noted, the patient has a history of cardiac problems and hypertension.

Review of the Nutrition Suggestions/Orders dated 04/25/10 confirmed the diet order was changed by the dietician to include a low salt, low fat 1800 ADA diet.

During an interview conducted with a Registered Dietician (RD) on 07/19/10 at 3:00 PM, the RD confirmed the diet ordered by the admitting physician, was not a diabetic diet. The RD reviewed the clinical record and confirmed that the dietician who performed the nutritional assessment at 11:45 AM on 04/24/10, had not notified the physician to obtain a diet clarification order, or changed the patient's diet order to the "1800 calorie ADA," diabetic diet. The RD also confirmed that dietary staff are available 24 hours for questions regarding the patient's diet if the patient's diet needed to be clarified. The RD stated that the patient may have received a snack after admission to the unit such as milk or graham crackers, and confirmed, that breakfast and lunch served the patient on 04/24/10 was not a diabetic diet, since the physician order at the time, was not a diabetic diet order.