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Based on a review of facility documentation and staff interviews, the facility failed to ensure nursing staff appropriately evaluated the nutritional intake of each patient for 10 of 10 patients (Patients #1-10). In addition, physicians were not notified when patient blood glucose levels were outside prescribed parameters or when they reached a critical value, for 5 of 8 diabetic patients (Patients #4, #6 and #8-10).

Findings were:

A review of facility policies revealed no policy existed related to recording percentages of meals consumed by patients - especially diabetic patients - or that defined subjective terms such as "fair" or "good" which were used to document patient dietary intake or appetite. No policy existed which addressed nursing assessment of patient dietary intake at all. In addition, no policy existed which delineated when to notify a physician that his/her patient had an extremely high or low blood sugar test result.

Facility policy #RR-001 entitled "Pavilion Patient Rights and Responsibilities," last revised Jan. 2016, included the following:
"...List of Rights
1. Without limitation patients shall be entitled to: ...
d. Medical care and treatment in accordance with the highest standards accepted in medical practice to the extent that the facility, equipment and personnel are available ...
h. Receive prompt evaluation and care, treatment, habilitation or rehabilitation about which he/she is informed insofar he/she is capable of understanding ..."

A review of patient medical records revealed that meal percentages consumed were not recorded for 10 of 10 patients (Patients #1-10). Nursing staff used descriptors related to intake and appetite of these patients that were subjective and nowhere defined, such as "fair" or "good." In addition, even the subjective descriptors were inconsistently documented, as full days were missed with no documentation related to intake status at all for 5 of 10 patients (Patients #1-2, #7-8 and #10).

For example, Patient #1 was a Type 1 diabetic patient. Her intake was documented by nursing staff as generally "Adequate." Her appetite was assessed only as either "Fair" or "Good." It was unclear exactly how "adequate," "fair," or "good," were defined. No percentages of meals consumed were recorded in the patient record.

A physician's order on 2/13/19 at 4:44 p.m. read as follows: "Diabetic/Carb consistent" diet. A physician's order on 2/14/19 made the correctional/sliding scale of insulin administration for this patient to be based on her dietary carb count/intake.

No documented evidence was available in the patient record to ascertain how many carbohydrates each patient meal had contained. With no listing of the number of carbs per meal retained in the record, or of the percentage of meals consumed by the patient, it was impossible to determine if Patient #1 received the appropriate dosage of insulin as prescribed by the physician correctional scale. The point-of-care blood glucose testing results for Patient #1 were often > 200 mg/dL. As examples, listing only a few of the blood glucose testing results for Patient #1:
- 2/13/19 at 11:36 a.m.: 249
- 2/13/19 at 7:36 p.m.: 382
- 2/13/19 at 10:41 p.m.: 272
- 2/14/19 at 5:17 p.m.: 245

In an interview with Staff #3, Chief Nursing Officer of the Pavilion, on the morning of 4/9/19 at 9:15 a.m. in the Pavilion meeting room during a review of Patient #1's medical record, she stated, " ... What happens with a carb-based correctional scale is that the tray comes with a print out of the number of carbs in the meal. So, the amount of insulin to be given is based on that slip of paper that has the carb count." When asked if the hospital retained those pieces of paper or recorded the carbohydrate count of meals in the patient record, she stated, "No, we don't keep those." When asked if the percentage of the meal consumed by the patient was recorded, she stated, "There's the documentation of whether the patient has "adequate" or "inadequate" intake ... There's also the area where appetite is documented as "good" or "fair."" When asked if these terms were defined more precisely in a hospital policy or protocol (i.e., as some type of meal percentage range), she stated, "Not that I'm aware ... I think our software doesn't lend itself to recording the amounts eaten by patients ..."

Staff #3 continued, "The night shift is supposed to document a patient's appetite assessment." A discussion ensued regarding patient meals being consumed on the day shift from 7:00 a.m. to 7:00 p.m. and whether it was appropriate for night shift to record that. Staff #3 stated, "We'll just get the patient to report how they're eating in general to the night shift staff." When it was pointed out that some of the patients at the Pavilion - a psychiatric unit of the hospital - might be psychotic, severely depressed or manipulative, she stated, "That's how we do it." She added, "It's really rare that we have an order where insulin is administered based on a carbohydrate count. Normally, it's just a regular sliding scale ..." She agreed that even for patients not on a carb-based corrective scale for insulin, the staff would still want to know how much a patient was eating. Also, when asked what the parameters were for notifying physicians of a patient's abnormal blood glucose level, she stated, "That's usually set forth by the physician in the order... If they don't specify it, I don't think we have a policy that states when we do that ..."

As another example, Patient #8 was a diabetic patient admitted to the Pavilion on 3/21/19 and discharged on 4/1/19. His primary diagnosis was Schizoaffective Disorder. From the National Alliance of Mental Illness (NAMI) (available at: https://www.nami.org/Learn-More/Mental-Health-Conditions/Schizoaffective-Disorder):
" ...Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression ..." Patient #8 was documented by nursing staff as having an "adequate" intake and "good" appetite. His dietary intake status was not assessed at all on 3/25/19 or 3/26/19. On 3/27/19 at 8:56 p.m., his blood sugar level was documented as 49. On 3/28/19, it was documented as 57. Both these readings are quite low. No nursing note in the patient record addressed either of these values. There was no real information available regarding the patient's dietary intake.

Patient #10 was a diabetic patient admitted to the Pavilion on 3/21/19 and discharged on 3/29/19. He was diagnosed with major depressive disorder. Physician orders indicated that the physician be notified if Patient #10's blood sugar was greater than 311 mg/dL. His intake/nutritional status was documented on 3/25/19 as only "no diarrhea." It was again documented only as "no diarrhea" on 3/26/19. On 3/26/19 at 4:40 p.m., his blood glucose level was 339. There was no documented evidence in the patient record that the physician was ever notified of this value. On 3/27/19 at 7:26 a.m., his blood sugar was documented as 314. Again, no documentation was available in the patient's record that the physician was ever notified of this.

Patient #6 was a type 2 diabetic patient admitted to the Pavilion on 3/5/19 and discharged on 3/11/19. She was also diagnosed with schizoaffective disorder. Physician orders included that the physician be notified if her blood sugar level was greater than 311. Her intake was documented as "adequate" and her appetite as "fair" or "good." Again, per staff interviews, this information was only recorded by the night shift based on the patient report of her own dietary intake. Patient #6's blood glucose testing results for which there was no nursing documentation of physician notification included the following:
- 3/5/19 at 9:05 p.m.: 354
- 3/6/19 at 12:02 p.m.: 366
- 3/6/19 at 4:45 p.m.: 329
- 3/7/19 at 7:30 a.m.: 326
- 3/8/19 at 7:22 p.m.: 429

Even the critical value of 429 did not include documentation that the nurse had notified the physician.

In an interview with Staff #6, Pavilion RN, on the morning of 4/9/19 in the Pavilion administration meeting room, she was asked if percentages of meals consumed by a patient were recorded any place in the patient record. She stated, "I'll document in my nursing note ... The night shift will ask the patient how their appetite is and whether or not they're eating. Then that gets passed on in report ... We're taught in orientation that we're supposed to record the percentages of meals a patient eats, but I guess there's really no place to record it with our software, so it's gotten lost ..."

In an interview with Staff #2, Director, Quality & Performance Improvement with Northwest Texas Healthcare System (NWTHS), Staff #1, Chief Nursing Officer NWTHS, and Staff #3, Pavilion Chief Nursing Officer, on the afternoon of 4/9/19 in the Pavilion administration meeting room during a review of patient records, all agreed that percentages of meals consumed by patients was important information regarding patient health status, especially for diabetic patients who were prescribed a carb-count based insulin regimen. In addition, Staff #1 stated, "We have a policy about when to notify physicians regarding blood glucose testing results for the main hospital, but we don't have one for the Pavilion ... A reading of 400 or greater would actually be a critical result. In that case, once entered it would trigger an automatic blood draw from the lab for re-testing. Then the lab would notify the nurse and the nurse would notify the physician. The result would be available within an hour ..." During the record review, all the above findings were confirmed with staff.