HospitalInspections.org

Based on document review and interview, the hospital failed to ensure that practitioner orders and patient dietary nutritional needs were in accordance with recognized dietary practices for 4 of 10 patients (P1, P6, P7 and P10).

Findings include:

1. Review of the policy titled Medical Staff Orders, Last Reviewed August 2017, indicated the following: Policy: Medication, medical treatment and procedures administered by direct care staff require a written order from the physician, physician assistant or nurse practitioner. 13. When orders are unclear, illegible and or incomplete the RN/LPN (registered nurse/licensed practical nurse) must contact the LIP (licensed independent practitioner) for clarification of order.

2. Review of the Indiana Diet Manual, Ninth edition, 2016, indicated the following:
A. Citrus Fruit Intolerance Diet: This diet is used for people with food intolerance to citrus fruits. Diet Principles: Avoid citron, grapefruit, kumquat, lemon, lime, orange, tangelo, tangerine. Avoid juices, fruit drinks or punch made with citrus fruits. Avoid baked goods made with candied fruit (such as fruit cake), fruit peel or zest, or citrus juices.
B. Low Lactose Diet: This diet is used for people who are unable to fully digest lactose, the natural sugar in milk and milk products. Those who are very sensitive to lactose will need to read ingredient labels on processed foods to identify less obvious sources of lactose in foods such as *Processed breakfast cereal *Bread and bake goods * Snack foods
C. Peanut Allergy Diet: This diet may also be called a peanut-free diet. It is used for people with allergies to peanuts. Since the allergic response to this allergy can be very serious the diet excludes peanuts, ingredients derived from peanuts, and, foods or ingredients that may be cross-contaminated with peanuts. Food services must take precautions to prevent cross-contamination during food preparation as well.
D. Shellfish Allergy Diet: This diet is used for people who are allergic to shellfish. Diet Principles: Avoid all species of shellfish when there is an allergy to any of them, since they contain similar allergens.

3. Review of medical records (MR) indicated the following:
A. Patient P1 was admitted 5/13/18 and discharged 5/17/18. Admission Physician's Orders indicated Diet: Regular. The History and Physical (H&P) Exam dated indicated the following: Allergies: Food(s): Peanuts, Pear, Mango, Peach, Grapefruit juice. The MR lacked documentation of a diet order to exclude peanuts, pears, mangos, peaches or grapefruit. Contact Note, dated 5/14/18, indicated a parent of P1 voiced request to watch P1's food, especially fruit cups, because they can be in pear juice. The MR lacked documentation of what food was served to or consumed by the patient.
B. Patient P6 was admitted 5/4/18 and discharged 5/14/18. Physician's Orders indicated Regular Diet. The History and Physical (H&P) Exam indicated the following: Allergies: Food(s): Lactose. The MR lacked documentation of a diet order to exclude or limit lactose. The MR lacked documentation of what food was served to or consumed by the patient.
C. Patient P7 was admitted 5/7/18 and discharged 5/11/18. Admission Physician's Orders indicated Diet: Regular. The History and Physical (H&P) Exam indicated the following: Allergies: Food(s): Nuts. The MR lacked documentation of a diet order to exclude nuts. The MR lacked documentation of what food was served to or consumed by the patient.
D. Patient P10 was admitted 1/18/18 and discharged 3/16/18. Physician's Orders indicated Regular Diet. The History and Physical (H&P) Exam indicated the following: Allergies: Food(s): peanuts and shellfish. The MR lacked documentation of a diet order to exclude peanuts and shellfish. General Note documentation dated 1/31/18 at 10:02am, indicated the following: Immediately after morning snack, nurse was notified that patient had eaten a muffin that potentially contained peanut butter. The kitchen was contacted and asked of ingredients of muffins while doctor was contacted to obtain order for Benedryl. Epi pen was pulled as precaution and 50mg IM (intramuscular) of benadryl was administered. Confirmed that muffins did contain peanut butter.

4. Review of kitchen menus indicated the following:
A. The kitchen rotated a weekly schedule of standardized meals every 2 weeks.
B. The Week 1 schedule included weeks of 4/29/18 through 5/5/18 and 5/13/18 through 5/19/18 with the following foods served: milk, mandarin oranges, banana nut muffin, cold cereal, fruit cup, diced pears, oatmeal cookie, and graham crackers and peanut butter.
C. The Week 2 schedule included the week of 1/28/18 through 2/3/18 and 5/6/8 through 5/12/18 with the following foods served: milk, nutrigrain bar, pecan crusted Tilapia, banana nut muffin, cold cereal, graham crackers and peanut butter, and peanut butter and jelly.

5. Review of facility, allergy related incident reports between 1/1/18 and 5/30/18, indicated the following:
A. RE: P1: On 5/13/18, evening shift failed to enter patient allergies: Allergies not put into TIER (electronic medical record system).
B. RE: P10: On 1/30/18, patient consumed food with allergen - peanut/peanut butter.

6. Review of product information indicated the following:
A. From product label. Fruit cups (Fruit Cocktail in light syrup): Ingredients: Diced peaches, diced pears, pineapple segments, grapes, cherry halves, water, sugar and citric acid.
B. From Dietary email dated 5/31/18 to A1, CAO (chief administrative officer): Product Description: Pear, Northwest Diced in juice canned. Ingredients: Bartlett pears, water, pear juice from concentrate.
C. From product label. Oatmeal Creme Pie: Ingredients included: Non-fat dried milk. Allergy information: Contains wheat, soy, milk, egg. May also be present in this product: peanuts, tree nuts.

7. On 5/31/18 the following was indicated in interview:
A. Between approximately 12:00pm and 12:30pm, A3, Dietary Manager, indicated the kitchen does get a diet form from nursing that is not maintained in the MR, nor is it signed by the physician as an official order. A3 indicated the facility does not maintain documentation of what foods are provided to individual patients or what is consumed by the patients.
B. At approximately 2:50pm, A5, Registered Dietician, indicated an order must be written for any special diet and/or consult. A5 verified he/she does not follow up to verify appropriateness of physician diet orders even if "regular diet" is ordered and the MR indicates the patient has food allergies. A5 also verified that the facility does not document foods provided to or consumed by patients, that the rotating menu showed foods available to all patients and that the facility could not provide evidence of allergen foods not having been given to patients with allergies.