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Upon review of medical record and interviews with facility staff found that the patient did not receive care in a safe setting.

Findings:

1. Upon review of medical record found that the physician ordered a dietary consult which was done by the dietician. The dietician found the need for a specific diet and the requirement for a speech language evaluation to assess the swalloing ability of the patient; both recommendations were not acted upon by facility staff.

2. Interviewed dietician and director of risk management who confirmed that recommendations were not acted upon by facility staff and could not provide evidence of compliance with this regulation.

Upon review of medical record and interview with facility staff, found that the nursing staff failed to keep current the nursing care plan for this patient.

Findings:

1. Upon review of medical record, found that nursing care plan was not updated or kept current after the evaluation by the dietician.

2. Interviewed director of risk managment and who confirmed that the nursing care plan was not updated or kept current for this patient.

Reviewed Medical Record and interviewed facility staff and found that hospital did not have an organized dietary service that provides constant liason with the hospital medical staff for recommendations on dietetic policies affecting patient treatment.

Findings:

1. Reviewed medical record and found that Clinical dietitian was consulted by medical staff to evaluate patient for required diet, found that dietitian completed evaluation and recommended a specific individual diet for the patient but the physician did not act on dietitian recommendation.

2. Interviewed Clinical dietitian who completed the requested dietitic consult for patient and she agreed that the diet she recommended for the patient was never put in place or acted upon by anyone of the medical staff. She agreed that she could not provide evidence of compliance with this requirement.

Upon review of medical record and interviews with facitliy staff, found that therapeutic diet was not prescribed the the practitioner responsible for the care of this patient.

Findings:

1. Upon review of medical record, found that the therapeutic diet identfified for this patient was not implemented by facitliy staff. The facility dietician completed two seperate evaluations within 3 days of each other and found the need for increase caloric intake and made the recommendation, but the practitioner responsible for the care of this patient did not act upon recommendation.

2. Interviewed dietician and director of risk managment who confirmed that the therapeutic diet needed for this patient was never implemented by the facility. They could not provide evidence of compliance with this requirement.