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Based on document review and interview, the hospital failed to have menus for four different therapeutic diets received by five of twenty patients reviewed (Patients #2, #9, #14, #15, and #16).

Findings include:

1. Review of document titled: "Inpatient Care Center Handbook," last approved 11-19-18, read: "Your diet is prescribed and monitored by the staff caring for you."

2. Review of patient records indicated the following patients had therapeutic diets ordered as follows:
a. Patient #2 was admitted on 11-18-18 with admission orders for a "2000 ADA" diet. The "Client Information" form indicated the patient had "diabetes type 2."
b. Patient #9 was admitted on 1-11-19 with admission orders for a "2000 ADA" diet. The "Kardex Info Sheet," dated 1-13-19, indicated the patient was a "Type 1 Diabetic"
c. Patient #14 was admitted on 11-15-18 with admission orders for a "regular - low fat" diet. The dietitian consultation, date unknown, indicated the patient requested a low fat diet to help lose weight.
d. Patient #15 was admitted on 11-20-18 with admission orders for a "regular" diet. A later physician's order, on 11-20-18 at 1450, read: "High Protein and High Calorie Diet." The "Nutrition Screening Tool," dated 11-20-18, indicated the patient had "Chrone's (sic) Disease and loss of appetite." The dietitian consultation, dated 11-20-18, indicated the patient had weight loss due to a decreased appetite.
e. Patient #16 was admitted on 10-22-18 with admission orders for a "2000 calorie NCS" diet.

3. Review of menus indicated the only menu the hospital had was for a regular diet. There were no menus for a "2000 ADA" diet; a regular, low fat diet; a high protein and high calorie diet; or a "2000 calorie NCS" diet.

4. In interview on 1-15-19 at 11:05 AM, A#5, Registered Dietitian, confirmed the hospital had no menus for special diets, including the above mentioned diets. A#5 further confirmed the "regular" menu was used for the "2000 ADA" diet and the Dietician spoke over the phone with the Caterer to formulate other special diets on a case by case basis. A#5 confirmed there was no documentation of the phone conversations between the Dietitian and Caterer in regards to formulating special diets for patients.

Based on document review, observation, and interview, the hospital failed to ensure patient diets were ordered by a practitioner or qualified dietitian for eight of 20 patient records reviewed (Patients #8, #10, #13, 14, #17, #18, #19, and #20).

Findings include:

1. Review of policy/procedure titled: "Physician's Orders," last approved on "02/21/2017" read: "Orders recorded on the Physician's Order Sheet pertain to admission, medication treatment, lab, dietary..." and "If order cannot be carried out, physician must be contacted and alternate orders given..."

2. Review of document titled: "Inpatient Care Center Handbook," last approved 11-19-18, read: "Your diet is prescribed and monitored by the staff caring for you."

3. Document review indicated the following:
a. Patient #8: The patient's medical record indicated Patient #8 was admitted on 1-10-19. Physician orders upon admission, dated 1-10-19 at "1800," indicated the patient was ordered a "regular" diet with "0 dairy 0 pork 0 eggs." There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. The "Inpatient Nutrition Log" indicated the patient received a "vegetarian" diet on 1-13-19 (breakfast, lunch, dinner, and evening snack); 1-14-19 (breakfast, morning snack, lunch, and evening snack); and 1-15-19 (breakfast, morning snack, and lunch).
b. Patient #10: The patient's medical record indicated Patient #10 was admitted on 1-10-19. Physician orders upon admission, dated 1-10-19 at "1420," indicated the patient was ordered a "regular" diet. There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. The "Inpatient Nutrition Log" indicated the patient received a "vegetarian" diet on 1-14-19 (breakfast, lunch, and evening snack) and 1-15-19 (breakfast and morning snack).
c. Patient #13: The patient's medical record indicated Patient #13 was admitted on 12-11-18 and discharged on 12-17-18. Physician orders upon admission, dated 12-11-18 at "2130," indicated the patient was ordered a "regular" diet. There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. Emails from the facility to the catering company, dated 12-13-18; 12-14-18; and 12-17-18 indicated Patient #13 was on a "Soft" diet. The "Inpatient Meal Record" indicated the patient received a "Reg Soft" diet on 12-12-18 (breakfast, morning snack, lunch, and dinner) and a "Soft" diet on 12-13-18 (breakfast, morning snack, dinner, and evening snack); 12-14-18 (breakfast, morning snack, lunch, dinner, and evening snack); 12-15-18 (breakfast, morning snack lunch, dinner, and evening snack); 12-16-18 (breakfast, morning snack, lunch, dinner, and evening snack); and 12-17-18 (breakfast, morning snack, and lunch).
d. Patient #14: The patient's medical record indicated Patient #14 was admitted on 11-15-18 and discharged on 11-20-18. Physician orders upon admission, dated 11-15-18 at "1830," indicated the patient was ordered a "regular low fat" diet. There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. Emails from the facility to the catering company dated 11-17-18 and 11-19-18 indicated Patient #14 was on a regular diet and did not indicate the patient's diet was low fat. The "Inpatient Meal Record" indicated the patient received a regular diet and did not indicate the patient's diet was low fat on the following dates: 11-17-18 (breakfast, lunch, dinner, and evening snack); 11-18-18 (breakfast, lunch, dinner, and evening snack); 11-19-18 (breakfast, morning snack, lunch, dinner, and evening snack); and 11-20-18 (breakfast, morning snack, and lunch).
e. Patient #17: The patient's medical record indicated Patient #17 was admitted on 11-9-18 and discharged on 11-21-18. Physician orders upon admission, dated 11-20-18 at "1320," indicated the patient was ordered a "regular" diet. There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. Emails from the facility to the catering company dated 11-14-18; 11-16-18; 11-17-18; 11-19-18; and 11-21-18 indicated the patient was on a "vegetarian" diet. The "Inpatient Meal Record" indicated the patient received a "reg-vegetarian" diet on 11-14-18 (dinner); 11-15-18 (breakfast and dinner); and 11-16-18 (breakfast, morning snack, lunch, dinner, and evening snack). The "Inpatient Meal Record further indicated the patient received a "vegetarian" diet on 11-17-18 (breakfast, morning snack, lunch, dinner, and evening snack); 11-18-18 (breakfast, morning snack, lunch, dinner, and evening snack); 11-19-18 (breakfast, lunch, dinner, and evening snack); 11-20-18 (morning snack, lunch, dinner, and evening snack); and 11-21-18 (breakfast and lunch).
f. Patient #18: The patient's medical record indicated Patient #18 was admitted on 11-29-18 and discharged on 12-3-18. Physician orders upon admission, dated 11-29-18 at "0800," indicate the patient was ordered a "regular" diet. There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. An email from the facility to the catering company, dated 12-2-18, indicated the patient was on a "vegetarian" diet. The "Inpatient Meal Record" indicated the patient received a "veggie" diet on 11-19-18 (morning snack, lunch, dinner, and evening snack) and a "vegetarian" diet on 11-30-18 (breakfast, morning snack, lunch, dinner, and evening snack); 12-1-18 (breakfast, morning snack, lunch, dinner, and evening snack); 12-2-18 (breakfast, lunch, dinner, and evening snack); and 12-3-18 (breakfast and morning snack).
g. Patient #19: The patient's medical record indicated Patent #19 was admitted on 12-9-18 and discharged on 12-11-18. Physician orders upon admission, dated 12-9-18 at "0120," indicated the patient was ordered a "regular - no Iodine/Shellfish/Brussell (sic) Sprouts" diet. There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. An email from the facility to the catering company, dated 12-11-18, indicated the patient was on a "Soft NO Brussel Sprouts, Shellfish, Iodine" diet. The "Inpatient Meal Record" indicated the patient received a "Soft 0 shellfish, iodine, brussel sprouts" diet on 12-10-18 (breakfast, morning snack, lunch, dinner, and evening snack); and 12-11-18 (breakfast, morning snack, and lunch).
h. Patient #20: The patient's medical record indicated Patient #20 was admitted on 12-1-18 and discharged on 12-6-18. Physician orders upon admission, dated 12-1-18 at "2310," indicated the patient was ordered a "regular" diet. There was no documentation in the medical record to indicate the patient's diet was later changed, the physician was contacted for a diet change, or there were alternate diet orders given. Emails from the facility to the catering company, dated 12-5-18 and 12-6-18 indicated the patient's diet included "No Milk, No Meat." The "Inpatient Meal Record" indicated the patient received a "reg 0 milk" diet on 12-3-18 (breakfast, morning snack, lunch, dinner, and evening snack) and a "reg 0 mile 0 meat) diet on 12-4-18 (breakfast, morning snack, lunch, and dinner). The "Inpatient Meal Record" further indicated Patient #20 received a "0 milk or meat" diet on 12-5-18 (breakfast, morning snack, lunch, and dinner); and 12-6-18 (breakfast and morning snack).

4. On 1-15-19 at 11:58 PM, during a tour of the inpatient unit while accompanied by A#3, the catering company was observed placing food on plates to serve to patients. While plating the food, Patient #10 requested, and was served, a "non-vegetarian" lunch.

5. In interview on 1-15-19 at 12:50 PM, A#3, Nursing Supervisor, acknowledged nursing staff will contact the catering company to change a patient's diet, without a physician's order, when a patient requests a special diet, such as a vegetarian or soft diet.