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RIDGEVIEW INSTITUTE MONROE 709 BREEDLOVE DRIVE MONROE, GA Dec. 13, 2017
VIOLATION: THERAPEUTIC DIETS Tag No: A0629
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, medical record review, and staff interview, the facility failed to ensure Patient #1 was assessed by the Registered Dietician.

Findings:

Review of facility policy, no number, "Assessment of Patients," effective 12/2016, revealed that patients would have a full nursing assessment within eight (8) hours of admission. A further review revealed that a full history and physical would be completed by a physician (MD) within twenty-four (24) hours of admission. Per the assessment policy, a nutritional assess would be performed by the Registered Dietician (RD) upon MD order or if a need was identified a result of the Nutritional Screening by the nurse.

Review of the facility policy, no number, "Assessment," effective date 01/2017, revealed that assessments are done to determine each patient's needs by determining the need for an evaluation by other professionals, i.e., Dietician. A further review revealed that the RN would review all assessment data with the patient and determine the patient's need for further evaluation by the Dietician or Chemical Dependency Counselor. A continued review revealed that evaluation by the RD would occur on Monday, Wednesday, and Friday. If an emergency existed, the RN would call for an Interim Assessment by a Dietician.

Review of facility policy, no number, "Institution of Diet Prescriptions," effective 01/2017, revealed that the Food and Nutrition Department would receive diet prescriptions for each new admission to the facility.

Review of facility policy, no number, "Client with Special Dietary Needs," effective 01/2017, revealed that the Food and Nutrition Department would provide extra food as needed in the form of between-meal snacks to any client with limited dietary intake as determined by the RD. A further review revealed that a client would receive meals that were nutritionally adequate based on criteria from the approved diet manual. Per the policy, the RD would evaluate the appropriateness of the diet and instruct the client on any dietary restrictions.

Review of facility policy, no number, "Nutritional Assessment Process," effective 01/2017, revealed that a comprehensive nutritional assessment would be completed on admission to identify any patient at potential dietary risk. A further review showed that the RD would be responsible for performing the nutritional assessments and consultations. Per the policy, patients identified at a nutritional risk with a physician ordered dietary consult, or through the nurse's nutritional screening tool, would receive a nutritional consult. A continued review revealed that a nutritional assessment would be completed within two (2) days of receiving the order for a nutrition consult.
Review of facility policy, no number, "Nutrition Screen and Assessment," effective 01/2017, revealed that patients determined to be at risk would have a nutrition assessment by the RD within twenty-four (24) hours.
Review of facility policy, no number, "Nutrition Risk," effective 01/2017, revealed that a patient with a medical history of diabetes would be determined to be at nutritional risk. A further review revealed that the RD would be notified of any patient found to be at nutritional risk.

Review of facility policy, no number, "Nutrition Service for Patients," effective 01/2017, revealed that snacks would be offered to all patients in the morning, afternoon and evening. A further review revealed that the facility nursing staff would be responsible for distributing snacks to patients on special diets. A continued review revealed that a plan of care is documented when a patient is determined to be at high nutritional risk, which may include a modified diet, patient education, and a follow up dietary assessment and teaching.

Review of facility policy, no number, "Nourishment between Meals," effective 01/2017, revealed that the RD would write special snacks and record the information on the special snack list. A further review revealed that snacks are made for 2:30 p.m. and 7:30 p.m. delivery times. A continued review revealed that snacks are made according to written orders of the RD, and the RD must approve substitutions.

Review of the Initial Nursing assessment dated [DATE] at 3:05 a.m. revealed that Patient #1 was independent with walking, eating, dressing, bathing, and toileting. The patient was assessed as a fall risk due to medications. The patient reported having a history of irritable bowel syndrome and some urinary incontinence. Patient #1 stated on admission that he/she ate a normal diet but did not like dairy or onions due to a history of irritable bowel syndrome. The patient confirmed a surgical history of gastric bypass. The BMI was documented as 31.2, and the nurse documented on the assessment form that the patient needed an RD consult.

Review of the Dietary Communication Form dated 10/07/17 revealed the form was filled out by the RN. The diet was ordered as General, Healthful Diet and lactose-free. The Nutrition Consult needed box was checked no. The patient's BMI was recorded as 31.2.

Review of the laboratory results dated [DATE] revealed Patient #1's glucose was 95 (normal is 74-106.)
Review of the Psychiatric Evaluation dated 10/08/17 revealed that the patient was admitted under a 1013 for worsening suicidal ideations. The patient reported that he/she was prone to episodes of intense anger and irritability. The patient had a past medical history of hypertension, arthritis, and sleep apnea. The patient also had a history of gastric bypass surgery. A further review revealed the admitting diagnoses of unspecified bipolar disorder, unspecified anxiety disorder, hypertension, chronic pain, sleep apnea, and arthritis. The patient had a history of two (2) prior psychiatric admissions at other psychiatric facilities. A continued review revealed that consults were to include Social Services and Dietary.

During an interview with the Registered Nurse (RN #1) on 12/10/17 at 10:03 a.m. in the Administrative Conference Room, the RN stated that the facility had employed him/her as a night supervisor for the past year. The RN added that he/she had been working in psychiatric nursing for the past five (5) years. The RN stated explained that a licensed social worker first assesses patients seeking admission to the facility. The RN stated that a nurse would also work in the assessment area with the social worker. All patients have their vital signs taken, and when the assessment is complete, the patient is moved to a unit in the facility. The RN stated that when patients arrive in the unit, a nurse completes a full head-to-toe assessment, and when the evaluation is completed within eight (8) hours. The RN added that all patient diets are documented on a dietary form, and the form is sent to the kitchen. The RN stated that if a patient requires a special diet, the form is faxed to the Registered Dietician (RD), which automatically triggers a dietary consult. The RN explained that during the night shift snacks are given to the patients each evening between 7:30 p.m. and 8:00 p.m. The RN stated that if a patient requested their snack earlier or later in the evening, the request would be accommodated. The RN said that if a patient asked for extra snacks, a request would be sent to dietary for approval based on the patient's recommended or ordered diet. Note: At approximately 10:40 a.m., RN #1 received a call from his/her manager and was instructed to go home as the RN had worked the night shift. The interview terminated at this point, per the RN #1's request.

During an interview with RN #2 on 12/10/17 at 3:35 p.m. in the Administration Conference Room, the RN stated that he/she worked as a daytime nursing supervisor at the facility. The RN explained that any patient with a history of Gastric Bypass Surgery or Irritable Bowel Syndrome (IBS) would be considered at high risk nutritionally. RN #2 confirmed that the Dietary Communication form for Patient #1 was marked no RD consult needed, and the communication form did not list Patient #1's history of Gastric Bypass Surgery or IBS. The RN stated that a patient with a history of gastric bypass surgery is given a diet with smaller portions and are offered meals several times over the course of a day. After reviewing Patient #1's nursing assessment, RN #2 stated that he/she would have considered the patient a nutritional high-risk patient, and the RN added that he/she would have ordered an RD consult.

During an interview with RN #3 on 12/11/17 at 9:15 a.m. in the Administration Conference Room, the RN #3 stated that he/she had been the Director of Nursing (DON) since the facility opened last year. The RN explained that patients with a history of gastric bypass surgery require an RD consult as they are considered to be at high risk nutritionally. RN #3 added that gastric bypass patients have a diet that consists of smaller portions staggered over several meals throughout the day. After reviewing Patient #1's chart, the RN stated that Patient #1 should have had an RD consult based on his/her history. The RN acknowledged that the Dietary Communication form for Patient #1 was marked no consult required. The RN stated that the patient did not receive a nutritional consult, and confirmed there was no RD consult or order for an RD consult in Patient #1's medical record.

During an interview with the Psychiatrist (MD #4) on 12/11/17 at 11:35 a.m. in the Administration Conference Room, MD #4 stated that he/she did not remember the patient having had gastric bypass surgery. The MD acknowledged that he/she documented that Patient #1 did have a history of gastric bypass. MD #4 explained that he/she would have assumed that based on the patient's history, the nursing staff would have ordered an RD consult. The MD stated that he/she does not normally order a patient's diet unless the patient specifically asked him/her to order one. The MD stated he/she had a patient in the past that had a gastric bypass. The MD stated that patient specifically stated that he/she required numerous small meals during the day and asked the MD to write a special diet order. MD #4 stated that Patient #1 never discussed any special needs or made any remarks regarding his/her gastric bypass surgery. The MD stated that the two (2) occasions that he/she saw the patient during the admission, the patient never complained about anything regarding food or water. MD #4 stated that his/her NP saw the patient four (4) times during the admission. The MD stated when he/she review the NP's notes, Patient #1 never mentioned any issues with his/her diet or water intake.

During a telephone interview with the Medical Physician (MD #5) on 12/11/17 at 12:15 p.m. in the Administration Conference Room, MD #5 stated that he/she had been working with psych patients for the past thirteen (13) years. The MD stated that he/she started seeing patients at the facility in the spring of 2017. MD #5 explained that he/she would review the chart from a transferring facility to get an idea of the patient's history before evaluation. The MD stated that he relies on the patient to communicate any special diet needs regarding diet unless the patient is psychotic or unable to contribute information regarding their needs. The MD stated that he/she had patients in the past that had undergone a gastric bypass that did not require special diets. The MD stated patients have a better understanding of what works best for them. MD #5 indicated that he/she saw the patient on four (4) occasions, and the patient never mentioned that he/she had gastric bypass or expressed any special needs or complaints regarding diet, snack, or water issues. The MD added that he/she would have no problem with the nursing staff if they had requested an RD consult. The MD stated that if he/she had known about the patient's history of gastric bypass, and the patient had been unable to communicate with him/her regarding his/her care or needs, he/she would have ordered an RD consult.
During an interview with the Patient Advocate (Employee #6) on 12/11/17 at 3:45 p.m. in the Administration Conference Room, Employee #6 stated that he/she began working at the facility in 05/2017. Employee #6 stated that he/she remembered Patient #1 very well. The employee stated that when he/she reported for work on 10/09/17, Patient #1 had left him/her a voicemail on the Advocate Line and the patient stated that he/she wanted to meet with Employee #6. Employee #6 stated that as soon as he/she got the message, he/she went to the unit to speak with Patient #1. The employee stated he/she met with the patient on 10/09/17 at 2:00 p.m. in the patient's room. The employee stated that Patient #1 expressed that he/she was angry that Employee #6 did not come in to see him/her over the weekend. Employee #6 stated that he/she explained to Patient #1 that he/she worked Monday through Friday and that he/she responded as soon as he/she got the message. Employee #6 stated that Patient #1 reported being upset that he/she did not receive any pain medications other than Tylenol and Motrin on the night of his/her admission on 09/07/17. Employee #6 stated that he/she explained to Patient #1 that he/she had not been evaluated by the MD (MD #5) until 10/08/17, and the MD #5 was the person that would need to write the order. Employee #6 explained to Patient #1 that he/she did have a Fentanyl patch on, and the nursing staff had explained to Employee #6 that the patient would have to see an MD before anything could be administered. The employee stated that Patient #1 also complained that his/her bed was too hard. The employee stated that he/she told the patient that he/she would try to see if the MD would write an order for something to help the patient sleep, and the patient indicated that he/she didn't want anything for sleep. Employee #6 stated that Patient #1 complained that he/she could not get any toilet paper from the staff. Employee #6 stated that he/she did investigate the toilet paper issue, and the staff informed Employee #6 that the patient's room was checked, and toilet paper was in the patient's bathroom. The employee said the patient complained that he/she did not receive food while in intake. Employee #6 stated that patients have to be evaluated by the nurse to ensure it is safe for the patients to eat. Employee #6 stated that patients admitted to the facility during off hours are provided with nourishment as soon as possible. Employee #6 stated that Patient #1 indicated the nursing staff was rude to her. The employee asked the patient the names of the employees, and the employee stated that the patient stated that he/she didn't care enough to find out what the nurse's names were. The patient also complained that the nurse's left the lights on at the nurse's station during the night. Employee #6 stated that he/she tried to follow-up with Patient #1 but was unable to reach him/her. Employee #6 stated that on 10/20/17 at 11:40 a.m. Patient #1 left a voicemail and stated that he/she was very upset that he/she had not received information regarding an Ombudsman. The patient also stated that he/she had no faith in Employee #6. Employee #6 stated that the patient had never mentioned an Ombudsman in any prior conversations with him/her. The employee stated that the facility does not have an Ombudsman, but does have a Patient Advocate to assist with any issues. The employee stated that he/she tried to call the patient back the same day, and the patient did not answer the phone. The employee stated that he/she left a voicemail for the patient, and the patient never called him/her back. Employee #6 stated that the patient never mentioned anything about food, water, or skin irritation during any conversation with him/her.

During an interview with the Registered Nurse (RN #7) on 12/12/17 at 3:45 p.m. in the Administration Conference Room, RN #7 stated that he/she had been working the 7:00 p.m. to 7:00 a.m. shift on 10//07/17. The RN explained that all high-risk nutritional patients receive an RD consult. The RN continued by stating that any patient with hypertension, high cholesterol, history of any gastrointestinal problems, food allergies, cardiac history, or any special diet history, would be considered at high risk nutritionally. The RN stated that he/she was the RN that had completed the initial assessment on Patient #1 on 10/07/17. After RN #7 reviewed Patient #1's assessment, the RN stated that Patient #1 had a history of gastric bypass surgery in 2001. The RN added that Patient #1 also had reported a history of irritable bowel syndrome (IBS) and chronic dieting. The patient also did not like raw onions or lactose due to issues with IBS. The RN stated that he/she did document that the patient's BMI was 32.1, which per facility policy, was assessed as mildly high. The RN stated that he/she did indicate on the Nursing Assessment form that Patient #1 required an RD consult. The RN then reviewed the Dietary Communication form and acknowledged that he/she had checked, no, where the form asked if the patient required an RD consult. The RN stated that he/she did document the patient's 31.2 BMI on the form, but that he/she had failed to list any of the pertinent histories regarding IBS or the patient's gastric bypass, or indicate the need for an RD consult. The RN stated he/she could not explain why he/she failed to indicate that Patient #1 required an RD consult on the Dietary Communication form. The RN stated it was a mistake on his/her part. The RN stated that patients with a history of gastric bypass would often require smaller meals staggered over the course of the day.

During an interview with the Registered Dietician (RN #8) on 12/12/17 at 10:00 a.m. in the Administration Conference Room, RN #8 stated he/she had been an RN since 2007. The RD added that he/she began working permanently at the facility early in December 2017. The RD explained that he/she was not the facility's RD at the time of Patient #1's admission. After reviewing the Initial Nursing Assessment and Dietary Communication Form for Patient #1, the RD stated the patient should have had an RD consult. The RD stated a BMI of 31.2, history of gastric bypass, IBS, chronic dieting, history of ETOH (alcohol) abuse, and high blood pressure were indicators that the patient required a consult with RD as the patient would have been considered a high-risk nutritional patient. The RD stated that nursing staff is historically good about communicating the nutritional needs of patients, and the RD could offer no explanation as to why RN #7 did not fill out Patient #1's Dietary Communication Form correctly.