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Based on observation, interview and record review the facility failed to provide care in a safe setting when the facility failed to adequately assess the nutritional aspects of a Diabetic patient when Patient #2 was receiving Ensure Plus and a regular diet, resulting in elevated blood sugars and did not complete the ordered laboratory testing to assess the patient's blood sugars.

Findings Include:

An observation on the afternoon of 1/28/20, on the facility's adult psychiatric unit accompanied by Staff #7, Risk Manager, revealed Patient #2 drinking a container of Ensure Plus, a non-diabetic nutritional supplement.

Review of Patient #2's medical record reflected on 1/21/20 3, the Nurse Practioner documented, "Diabetes Type 2: Per medical record. She is not on any medications for dx.
She refused accuchecks today. Cont FSBG BID and notifi/if glucose > 300.
Cont Dm diet. Consult dietician. Will order hgba1 c in AM.
Monitor glucose trends and nursing to notifl/ of any hypo/hyperglycemic readings."

Review of the Nurse Practioner orders reflected, "Dietitian Consult, BMP and HgbA1c (used to a patient's history of blood sugars) in the am, mechanical soft diet and Ensure (non-diabetic nutritional supplement) 1 bottle TID, (three times a day).

During an interview on the afternoon of 1/28/20, on the nursing unit, Staff #2, Risk Manager confirmed there was no Dietitian consult conducted and the HgbA1c had not been completed.

Review of Patient #2's blood glucose monitoring dated 1/27/20 reflected at 10:00 pm a reading of 200 and on 1/28/20 at 8:00 am a reading of 153. The patient had been refusing all other attempts to check her blood glucose.

During an interview on the afternoon of 1/28/20, in the facility conference room, Staff #7, LDRD (Registered/Licensed Dietitian) confirmed the Dietitian Consult had not been conducted. The Dietitians were not aware an order had been placed. Staff #7 stated, "We don't see every patient that is admitted ." When asked if the consult had been completed what would she have recommended, Staff #7, LDRD stated she would have recommended Patient #2 be changed to a low carbohydrate diet and the Ensure changed to Glucerna (a diabetic nutritional supplement).

Review of the facility provided policy Patient's Rights (Revised 10/2015) reflected," 3. You have the right to a clean and humane environment in which you are protected from harm..."