The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SMOKEY POINT BEHAVIORAL HOSPITAL 3955 156TH ST NE MARYSVILLE, WA 98271 Feb. 6, 2020
VIOLATION: GOVERNING BODY Tag No: A0043
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Based on observation, interview, record review, and review of hospital policies and procedures, the hospital's governing body failed to provide effective oversight of the hospital.

Failure to provide effective oversight for patient rights puts patients at risk of harm from inconsistent and inadequate treatment.

Findings included:

Failed to ensure staff protected and promoted each patient's rights to prevent patient's loss of personal freedom, privacy, dignity, and psychological harm.

Cross Reference: A0115
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VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on observation, interview, and document review, the hospital failed to protect and promote patients' rights related to care in a safe setting and restraint use.

Failure to protect and promote each patient's rights risk patient's loss of personal freedom, dignity, physical and psychological harm.

Findings included:

1. Failure to develop and implement a system to ensure the safety of patients that reflected their risk for suicide.

Cross Reference A0144

2. The hospital delayed in implementing appropriate interventions to prevent patient to patient touching.

Cross Reference A0144

3. Failure to monitor patients in restraints as directed by hospital policies and procedures.

Cross Reference A0167

Due to the scope and severity of deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET.
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VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on observation, interview, document review, and review of hospital policy and procedures, the hospital failed to develop and implement a system to ensure the safety of patients: that reflected the patient's risk for suicide (Item #1), delayed in implementing appropriate observational monitoring, enhanced precautions, and medical treatment evaluation following an inappropriate sexual touching between two patients (Item #2), and failed to ensure staff understood and implemented policy and procedure for patient rights surrounding abuse to include reporting of suspected incidents (Item #3).

Failure to protect patients from self-harm and failure to implement appropriate interventions to prevent patient to patient touching incidents risks an unsafe therapeutic environment, psychological harm, and serious injury or death.

Findings included:

Item #1 - Suicide Precautions

1. Document review of the hospital's policy and procedure titled, "Precaution: Suicide," no policy number, revised date 03/18, showed that the purpose of the policy is to provide a safe and secure environment for the patient who requires protection. Suicide precautions is a category used for any newly admitted patient who, prior to admission, has either attempted suicide or has suicidal ideation. Line of Sight (LOS), every 5-minute observation, and one-to-one (1:1) are categories used for any patient who, in the opinion of the attending physician or a Registered Nurse (RN), represents an active suicide risk. Patients on suicide precautions will be checked on at least every 5 minutes.

2. On 01/06/20, Investigator #5 reviewed hospital documents and the medical record for Patient #502. The review showed:

a. Patient #502 was admitted on [DATE] for the treatment of a suicide attempt.

b. A documented Psychiatric Evaluation completed on 11/02/19 at 12:40 PM showed that the patient had a diagnosis of major depressive disorder with severe psychosis. The patient's psychiatric history included anxiety, and post-traumatic stress disorder (PTSD). The patient had a history of multiple suicide attempts and self-harm by "cutting."

c. On 11/04/19 at 12:00 AM, hospital staff placed the patient on suicide precautions and on every (Q) 5-minute monitoring.

d. A nursing note dated 11/04/19 at 6:00 AM showed that the patient was found with socks tied around her neck with "Suicidal Ideation" (SI).

e. The document titled, "Observation Record-Q 5-minute," dated 11/04/19, showed a hand written communication at the bottom of the page that stated, "DO NOT GIVE HER SOCKS!" Investigator #5 found no evidence the patient Treatment Plan was updated to reflect the suicidal ideation/suicide attempt or the removal of socks from the patient.

f. A nursing note dated 11/05/19 at 6:00 PM showed that at 4:15 PM, Patient #502 was found in the shower with socks tied around her neck. The note showed that staff called a Code Gray (staff need help with a combative person) emergency, removed the socks from the patient's neck and transferred the patient to a local hospital emergency room (ER) for follow-up.

g. On 11/06/19 at 12:00 AM, Patient #502 was placed on LOS observation at all times. At 10:00 AM that same day, the order was modified to LOS while the patient was awake.

h. A provider note dated 11/06/19 at 3:00 PM, showed that the night prior, the patient had tried to "strangle" herself with her socks and a code was called.

3. On 02/06/20 at 12:05 PM, Investigator #5 asked the Chief Nursing Officer (Staff #503) how the hospital mitigated the risk of suicide attempts for patients who have attempted to commit suicide while an inpatient at the hospital. Staff #503 stated that rather than restrict privileges, the hospital increases monitoring of the patient. If a patient is still active in their suicidal ideation, monitoring is increased to 1:1 monitoring before the hospital would have removed the socks from the patient.

4. On 01/29/20, Investigator #12 reviewed the medical record of Patient #1201. The review showed:

a. Patient #1201 was admitted on [DATE] for treatment of increased suicidal ideation and danger to self.

b. A documented Psychiatric Evaluation completed on 11/19/19 at 12:00 PM showed a diagnosis of schizoaffective disorder. The patient's psychiatric history showed multiple admissions and suicide attempts/self-harm with current admission for increased suicidal ideation with a plan to overdose on insulin.

c. On 11/19/19 at 6:00 AM, hospital staff placed the patient on suicide precautions, unit restriction, and every (Q) 5-minute monitoring. At 1:30 PM, hospital staff changed the monitoring to Q 15 minute monitoring checks. Suicide precautions were discontinued the same day at 3:00 PM.

d. On 11/24/19 during group therapy, the patient wrote "suicidal big time in a lot of pain" on her daily wrap up goal. Investigator#12 found no evidence that the patient's treatment plan was updated to include the problem of increased suicidal ideation.

e. A nursing note dated 11/24/19 at 9:15 PM, showed that the patient " ...was found in a sitting position with her back up against her bedroom door. She had a pair of socks tied tight around her neck. She was unresponsive and dusky. Socks were removed and her color returned to normal".

The same nursing note showed that a provider was notified and staff placed the patient on 1:1 monitoring with Q5-minute checks. The patient was eventually transferred emergently to a local hospital ER on 11/25/19 at 10:10 AM. The patient returned to the facility on [DATE] at 10:40 PM.

Investigator #12 found no evidence the patient's Treatment Plan was updated to reflect an intervention to remove socks from the patient. Upon return from the ER, the patient was placed on suicide precautions with 1:1 observation and Q5 minute monitoring. Suicide precautions and Q5 minute checks were discontinued on 11/27/19 at 11:02 AM

f. A provider note dated 11/26/19 at 8:10 am showed that "Pt was sent to ED after trying to strangle herself with socks and did have a syncopal episode after that ..." Investigator #12 found no evidence the patient's Treatment Plan was updated to reflect an intervention to remove socks from the patient.

g. A nursing note dated 11/28/19 at 6:08 PM showed that at 6:35 PM, "Pt. had her door bared (sic)/shut with her body. Pushed door open. She was sitting on her buttocks with her back up against the door. She was slumped over and not breathing."

"The yellow hospital socks were tied together to make a tourniquet around her neck. Her face was blue. The sox (sic) were tied in a double knot and was very tight ...." Investigator #12 found no evidence the patient Treatment Plan was updated to reflect removal of socks from the patient.

h. A provider note dated 11/29/19 at 8:20 AM showed "Patient had attempted suicide yesterday via strangulation by using two socks tied together and then blocking her door. This is the third attempt, the most recent being about three days prior ..." Investigator #12 found no evidence the patient Treatment Plan was updated to reflect removal of socks from the patient.

i. On 11/29/19 at 2:00 PM, after the patient's third attempt at self-strangulation with socks, a provider order was entered for "no socks".

5. On 02/06/20 at 2:10 PM, Investigator #12 interviewed the Chief Nursing Officer (Staff #503) about how the hospital mitigates the suicide risk for patients who have attempted to commit suicide while being an inpatient at the hospital. Staff #503 stated that rather than restrict privileges, the hospital increases monitoring. If patients are still active in their suicidal ideation, monitoring is increased to 1:1 thus mitigating the risk for self-strangulation with socks.

Item #2 - Inappropriate Sexual Touching

1. Document review of the hospital's policy and procedure titled, "Precautions: Sexual Acting Out (SAO)", no policy number, effective 05/17, showed that a physician's order is required for a patient to be placed on SAO precautions.

Document review of the hospital's policy and procedure titled, "Precautions: Sexual Victimization," no policy number, effective 08/19, showed that sexual victimization may include boundary violation, allegations of sexual encounters, unwanted touching, sexual misconduct, sexual intercourse, and sexual assault. A physician's order is required for a patient to be placed on sexual victimization precautions. A nurse may place the patient on sexual victimization precautions without prior physician's approval and then notify the Attending Physician for the order.

Document review of the hospital's policy titled, "Protection of Evidence from Assault," no policy number, effective 05/17, showed that immediately upon receiving any information concerning a possible assault, the nurse will immediately ensure the patient's safety. Documentation of the allegation, intervention to ensure the safety of the patient and all notifications need to be placed in the medical record.

2. On 01/28/20, Investigator #3 reviewed the medical record of Patient #301, a [AGE] year old female who was admitted on [DATE] for the treatment of schizoaffective disorder. The review showed:

a. The Intake assessment dated [DATE] showed that the patient's thought processes were disorganized and tangential. The patient was assessed for being at risk for victimization as a vulnerable adult.

b. The Psychiatric Evaluation dated 12/31/19 showed that the patient had very limited insight into her recent behavior of writing bad checks and was displaying manic symptoms with poor impulse control and judgement.

c. On 12/30/19 at 7:45 PM, the admitting provider wrote orders for unit restriction and observational monitoring with 15-minute checks.

d. On 01/04/20 at 11:30 AM, the Daily Nursing Note showed the patient was delusional with disorganized illogical thoughts. The patient was noted to be intrusive with peers. A review of the note showed that the patient was on fall risk precaution, with no other identified risk status.

e. The Daily Nursing Note dated 01/05/20 at 5:00 AM showed the patient was disorganized and found in the room of another patient doing an "inappropriate act". The other patient (Patient #302) was moved to a different unit.

The investigator could find no evidence that enhanced observational monitoring or additional precautions were ordered at that time. The investigator also found no evidence in the medical record that the on-call provider was contacted at the time of the incident.

f. A progress note dated 01/06/20 at 6:00 AM (late entry) written by a licensed practical nurse, showed that on 01/05/20 at approximately 1:30 AM, the nurse noticed that Patient #301 was not in the day room where she primarily spent her time. A search of rooms found Patient #301 in room 117 with a male patient (Patient #302) "half-naked" on top of the bed. Staff notified the charge nurse and the house supervisor.

g. A provider psychiatric note dated 01/05/20 at 9:50 AM showed that Patient #301 was reportedly having sexual intercourse with a male patient in his room. The patient reported that it was not forced and was not worried about sexually transmitted diseases (STD).

h. A note titled, "Decisional Capacity Evaluation" dated 01/05/20 at 9:30 AM showed that the case was reviewed with the physician assistant provider (Staff #302) and the Medical Director (Staff #303). The review showed that the patient lacked decision-making capacity to consent to sex based on her dismissal of STD risks and her irrational description of the other person.

i. On 01/05/20 at 9:44 AM, approximately 8 hours after the incident described in (f), a provider wrote an order for the patient to be placed on enhanced monitoring with every 5-minute checks, sexual victimization, and sexually acting out precautions.

j. On 01/05/20 at 11:15 AM, the patient was transported to a local hospital for a forensic nurse examination which is over 8 hours after the incident. The patient refused to consent to the examination and returned to the facility at 3:54 PM.

3. On 01/28/20 at 2:30 PM, Investigator #3 interviewed the Charge Nurse (Staff #304) who was on duty the morning after the incident. Staff #304 stated that the night shift off-going charge nurse reported the inappropriate sexual touching which had occurred on the shift. Staff #303 stated that she then reported the sexual touching to the House Supervisor and "things happened". She stated they should have called immediately after the incident.

4. On 01/29/20 at 8:35 AM, Investigator #3 interviewed the Chief Nursing Officer (CNO) (Staff #305) about the inappropriate sexual touching. Staff #305 stated that whenever there is any allegation of inappropriate sexual contact, the charge nurse will notify the nursing supervisor who will call the CNO and or the Chief Executive Officer. She stated that it was reported to her the two patients were kissing at the time of the incident. She also stated that she did not receive a report that reflected an accurate depiction of the incident, and once she received the correct information, hospital leadership discussed the incident and the plan going forward.

Item #3 - Failure to Implement Abuse Policy

1. On 01/27/20, Investigator #3 and Investigator #12 reviewed the medical record of Patient #305, a [AGE] year old female who was admitted on [DATE]. The review showed:

a. A Progress Note dated 01/18/20 at 7:30 PM showed that Patient #305's room-mate (Patient #306) disclosed to a mental health technician that Patient #305 entered her bed and asked to touch her. Patient #305 initially denied any sexual behavior occurring and then later reported touching her room-mate (Patient #306) above the waist. Patient #305 reported that she had asked the night shift staff to move her to a private room last night because she felt uncomfortable around Patient #306. Patient #305 was moved to another unit and placed in a private room.

b. A Provider Psychiatric Note dated 01/18/20 at 3:30 PM, showed that Patient #305 stated she was approached by her room-mate (Patient #306) last night to touch each other, and told staff this morning about what happened. Her room-mate (Patient #306) reported a different story, stating it was Patient #305 who initiated the touching. Patient #305 was adamant that she did it because she was told by her room-mate to do it because "she is older than me".

2. On 01/27/20 at approximately 9:30 AM, Investigator #12 interviewed a charge nurse (Staff #1202) about the inappropriate sexual touching between Patient #305 and Patient #306 and about mandatory abuse reporting requirements. Staff #1202 stated that she was initially unaware of the mandatory reporting requirements regarding alleged sexual assault for patients under the age of sixteen. When she became aware, approximately two days after the alleged assault, she notified Child Protective Services (CPS) immediately.

3. On 01/28/20, Investigator #3 reviewed the medical record of Patient #301, a [AGE] year old female who was admitted on [DATE]. The review showed:

a. A Daily Nursing Note dated 01/05/20 at 5:00 AM showed the patient was disorganized and found in the room of another patient doing an "inappropriate act."

b. A progress note dated 01/06/20 at 6:00 AM (late entry) written by a licensed practical nurse, showed that on 01/05/20 at approximately 1:30 AM, the nurse noticed that Patient #301 was not in the day room where she primarily spent her time. A search of rooms found Patient #301 in room 117 with a male patient (Patient #302) "half-naked" on top of the bed. Staff notified the charge nurse and the house supervisor.

The investigator could find no evidence in the record that the Chief Executive Officer or the on-call provider was contacted at the time of the incident.

4. On 01/28/20 at 2:30 PM, Investigator #3 interviewed the Charge Nurse (Staff #304) who was on duty the morning after the incident. Staff #304 stated that the night shift off-going charge nurse reported the inappropriate sexual touching which had occurred on the shift. Staff #303 stated that she then reported the sexual touching to the House Supervisor and "things happened". She stated they should have called immediately after the incident.

5. On 01/29/20 at 8:35 AM, Investigator #3 interviewed the Chief Nursing Officer (CNO) (Staff #305) about the inappropriate sexual touching. Staff #305 stated that whenever there is any allegation of inappropriate sexual contact, the charge nurse will notify the nursing supervisor who will call the CNO and/or the Chief Executive Officer. She stated that it was reported to her the two patients were kissing at the time of the incident. She also stated that she did not receive a report that reflected an accurate depiction of the incident, and once she received the correct information, hospital leadership discussed the incident and the plan going forward.

6. On 01/28/20 at approximately 1:30 PM, Investigator #12 interviewed a staff nurse (Staff # 1203) about mandatory abuse reporting requirements. Staff #1203 stated that if a sexual assault occurred on her shift she would contact the CNO or CEO for further instruction.

7. On 1/28/20 at approximately 1:00 PM, Investigator #12 interviewed the Director of Clinical Services (Staff #1201) about mandatory reporting requirements. Staff #1201 stated that responding to an alleged incident of abuse or assault is a team effort. Staff #1201 further stated that all staff received mandatory reporter training and that signs regarding mandatory reporting are posted "all over the units."

8. Document review of the hospital's policy and procedure titled, "Patient Abuse and Neglect," no policy number, effective 05/17, showed that staff will be educated about requirements for identifying, reporting, and intervening in incidents of abuse and/or neglect. The policy showed that any hospital employee, agent or affiliate who observes or suspects or becomes aware of a situation at any time after the fact of patient abuse shall report the suspicion to the Chief Executive Officer (CEO) verbally within one hour. Once the CEO receives such a report, the attending physician shall be notified. The review showed no alternative notification procedures such as notifying the House Supervisor or Chief Nursing Office for suspicions of patient abuse.

Document review of the hospital's PowerPoint presentation given at new employee orientation on abuse, neglect, and exploitation showed, "If you suspect abuse, you'll need to follow the reporting policy set down by your state laws as well as your facility policies. Some states require you to contact a particular individual within your facility, who is then responsible for reporting the abuse to the designated agency or person. . . The report may be made orally or in writing and some states mandate a time frame, such as within 24 hours or the next business day."

The investigator found no evidence that the hospital's PowerPoint presentation document discussed the State of Washington laws regarding abuse and neglect. The presentation did not reference or include any information on the hospital's specific policy and procedure for suspected child or adult abuse or neglect incidents.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
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Based on record review and review of hospital policy and procedures, the hospital failed to follow its policy and procedure for monitoring patients while in restraints for 5 of 5 patients reviewed.

Failure to follow established procedures for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Use of Restraints," no policy number, effective 05/17, showed that bathroom privileges shall be offered or provided at least every 15 minutes or more frequently.

2. Investigator #12 reviewed the medical records of five patients who were restrained. The investigator found no evidence that staff offered or provided bathroom privileges for 5 out of 5 records reviewed.

3. Record review of a nursing progress note dated 09/18/19 showed that Patient #1205 was incontinent of urine while restrained. The patient received assistance with showering and personal hygiene following their release from restraints. Investigator #12 found no documentation in the restraint/seclusion record which showed that bathroom privileges were offered to the patient.

4. On 02/05/20 at approximately 11:00 AM, Investigator #12 interviewed the Chief Nursing Officer (Staff #503) about her findings in the restraint record review. Staff #503 commented that staff reeducation surrounding documentation of bathroom privileges probably needed to occur.
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VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
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Based on record review, interview, and review of hospital policy and procedures, the hospital staff failed to follow its procedure for late administration of scheduled medications for 2 of 7 medical records reviewed (Patient #303, #304).

Failure to administer scheduled medications on time risks delayed treatment and medication errors.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Administration," no policy number, no effective date, showed that timing of medication administration is based on the nature of the medication and clinical application. Scheduled medications which are ordered more frequently than daily must be taken one hour before or after scheduled time. Time critical scheduled medications like anticonvulsant medications must be administered within thirty minutes prior or after their scheduled time. All late administration of medications must be reported to the physician, pharmacist, and must be on the report submitted to the Performance Improvement Director by the Chief Nursing Officer. The reason for late administration or missing the dose to be administered must be included in the report.

2. Investigator #3 reviewed the medication administration records (MAR) of five patients. The review showed:

a. Patient #303 was to receive metoprolol (a medication used to treat high blood pressure) twice a day at 8:30 AM and 8:30 PM. The MAR on 02/02/20 showed the patient received the medication at 10:02 AM which is 1 hour and 32 minutes beyond the scheduled time. The investigator could find no evidence that the nurse documented any reason for the late administration or was reported on the hospital's variance log.

b. Patient #303 was to receive olanzapine (a medication used to treat schizophrenia and bipolar disorder) twice a day at 8:30 AM and 8:30 PM. The MAR on 02/02/20 showed the patient received the medication at 10:00 AM which is 1 hour and 30 minutes beyond the scheduled time. The investigator could find no evidence that the nurse documented any reason for the late administration or was reported on the hospital's variance log.

3. Investigator #11 reviewed the MARs of two patients. The review showed that Patient #304 was to receive oxcarbazepine (an anticonvulsant medication used to treat seizures) twice a day at 8:30 AM and 8:30 PM. The MAR on 02/03/20 and 02/04/20 showed the patient received the morning dose of the medication at 11:07 AM and 11:04 AM, which is 2 hours and 32 minutes and 2 hours and 34 minutes late, respectively. The investigator could find no evidence that the nurse documented the reason for the late administration or was reported on the hospital's variance log.

4. On 02/04/20 at 2:30 PM, Investigator #3 interviewed the Charge Nurse (Staff #306) about the late administration of the medications. She confirmed that the electronic MAR did not show any annotation indicating why the medication administration was given late. Staff #306 stated that medications can be given up to an hour early and an hour late. She also stated that often patients must be approached more than once before they agree to take their medications.
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VIOLATION: THERAPEUTIC DIETS Tag No: A0629
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Based on observation, document review, and interview, the hospital failed to ensure that patients with medical conditions, medical histories, allergies, or lifestyle choices that required dietary modifications received the appropriate diets for 1 of 1 patients reviewed (Patient #501).

Failure to ensure that patients requiring dietary modifications receive the appropriate diet risks improper nutrition that could lead to unanticipated patient outcomes, harm, and death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Nourishment between Meals," no policy number, reviewed 01/19, showed that special snacks will be written by the dietician and recorded on the special snack list. The dietary aide will prepare the special snacks; these are labeled and placed in the bin with the general snacks for each unit.

2. On 02/04/20 at 11:10 AM, Investigator #5 observed hospital staff distribute patient snacks. The observation showed a Mental Health Technician (MHT) (Staff #501) asked Patient #501 what kind of snack he wanted and allowed the patient to choose his snack from the options in the bin. During prior review of Patient #501's medical record, Investigator #5 noted that the patient was Diabetic.

3. At the time of the observation, Investigator #5 asked Staff #501 what the hospital process was for snacks for patients with dietary modifications. Staff #501 stated that for patients with dietary modifications, the snacks are delivered by the kitchen already prepackaged in a brown paper bag. Staff #505 showed Investigator #5 a brown paper bag containing a piece of fruit. The bag was labeled with Patient #501's name. Staff #501 stated that the patient did not like the snacks that came up in the brown bag so they let him choose what he wanted. Staff #501 stated that she had not informed the dietician that the patient did not like snacks in the brown paper bags.

4. On 02/04/20 at 11:45 AM, Investigator #5 observed Patient #501 present to the nurses station and ask for something to drink. The observation showed that a Registered Nurse (RN) (Staff #502) gave the patients drink options that included Orange Crush soda, Sweet Raspberry tea, SOBE water, or plain water. Patient #501 chose the Orange Crush Soda. Staff #502 began pouring the Orange Crush soda into a paper cup. At this time, the Charge Nurse (Staff #503) reminded Staff #502 that the patient was Diabetic. Staff #502 then told the patient he could not have the soda because he was diabetic and gave the patient the remaining options. The Patient chose the sweetened tea. Staff #502 poured the sweetened tea and gave the glass to the patient.

5. On 02/04/20 at 11:50 AM, Investigator #5 asked Staff #502 about the hospital's process for staff communication about patient dietary modifications for snacks and beverages. She stated that she was a PRN (as needed) nurse and did not know all the patients or processes. Staff #502 stated that she had intended to half the orange soda. Investigator #5 and Staff #502 verified on the container that the tea provided to the patient was Sweetened Raspberry tea.

THIS IS A REPEAT CITATION, PREVIOUSLY CITED ON 04/05/19.
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