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Based on observation, menu review, policy review, document review and staff interview, it was determined the facility lacked a procedure to ensure diabetic patients consistently received therapeutic bedtime (HS) snacks as needed and as ordered by the physician. The failed practice had the potential to affect all patients admitted to the facility on diabetic diets. Evidence follows:

A. Review of the Patient Menus revealed a lack of HS snacks for the Medium Carbohydrate Diabetic Diet. The Registered Dietitian (RD) confirmed the lack of an HS snack on the Medium Carbohydrate Diabetic Diet at 0900 on 07/08/10.
B. Interview with the Dietary Director at 1325 on 07/07/10 revealed the RD inserviced Dietary employees on the "Changes in Diabetic Diet Prescriptions Consistent Carbohydrate approach to Diabetic Diets" (American Diabetic Association recommendation for a diabetic diet) and instructed them to begin the procedure in August 2009. At that time, Dietary stopped sending individually labeled HS snacks for diabetic patients. She stated the nurses decided what to give and when to give the HS snack to diabetic patients. Interview with the RD at 0830 on 07/08/10 revealed she educated the nursing staff on the "Changes in Diabetic Diet Prescriptions Consistent Carbohydrate approach to Diabetic Diets" as recommendations by the American Diabetes Association. The procedure for HS snacks was not changed. Interview with the Chief Nursing Officer (DNO) at 1345 on 07/07/10 revealed the "Changes in Diabetic Diet Prescriptions Consistent Carbohydrate approach to Diabetic Diets" was just a recommendation, not an approved protocol.
C. Review of the Dietary policy originated 06/01/09 entitled "Therapeutic Nourishments" revealed the following:
1) Therapeutic nourishments were available for patients on low, medium and high carbohydrate diets.
2) Patients with diabetes would automatically be given a therapeutic snack if blood glucose levels permitted. The policy did not specify what blood glucose levels would indicate the need for a therapeutic snack.
3) Morning and afternoon snacks were delivered and documented by food service staff and the HS snacks were delivered and documented by nursing staff. The policy did not say when snacks were given or what snacks were to be provided.
4) Attached to the policy was a list of HS snacks and information regarding how many HS snacks to give for low, medium and high carbohydrate diets. The carbohydrate content of each snack was not consistent, which allowed for patients to receive variable amounts of carbohydrate, depending on which snack the nurse chose to give.
D. Observation at 1010 on 07/07/10 revealed "Changes in Diabetic Diet Prescriptions Consistent Carbohydrate approach to Diabetic Diets" and a copy of the HS Snack list provided in the Dietary Policy Manual were located at the Nurses' Station in the communications basket. Interview with the Charge Nurse at 1100 on 07/07/10 revealed she was unaware of any guidelines to follow regarding provision of HS snacks for diabetics. She stated Dietary left a sticker at the nurses' desk for all diabetic patients who needed a snack. All diabetics got an HS snack nightly. She stated the nurses decided what to give the patients unless the physician ordered a specific snack. She usually gave graham crackers and milk, something with protein. She was unaware of a list of HS snacks or any blood glucose level which would indicate the need for an HS snack.
E. Review of "Changes in Diabetic Diet Prescriptions Consistent Carbohydrate approach to Diabetic Diets" revealed one to two snacks were recommended (only if needed) for Consistent Low, Medium and High Carbohydrate Diets. The recommendations did not specify the snacks to be given at HS. Interview with the RD at 1000 on 07/08/10 revealed the "Changes in Diabetic Diet Prescriptions Consistent Carbohydrate approach to Diabetic Diets" was a review of the American Diabetic Association's recommendations for diabetic diets. She agreed the format was unclear and the snacks were meant to be given only at HS and only if needed. She stated she did not know the list of HS snacks was provided at the nurses' desk and she had never seen the list before.
F. Interview with the Chief Nursing Officer and the RD at 0900 on 07/08/10 confirmed the miscommunication between Dietary and Nursing related to a clear procedure for providing diabetic patients with HS snacks per physician order and consistent with the facility's approved patient menus.