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Based on medical record review, interviews and review of hospital policy and procedure, Nursing Services failed to develop a plan of care to include communication of Patient Identifier (PI) # Number 1's allergy to artifical sweeteners (except Splenda) to the Dietary Services. As a result of this failure in communication, PI # 1 received Sweet N Low, an allergen identified by a Registered Nurse (RN) during the patient's Admission Assessment on 4/30/2012, on multiple meal trays beginning 5/3/2013 through 5/10/2013.

This deficient practice affected PI # 1, one of four sampled patients, but has the potential to effect all patients with dietary related allergies.

Findings include:

Policy and Procedure Review:

Policy: Assessment of the Patient
Policy Number: HD-NUR 401.04
Effective Date: 3/1/2012

Policy: I. Admission Assessment:
"...It is the RN's (Registered Nurse) responsibility to verify the data, analyze and synthesize the data and assure the completeness of the admission assessment...Admission Assessment shall include:...Allergies...Nutritional Screen...

IV. Plan of Care: The nursing plan of care will be developed by the RN based on the findings of the admission assessment...The plan of care is to be individualized based on the patient's needs for nursing care..."


Policy: Nursing Plan of Care
Policy Number: HD-NUR 416.50
Effective Date: 3/1/2012

Policy: "The Nursing Process is utilized in assessing, planning, implementing and evaluating patient care. The process will be continuous
and documentation will be appropriate to each step...The patient's plan of care will serve as a guide for Registered Nurses and other staff members in the delivery of patient care. Established Standards of Practice will be utilized as appropriate in developing the patient's plan of care...The plan will support and be consistent with the medical plan and therapies of other disciplines through recognition and consideration of treatment plans, protocols and guidelines...The plan of care will be available to all staff involved in the patient's care.

Procedure:
A. Assessment
RN:
1. Interviews patient or significant other...to obtain information related to the assessment of nursing care needs and problems...
7. Reviews data collected...
8. Collaborates as appropriate with physicians and other clinical disciplines for identified patient problems...
9. Communicates data relative to other...departments, i.e. Medical Staff...Pharmacy, etc...

B. Planning
"During the planning phase the RN uses data gathered during the assessment phase to determine what can be done to overcome the patient's identified problems and prevent potential problems.

C. Implementation
The implementation phase of the Nursing Process is defined as the initiation of the plan by the nurse...
2. The nursing actions, interventions, and responses/outcomes will be documented in the medical record and communicated to other care providers when appropriate..."


Medical Record Review:

According to the History and Physical dated 5/1/2013 PI # 1 was admitted on 4/30/2013 with diagnoses to include:
1. Severe Coronary Artery Disease status post coronary artery bypass graft.
2. Recent Pneumonia...
7. Diabetes...
12. Altered Mental Status.

A review of the Pre-Admission Screening Form dated 4/30/2013 reveals,
"Allergies: Tussin CF, Liver, Oyster."

A review of the Nursing Admission Assessment dated 4/30/2013 reveals,
"Allergies: Tussin CF, Oyster, Liver, Spinach, Artificial Sweetners except Splenda...Nutritional Screen (part of the nursing assessment): Sugar subs, Liver, Oyster."

A review of the Physician Admission Order Set dated 4/30/2013 reveals, "Allergies: Tussin, Liver,Oyster."

A review of PI # 1's History and Physical dated 5/1/2013 reveals, "NKDA (No Known Drug Allergies)...Patient also allergic to possible liver, oysters, and Tussend..."


Interviews:
During an interview on 5/21/2013 at 11:15 AM, the Registered Dietician (RD) / Employee Identifier (EI) # 2 said she was not aware of any dietary concerns regarding PI # 1 while the patient was in the hospital. According to the RD, the patient was allergic to Aspartame (Equal). Patient meals are delivered to the Hospital Unit by Dietary Services staff. Nursing staff is responsible for meal set up and feeding of patients. On 5/2/2013, an order was received in Dietary Services to begin a Controlled Carbohydrate Diet (a diet for diabetic patients).

The RD said Sweet N Low, Splenda and Equal are available from Dietary Services for patients on diabetic diets. A single type of sweetener or a combination of sweeteners may be sent on a patient tray unless a patient preference is specified. Routinely, two packets of artificial sweetener are placed on meals trays. The exception is breakfast when four packets of sweeteners are placed on the trays. According to the RD, there is no way to know the type of sweetener that was placed on PI # 's meal trays during her hospitalization.

During an interview on 5/21/2013 at 3:05 PM, the RN / EI # 4 assigned to care for the patient on 5/10/2013 described the patient as alert with no confusion. According to the RN, the patient received Sweet N Low on her lunch tray on 5/10/2013, prior to discharge. The patient's family became upset about the Sweet N Low and said the patient preferred Splenda. The RN reported the family's concern to the Nurse Manager.


During an interview on 5/21/2013 at 3:15 PM, the Patient Care Technician (PCT) / EI # 3, reported diet trays are brought to the unit by dietary staff and passed out to the patients by nursing staff. According to the PCT, the patient (PI # 1) wanted a sugar substitute that the hospital did not have.


During an interview on 5/22/2012 at 12:30 AM, the RN who admitted the patient, Employee Identifier (EI) # 1, stated the patient's allergies were reported by the family during the nursing admission process on 4/30/2013. The patient's allergies included Tussin CF, Oyster, Liver, Spinach, Artificial Sweeteners except Splenda. The RN was asked to describe the action taken, if any, when the RN identified the patient's allergy to all sweeteners except Splenda. The RN stated," I don't know if you can add a food allergy after the diet order is entered."

The RN was asked how the patient's allergy to artifical sweetener except Splenda was communicated to Dietary Services. The RN indicated the communication would occur via, "Notes passed to each nurse."


During an interview on 5/22/2013 at 9:00 AM, the Director of Clinical Operations / EI # 6 stated the nurse who identified the patient's allergy
(all sweeteners except Splenda) should have written an order in the medical record specifying the allergy and also notified dietary via phone about the allergy. EI # 6 confirmed the hospital has an issue related to lack of communication of food related allergies by Nursing Services to Dietary Services.

During an interview on 5/22/2013 at 11:20 AM, the Hospital Administrator / EI # 5 stated, "I think we have a hole in communication with Dietary. Nursing must communicate with pharmacy and dietary."