HospitalInspections.org

Based on interview and record review, the facility failed to ensure that nursing staff documented the intake for one patient (P-1) of 10 patient charts reviewed, resulting in the potential for less than optimal outcomes for all patients in restraints at the facility. Findings include:

Record review revealed P-1 was admitted to the Emergency Department (ED) on 08/13/2023 at 1348 for alcohol intoxication and placed in non-violent restraints at 2314. Review of "ED Care Timeline" on 12/05/23 at 1400 demonstrated that P-1 was ordered an "adult diet" by treating physician Staff M at 1634 on 08/13/23. Review of the medical record revealed no documentation of food being provided to P-1. Additionally, a single reference was located in the "ED Notes", dated 08/13/23 at 2138 indicating the presence of a water cup, stating, "Pt kicked her water cup with the free leg..." A chart review was conducted on 12/05/23 at approximately 1000 with ED manager Staff O. Staff O was requested to search for documentation of food or water being provided to P-1, Staff O replied, "There is none."

An interview was conducted with Staff N on 12/04/23 at 1300. Staff N was questioned how she knows if a patient has been eating or not? Staff N stated that patients are continuously monitored, and un-eaten trays would be questioned. Staff N related that additional food is available in the unit pantry. Staff N was questioned if patient meals are documented? Staff N stated that "Intake and Output" should be documented, but that an aide or tech may have delivered food to a patient without documenting that."