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Based on review of medical records, facility documents, policies/procedures and staff interviews, the hospital nursing staff failed to document that patients received meals and record the amount of food and fluids that patient consumed at each meal in 2 of 20 sample patients. The actual food intake of the two patients could only be determined by reviewing temporary dietary records, which documented each meal, including time ordered, time delivered, and all food and beverages orders. The failures created the potential for negative patient outcomes.

The findings were:

1. Medical Record Reviews:

Review on 12/28/11 of sample medical record #2 revealed that the patient was admitted, on 10/18/11 at approximately 7:30 p.m., from the emergency department for evaluation of a possible stroke. Admission orders received at 8:35 p.m., included restricting oral intake until a bedside swallow assessment could be completed by the nurse. The record indicated that the swallow assessment was completed at 8:50 p.m., clearing the patient to have food and fluids. The first documentation of a patient meal was found on 10/19/11 at approximately 7 p.m. No other meals were documented.

Review on 1/3/12 of sample record #4 revealed the patient was admitted to the intensive care unit from the emergency department, on 12/27/11, for a traumatic ski injury that included a renal laceration. The patient was ordered to be NPO (nothing by mouth) initially with subsequent orders for progressive diets of clear liquids and then "age-appropriate" regular diet as tolerated. Review of the record revealed no documentation of any meals provided to the patient or information about amounts consumed. The record revealed that the patient was discharged with his/her family to drive back home to the Midwest.

2. Review of Dietary Records:

On 12/29/11 at approximately 3 p.m., the dietary technician was able to provide records of the meals ordered and received for sample patient #2.

The records revealed that the patient had ordered breakfast, lunch and dinner, on 10/19/11 and breakfast on 10/20/11. The information provided revealed who had ordered the meal (in this case the patient), each item ordered off of the menu, the time the order was received and the time the order was delivered to the patient.

On 1/3/12 at approximately 10 a.m., the dietary department provided a similar report of meals order and times delivered for sample patient #4. The records indicated that someone other than the patient had ordered meals for the patient for the lunch and dinner meals, for 12/30/11, the day before discharge. There was a note for 12/31/11 stating no breakfast had been ordered for the patient.

3. Staff Interviews:

During tours of the fifth floor nursing unit, on 12/29/11 at approximately 9:30 a.m., the nursing manager stated that it was the expectation that all meals would be documented in the medical record under the feeding assessment area of the electronic record. S/he stated that the primary responsibility for documenting meals usually rested with the patient care techs (certified nursing assistants). She confirmed that even though the documentation standard was "charting by exception", for patient meals, the expectation was that all meals or refusal of meals would be documented in the medical record. S/he confirmed that the staffing ratio for patient care techs was usually 12 patients assigned to each technician.

It was confirmed during the medical record review with numerous nursing managers, on 1/3/12, that the records for sample patients #2 and #4 did not have documentation of all of the meals provided to them.

4. Policy/Procedure Review:

Review on 1/3/12 of facility policy/procedure "Meal Consumption" revealed the following, in pertinent parts:
" ...I. Purpose:
A. To delineate responsibility for monitoring dietary intake and nutritional status with documentation of patient meal consumption in the medical record.
III. Procedure:
A. Nursing Services is responsible for observing and recording food consumption of each patient.
B. Nursing Services shall be aware of diet order of each patient and should record food intake after each meal in the computerized information (IS) under Feeding Assessment.
C. An estimated percentage of a meal consumed is the recommended method for documentation. The chart below is a suggested guide which may be used for reference if needed ..."
The referenced "Dietary Intake Guide" chart contained Intake categories of Refused (0% intake), Poor (25% intake), Fair (50% intake), Good (75% intake) and All (100% intake). The categories also contained examples of how to accurately estimate food consumption.

The policy/procedure was provided with a note stating that the policy had been "retired" as of 12/11, because it was not considered necessary, although there were plans to incorporate the "Dietary Intake Guide" chart in the electronic medical record as a resource. After observing that documentation of meals had not occurred in sample patients #2 and #4, the nurse managers stated that they "might need to revisit that decision." Based on interviews with the nurse managers, there was no indication that the expectation that nursing staff would document all patient meal consumption had been "retired."