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Based on record review and interview the facility failed to have a registered nurse supervise and evaluate the nursing care for each patient. Specifically, the facility failed to maintain a record of the patient's meal intake for Patient's #1, #2, #3, #4, #5, #6, #7, #9 and #10. According to the facility's policy, the patient's meal intake is to be documented on the Patient Care Notes. Review of Patients #1, #2, #3, #4, #5, #6, #7, #9 and #10's charts revealed missing meal intake documentation.

This failure has the potential to affect all patients who require nursing care by a registered nurse.

Findings include:

Review of several Adult Patient Care Notes for Patient's #1, #2, #3, #4, #5, #6, #7, #9 and #10 revealed patient's intake monitoring was incomplete.

Interview on 03/04/2014 at 1:40 pm with Personnel #11 revealed that the clinical assistants should be monitoring and documenting each patient's intake on the Patient Care Notes. When shown that several intake monitoring was incomplete on the Adult Patient Care Notes for Patient's #1, 2, 3, 4, 5, 6, 7, 9 and 10's, Personnel #11 stated, "The staff should be documenting every patient's intake for all meals." Personnel #11 also stated that she was unaware that staff was not documenting the intake of all meals on the Patient Care Forms.

Review of the facility's Monitoring Intake and Output policy dated 06/2009 read, "Intake and output will be totaled every eight hours or more often if ordered. Measuring intake and output will help to maintain an ongoing assessment of the patient's fluid status, including their ability to tolerate oral fluids and potential for significant fluid losses. Each source of intake and output must be considered for accurate measurement. Record intake and output on the appropriate section of the patient care record."