HospitalInspections.org

Based on medical record review, staff interviews and review of policy and procedures the facility failed to ensure that 1 of 13 (Patient 4) patients medical records reviewed had a completed nutritional assessment. This failed practice has the potential to affect all inpatients of the facility. Inpatient census on day of entrance was 71.

Findings are:

A. Review of Patient 4's medical record revealed the patient was admitted for 4 days (4/30-5/4/23). Review of the entire medical record revealed a lack of a completed nutritional assessment.
B. Review of policy and procedure procedure titled Patient Admission and Initial Assessment (Revised 1/2022) revealed a "Nutritional Assessment is completed within 24 hours after admission."
C. Interview with the Interim CNO (Chief Nursing Officer) (6/13/23 at 2:00PM) confirmed that Patient 4's medical record lacked evidence of a completed nutritional assessment.