HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to ensure medical records were complete for dietary intake for 1 patient (Patient #1) of 5 records reviewed for Activities of Daily Living (ADLs).

The findings include:

Review of the facility policy titled "Documentation of Patient Care" dated May 2019, showed "...clinical information is used for providing current and future care as well as to demonstrate evidenced-based clinical practice...All caregivers are responsible and accountable for documenting care and responses to the patient. Every effort should be made to ensure timely documentation in the patient's medical record...Daily patient care documentation...interventions performed during care delivery (including ADL's performed by trained licensed staff)..."

Medical record review showed Patient #1 was admitted to the facility on 5/7/2021 with a diagnosis of Right Hip Pain and Inability to Ambulate. The patient was discharged to an assisted living facility on 5/17/2021.

Medical record review of Patient #1's daily ADL flow record showed the following:
5/7/2021 no lunch intake was documented
5/8/2021 no breakfast, lunch, or dinner intake was documented
5/9/2021 no breakfast or lunch intake was documented
5/10/2021 no breakfast or lunch intake was documented
5/11/2021 no dinner intake was documented
5/13/2021 no breakfast, lunch, or dinner intake was documented
5/14/2021 no breakfast, lunch, or dinner intake was documented
5/15/2021 no breakfast, lunch, or dinner intake was documented.
5/16/2021 no breakfast, lunch, or dinner intake was documented
5/17/2021 no breakfast, lunch, or dinner intake was documented

During an interview on 6/2/2021 at 3:15 PM, Registered Nurse (RN) #1 stated Dietary Service will sometimes pick up patients' tray before nursing has had a chance to observe the patient's meal intake.

During an interview on 6/2/2021 at 3:45 PM, RN #2 stated sometimes there are emergencies and she may not have time to document ADLs.

During an interview on 6/2/2021 at 3:56 PM, the Director of Nursing stated he was not aware of ADL documentation issues or patient care concerns. The Director of Nursing confirmed per facility policy it was expected for nursing staff to record every meal, every shift along with other ADLs.

During an interview on 6/2/2021 at 4:05 PM, the Manager of Regulatory Compliance confirmed all ADL documentation be included in the medical record.