HospitalInspections.org

Based on a review of documentation the facility failed to ensure that individual patient nutritional needs were met in accordance with recognized dietary practices as evidence by failing to document the percentage of meals that were consumed while inpatient.

Findings included:

Facility based policy entitled, "Intake and Output-Monitoring" stated in part,
"STEPS ...
4. For routine intake and output, frequently check with patient/family to assess patient's intake. Record all intake provided to the patient, (ie. formula feedings, g-tube feedings, oral fluids, IV fluids, etc.). Solid inputs are to be recorded by percentages, i.e. 50 %, 75 % of meal tray."

Review of medical records revealed that 3 of 5 patients (#1, 2, and 5) did not have meal percentages documented while inpatient at the facility per policy.
* Patient #1 had a physician order on 10/31/17 for Strict Intake and Output, this order was in effect until the patient's discharge. The only meal percentage documented was dinner on 10/31/17. No other meal intake percentages were documented for this patient.
* Patient #2 had a physician order on 10/29/17 for Adult diet with Strict Intake and Output, this order was in effect until the patient's discharge. On 10/29/17 lunch was the only meal documented. On 10/30/2017 dinner was the only meal documented. There were no meals documented on 10/31/2017.
* Patient # 5 had had a physician order on 11/04/17 for Strict Intake and Output, this order was in effect until the patient's discharge. There was no documented meal intake percentage for this patient during the entire inpatient stay from 11/04 through 11/07.

The above findings were confirmed with Staff member #1 on 12/18/17.