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Based on medical record review and interview, the facility failed to ensure a complete medical record of solid and fluid intake for one patient (#1) of six records reviewed.

The findings included:

Patient #1 presented to the Emergency Department (ED), via ambulance, on February 28, 2011, at 1:26 p.m., with complaint's of Shortness of Breath and a history of Asthma and Chronic Obstructive Pulmonary Disease (COPD) requiring oxygen (O2) around the clock. The patient was alert and oriented; had an increased heart rate of 119 (normal range 70 - 80); breathing was moderately labored with decreased breath sounds in the upper right, middle right and left and lower left lobes; wheezes in the upper right lobe; and an (blood ) oxygen saturation of 98% (normal range (95% - 100%). The patient was seen by the physician for a history and physical, which revealed the patient complained of worsening shortness of breath over the past week, feeling weak, loss of appetite, and weight loss. The physical exam conducted by the physician revealed the patient was alert and oriented, well nourished, in no acute distress, well hydrated, mildly labored respirations, and moving very little air with prolonged expiratory phase with soft wheezes noted. An INT (Intermittent Needle Therapy is when an intravenous (IV) catheter is inserted and capped off to be used at a later time for intravenous medication administration) was initiated at 1:35 p.m., and IV antibiotic and steroid medications were initiated along with nebulizer treatments (breathing treatment). The patient was admitted to the hospital on the cardiac monitoring unit with COPD with Acute Exacerbation and Bronchitis.

The Nursing admission notation documented the patient as alert and oriented. Review revealed the physician gave a verbal order to continue all home medications as reported by the patient to the admitting nurse, and after review, the physician signed the verbal order 18 hours later. Review of the Physician's Order, dated March 2, 2011, revealed Megace (appetite stimulant) 400 mg po daily, and 1 can (240 ml) of Ensure (liquid supplemental feeding solution) with meals was ordered.

Review of the History and Physical, dated as transcribed March 1, 2011, at 3:50 p.m., and dictated March 1, 2011, at 5:46 p.m., revealed the patient was admitted with COPD disease Exacerbation, Acute Tracheobronchitis, and Metabolic Acidosis (acidosis is a condition in which a build-up of carbon dioxide in the blood produces a shift in the body's pH balance and causes the body's system to become more acidic and can be caused by diseases or conditions that affect the lungs such as emphysema and chronic bronchitis).

Ordered labs revealed a blood culture, which showed no growth for five consecutive days, and blood C02 (carbon dioxide) level on March 2, 2011 was noted high at 39 (range 21 -32 millimoles per liter) compared to a C02 high of 44 obtained in the ED lab studies. No additional studies were conducted on the patient's white blood count beyond the ED lab work. Other labs ordered were within normal limits or of no significant abnormal value.

Review of the Physician's Progress Notes, Nursing Notes, and Nursing Flow Sheets throughout the patients hospital stay revealed the patient remained alert, oriented, and able to make needs known throughout the hospital stay when the patient was discharged on March 3, 2011.

Review of the Medication Administration Records and Nursing Flow Sheets revealed the following food and fluid intake record: February 28 - 620 ml (milliliters) oral fluids, 270 ml IV fluids, and no meal intake recorded ; March 1 - 740 oral fluids, 250 ml IV fluids, bites of breakfast, 20% of lunch, and 25% of dinner; March 2 - 1087 ml oral fluids, 300 ml IV fluids, 100% of breakfast, 75% of lunch, no dinner intake recorded, 240 ml of Ensure; March 3 - 250 ml oral fluids, 300 ml IV fluids, no breakfast, lunch or dinner recorded, 720 ml Ensure; and March 4 - no oral intake recorded, 250 ml IV, no meal intake recorded, 240 ml Ensure.

Interview in the conference room with the Chief Nursing Officer and Risk Manager on July 12, 2012, at 3:40 p.m., confirmed the lack of any meal intake would be recorded as 0%; all intake was to be recorded; and confirmed the medical record was incomplete related to required documented information on the patient's intake of meals and fluids for February 28, March 3, and March 4, 2011.