HospitalInspections.org

Based on document review and interview, nursing services failed to document dietary intake in 1 of 10 (Patient 3) medical records reviewed.

Findings include:

1. Facility document titled Neurology Unit Standards and Documentation Requirements - PCT, updated 01/03/2025, indicated under Intake and Output, Dietary Intake, every meal (to be documented in room before tray is removed).

2. Review of patient 3's medical record indicated the following:
a. On 10/11/2025 patient 3 was admitted for a cerebrovascular accident (CVA).
b. On 10/17/2029 provider ordered a chopped diet.
c. On 10/19/2025, 10/20/2025, and 10/21/2025 medical record lacked documentation for 1 of 3 dietary intake entries.
d. On 10/23/2025 the medical record lacked documentation for 2 of 3 dietary intake entries.
e. On 10/24/2025, 10/25/2025, and 10/26/2025 the medical record lacked documentation for 3 of 3 dietary intake entries.
f. On 10/27/2025 and 10/28/2025 the medical record lacked documentation for 2 of 3 dietary intake entries.
g. On 10/29/2025 the medical record lacked documentation for 3 of 3 dietary intake entries.
h. On 10/30/2025 and 10/31/2025 the medical record lacked documentation for 2 of 3 dietary intake entries.
i. On 11/01/2025 and 11/02/2025 the medical record lacked documentation for 3 of 3 dietary intake entries.
j. On 11/03/2025 the medical record lacked documentation for 1 of 3 dietary intake entries.
k. On 11/04/2025 and 11/05/2025 the medical record lacked documentation for 3 of 3 dietary intake entries.
l. On 11/06/2025 and 11/07/2025 the medical record lacked documentation for 1 of 3 dietary intake entries.
m. On 11/08/2025 and 11/09/2025 the medical record lacked documentation for 3 of 3 dietary intake entries.

3. Interview with A8 (Clinical Supervisor) on 11/12/2024 at approximately 4:10 p.m. confirmed that patient care technicians (PCT) and nursing staff are to document dietary intake for all meals daily.

4. Interview with A4 (Accreditation) on 11/12/2025 at approximately 4:23 p.m. confirmed patient 3's medical record lacked documentation of patient meals as indicated above.