HospitalInspections.org

Based on observation, clinical record review, policy review and interview, it was determined the Facility failed to ensure meal intake percentage was documented for 11 (#1, #3-#9, #17, #21 and #24) of 25 (#1-#25) patients. The failed practice did not ensure the patients' dietary intake was being monitored, thus creating the potential for inadequate calorie intake to go unnoticed and could affect any patient in the facility. Findings follow.

A. Review of policy titled "PCT Documentation Using the 24 Hour Patient Flow Sheet" stated, "The PCT is expected to ...enter percentage of diet taken and initial."
B. Review of clinical records revealed the following:
1) Patient #1 - admitted 04/30/14-05/03/14, 4 of 9 meals were not documented.
2) Patient #3 - admitted 03/22/14-04/01/14, 11 of 30 meals were not documented.
3) Patient #4 - admitted 03/21/14-04/07/14, 15 of 50 meals were not documented.
4) Patient #5 - admitted 04/05/14-04/05/14, 5 of 8 meals were not documented.
5) Patient #6 - admitted 04/03/14-04/06/14, 4 of 9 meals were not documented.
6) Patient #7 - admitted 03/31/14-04/08/14, 10 of 23 meals were not documented.
7) Patient #8 - admitted 04/26/14-05/01/14, 3 of 14 meals were not documented.
8) Patient #9 - admitted 04/23/14-05/03/14, 9 of 30 meals were not documented.
9) Patient #17 - admitted 07/12/14 and had not been discharge at the time of the survey, 18 of 58 meals were not documented.
10) Patient #21 - admitted 07/25/14 and had not been discharged at the time of the survey, 7 of 16 meals were not documented.
11) Patient #24 - admitted 07/24/14 and had not been discharged at the time of the survey, 24 of 24 meals had not been documented.
C. Findings were confirmed by the Director of Nursing Quality on 07/31/14 at 1150.