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Based on record review, interview, and facility policy review, the facility failed to ensure that nursing staff supervised and evaluated nursing care for one patient (P) (P#1) of three sampled patients reviewed for nutrition.


Findings included:


Review of facility policy titled "Guide to Clinical Nutrition Services - SYSTEM," revised 04/25/2024, revealed a graph that indicated, "MEAL SERVICE/NOURISHMENTS As ordered" with "TIME FRAME FOR DELIVERY" as "Next meal after diet order received or as requested."


Review of P#1's "History and Physical" indicated the facility admitted the patient on 11/25/2024. the patient had a medical history that included diagnoses of accelerated hypertension, dysphagia (difficulty swallowing), nonspecific chest pain, supraventricular tachycardia (fast heart rhythm), upper back pain, and upper extremity weakness.


Review of "Orders" flowsheet for P#1 included an order for "Consistent Carbohydrate Diet" dated 12/03/2024 at 3:59 p.m. Per the order, the order expired on 12/11/2024 at 12:11 a.m.


Review of P#1's "Nutrition - ADLs [activities of daily living]" flowsheet from 12/08/2024 to 12/12/2024 revealed no documentation to indicate the patient received a breakfast meal tray for 12/09/2024.


Review of P#1's "Nutrition - ADLs" flowsheet from 12/08/2024 to 12/12/2024 revealed no documentation to indicate the patient received a lunch meal tray for 12/08/2024, 12/09/2024, and 12/10/2024.

Review of P#1's "Nutrition - ADLs" flowsheet from 12/08/2024 to 12/12/2024 revealed no documentation to indicate the patient received a dinner meal tray for 12/08/2024, 12/09/2024, and 12/10/2024.


During an interview on 01/16/2025 at 2:47 p.m., Quality and Accreditation Coordinator (QAC) #2 stated that she did not see any documentation in P#1's record to indicate the patient was provided a breakfast tray on 12/09/2024; lunch tray on 12/08/2024, 12/09/2024, and 12/10/2024; and dinner tray on 12/08/2024, 12/09/2024, and 12/10/2024.