HospitalInspections.org

Based on observation, clinical record review and interview, it was determined the Facility failed to ensure meal intake percentage was documented for three (#21-#23) of 10 (#21-#30) inpatients. The failed practice did not ensure the patient's 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 clinical records revealed the following:
1) Patient #21 was admitted 08/20/14 through 08/22/14 with an order for a diabetic diet. No meal intake percentage was documented.
2) Patient #22 was admitted 08/14/14 thorough 08/22/14 with an order for a renal diet. No meal intake percentage was documented.
3) Patient #23 was admitted 07/04/14 through 07/09/14 with an order for a regular diet. No meal intake percentage was documented.

B. Findings were confirmed by the Clinical Director of 4 South Unit on 08/29/14 from 1000 through 1135.