HospitalInspections.org

Based on document review and interview, it was determined for 4 of 5 (Pts #1, #2, #3, and #5) patients who required feeding assistance, the Hospital failed to ensure accurate and complete documentation in the medical record to include nutritional intake to communicate progress, or lack of progress, in the patient's nutritional status. This has the potential to affect all patients who may require feeding assistance.

Findings include:

1. Policy Number 6010-060 (Hospital effective date 2/1/19) was reviewed on 9/5/19 at approximately 1:50 PM. The policy indicated, "1. The Patient Medical Record is to serve as a tool of communication among the health care team presenting a comprehensive picture of the progress or lack of progress of the patient."

2. Five records of patients who required feeding assistance were reviewed throughout 9/4/19 and 9/5/19. Four out of five (Pt #1, Pt #2, Pt #3, and Pt #5) lacked accurate and complete documentation of nutritional intake.
a. Pt #1 Admitted: 7/20/19 Diagnoses: Fever, Dehydration, Asthenia.
Between 7/21/19 and 7/23/19, 2 out of 4 supper meals lacked documentation of nutritional intake. On 7/25/19, the day of discharge, both breakfast and lunch documentation indicate "Note: npo (nothing by mouth) ... NOTE ONLY" by E#5 at 2:44 PM.
b. Pt #2 Admitted: 8/30/19 Diagnosis: Acute Hypoxic Respiratory Failure.
Between 8/31/19 and 9/3/19, 3 out of 4 supper meals lacked documentation of nutritional intake.
c. Pt #3 Admitted: 8/29/19 Diagnosis: Left Lower Lobe Pneumonia.
Between 8/31/19 and 9/3/19, 6 out of 13 meals, of varying times, lacked documentation of nutritional intake.
d. Pt #5 Admitted: 8/29/19 Diagnosis: Intestinal Obstruction.
Between 9/1/19 and 9/4/19, 2 out of 4 supper meals lacked documentation of nutritional intake.

3. An interview was conducted with the Patient Care Technician (E#5) on 9/5/19 at approximately 9:55 AM. E#5 stated remembering Pt #1 and "I remember (Pt #1) being NPO (nothing by mouth) for a lab (laboratory) test, but I honestly can't remember whether or not I fed (Pt #1). I saw in the chart that it still had NPO for breakfast and lunch. I wish I could remember."

4. An interview was conducted with the Vice President of Operations (E#1) and the Chief Nursing Officer (E#2) on 9/5/19 at approximately 10:00 AM. E#2 had reviewed the nutritional intake records for Pts #1, #2, #3, and #5 and verbally agreed the documentation was not accurate or complete.