HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that nursing notes monitor the patient's consumption of meals and dietary supplements, for two of 10 medical records reviewed (MR1, MR2).

Findings include:

Review of facility documentation provided on May 14, 2018, at approximately 11:00 AM revealed, " ...UPMC Feeding/[Lippincott Procedures - Feeding] Revised May 12, 2017... Inability to perform self-feeding increases a patient's susceptibility to malnutrition. Various disabilities and conditions can prevent a patient from being able to feed herself, including cognitive deficits ... and traumatic injury. ... Documentation ... In your notes, record the amount of food and fluid consumed; also note the amount of fluid consumed on the intake and output record, if required. Record the patient's level of independence. ..."

Review of facility procedure, "...Documentation by Nursing Personnel ... Purpose: 1. To define the role and responsibility of nursing personnel in documentation. 2. To standardize documentation guidelines for collection of nursing data for a 24-hour period. 3. To provide a mechanism for accurate, comprehensive data collection and communication that meets appropriate legal and accrediting body ... 1. All documentation will be complete via approved documentation system. ... May collect and document care provided within their scope of practice which may include but not limited to: ... Intake and Output Dietary intake % ..."

1. Review of MR1 on May 10, 2018, at approximately 2:00 PM revealed that MR1 was admitted on March 7, 2018, and discharged on March 27, 2018. The patient to MR1 was ordered a dental easy to chew diet to begin on March 20, 2018. On March 21, 2018, no meal consumption was documented. On March 22, 2018, there was no documentation of dinner. On March 23 and March 25, 2018 there no documentation of the lunch or dinner meal consumption.
2. Continued review of MR1 on May 10, 2018, at approximately 2:30 PM revealed that the patient was ordered [Brand name dietary supplement] one serving twice daily on March 20, 2018. There was no documentation of the [Brand name dietary supplement] consumption on March 22, 23, 25, or March 26, 2018.
3. Review of MR2 on May 10, 2018, at approximately 10:30 AM revealed that the patient to MR2 was admitted in the evening hours of April 23, 2018, and discharged on April 27, 2018. There was no meal consumption documented for MR2 on April 24, 2018.

4. Continued review of MR2 on May 10, 2018, at approximately 2:30 PM revealed that the patient was ordered [Brand name dietary supplement] one serving twice daily on April 24, 2018. There was no documentation of the [Brand name dietary supplement] consumption on April 25, 26 or 27, 2018.
Interview with EMP3 on May 14, 2018, at approximately 11:00 AM, confirmed the lack of documentation of meal consumption and [Brand name dietary supplement] as listed above for MR1 and MR2.