HospitalInspections.org

Based on review of facility documentation, medical record, and staff interview revealed the facility failed to follow policies and procedures to govern all dietetic service activities for one of one medical record reviewed (MR1).


Findings include:

Review of facility policy and procedure "Nutritional Assessment" date of review August 2017, revealed "A nutritional assessment is completed upon an order from a physician, as part of a critical pathway protocol, or as deemed necessary as a result of the Nutritional Screening Process. ... C. Information for the assessment is gathered through; 1. An interview with the patient or caretaker and/or; 2. Staff observation and; 3. Medical record review ... D. Parameters that are evaluated include but are not limited to: ... 2. Weight and Weight History."

Review of MR1 on January 25 & 26, 2018, revealed Nutrition Reassessments dated August 21, 28, 31, September 6, 13, 20, 27, October 4, 17, 24, 27, November 1, 6, 9, 14, 17, 22, and 24, 2017 listed the patient's weight as 128 pounds.

Review of MR1 revealed documentation of a following weights:
August 14 at 112#
August 17 at 135#
August 21 at 129#
August 24 at 106#
August 25 at 123#
August 28 at 129#
September 13 at 145.3#
October 12 at 145#
October 24 at 145#
November 1 at 145#
November 6 at 145#
November 9 at 145.3#
November 20 at 104# Actual
November 22 at 105#
November 24 at 105# Actual
November 25 at 123# Actual

Interview with EMP4 on January 26, 2018, revealed "Your right, I see that. I understand what you are saying, they [ the weights] don't match what the medical record say."