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GLENN MEDICAL CENTER
No Description Available
Tag No.: C0295
Based on interview and record review, the facility failed to ensure that staff met the needs of one of 15 sampled patients when staff failed to document the administration of nutritional supplements ordered by the physician and the quantity consumed and tolerated by the patient. The lack of documentation could result in an inaccurate evaluation of the effectiveness of the supplement, delay the implementation of more effective interventions, and result in a decline in the health status of the patient. (Patient 43)
Findings:
A review of Patient 43's record disclosed that he was admitted on 4/18/13 with a diagnosis of an infected wound of the right leg and foot. Patient 43 had a history of weight loss prior to admission to the facility. A nutritional assessment screening form was completed upon admission and faxed to the Registered Dietitian (RD). RD completed an assessment on 4/19/13 and made a recommendation for Patient 43 to receive Ensure Plus (a nutritional supplement) three times per day. Patient 43's physician agreed with that recommendation and ordered Ensure Plus, one can three times per day, on 4/19/13 at 8:30 am.
The nursing flowsheets from 4/19 - 4/22/13, were reviewed. During this three day period, Patient 43 should have received nine cans of Ensure Plus. There was one entry that showed Patient 43 consumed one can of Ensure. There was no other documentation to show how much, if any, Patient 43 had consumed.
During a concurrent interview and review of the nursing flowsheets, on 4/22/13 at 2:35 pm, Staff Nurse T confirmed she was unable to tell how much Ensure Patient 43 had consumed. She stated that although there was a place for oral intake on the flowsheet there was no place to document supplements.
During an interview on 4/23/13 at 2:15 pm, RD stated there was no place on the flowsheets for the nurses to document nutritional supplements. She stated she needed to know how much was consumed by the patient so she could make an accurate evaluation and, if necessary, try another intervention.