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KALEIDA HEALTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on medical record review, staff interview, and policy and procedure review, the nursing staff did not ensure patient dietary intake was consistently documented for 8 of 9 patients.
Findings include:
Interview on 4/13/15 at 9:30am with Staff #1 revealed Patient Care Assistants (PCA) are responsible for picking up the patient trays after the completion of meals and documenting on the PCA Patient Care Record the percentage of meals consumed.
Review of PCA Patient Care Record for Patient #3, 4, 5, 6, 7, 8, 20 and 21 on 4/15/15 under nutrition/activities of daily living revealed the percentage of meals consumed was not consistently documented. Examples include:
-Patient #3: From 12/28/14 to 1/28/15 the patient was on an oral diet. The percentage of meals consumed for all three daily meals is complete for only one day during this 30 day time period.
-Patient #5: From 12/25/14 to 1/4/15 the patient was on an oral diet. The percentage of meals consumed for all three daily meals is complete for only one day during this 11 day time period.
-Patient #8: From 1/2/15 to 1/11/15 the patient was on an oral diet. The percentage of meals consumed for all three daily meals is complete for only two days during this 10 day time period.
Review of the Unlicensed Assistive Personnel Role Essential Competency Assessment Tool under the nutrition category revealed the PCA ' s are to assist the patient with meals, determine the percentage of meals consumed, and document on the patient care record.
Review of facility policy and procedure titiled Documentation of Adult Patient Care, policy #PE.2 revealed the following:
-The registered nurse is responsible for all components of the nursing process and accountable for its implementation and documentation from admission through discharge.
-Unlicensed assistive personnel are responsible for documentation in accordance with their job description and/or department performance standards.
These inconsistencies in documentation were verified by Staff #20 on 4/15/15 at 2:45pm.