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TRUSTPOINT HOSPITAL
FORM AND RETENTION OF RECORDS
Tag No.: A0438
Based on medical record review and interview, the facility failed to maintain an accurate medical record for one (#1) patient of 12 medical records reviewed.
The findings included:
Medical record review revealed Patient #1 was admitted to the facility on 9/14/17 with diagnosis of Major Neurocognitive Disorder, Alzheimer Type with Psychosis, Pseudobulbar Affect (involuntary laughing and/or crying), Diabetes, Cerebrovascular Accident (CVA), and Chronic Obstructive Pulmonary Disease (COPD). Further review of the medical history revealed "...status post PEG [percutaneous endoscopic gastrostomy] [feeding] tube insertion..."
Medical record review of a physician's order dated 9/15/17 revealed "...Diet: NPO [nothing by mouth]...Tube Feeding Order: Jevity [liquid meal replacement]...via PEG Tube...Pt [patient] continues with NPO orders..." Further review revealed no order or plan for the patient to receive oral food or fluids.
Review of a Flowsheet Report dated 9/16/17 at 10:50 AM revealed "...Breakfast Intake...75%...Oral Fluids...240 ml [milliliters]..."
Interview with Certified Nursing Assistant (CNA) #1 on 4/3/18 at 9:40 AM, in the Chief Nursing Officer's (CNO) office, confirmed the documentation was incorrect and the patient was not given food or fluids by mouth.
Interview with the Risk Manager on 4/11/18 at 11:45 AM, in the CNO's office, confirmed the facility failed to maintain an accurate medical record for Patient #1.