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INDIANA UNIVERSITY HEALTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, the facility failed to ensure that oral intake was recorded for 1 (P1) out of 10 patients' medical records reviewed.
Findings include:
1. Review of patient P1's medical record lacked documentation of P1 having any oral intake during his/her stay 10/01/2021 through 12/18/2021.
2. Review of P1's medical record indicated a dietitian order dated 12/15/2021 for P.O. (by mouth) to continue intake and supplement use to be documented. P1's medical record lacked documentation of P.O. intake for his/her entire hospitalization.
3. Interview on 01/10/2022, at approximately 1405 hours with A3 (Clinical Manager) confirmed that "we are supposed to chart intakes on all patients, this is an area we need to work on".
4. On 01/10/2022, beginning at approximately 1330, A1 (Quality Improvement Consultant) indicated that she/he was not able to obtain any oral intake recorded for P1 from MR dates reviewed 10/01/2021 through 12/18/2021.