HospitalInspections.org

Based on medical record review, staff interviews and review of policy and procedures the Critical Access Hospital (CAH) failed to ensure that 4 of 20 inpatients (Patients 2, 10, 12 and 13) reviewed had diet orders by the responsible practitioner. The CAH also failed to ensure that 3 of 20 inpatients (Patients 2, 4 and 16) reviewed had a completed nutritional assessment. This failed practice has the potential to affect all inpatients of the CAH. The number of inpatients at the CAH for Fiscal Year Ending 6/2022 was 107.

Findings are:

A. Review of Patient 2's medical record revealed the patient was admitted for 3 days (12/9-12/12/2022). Review of the entire medical record revealed a lack of evidence of a diet order and a nutritional assessment.
- Review of Patient 10's medical record revealed the patient was admitted for 5 days (12/26-12/31/2022). Review of the entire medical record revealed a lack of evidence of a diet order.
- Review of Patient 12's medical record revealed the patient was admitted for 6 days (1/3-1/09/2023). Review of the entire medical record revealed a lack of evidence of a diet order.
- Review of Patient 13's medical record revealed the patient was admitted for 3 days (11/4-11/07/2022). Review of the entire medical record revealed a lack of evidence of a diet order.
- Review of Patient 4's medical record revealed the patient was admitted for 3 days (2/6-2/9/2023). Review of the entire medical record revealed a lack of evidence of a diet order and a nutritional assessment.
- Review of Patient 16's medical record revealed the patient was admitted for 3 days (10/11-10/14/2022). Review of the entire medical record revealed a lack of evidence of a diet order and a nutritional assessment.

B. Review of policy and procedure titled Nutritional Assessment (Reviewed 3/17/20) revealed "a. A nutritional assessment shall be performed for all patients upon admission to Syracuse Area Health to inpatient or swing bed status."

C. Interview with the EMR (Electronic Medical Record) Specialist (4/3/23 at 1:30 PM) confirmed the above medical records (Patients 2, 10, 12 and 13) lacked evidence of diet orders by the responsible practitioner and also confirmed the above medical records (Patients 2, 4 and 16) lacked evidence of completed nutritional assessments.