HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that the nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed, as evidence by failing to document the oral intake of a patient as ordered.

Findings included:

Review of the medical record for Patient # 1 revealed an order for intake and output monitoring on 5/22/15 at 22:27.

Intake and Output documentation did not record any oral intake until 5/23/15 from 0700-1900. No oral intake was documented on 5/22/15.

In an interview on 8/20/15 staff members # 1 and 2 confirmed that the intake and output of Patient # 1 should have been documented as ordered.