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Based on staff interview and record review the facility failed to monitor meal consumption for 1(#2) of 8 sampled patients. This practice does not ensure desired outcomes are achieved.

Findings include:

Patient #2 was admitted to the facility on 1/6/11 for dehydration, acute renal failure, fever, urinary tract infection and weakness. The patient has a history of CHF, COPD and hypertension. The physician ordered on 01/06/11 a low fat, low sodium and low cholesterol diet. The patient received antibiotics for her urinary tract infection. Per the physician progress notes dated 1/10/11, an order for discharge was written. The patient was discharged on 1/11/11. While awaiting for discharge on 1/11/11, a review of the medical record revealed no documentation of 2 of 3 meals for that day. The nurses notes for 1/11/11 revealed no documentation the patient refused meals. The care plan dated 01/07/11 thru 01/11/11 revealed problem: impaired hydration/nutrition with a goal listed to optimize hydration and nutrition. Furthermore, the nursing documentation revealed on 1/11/11 the patient needed assistance with meals.

During an interview with the 5th floor staff nurse on 3/10/11 at 10:40 a.m., she stated that meal consumption documentation gets placed in the computer on every patient on the unit. The care plan dated 01/07/11 at 7:09 a.m.. revealed impaired hydration/nutrition with a goal to optimize hydration and nutrition.
At 1:20 p.m. on 3/10/11, the Clinical Nurse Leader reviewed the patient's medical record and confirmed that meal consumption was not charted. The Assistant Director of Nursing was interviewed at 3:30 p.m. on 1/11/11 and stated that it was a standard of nursing care that meals are documented on the patients chart

Review of the Policy and Procedure for Assessment and Reassessment, policy #2.600.048, effective date: 4/2009 revealed that assessment/reassessment requires collection and review of the patient-specific data as per the scope of practice for each discipline. assessment includes prioritization of patient problem needs. Data includes subjective, objective, physical, clinical, environmental, psychosocial, spiritual, cultural, rehabilitative, safety, nutritional and educational needs including end of life care.