HospitalInspections.org

Based on interviews, record review, and facility policy review, the facility failed to ensure that hospital policies and procedures were followed for 1 (Patient #2) of 2 patient records reviewed.

Findings included:

A review of a facility policy titled "Documentation System," effective 07/20/2020, revealed, "Within the nursing process framework documentation should be pertinent, concise, simple and not redundant." Further review revealed, "Nursing technicians, patient care assistants, and nurse externs may make entries to document selected interventions, e.g., vital signs, height, weight, point of care glucose, I&O [intake and output], including percentage of meal content consumed."

A review of Patient #2's medical record revealed the facility admitted the patient on 02/03/2023 with diagnoses that included acute encephalopathy.

A review of Patient #2's physician orders revealed an order dated 02/04/2023 for a diet consisting of texture-modified, pureed-4 (extremely thick), and fluid consistency of mildly thick. Further review revealed an order dated 02/06/2023 for a diet consisting of soft and bite-sized food and pureed food with instructions to make sure the patient sits upright.

A review of Patient #2's medical record revealed no evidence that Patient #2 received a meal tray. Further review revealed there was no percentage or documentation of breakfast, lunch, or dinner on 02/03/2023, 02/04/2023, or 02/05/2023. The medical record revealed there was no percentage or documentation of breakfast or lunch on 02/06/2023, and documentation of dinner on 02/06/2023 was 0%.

On 10/12/2023 at 9:05 AM, Registered Nurse (RN) #1 was assisting with remote medical record review. RN #1 confirmed that the percentage of meals consumed was a section that required documentation and confirmed that it was not documented in Patient #2's medical record.

During an interview on 10/12/2023 at 9:52 AM, RN #13 indicated that staff were expected to document meal intake percentages.

During an interview on 10/12/2023 at 9:55 AM, Patient Care Technician (PCT) #6 stated that meal intake percentage was something that was documented "for the most part."