HospitalInspections.org

Based on record review and interview, the facility failed to complete a nutritional assessment by a registered dietitian that had been ordered on admit by the physician, for 1 (#3) of 20 patients sampled. Findings include:

Review of patient #3's electronic record showed a nutritional assessment had been ordered by the physician when patient #3 was admitted on 6/23/15. The assessment had not been completed by 6/27/15 when the patient passed away.

Review of the Dietary policy showed: 2. The RD (registered dietitian) will receive an order requisition through Cerner (RD Nutrition Care Process Protocol), whereby the RD will complete a nutrition assessment using the Nutrition Care Process. 3. The dietitian will provide documentation under "Notes" in the Patient's Electronic Medical Record (Cerner).

During an interview on 8/26/15 at 10:08 a.m., staff member A, chief quality officer, was unable to find evidence the nutritional assessment had been completed. She said she was not sure why the assessment had not completed. Documentation of the nutritional assessment had not been provided by the facility by the time of the survey exit.