HospitalInspections.org

Based on review of clinical records as well as facility policies and procedures, the director of the nursing service failed to be responsible for the operation of the service, as nursing staff failed to follow the facility's policy regarding nutritional intake.

Findings were:

Facility policy entitled "Documentation Policy #NC-B2-23" stated in part, " Documentation is required on every patient, every shift by all Associates involved in the care of the patient. NA and NTs will document the following in accordance with Hospital/Nursing policy and procedure: a. Intake and output; b. current measured/dosing height and weight, in centimeters(cm) and kilograms (KG) only to include Body Mass Index (BMI); c. vital signs; d. Activities of Daily living. A comprehensive shift assessment is required for all patients."

Facility policy entitled "Assessment (Admission and Reassessment) NC-B2-8" stated in part, "Nursing Associates will document data collected in the appropriate nursing assessment screens in the EMR. Reassessment- Data collection is an ongoing process to ensure identification of changes from baseline data. When baseline data changes, an RN will reassess and reevaluate patient care needs/problems."

Documentation of the patient's nutritional intake was missing for the following meals:

o10-31-20 Dinner
o11-2-20 Dinner
o11-3-20 Dinner
o11-4-20 Breakfast\Lunch\Dinner
o11-5-20 Breakfast\Lunch\Dinner
o11-6-20 Dinner
o11-7-20 Breakfast/Dinner
o11-8-20 Breakfast/Dinner
o11-10-20 Breakfast/Dinner
o11-11-20 Breakfast/Dinner

On February 10, 2021, the missing documentation and nursing reassessment/notes were confirmed with the Director of Quality and other administrative staff.