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MERCY MEDICAL CENTER 333 MERCY AVENUE MERCED, CA 95340 April 18, 2011
VIOLATION: DIETS Tag No: A0630
The facility failed to meet the nutritional needs of Patient 1, when a meal tray was not provided until 21 hours after admission, from 2/8/11 at 3:30 p.m. until 2/9/11 at 1200 p.m.. Therapeutic diets must be provided to Patient's as ordered by the Doctor responsible for the care of the patient. These failures had the potential for Patient 1 to develop low blood sugar, and dehydration from not receiving food and fluids.

FINDINGS:

On 4/18/11 at 12:30 p.m., during an interview, the Director of Regulatory Compliance stated that the Physician (MD 1) had ordered a meal for Patient 1 with Admission orders on 2/8/11 at 3:30 p.m., there was no indication that Patient 1 received any food until 2/9/11 at 12:00 p.m. The amount of food and fluids should have been recorded in the Clinical record.

On 4/18/11 at 3:05 p.m., during an interview, the Director of Quality Management stated there was no documentation in the clinical record about a diet being provided or consumed by Patient 1 on 2/8//11 for dinner, or on 2/9/11 for breakfast but should have been.

On 4/18/11 at 3:05 p.m., during a review of the clinical record, no entries about dinner on 2/8/11 or breakfast on 2/9/11 had been recorded. No additional information had been entered into the clinical record about refusal, having ordered, or not providing a meal by the Nurses.

On 4/18/11 during review of an Administrative Policy titled, "Patient Care General Rules for Documentation, revised on 4/09," indicated "I. Policy: ...Permanent legal record of the total daily activity and care provided for all...patients...II. Departments Affected: House wide. III. Guidelines: ...L. Special Considerations for Nursing Documentation...3. b. Patient Notes 1. Narrative entries should be reserved for documentation...information that is not...addressed in another area...of the clinical record. 2. Clinical notes should show evidence of assessment, intervention, and evaluation...4. One time occurrences will be documented in the narrative fashion..."