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|SAINT THOMAS RUTHERFORD HOSPITAL||1700 MEDICAL CENTER PARKWAY MURFREESBORO, TN 37129||May 5, 2021|
|VIOLATION: FORM AND RETENTION OF RECORDS||Tag No: A0438|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policy review, medical record review, and interviews, the facility failed to ensure the medical record contained complete dietary intake for one patient (Patient #2) of 15 patients reviewed for complete medical records.
The findings included:
Review of the facility's policy titled "Nursing Electronic Documentation, 805,013" effective date 2/4/2019 showed "...Staff will document routine patient care including nutrition, hygiene, patient care activity, safety interventions/precautions, equipment in use, and other nursing interventions..."
Review of the medical record showed Patient #2 was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED].
Medical record review of a physician's order dated 3/23/2021 showed the patient was placed on a regular diet.
Medical record review of the "Nutrition/ADL's [activities of daily living]/Interventions" documentation for Patient #2 showed dietary intake was documented as zero percent (0%) from lunch on 3/26/2021 through supper on 3/31/2021, with the exception where no percentage of the amount consumed was documented for dinner on 3/26/2021, dinner on 3/27/2021, breakfast, lunch, and dinner on 3/28/2021, and dinner on 3/29/2021.
Medical record review of a Nutrition Therapy Consult dated 3/31/2021 at 1:57 PM showed "...Reason for visit: Initial Consult, Poor PO [by mouth] Intake...Pt [patient] on regular diet with no PO intake x [for] 6 days. Prior to past 6 days patient was eating 0-100% of meals. Attempted to meet with patient at bedside but patient was sleeping soundly...observed lunch tray untouched on bedside table. Spoke with RN [Registered Nurse] who reports that patient will only wake up once during her twelve hour shift, take a few sips of water, and maybe a couple bites of apple sauce before going back to sleep...Daughter would like PEG [percutaneous endoscopic gastrostomy/feeding tube surgically inserted through abdominal wall into stomach] tube placed. Do not feel that PEG tube would be beneficial in a patient with such advanced dementia and it would not add to his quality of life. Also concerned that with his agitation, patient may pull PEG tube out. Feel that palliative care consultation would be beneficial to determine goals of care...will order Ensure Enlive [liquid nutritional supplement] BID [twice a day]...Patient does not meet criteria for diagnosis of [DIAGNOSES REDACTED]
During an interview on 4/28/2021 at 11:00 AM, the Fourth Floor Nurse Manager confirmed Patient #2's dietary intake was documented as 0% from lunch on 3/26/2021 through supper on 3/31/2021and the percentage of meals consumed was not documented for dinner on 3/26/2021, dinner on 3/27/2021, breakfast, lunch, and dinner on 3/28/2021, and dinner on 3/29/2021.
During an interview on 4/28/2021 at 1:00 PM, Registered Dietitian (RD) #1 stated she was the RD consulted on Patient #2 on 3/31/2021 because of poor PO intake for 6 days. Continued interview revealed the facility's computer system would have triggered an automatic referral for a Dietary Consultation after 3 days of patient eating 50% or less of his meals, but because no percentage was documented for some of the patient's meals, the facility's computer's tracking for dietary intake would reset the 3 day tracking period. Further interview confirmed if the percentages of meals consumed had been documented for every meal, the patient would have had a dietary consult on the third day of 50% or less of PO meal intake.