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Based on interview and documentation review it was determined the Hospital failed to ensure all medical records were accurately written in one of one applicable medical record reviewed.

Findings included:

Review of the Attending Physician ' s 3/24/10 8:14 AM physician orders indicated the tube feedings were discontinued.

Review of 3/24/10, 7:28 PM-11:33 PM nursing documentation indicated the Patient's tube feeding was infusing.

The Staff Registered Nurse (RN #5) who was assigned to provide the Patient ' s care from 7:00 PM on 3/23/10 to 7:00 AM on 3/24/10 was interviewed in person on 5/18/10 at 7:45 AM. RN # 5 said I made a mistake in my documentation related to the tube feeding although my computer entry identified the tube feeding as infusing, the Patient did not receive any liquid tube feeding as it was on hold when I provided his care.

Based on documentation review it was determined the Hospital failed to ensure orders were entered and present in the medical record for one of one applicable medical record reviewed.

Findings included:

Review of 3/18/10 physician orders indicated orders were written for the Patient to receive tube feedings with Perative at an infusion rate of 75 ml per hour.

Review of the Attending Physician ' s 3/23/10, 7:33 AM patient care summary note indicated the Patient had developed a fever during the night, which suggested the Patient had probably aspirated during the night, The Patient ' s tube feeding had been placed on hold.

Review of 3/23/10 physician orders did not indicate an order was written for the tube feeding to be placed on hold.

Review of 3/23/10 nursing documentation indicated nursing staff noted, at 8:05 PM the feeding tube had been clamped.