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J PAUL JONES HOSPITAL
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on record review and interview, it was determined the facility failed to ensure all documentation by Registered Nurse (RN) and Registered Dietician occurred prior to the patients' discharge for the hospital. This affected Patient Indentifer (PI) #s 4 and 5 (2 of 2 discharged medical records) and had the potential to negatively affect all patients served by this facility.
Findings include:
1. PI # 4 was admitted to the facility with diagnosis of Kidney Disease on 4/9/15 and was transferred to another acute care facility on 4/12/15.
Review of the Nursing Notes revealed a General Assessment Nurse Note dated 4/13/15 at 8:25 AM. The patient left the hospital on 4/12/15 at 7:30 PM.
An interview was conducted on 4/15/15 at 1:25 PM with Employee Identifier # 2, Director of Nursing Service who verified the above findings.
2. PI # 5 was admitted to the facility on 3/30/15 and was discharge to a Long Term Care facility on 4/2/15.
Review of the Nursing Notes revealed a General Assessment Nurse Note dated 4/2/15 at 6:00 PM. The patient left the hospital on 4/2/15 at 1:00 PM.
Review of the physician's order dated 3/30/15 revealed the patient was to receive a soft 2 gm (gram) sodium diet.
Review of the Initial Nutritional Assessment revealed it was completed on 4/9/15 (7 days after discharge). The Registered Dietician (RD) recommended a soft 2 gm sodium renal diet due to the patients kidney disease.
An interview was conducted on 4/15/15 at 1:30 PM with EI # 2 who verified the above finding. When the surveyor asked why the RD completed the Initial Nutritional Assessment 7 days after discharge, the response was, "The RD comes 1 time a month."
DIRECTOR OF DIETARY SERVICES
Tag No.: A0620
Based on record review and interview, it was determined the facility failed to ensure the Registered Dietician (RD) completed an Initial Nutritional Assessment prior to the patient's discharge. This affect Patient Identifier (PI) # 5 (1 of 1 records reviewed with an Initial Nutritional Assessment ) and had the potential to negatively affect all patients served by this facility.
Findings include:
1. PI # 5 was admitted to the facility on 3/30/15 and was discharge to a Long Term Care facility on 4/2/15.
Review of the physician's order dated 3/30/15 revealed the patient was to receive a soft 2 gm (gram) sodium diet.
Review of the Initial Nutritional Assessment revealed it was completed on 4/9/15 (7 days after discharge). The RD recommended a soft 2 gm sodium renal diet due to the patients kidney disease.
An interview was conducted on 4/15/15 at 1:30 PM with EI # 2 who verified the above finding. When the surveyor asked why the RD completed the Initial Nutritional Assessment 7 days after discharge, the response was, "The RD comes 1 time a month."