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Tag No.: A0628
Based a review of records and an interview, it was determined that the facility failed to meet 1 of 1 patient's dietary needs.
Findings were:
Review of patient #1's medical record on 4/11/12, revealed that on 2/15/12 patient #1 only ate 50% of breakfast; the percentage of lunch, dinner, and the evening snack were documented as 0%. There was no documentation found by, or provided to the surveyor indicating why the patient only ate breakfast on 2/15/12.
A facility policy entitled "Interdisciplinary Daily Documentation," reviewed on 4/11/12, stated the following on page 1 of 9, the facility "will document updated information daily regarding each patient's functional status, care, and response to care, utilizing the Interdisciplinary Daily Documentation (IDD) form." On page 3 of 9 this policy stated "...Interdisciplinary Team Members chart percentage of meal eaten. Chart % snack eaten in last column."
The Director of Quality/Risk confirmed, during an interview on 4/11/12, that only the percentage of the patient's breakfast was documented, and that the percentage of lunch, dinner, and the evening snack were documented as 0% on 2/15/12.