Back to Standards/Criterion 15.1.4.14
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot applicable
Mr Ganesh PillaiRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

15.1.4.14
Safety and performance improvement activities

Enteral Nutrition Protocol 1.4

The Dietary and Food Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for enteral nutrition.

Compliance Criteria

  • 1Approved standard operating procedure for enteral nutrition reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day enteral nutrition compliance
  • 3Regular documentation audits and evidence of corrective action implementation
  • 4Staff training records and competency assessments maintained in the department

Hospital Self-Rating

Rated by En. Khairul Anuar on 14 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for enteral nutrition. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

Evidence Documents (0)

A criterion with no document reads as unevidenced to the survey team.

Attach relevant hospital policies, registers, audit reports, or training records.

KA
Person-in-ChargeHead of Food and Dietary Services
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Departmental scope verification confirms that enteral nutrition is not applicable to the operational services provided by Dietary and Food Services at this facility.

None specified.

None specified.