Inaccurate Documentation of Resident Meal Intake
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that a CNA documented the resident's meal intake percentages at the correct times. Specifically, the CNA recorded the percentages for breakfast and lunch meals at times that did not correspond to when the meals were actually consumed, as evidenced by multiple entries where both breakfast and lunch intakes were documented at the same time in the afternoon. The CNA acknowledged that the documentation times were inaccurate and that meal intake should be recorded after the resident has eaten. The Director of Staff Development and the Director of Nursing both confirmed that the documentation was inaccurate and did not reflect the resident's actual meal intake for each respective meal. The facility's policy requires that all services and changes in a resident's condition be documented objectively, completely, and accurately to facilitate communication among the interdisciplinary team. The resident involved had multiple diagnoses, including a cervical vertebra fracture, epilepsy, and anemia in chronic kidney disease, and required moderate assistance with eating. The inaccurate documentation resulted in incomplete and inaccurate medical records for the resident.