Failure to Accurately Document Resident Meal Intake in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for three residents were maintained in accordance with accepted professional standards and practice. Certified Nursing Assistants (CNAs) did not consistently document the percentage of food consumed by the residents at the correct times, resulting in incomplete and inaccurate nutritional intake records. For example, there were multiple instances where meal intakes were either not documented at all or were recorded at times that did not correspond with actual meal times, such as breakfast and lunch intakes being documented in the afternoon or evening. Resident 1, who had diagnoses including pneumonia, osteoarthritis, and dementia with severely impaired cognitive skills, had several days where meal intakes were missing or documented inaccurately. CNA 1 confirmed that the documentation was incomplete and not reflective of when meals were actually consumed. The Director of Staff Development also acknowledged that the documentation was incomplete and inaccurate, which could affect the identification of causes for weight changes. Similar issues were found for two other residents, both with significant cognitive impairments and medical conditions such as chronic kidney disease, hemiplegia, encephalopathy, and osteoarthritis. Their records also showed missing or inaccurately timed meal intake documentation. The Director of Nursing confirmed that CNAs should document meal intake after consumption and that records should not be left blank. The facility's own policy required that all services and changes in condition be documented objectively, completely, and accurately, but this standard was not met in these cases.