Failure to Assist and Accurately Document Meal Intake for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary assistance and accurate documentation of meal intake for a resident with severe cognitive impairment and a history of weight loss. The resident, who had diagnoses including dementia, anxiety, and malnutrition, required supervision and set-up for eating, as well as cueing and encouragement to consume meals. Observations revealed that staff frequently left the resident alone during mealtimes, did not provide adequate assistance or encouragement, and failed to reposition the meal tray for optimal access. On multiple occasions, the resident consumed little to none of the meals provided, yet staff documented inaccurately that the resident had eaten 51-75% of the meals. The resident's care plan specifically required staff to record food intake at each meal and provide assistance with ADLs as needed. Despite this, staff did not follow through with these interventions, as evidenced by direct observations and staff interviews. The documentation of meal intake did not reflect the actual consumption observed, and staff did not offer alternatives or sufficient encouragement when the resident was not eating. These failures contributed to the deficiency in maintaining the resident's nutritional status.