Failure to Document Food Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were consistently completed for residents with a history of weight loss. For three out of four residents reviewed for nutrition, there were multiple instances where meal intake was not documented as required. This deficiency was identified through observation, record review, and staff interviews. One resident with diagnoses including mild cognitive impairment, adult failure to thrive, and dysphagia had a significant weight loss of 27% over six months. Despite care plans and physician orders addressing her nutritional needs, her food consumption logs had missing entries for several meals throughout the month. Another resident, who had a history of stroke, congestive heart failure, and dependence on renal dialysis, experienced a 12% weight loss in one month following hospitalization. His care plan required monitoring due to dietary restrictions and fluctuating intake, yet his dinner intake was not documented on multiple occasions. A third resident, diagnosed with neurocognitive disorder, protein-calorie malnutrition, and dysphagia, was also identified as being at nutritional risk. Her care plan included interventions to monitor and record meal intake at every meal, but her logs showed missing documentation for several lunches and dinners. In each case, the DON confirmed that food consumption should have been documented for every meal, but this was not consistently done.