Failure to Consistently Document Meal Intake for High-Risk Resident
Penalty
Summary
The facility failed to consistently document meal intakes for a resident with significant medical concerns, including vascular dementia, heart failure, and moderate protein-calorie malnutrition. The resident was identified as severely cognitively impaired, required supervision or assistance with meals, and had experienced notable weight loss in the previous six months. Staff interviews confirmed that the resident had a marked decline in eating and drinking abilities prior to being sent to the hospital, with minimal intake even when fed by staff. The interdisciplinary team, including the Registered Dietitian and Certified Dietary Assistant, documented significant weight loss and ongoing monitoring for this issue. A review of the resident's meal intake records for February and March revealed numerous instances where meal consumption was not documented, including multiple days with missing entries for breakfast, lunch, or dinner. The facility's procedure required nursing staff to document the percentage of food consumed after each meal, but this was not consistently followed. The lack of routine documentation occurred despite the resident's high risk for nutritional decline and ongoing monitoring for weight loss.