Incomplete Documentation of Meal Intakes in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurately documented regarding meal intakes. A resident reported not receiving her lunch meal on some occasions. Upon review of her clinical record, which included diagnoses such as vitamin deficiency, repeated falls, and muscle weakness, it was found that lunch meal intake was not documented on several specific dates. Interviews with an LPN and a Clinical Support nurse confirmed that meal intakes should be recorded in the electronic health record before the end of each shift, and that refusals should be documented as such. However, the lunch meal intakes were missing from the resident's record on the identified dates, contrary to facility policy requiring such documentation.