Failure to Accurately Document Nutrition Supplement Intake in Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who had a physician's order for 4 ounces of house nourishment (HN shake) with breakfast. The electronic health record (EHR) did not contain documentation that this order was provided, and the amount of HN shake consumed was not separately recorded but instead included in the total fluid intake for breakfast. This practice impeded the interdisciplinary team's ability to assess the effectiveness of the nutrition intervention, as the specific intake of the HN shake could not be determined from the records. Additionally, a Certified Nursing Assistant (CNA) documented the resident's breakfast fluid intake as a late entry, recording the total fluids consumed at a time inconsistent with the actual meal time. The facility's policies and procedures did not provide clear guidance on how to document oral nutrition supplements, and staff training instructed CNAs to include these supplements in the overall fluid intake. As a result, the medical record did not accurately reflect the implementation of the nutrition order or the resident's actual intake, limiting the ability to monitor and evaluate the resident's nutritional status.