Failure to Accurately Document Meal Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to accurately document meal intake for two residents who were being monitored for nutrition. Observations showed that both residents consumed only 25% of their lunch meal, yet documentation in the point of care system indicated that one resident had consumed 76-100% of the meal. Staff interviews confirmed that CNAs are responsible for documenting meal intake after each meal and are expected to notify nursing staff if a resident eats very little or nothing. However, the Director of Nursing was unable to provide complete meal intake documentation for the past three months for either resident, and review of records showed missing documentation for multiple meal opportunities. Both residents had documented histories of significant weight loss over several months, with one resident experiencing a decrease from 181 to 146.6 pounds and the other from 93 to 80 pounds. The registered dietitian and interdisciplinary team had initiated weekly weights and nutritional interventions, including supplements and appetite-stimulating medication, due to ongoing weight loss and decreased oral intake. Despite these interventions, the lack of accurate and complete meal intake documentation hindered effective monitoring and response to the residents' nutritional needs.