Failure to Document and Implement Dietary Interventions for At-Risk Resident
Penalty
Summary
The facility failed to fully implement care-planned dietary interventions for a resident at risk for weight loss. The resident, who had diagnoses including dementia, COPD, and type 2 diabetes mellitus, was severely cognitively impaired and required setup help for eating. Care plans required staff to record meal and fluid intake percentages and to offer a substitute if the resident consumed less than 50% of a meal. However, review of intake records over a one-month period showed multiple instances where the resident consumed 50% or less of meals, with no documentation that a supplement or substitute was offered. Additionally, there were several meals with no intake documentation at all. During an interview, the DON confirmed that staff were expected to document substitutes offered in the electronic record, but acknowledged that while substitutes were always available and offered, this was not documented. Facility policy required documentation of foods and fluids consumed at each meal, as well as documentation of substitute offerings and resident acceptance or refusal when intake was 50% or less. The lack of documentation for both meal intake and substitute offerings constituted a failure to follow the care plan and facility policy for this resident.