Incomplete Clinical Record Documentation for Nutrition Orders
Penalty
Summary
The facility failed to ensure that clinical records for a resident with protein-calorie malnutrition were complete and accurately documented. An active physician order was present for the resident to receive 8oz whole milk and full fat ice cream milkshakes three times daily with meals and at bedtime. However, physician progress notes indicated that the order for milkshakes could not be found on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and this issue persisted over multiple months. Review of the resident's MAR and TAR for January, February, and March showed no documentation that the milkshakes were given or refused. The unit manager confirmed the absence of this documentation during a record review with the surveyor.