Failure to Document Resident Oral Intake
Penalty
Summary
The facility failed to ensure that nursing records were completely and accurately documented by not recording the oral intake for a resident with significant cognitive impairment and multiple diagnoses, including Alzheimer's disease, dementia, and anemia. The resident required varying levels of assistance with daily activities and had care plans in place to monitor nutritional status and address unplanned weight changes. The care plans specifically required staff to monitor, record, and report oral intake at each meal to maintain adequate nutrition and identify potential issues. On at least one occasion, a Certified Nursing Assistant (CNA) did not document the resident's oral intake for breakfast and lunch, citing lack of access to the charting system as the reason. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Assistant Director of Nursing (ADON), confirmed that CNAs were expected to document meal percentages after each meal as part of their responsibilities. The ADON reviewed the resident's Nutrition Report and found missing documentation of oral intake for multiple days, emphasizing that lack of access to the charting system was not an acceptable reason for failing to document. Review of the CNA job description and facility policies further confirmed that recording residents' oral intake is a required duty. Facility policies also stated that documentation should be complete, factual, and promptly recorded to accurately reflect services provided. The failure to document oral intake as required resulted in incomplete medical records and had the potential to disrupt communication among staff and delay necessary care for the resident.
Plan Of Correction
A. How corrective actions will be accomplished for those residents found to be affected by the deficient practice? a) On 7/25/25, CNA 1's access to PointClickCare (PCC) was reviewed, and CNA1 PCC password was reset by the Administrator to ensure proper access to the electronic documentation system. b) On 7/28/25, CNA 1 documented Resident 5's food intake for all meals to ensure that current data was recorded. c) On 7/26/25, the Director of Nursing (DON) reviewed Resident 5's weights and there was no impact as a result of the documentation failure. d) On 7/25/2025, CNA 1 received a 1:1 in-service training on the importance of timely and accurate documentation of resident food intake after each meal. The training also emphasized the requirement to immediately notify a supervisor, the Director of Staff Development (DSD), or the Administrator if there are any access issues with the PCC system. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a) All residents who were identified as having nutritional or weight related issues are at risk due to this deficient practice. b) The DON or Medical Records Director (MRD) conducted a facility-wide audit of oral intake documentation for all residents with nutritional risk or weight-related care plans was initiated on 7/25/25 and completed by 7/28/25. c) There were no additional residents identified with deficiencies related to the documentation of food intake. C. What measures will be put in place or what systematic changes the facility will make to ensure that the deficient practice does not recur? a) On 7/28/25, mandatory re-education was provided to all CNAs, LVNs, and RNs on: The importance of accurate, timely documentation of oral intake. The requirement to report immediately if PCC access is unavailable or not functioning. b) On 7/28/25, the Director of Staff Development (DSD) reviewed the PCC access status of all CNAs to identify and resolve any issues with login credentials or system access. c) The DON or Medical Records Director will perform random daily audits of oral intake documentation using audit tools for 10 residents daily x3 days, then weekly for 4 weeks, and monthly thereafter for 3 months. Any staff found not documenting resident food intake were immediately re-educated by the DSD or DON. D. How the facility plans to monitor its performance to make sure the solutions are sustained? a) All audit findings related to oral intake documentation and identified trends will be presented during the monthly QAPI meetings by the Facility Administrator, Director of Nursing (DON), and Medical Records. b) Any patterns of non-compliance will result in immediate corrective actions, including individual coaching, counseling, and re-training of involved staff. c) The QAPI Committee will continue to monitor oral intake documentation compliance for a period of 3 months, or until sustained compliance is achieved.