Incomplete Documentation of Meal Intake in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurate and complete, specifically regarding the documentation of meal intakes. Review of the resident's nutrition records for several dates showed missing entries for the amount eaten at various meals, including breakfast, lunch, and dinner. The facility's policy required prompt, complete, and accurate documentation of care and services provided, but these requirements were not met for the resident in question. Interviews with facility staff, including an LVN and the DON, confirmed the missing documentation and emphasized the importance of recording meal intake, especially for residents at risk for weight loss. The DON stated that CNAs are responsible for documenting meal intake after each meal and must report refusals to the charge nurse for further action. The absence of this documentation meant there was no proof that the tasks were completed as required by facility policy.