Incomplete Meal Intake Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for a resident with Alzheimer's disease and anxiety who was at risk for weight loss. The resident was identified as being severely cognitively impaired and required maximum assistance with eating. Review of the resident's care plan directed staff to feed the resident meals. However, meal intake documentation was missing for multiple breakfasts, lunches, and dinners over a period of nearly one month. Specifically, several dates were identified where meal intakes were not recorded in the electronic medical record. Interviews with the dietician and the DON confirmed that it was the expectation for staff to document meal intakes accurately after each meal, and that the facility's policy required records to be accurate and based on resident information. The DON was unable to provide an explanation for the missing documentation. The deficiency was identified through clinical record review, facility documentation review, policy review, and staff interviews.