Failure to Consistently Document Meal Intake for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure consistent documentation of meal intake percentages for a resident with significant weight loss and multiple complex medical conditions, including dementia, dysphagia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. The resident's care plan required monitoring of dietary intake, and clinical notes indicated ongoing weight loss and poor oral intake, averaging around 50%. However, review of nurse aide documentation revealed multiple instances where meal intake percentages were not recorded for breakfast, lunch, and dinner over several days in April and May. This lack of documentation occurred despite the resident's ongoing nutritional decline and the need for accurate intake records to inform care decisions. Interviews with facility staff, including the dietician and Director of Nursing Services (DNS), confirmed that nurse aides were expected to document meal intake accurately and consistently for all residents, especially those with significant weight loss. The dietician relied on this documentation to calculate intake trends and guide treatment, while the DNS was unaware of the omissions until the review. The facility was unable to provide a specific policy regarding nurse aide documentation, though staff reported that training on electronic documentation was provided. The deficiency was identified due to the failure to maintain complete and accurate medical records in accordance with professional standards.