Failure to Complete Food Consumption Logs for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for a resident with a history of weight loss. Record review and interviews revealed that for one resident with multiple diagnoses, including pneumonitis due to inhalation of food and vomit, dementia, Huntington's disease, Parkinson's disease, bipolar disorder, chronic kidney disease, high blood pressure, depression, and dysphagia, there were significant gaps in the documentation of meal intake. The resident had experienced a significant weight loss of more than 5% in 30 days, as noted by a registered dietitian, which was related to a recent hospitalization. Despite the resident's complex medical history and dietary needs, food consumption logs were found to be incomplete for multiple meals across several dates. The Director of Nursing confirmed that these logs were required to be completed after every meal, but review of the CNA task section showed missing documentation for breakfast, lunch, and dinner on numerous occasions. This lack of documentation occurred even though the resident was identified as being at risk due to recent weight loss and ongoing health concerns.