Failure to Maintain Accurate and Complete Medical Records for Meal and Fluid Intake
Penalty
Summary
The facility failed to ensure that medical records were accurate and complete for three residents, specifically regarding documentation of meal, snack, and fluid intakes. For one resident with severe cognitive deficits and multiple diagnoses, including myasthenia gravis and cyclical vomiting syndrome, numerous meal consumption entries were missing from the Task Meal Consumption Logs for breakfast, lunch, and dinner over several days. The resident's care plan required monitoring of oral intakes due to nutritional risk, but the required documentation was not present for many dates. Another resident, diagnosed with diabetes, dementia, and end stage renal disease on dialysis, had a physician's order for a strict daily fluid restriction. The care plan required monitoring and recording of fluid intake, but the August Vitals Report lacked fluid documentation for multiple meals. A third resident with Parkinson’s disease and Lewy body dementia, who was dependent on staff for eating and drinking, also had missing documentation for snacks and meals over a 30-day period, despite physician orders and care plan interventions requiring daily intake charting. In each case, facility leadership was unable to provide the missing documentation when interviewed.