Incomplete and Inaccessible Nutrition Documentation in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for two residents reviewed for nutrition. For one resident with diabetes and end stage renal disease, the electronic health record (EHR) lacked nutrition documentation for over nine months, with the last dietary assessment dated several months prior to the most recent care plan revision. The care plan required quarterly registered dietitian (RD) consultations and monitoring for malnutrition, but the required documentation was not present in the EHR. For another resident with severe cognitive impairment, Alzheimer's disease, and other comorbidities, the EHR similarly lacked current nutrition documentation, with the last nutrition risk assessment completed several months before the most recent care plan update. This resident's care plan included interventions for a mechanically altered diet and history of weight loss, but the supporting RD documentation was missing from the EHR. Interviews with the DON revealed uncertainty about the RD's charting process and an inability to locate current RD documentation in the EHR. The DON later found that some RD progress notes had been scanned into the EHR, but this process was not consistent or timely. The RD confirmed that nutrition-related entries were kept on a personal jump drive and that the process of printing and sending notes to the facility had not been routinely completed for an unknown period. As a result, staff did not have timely access to up-to-date nutrition assessments and progress notes for these residents.