Failure to Accurately Document Enteral Feeding Intake
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident who had a gastrostomy and was receiving enteral feedings. The facility's policies required staff to document the procedure, including the intake, flush, and free water volume administered, as well as to ensure that nursing documentation was clear, concise, and included information related to the resident's condition and care provided. Despite these requirements, review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for the relevant months did not show documentation of the total amount of enteral formula administered daily to the resident. Interviews with facility staff, including the dietician and the Assistant Director of Nursing (ADNS), confirmed that the resident's enteral fluid intake was not being accurately documented. The dietician stated that she relied on this documentation to monitor the resident's daily intake, and the ADNS acknowledged that the staff had not been recording the total enteral fluid intake as required. No evidence was found elsewhere in the clinical record to indicate that this information was being documented.