Failure to Document Evening Meal Intake Percentages
Penalty
Summary
Staff failed to document evening meal intake percentages for nine residents over a period of nearly one month. Record review showed that the evening meal intake was not recorded for any of these residents, and multiple staff interviews revealed confusion regarding which shift was responsible for this documentation. Registered nurses and a CNA indicated that the dinner meal was typically served during the shift change, leading to uncertainty about whether the evening or night shift should complete the documentation. The Director of Nursing confirmed that the night shift was expected to document the dinner meal percentages, but this was not consistently done. The Registered Dietician stated that she relies on meal intake documentation to complete quarterly nutrition assessments and determine if interventions are needed. She noted that missing dinner meal intake information made it more challenging to assess residents' nutritional needs. The lack of documentation affected all nine residents reviewed for meal intakes, and the issue had been previously addressed with staff, but the deficiency persisted.