Incomplete Documentation of Enteral and Pleasure Feeds
Penalty
Summary
The facility failed to ensure that clinical records for a resident who was cognitively impaired and required substantial assistance were complete and accurately documented. The resident was receiving enteral nutrition via PEG tube feedings, as well as pleasure feeds. A review of nurse aide documentation for multiple dates revealed missing entries for both PEG feeds and the amount of pleasure feeds consumed across various shifts. In several instances, 'Not applicable' (NA) was documented instead of the required information, and on other occasions, there was no documentation at all for the provision of these feeds. Interviews with the Registered Dietician and the Nursing Home Administrator confirmed that the resident was receiving both tube and pleasure feeds, but staff were not consistently documenting this care in the clinical record as required. The lack of documentation was identified through a review of clinical records and staff interviews, and it was acknowledged that the amounts of tube and pleasure feeds should have been recorded in the resident's chart.