Inaccurate Documentation of Meal Consumption
Penalty
Summary
The facility failed to accurately document meal consumption for six of seven residents observed. According to the facility's policy, documentation in the medical record must be objective, complete, and accurate. However, observations revealed discrepancies between the actual amount of food consumed by residents and what was recorded in their clinical records. For example, one resident was observed to have consumed approximately 25% of their meal, but the record indicated 75% consumption. Similar inconsistencies were found for five other residents, with documentation often completed before the meal was finished or with amounts that did not match direct observation. Staff interviews confirmed that documentation was sometimes completed prematurely, with one nursing assistant admitting to charting meal consumption too quickly. The Nursing Home Administrator acknowledged that the facility did not accurately document meal consumption for the majority of residents observed during the survey. These findings were determined to be non-compliant with the facility's own documentation policy and state regulations regarding clinical records.