Failure to Accurately Document Physician-Ordered Snacks and Supplements
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for three residents who had physician-ordered snacks and supplements. For one resident with muscle wasting, diabetes, and failure to thrive, the physician's order for a high protein snack at bedtime was not documented on the Treatment Administration Record (TAR), and there was no evidence the snack was being provided. The resident reported not being offered snacks for a long time, and the dietary profile and care plan indicated the need for a high protein snack due to his medical conditions. Another resident with protein-calorie malnutrition, muscle weakness, and feeding difficulties had a physician's order for health shakes at bedtime, but this order was not included on the MAR/TAR, and there was no documentation that the shakes were being provided. The resident's care plan and dietary profile reflected the need for supplements due to decreased intake and unplanned weight loss, but the required documentation and administration were missing. A third resident with dysphagia, muscle weakness, and anemia had orders for a mechanical soft diet, health shakes with snacks three times daily, and nightly snacks with documentation of acceptance or refusal. While the nightly snack was partially documented, the health shake order was not present on the MAR/TAR. The resident reported inconsistencies in receiving snacks, especially when agency staff were present. Interviews with staff revealed confusion about documentation responsibilities and unfamiliarity with the electronic record system, leading to incomplete records and potential lapses in care.