Failure to Accurately Document Mechanically Altered Diet in Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident with significant medical needs, including pneumonitis due to aspiration, COPD, dysphagia, heart failure, and edema. The resident, who had severe cognitive impairment and required a mechanically altered diet (pureed food and thin liquids) as ordered by the physician, was incorrectly documented by facility nurses on the Weekly Swallowing/Nutritional Status form. Specifically, the form indicated that the resident had not required a mechanically altered diet in the past seven days, despite clear orders and observations to the contrary. This inaccurate documentation was confirmed through interviews and record reviews, with the ADON acknowledging the error and stating that the resident's medical record should have reflected the actual diet provided. The facility did not have a policy regarding accurate clinical records, and the failure to document the resident's diet correctly could have led to missed treatment and care.