Failure to Accurately Monitor and Document Meal Intake
Penalty
Summary
Facility staff failed to provide nutritional care and services consistent with a resident's comprehensive care plan by not accurately monitoring and documenting a resident's breakfast meal intake. The resident, who was cognitively intact and had a history of sepsis, COPD, GERD, bipolar disorder, and significant weight gain, was care planned for meal intake monitoring and documentation at each meal. On the specified date, the resident consumed only coffee and juice at breakfast and did not eat any of the provided food items. The CNA responsible for monitoring and documenting meal intake removed the tray without checking the amount of food consumed and subsequently recorded that the resident had eaten 51% to 75% of the meal. Interviews revealed discrepancies between the CNA's documentation and the resident's account, as the resident stated he did not eat breakfast and that his wife did not consume any food from his tray. The CNA admitted to documenting intake based on observation of the plate rather than confirming with the resident, despite knowing that the resident's wife sometimes ate from the tray. The facility's policy required meal intake to be documented after each meal, but this was not followed in this instance, resulting in inaccurate documentation of the resident's nutritional intake.