Failure to Document and Provide Evidence of Therapeutic Diet Delivery
Penalty
Summary
Facility staff failed to provide evidence that a resident with multiple complex medical diagnoses, including atrial fibrillation, dementia, heart failure, and a history of falls, received or refused a therapeutic diet as ordered by the medical provider during several evening meals. The resident was assessed as moderately cognitively impaired and had a care plan in place to provide and monitor a regular diet, with intake to be recorded at each meal. However, meal intake records for specific dates showed no documentation of meal percentages consumed or refusals for the evening meals in question. Interviews with staff and the local ombudsman did not yield direct observations of the resident missing meals, and staff recalled the resident typically ate independently after tray setup, preferring finger foods. Despite this, the facility was unable to provide documentation for meal delivery or refusals on the specified dates, except for one instance where partial intake was recorded. The facility's policy required encouragement of resident participation in meals, but no further information was provided to demonstrate compliance with ordered dietary interventions during the identified periods.