Inaccurate Meal Intake Documentation for Mentally Intact Resident
Penalty
Summary
A nursing assistant was observed removing a meal tray from a resident's room, with the tray showing little food consumed and the silverware still wrapped, indicating the meal was likely untouched. The nursing assistant stated that the resident was able to feed herself. However, a review of the resident's electronic health records for that meal documented that the resident had eaten 76 to 100% of her lunch, which conflicted with the direct observation. The resident was noted to be mentally intact, with a BIMS score of 15, and her records confirmed she could feed herself after set up. The discrepancy between the observed meal consumption and the documentation in the medical record was brought to the attention of the Director of Nursing, but no further clarification or information was provided during the survey.