Inaccurate Documentation of Supplement Intake and Nutrition Status
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records of several residents. For two residents, unopened nutritional supplements (mighty shakes) were observed at the nurses' station in the afternoon, despite the Medication Administration Record (MAR) indicating that both had consumed 100% of their supplements at 10:00 AM. Upon interview, the registered nurse responsible acknowledged that she should have documented the supplements as refused rather than consumed. Additionally, a review of another resident's records revealed inconsistencies between the physician's order and the skilled nursing evaluation. The physician's order specified enteral feeding via G-tube, with the resident marked as NPO (nothing by mouth), yet the skilled nursing evaluation documented that the resident was taking nutrition and hydration orally and showed no signs of swallowing disorder. Corporate nursing staff later confirmed that the resident was receiving all nutrition through the G-tube and not orally.