Failure to Document Meal Refusals in Medical Record
Penalty
Fine: $66,123
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was admitted and discharged on the same day. Review of the resident's tray cards indicated that meal trays were scheduled for the day of admission, but the task documentation for meal intake was left blank for that day. According to an interview with a nurse aide, the resident was admitted, became upset due to a disagreement with family and delays in meal tray delivery, and ultimately refused both breakfast and lunch. The nurse aide retrieved the trays for the resident, but the refusals were not documented in the medical record as required.