Failure to Document Meal Intake and Address Weight Loss
Penalty
Summary
The facility failed to document all meal intake percentages for a resident identified with weight loss, as evidenced by missing documentation for several meals over a period of time. The resident experienced a 5.1% weight loss within one month, with weights recorded at multiple intervals showing a consistent decline. The resident's representative expressed concern about poor eating and specific food dislikes, but there was no documentation of food preferences or dislikes in the resident's records. Additionally, there was no documentation from the facility physician or registered dietician regarding the resident's nutritional status or interventions. The Director of Nursing acknowledged the lack of information on food preferences and indicated that dietary management was handled by another facility.