Failure to Accurately Document Calorie Counts and Maintain Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident with multiple diagnoses, including hemiplegia, hemiparesis, dysphagia, dementia, and depression. Specifically, the facility did not accurately document the required seven-day calorie count on the resident's Medication Administration Record (MAR), as there was no indication that staff had signed off on this task. Additionally, discrepancies were found between the resident's Calorie Count records and Meal Intake documentation for several days, with conflicting percentages and missing entries. The Director of Nursing (DON) confirmed that the documentation was inconsistent and that the MAR should have been checked off and initialed by licensed staff to validate that the task was completed. The facility's policy and procedure on charting and documentation requires that treatments or services performed be objectively, completely, and accurately documented in the resident's medical record. However, the review revealed that the calorie count documentation did not align with the meal intake records, and the MAR was not properly completed to reflect the physician's order. The DON acknowledged these inconsistencies and the inability to validate that the required interventions were performed, resulting in inaccurate documentation of the resident's records.