Failure to Document and Monitor Nutritional Supplement Intake
Penalty
Summary
Facility staff failed to monitor and document the consumption of a prescribed nutritional supplement, Boost, for a resident who was underweight and had multiple medical conditions, including major depression, anemia, fatigue, and a major neurocognitive disorder due to possible Alzheimer's Disease. The care plan for this resident included an intervention to provide Boost with breakfast and lunch, as ordered by the physician. However, interviews with staff, including a CNA, LN, RD, DSD, and RNA, revealed that there was no system in place to document the specific amount of Boost consumed by the resident. The Medication Administration Record (MAR) and fluid intake reports did not include a section for recording Boost intake, and staff confirmed that only combined fluid intake was documented, not the intake of individual supplements like Boost. As a result, the facility was unable to monitor or evaluate the effectiveness of the nutritional intervention as required by their own policies and procedures. The lack of documentation meant that staff could not determine whether the resident was receiving the intended nutritional support, and there was no way to assess if the intervention was achieving its goal of addressing the resident's underweight status. The deficiency was identified through interviews and record reviews, which confirmed the absence of documentation and the inability to track the resident's supplement intake.