Failure to Document Resident Meal Consumption
Penalty
Summary
The facility failed to document meal consumption values for 8 out of 10 residents reviewed for nutrition, as evidenced by missing entries in the Meal Consumption Records for multiple dates across August and September 2025. The residents affected had a range of medical conditions, including heart failure, hypertension, stroke, COPD, bipolar disorder, diabetes, dementia, anxiety, depression, malnutrition, anemia, wound infection, and psychotic disorder. The documentation gaps included missing records for breakfast, lunch, and dinner on various days, with some residents lacking documentation for all meals on certain dates. Interviews and record reviews confirmed that residents typically ate their meals within the facility and did not leave to eat elsewhere. For example, one resident stated that he always ate all meals in his room and had not eaten outside the facility. Despite this, the corresponding meal consumption records for these residents showed numerous undocumented meals, indicating a failure to consistently monitor and record daily nutritional intake as required by facility policy. The facility's policy mandates that the percentage of meals consumed daily be recorded on a designated document to monitor residents' daily intakes. However, the lack of documentation for multiple meals across several residents demonstrates noncompliance with this policy. The deficiency was identified through both clinical record reviews and staff interviews, which confirmed that the expected documentation process was not consistently followed.