Inaccurate Documentation of Required Supervision During Meals
Penalty
Summary
The facility failed to maintain accurate documentation regarding the level of assistance required for a resident during meals. The resident's care plan and a speech-language pathologist's recommendation both specified that the resident required supervision while eating. However, a review of the Activities of Daily Living (ADL) documentation for May and June showed that the resident was repeatedly marked as 'Independent' for eating on several dates, which contradicted the care plan and professional recommendations. Interviews with the unit manager confirmed that the resident should not have been considered independent, as supervision was necessary during meals. The unit manager was unable to explain why the resident was documented as independent on those occasions. The administrator acknowledged that the discrepancy was likely due to staff not understanding the difference between 'Independent' and 'Supervision' when documenting the resident's level of assistance.