Failure to Document Meal Intake for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident who was cognitively impaired, dependent on staff for personal care, and had a diagnosis of dysphagia. According to facility policy, staff are required to document the provision of Activities of Daily Living (ADL) care, including actual meal consumption, each shift. However, a review of the resident's records showed that meal intakes were not documented for several breakfast meals in August and September 2025. The care plan specified that the resident required a texture modified diet and staff assistance at meals, but there was no evidence that meal intakes were recorded on the specified dates. The Nursing Home Administrator confirmed the lack of documentation for these meals, which was not in accordance with the facility's policy.