Inaccurate Documentation of Eating Assistance
Penalty
Summary
The facility failed to ensure that a clinical record contained accurate and complete information for a resident who required total assistance with eating. The resident's care plan indicated a need for total assistance with activities of daily living, specifically eating, as documented in the care plan and its interventions. However, a review of meal documentation over an eight-day period revealed that 14 out of 24 meal entries were either blank or inaccurately recorded, with some meals marked as supervision, independent, setup, or substantial assist, contrary to the care plan requirements. Interviews with staff confirmed that the resident was indeed a total assist for eating, and the administrator acknowledged that staff were aware of this but had documented incorrectly.