Incomplete Documentation of Meal Intake Percentages
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident by not documenting required meal intake percentages over multiple dates. Specifically, the resident's nutrition records from early to late January showed repeated omissions, including missing documentation for breakfast, lunch, and dinner intake percentages on several days. This lack of documentation was identified during a review of the resident's records, which revealed a pattern of incomplete entries for meal intake. The resident involved had diagnoses of dementia and diabetes mellitus, with documented moderate cognitive impairment and required varying levels of assistance with eating and other activities of daily living. Interviews with facility staff, including a CNA and the DON, confirmed that meal intake percentages were required to be documented for each meal and that records were expected to be complete and accurate. The facility's policy also required nursing staff to document care provided, including ADL completion.