Incomplete CNA Meal Intake Documentation for a Resident with Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident when CNA documentation of meal intake was left incomplete. The facility’s Clinical Documentation policy, last revised 12/29/25, requires that Nursing Assistant documentation be completed at point of care in the electronic health record and that the facility meet Department of Public Health requirements for documentation every shift. Resident #1, admitted in May 2025 with diagnoses including dementia and generalized anxiety disorder, had a Meal Intake by Day report used to record the amount of food and fluids consumed daily. Review of this resident’s Meal Intake by Day report showed multiple blank entries where intake amounts should have been recorded. In July 2025, breakfast intake was left blank for 2 of 31 opportunities and lunch for 7 of 31 opportunities. In August 2025, breakfast was blank for 4 of 31, lunch for 7 of 31, and dinner for 1 of 31 opportunities. In September 2025, breakfast was blank for 6 of 30 and lunch for 10 of 30 opportunities. In October 2025, breakfast was blank for 7 of 23, lunch for 12 of 23, and dinner for 1 of 23 opportunities. During an interview, the DON confirmed that any blank spaces meant the CNA did not complete their documentation as required and stated that the CNA should have entered the appropriate amount of food and fluids consumed, especially given that the resident had experienced significant weight loss.
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