Incomplete Documentation of Enteral Feeding in EMR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that clinical records were complete and accurately documented for a resident receiving enteral nutrition. The resident had diagnoses including acute and chronic respiratory failure (unspecified for hypoxia or hypercapnia), gastrostomy status, and anoxic brain damage, and was rarely/never understood per the most recent quarterly MDS, which prevented completion of a BIMS assessment. Facility staff, including an LPN and RN, reported that enteral feeds are to be documented on the MAR, TAR, and an enteral nutrition log, and that documentation for resident care is to be completed in PointClickCare (PCC) within the shift and as soon as possible. The RN stated that documentation is important to track what is happening with residents and that many residents are vulnerable and nonverbal. During review of the resident’s January nutrition log, the surveyor identified missing documentation for a scheduled feeding time on 1/7/26 at 5:00 AM. This omission was shown to the LNHA, ADON, and DSW. The DON later stated that the expectation is that all documentation for residents should be completed. Facility policies titled “EMR Documentation-PCC” and “Nutrition: Enteral (GT, JT, NJT, NGT)” require timely, accurate, and complete clinical documentation in PCC, including recording enteral feedings in the EMR. Despite these policies and stated expectations, the enteral feeding for the identified date and time was not recorded, resulting in an incomplete clinical record for the resident’s nutrition.
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