Failure to Accurately Document Nutritional Intake for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete documentation of a resident’s meal intake in accordance with professional standards and its own documentation policy. A resident admitted with metabolic encephalopathy, kidney calculi, severe protein-calorie malnutrition, bipolar disorder, oropharyngeal dysphagia, and COPD had a care plan identifying risk for altered nutrition and hydration due to severe malnutrition, altered mental status, dysphagia, low BMI, and recent significant weight loss. An MDS assessment documented the resident as cognitively intact, and a nutritional assessment by an RD indicated the resident was consuming 25–50% of three daily meals. A physician’s order directed staff to monitor the resident’s meal intake. Despite this order and the resident’s identified nutritional risks, review of NA tracking sheets for November and December showed no recorded meal intake for the resident. Dietary progress notes and the RD’s nutritional assessment, which both stated the resident consumed 25–50% of three daily meals, were confirmed by the RDs to have been based on these NA tracking sheets, even though the facility could not produce any such documentation. The DON confirmed the facility was unable to provide documentation of meal intake tracking for the resident for those two months. The facility’s policy on documentation stated that charting should provide a complete account of care, treatment, responses, signs and symptoms, guidance for prescribers, a tool for measuring quality of care and developing care plans, and serve as a legal record, underscoring the discrepancy between policy and practice in this case.
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