Inaccurate Pre-Meal Documentation of Resident’s Food Intake
Penalty
Summary
The deficiency involves inaccurate documentation of a resident’s meal consumption. Surveyors observed Resident B, who had diagnoses including dementia, malnutrition, and heart failure, sitting up in bed with a breakfast tray in front of her. The food items, including scrambled eggs, toast, a sausage patty, oatmeal, and orange juice, were uncovered and uneaten, and the silverware remained wrapped in the napkin. When a CNA entered the room, the CNA asked the resident why she had not eaten and then attempted to feed her, while the resident spoke nonsensically and repeated the same words. Record review showed that Resident B’s MDS documented severe cognitive impairment, complaints of difficulty and pain with swallowing, and a mechanically altered diet. A care plan identified the resident as being at risk for unintentional weight loss and directed staff to monitor food and fluid intake at meals. Despite this, the electronic medical record showed that the CNA had documented that the resident consumed 26–50% of her breakfast approximately ten minutes before entering the room and seeing that no food had been eaten. An RN confirmed that the CNA should not have documented meal consumption before checking whether the resident had actually eaten, and the facility’s skills competency for assisting to eat required documenting meal consumption after the meal is finished.
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