F0842

D

Failure to Consistently Document Resident Meal Intake in Medical Record

Glendora, California Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

Facility staff failed to consistently document a resident’s meal intake in the medical record as required by facility policy and CNA job expectations. The resident was admitted with sepsis and diabetes mellitus and had intact cognition and decision-making capacity. According to the MDS, the resident required setup assistance with eating, supervision with oral hygiene, moderate assistance with toileting hygiene, showering/bathing, and personal hygiene, and maximal assistance with bed-to-chair transfers. Review of the Documentation Survey Report (DSR) for January 2025 showed CNAs documented the resident’s meal intake for 90 of 93 meals, and for February 1–15, 2025, CNAs documented meal intake for 40 of 45 meals, leaving multiple meals without recorded intake amounts.

During interview, a CNA stated that CNAs were expected to document after each meal, including when a resident refused to eat, and that documentation should be completed before the end of the shift as a standard of practice. The CNA further stated that if there was no documentation on the DSR, staff would not know how much residents ate and that incomplete documentation would affect continuity of care. The DON similarly stated that without documentation, nursing staff would not know if the resident ate or refused the meal. The CNA job description required recording residents’ food and fluid intake, and the facility’s Charting and Documentation policy required that all services provided to residents be documented completely in the medical record, including date, time, and the signature and title of the person documenting. Despite these requirements, staff did not document the amount of meal intake for all meals during the review period for this resident.