Failure to Document Nursing Interventions Related to Missed Meal Before Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one resident by not documenting nursing interventions related to a missed meal and sack lunch prior to dialysis. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus, and end stage renal disease requiring dialysis three times weekly, with a scheduled pick-up time from the facility at 8:00 a.m. The resident’s orders also indicated a need for feeding assistance and the Minimum Data Set documented that the resident was cognitively intact but dependent on staff for all activities of daily living. On the morning in question, transportation arrived at approximately 7:30 a.m. to take the resident to the dialysis center before the resident had received breakfast. A progress note timed at 8:30 a.m. documented that transportation picked up the resident before breakfast and that the Dietary Supervisor was informed, made a sack lunch, and sent it to the dialysis center. However, during interview, the Dietary Supervisor stated that the resident was picked up with no sack lunch provided at the time of pick-up and that the sack lunch was delivered later to the dialysis center. During interviews, the RN assigned to the resident stated that the resident had necrotic hands and required feeding, and that a CNA reported transportation had arrived before the resident was fed. The RN stated that when she went to the resident’s room, the resident had already been picked up, and that the CNA reported the resident was upset. The RN reported that she notified the DON and a family member, who was also upset, but acknowledged she did not document what happened that day, including her notifications to the family member and DON. The ADON confirmed there was no documentation from the RN on that date and stated the medical record was not complete. The facility’s charting and documentation policy required that all services, changes in condition, events, and incidents be documented in the medical record, and that documentation be objective, complete, and accurate.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.