Failure to Document Meal Intake Percentages in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident in accordance with its medical record documentation policy and accepted professional standards. Record review showed that the resident, who had Alzheimer’s disease, dementia, muscle wasting and atrophy, lack of coordination, and required assistance with personal care and ADLs, had no documented meal intake percentages in the electronic health record on 02/28/2026, 03/17/2026, and 03/23/2026. The resident’s Significant Change MDS reflected a BIMS score of 1, indicating severe cognitive impairment, and the resident was on a mechanically altered diet. The care plan included monitoring and documenting meal intake and tolerance, and recording meal intake percentages, but the meal percentage logs for the identified dates were blank. During interviews, three CNAs each stated they had assisted the resident with meals on the dates in question but admitted they forgot to document the meal percentages due to the heavy workload and demanding needs on the hallway. All three CNAs acknowledged the importance of documenting meal percentages and confirmed that they had received recent education on documentation. The dietician reported that the resident’s BMI was 27.9 and within normal limits for age and weight range, and stated there were no concerns about the resident’s nutritional status, weight, or muscle wasting at that time. The DON confirmed that it was the facility’s expectation that all clinical staff document care provided, including meal assistance, in the electronic health record and acknowledged that the lack of documentation for this resident’s meal percentages occurred on the identified dates.
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