Failure to Monitor and Document Nutritional Status
Penalty
Summary
The facility failed to ensure acceptable parameters of nutritional status for Resident #65, who experienced significant weight loss. Resident #65, diagnosed with dementia, protein-calorie malnutrition, and macular degeneration, required extensive assistance with eating. Observations during meal times revealed that the resident was not receiving the necessary assistance, as staff were occupied with other residents. The meal ticket indicated the need for extensive assist feeding, but no staff were present to provide this support. Additionally, there was a lack of documentation regarding meal and supplement acceptance, and the medical provider was not informed of the resident's significant weight loss. Resident #65's weight decreased from 114 pounds at admission to 98 pounds, indicating a 14% loss over several months. Despite the resident being on a therapeutic diet with supplements like Boost Plus and Magic Cup, the documentation of meal and supplement intake was inconsistent and incomplete. The dietary progress notes and nutrition assessments highlighted the resident's weight loss trend, but there was no evidence that the medical provider or the resident's representative was notified of the significant weight loss. Interviews with staff, including LPNs, the Unit Manager, and the Dietary Technician, revealed a lack of awareness and communication regarding the resident's weight loss. The facility's failure to monitor and document Resident #65's nutritional intake and weight loss adequately, as well as the lack of communication with the medical provider, contributed to the deficiency. The Dietary Technician and Dietitian acknowledged the importance of monitoring residents' weights and notifying the medical provider of significant changes. However, the documentation and communication processes were insufficient, leading to the oversight of Resident #65's nutritional needs and weight loss.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 1. Resident #65 was reviewed by Dietitian for weight loss and conducted detailed nutritional assessment. Physician was updated on any change in weight. Any deficient findings were corrected immediately. The Occupational Therapy department conducted a review of the resident #65's plan of care and observed resident in unit dining including using adaptive equipment as per plan of care. Any deficient practices were corrected immediately. The MD conducted full review of the patient to review for weight loss. The Unit manager and/or designee will review meal consumption and ensure accuracy on daily basis. Any deficient practices were corrected immediately. The Director of Nursing reviewed the resident #65 meal consumption record. Any deficient findings were corrected immediately. All staff members who take care of Resident #65 were reeducated on residents plan of care related to meal intake and documentation on food consumption by RN Educator. It is the Dietitian's responsibility to alert Nursing to update Physician of any weight loss and document in medical record. 2. All residents with significant weight loss are at risk for deficient practice of resident not being reviewed by IDT and MD for weight loss and lack of nourishment and meal acceptance by nursing staff. 3. Policy and procedure for meal and nourishment was reviewed by Director of Nursing and no changes were made. 4. All nursing staff were trained by RN Educator on meal and nourishment intakes. 5. All residents meal intakes with significant weight loss were audited by Dietitian for lack of documentation. Dietitian reported any weight loss to nursing manager to update physicians of weight loss. Any deficient findings were immediately addressed. 6. All resident meal consumption records will be audited by Diet Tech / Nursing Supervisor daily for 3 months and weekly for 2 months for deficient practice of lack of documentation for meal consumption. Any deficient findings will be corrected immediately and brought to QAPI for further review. Diet tech/Dietitian and designee will audit meal pass weekly for meal acceptance. Any deficient practice will be corrected. The Unit manager/designee will audit meal consumption daily for meal observation versus documentation accuracy. Any deficient practices will be corrected immediately and brought to QAPI for further review. Person Responsible: Dietitian