Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately assess, evaluate, and monitor the nutritional needs of three residents, leading to significant weight loss and inadequate nutritional interventions. Resident 18, diagnosed with Huntington's disease and oropharyngeal dysphagia, experienced a weight loss from 129.7 pounds in July 2024 to 114 pounds by January 2025. Despite the significant weight loss and the resident's high aspiration risk, the facility did not obtain timely weights or update the care plan following the implementation of enteral feeding. The registered dietitian did not evaluate the resident's nutritional requirements or update the care plan, and the facility lacked an on-site dietitian, relying instead on a part-time remote dietitian. Resident 12, admitted with a diagnosis of cerebral infarction, experienced a 6.8-pound weight loss between December 2024 and January 2025. The facility failed to obtain a reweight within the required 72-hour timeframe, and the reweight was only obtained 14 days late following surveyor inquiry. The Director of Nursing confirmed that the reweight was not timely obtained, indicating a lapse in the facility's adherence to its own policies regarding weight monitoring and nutritional assessment. Resident 29, with diagnoses including atherosclerotic heart disease, hypertension, and dementia, experienced significant weight loss from 140.2 pounds in June 2024 to 127.4 pounds by September 2024. The facility did not conduct a reweight within the required timeframe, nor did it notify the physician, dietitian, or interdisciplinary team of the significant weight change. There was no evidence of updated nutritional assessments or individualized interventions between the resident's admission in October 2023 and September 2024. The Director of Nursing confirmed the facility's failure to obtain and record reweights and to notify the necessary parties of the resident's significant weight loss, impacting the ability to accurately assess and address the resident's nutritional needs.
Plan Of Correction
1. Residents 12, 18 and 29 have been weighed. A nutritional assessment will be completed and their care plans updated. 2. The facility has hired an RD for 10 hrs/week to provide onsite support. 3. The licensed staff were re-educated on the Weight/Re weight policy. The RD was re-educated on the importance of completing nutritional assessments timely and updating the care plans as needed. 4. The RD/Designee will audit resident weights to ensure resident weights are obtained per policy. The Registered Dietician will be notified of any weight changes that are of concern. The results of the audits will be reviewed at QAPI for review and analysis of ongoing education.