Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to implement necessary interventions to maintain acceptable nutritional parameters for two residents, resulting in significant weight loss. Resident 100, who had a history of multiple strokes and a PEG tube insertion, was admitted to the facility with a regular diet and a sodium restriction due to congestive heart failure. Despite the resident's high nutritional risk and initial weight loss, the facility did not utilize the PEG tube for supplemental feeding or adjust the dietary plan adequately. The resident's weight continued to decline significantly over the following months without appropriate monitoring or intervention. Resident 100's weight was not consistently monitored, with significant gaps in weight assessments and dietary evaluations. The resident's meal intake records indicated a decline in consumption, yet no adjustments were made to address the nutritional needs. The facility's failure to implement timely interventions, such as utilizing the PEG tube or adjusting the diet, contributed to a severe weight loss of 15.7% since admission. Similarly, Resident 101 experienced a rapid and significant weight loss over a short period. The facility failed to notify the resident's physician of the continued weight loss and did not implement additional interventions to prevent further decline. The lack of timely and adequate response to the residents' nutritional needs highlights the facility's deficiency in maintaining acceptable nutritional status for its residents.
Plan Of Correction
The facility is unable to retroactively put in place interventions to prevent weight loss for residents 100 and 101. Both residents will receive an evaluation by the facility RD and have their care plans reviewed. The facility will complete a 30-day look back of significant weight changes to ensure physician notification was provided and appropriate interventions were implemented. The facility will notify the RD and physician of any identified significant weight changes for additional evaluation, and the resident's care plan will be reviewed. The facility RD, licensed nursing staff, and IDT will be educated on the facility weight policy. The DON or designee will complete audits of 5 residents a week for 8 weeks to ensure that weights have been obtained and documented as ordered and that unplanned significant weight changes have been communicated to the physician and that care plan updates occurred if applicable. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.