Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by significant weight loss over several months. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, experienced a weight loss of 23.5% over 195 days. Despite being on a regular diet with nutritional supplements and fluids, the resident's weight continued to decline, indicating a failure to maintain nutritional status. The resident's care plan identified increased nutrition and hydration risk, yet interventions such as offering alternate foods and monitoring nutritional needs were insufficient to prevent significant weight loss. The facility's documentation revealed inconsistent recording of the resident's bowel movements, making it difficult to assess the onset and severity of diarrhea, which was reported by the resident and confirmed by staff. The lack of timely and thorough documentation hindered the facility's ability to address the resident's nutritional and hydration needs effectively. Interviews with the Director of Nursing confirmed the facility's failure to document and address the resident's diarrhea and weight loss adequately. The facility did not provide evidence that the resident's weight loss or dehydration was unavoidable, highlighting a deficiency in maintaining the resident's nutritional status and electrolyte balance as required by regulations.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Step 1 Resident # 1 loose bowel movements followed up MD/RP on 1/8/2025. Resident #1 weight loss stabilized 2 weeks post loss identification on 1/29/2025. Step 2 To identify like residents that have the potential to be affected, an in-house audit of progress notes and point of care documentation for last 2 weeks to verify that bowel movements documented accurately with MD/RP follow-up as applicable. In-house audit of residents with weight loss in last 14 days to ensure adequately investigated and followed up timely. Step 3 To prevent this from happening again, DON/designee will educate the licensed staff on documentation and follow-up in resident change in condition. DON/designee will educate the C.N.A staff on documentation in point of care changes in the resident continence and consistency of bowel movement and notification of the licensed nurse. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with changes in condition per week for 4 weeks, then monthly for 2 months to ensure timely follow-up. To monitor and maintain compliance, the DON/designee will conduct audits of 5 residents' bowel management point of care documentation to ensure that documentation accurately reflects resident bowel status per week, then monthly for 2 months to ensure compliance. Results of audits will be submitted to the QAPI committee for further review and recommendation.