Failure to Maintain Nutritional Parameters for Resident
Penalty
Summary
The facility failed to maintain appropriate nutritional parameters for a resident, identified as Resident 65, who was at risk for nutritional and hydration issues due to impaired skin integrity and a need for a mechanically altered and therapeutic diet. The facility's policy required residents to be weighed on admission, weekly for the first four weeks, and monthly thereafter. However, the facility did not adhere to this policy, as evidenced by the lack of a recorded weight for Resident 65 on December 30, 2024, despite a physician's order for weekly weights. The resident experienced a significant weight loss of 11.4 pounds (9.96%) over seven days, and further weight loss was noted over 30 days, yet the facility did not reweigh the resident or confirm the weight loss as ordered. Additionally, the facility did not assess the resident in a timely manner following the initial weight loss. The dietician did not evaluate the resident until more than two weeks after the weight loss was documented, and there was no evidence that the physician was notified or conducted an assessment in response to the weight loss. An interview with the Registered Dietician confirmed these deficiencies, acknowledging that the resident was at nutritional risk and that the required assessments and notifications were not completed as per the facility's policy and physician's orders.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R65 the facility cannot go back retroactively to correct this issue. The Dietician/designee conducted an audit of residents with significant weight loss in the last 30 days to ensure timely assessment with interventions, as well as physician notification and documentation completed by the physician in response to the weight loss. The DON/designee educated the Dietician on timely follow up on residents with significant weight loss as well as physician notification of residents with significant weight loss. The Dietician/designee will audit residents with significant weight loss to ensure timely follow up as well as physician notification of the weight loss. Audits will be done weekly x 4 weeks then monthly thereafter. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.