Failure to Monitor Nutritional and Hydration Needs
Penalty
Summary
Mountain City Nursing & Rehabilitation Center was found to be non-compliant with federal and state regulations regarding the maintenance of nutritional and hydration status for a resident. The facility failed to adequately monitor and evaluate the weight and hydration needs of a resident, identified as Resident A1, who was admitted with diagnoses including dementia, congestive heart failure, and chronic kidney disease. The resident experienced significant weight loss shortly after admission, dropping from 114 pounds to 107 pounds within a week, and continued to lose weight over the following weeks without documented re-evaluation or intervention by the facility's dietitian. The facility's records showed that the resident's fluid intake was consistently below the required range, with daily intake ranging from 320 cc to 1140 cc, while the resident's needs were between 1375 ml and 1650 ml per day. Despite the resident's decreased appetite and fluid intake, and the use of a diuretic medication that increased the risk of dehydration, there was no evidence that the facility took timely action to address these issues. The resident's condition deteriorated, leading to lethargy and poor appetite, and eventually required hospitalization for treatment of hypernatremia, acute kidney injury, and a urinary tract infection. The facility's failure to monitor and address the resident's nutritional and hydration needs was further highlighted by the lack of documented evidence of physician or resident representative notification regarding the significant weight changes. Interviews with the director of nursing confirmed the absence of timely identification and reassessment of the resident's nutritional and hydration needs, which contributed to the resident's adverse health outcomes.
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 RA1 was discharged on 1/4/2025. Step 2 To identify other residents that have the potential to be affected, the DON / designee audited current in house residents for significant weight changes. Those identified with significant weight changes were addressed as necessary. Current residents were assessed by nursing for hydration status via visual observation. Follow up completed based on findings of the audits as needed. Step 3 To prevent this from reoccurring, the DON/ designee will educate nursing staff on s/s of dehydration and weight policy. The Registered Dietician will be educated by the Regional Dietician on the weight policy. Step 4 To monitor and maintain compliance, the DON / designee will randomly audit 25 residents per day to review weight, meal consumption, and fluid intake to ensure concerns related to hydration and significant weight changes are addressed. The audits will be completed 5 days per week times 4, then weekly times 4, then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.