Failure to Monitor and Communicate Nutritional Status
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of acceptable nutritional parameters for three residents, leading to significant weight loss and inadequate physician notification. Resident 17 experienced a significant weight loss of 28 pounds over several months, which was not properly addressed due to missed weekly weight checks and lack of physician notification. The resident's diet was downgraded to puree without reassessment by speech therapy, and the resident's POA was not interested in supplementation, contributing to the ongoing weight loss. Resident 28 also experienced issues with weight monitoring, as daily weights were not consistently documented, and significant weight gains were not reported to the physician as required. The resident had a history of heart failure and chronic kidney disease, necessitating careful fluid balance management. Despite orders for daily weight monitoring, there were multiple instances where weights were either not recorded or not communicated to the physician, leading to a lack of timely medical intervention. Resident 58, diagnosed with dementia and heart failure, experienced significant weight loss over several months. The facility failed to document physician awareness or evaluation of the weight loss, despite it being discussed in QAPI meetings. The resident's weight loss was attributed to diuretic therapy, but there was no evidence of physician involvement in addressing the issue. The facility's failure to consistently monitor and communicate weight changes to physicians resulted in inadequate management of the residents' nutritional and hydration needs.
Plan Of Correction
1. R17 corrected with new order in an effort to advance diet texture, along with double portions of protein with each meal. R28 and R58 missing weight and documentation was corrected and MD notification was made aware of current weight along with dietician. All residents continue to reside at the facility. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. The DON and/or Dieticians will conduct an order review by March 14, 2025, to identify any residents that have orders for daily weights perimeters to notify the MD with weight changes to also ensure they are appropriately calculated based on weight and medical diagnosis and following the dietitian comprehensive nutrition assessment. A facility-wide audit will be conducted by the dietician and DON for any resident identified with missing documentation, missing MD notification, and physician orders not followed up on by March 14, 2025. 3. DON will educate the Dietitian to fill out a communication form upon a significant weight gain over 30 days, 3 months, and 6 months to be given to the DON and placed in the MDs review folder. In the daily standup meetings, the dietitian notes will be reviewed for significant weight loss/gain with the IDT team to ensure communication and MD notification is implemented and documented timely in the Treatment Administration Record. The DON will also educate the Rehab Department on documenting refusals as evidenced in speech therapy to ensure consult or supplements were discussed with the physician and documented in the EHR (PCC) by March 14, 2025. The DON and Dietician will educate all nursing staff and the IDT team on the policy and procedure of nutrition and hydration status maintenance of the clinical process of fluid and dietary status per individual resident to monitor fluctuations that would be anticipated and may trigger significant weight loss/gain by March 14, 2025. 4. An audit of all residents will be conducted to ensure weights are being completed according to physician orders, therapy refusals are being conducted, and ensuring documentation is completed weekly x 4 then monthly x 2 by the DON and/or Dietitian to ensure the resident has no signs of significant weight loss, until 100% compliance is achieved. The findings of the audits will be reported at the monthly and quarterly QAPI meeting until consistent compliance has been met.