Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of three residents, leading to significant weight loss and potential health risks. Resident #52, a female with multiple diagnoses including dementia and diabetes, experienced an 8.7% weight loss over two months. Despite orders for monthly weights and nutritional supplements, no weights were recorded for three months after November 2024. The dietary staff was unaware of the resident's status due to the lack of updated weights, which hindered timely interventions. Resident #15, a female with severe cognitive impairment and multiple health conditions, also experienced significant weight loss. She lost 24.4 pounds, or 15.8% of her body weight, over five months. Although the dietician had recommended increased protein intake, the facility failed to report the resident's weight loss for three months, delaying necessary re-evaluation and interventions. The facility's policy required monthly weights, but this was not adhered to, resulting in unmonitored weight loss. Resident #34, admitted with end-stage renal disease and other conditions, did not have an initial weight recorded upon admission. The facility used a weight from a previous hospital stay, which was not best practice. This resident had a stage IV pressure ulcer, but the nutritional assessment did not reflect this, leading to inadequate nutritional support. The dietician failed to order recommended supplements, and no food preferences were obtained to improve the resident's intake. The lack of an initial weight and failure to implement dietary recommendations contributed to a 13% weight loss, highlighting the facility's inadequate monitoring and response to residents' nutritional needs.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On RD completed review to assess nutritional status of resident numbers, 15, 52, and 34. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed to ensure nutritional status of residents has been assessed. b. On Audit completed to ensure nutritional status of resident with have been assessed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with RD and nurse management team to ensure nutritional status is reviewed and assessed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure nutritional status of residents has been assessed to ensure compliance with federal regulation F692 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.