Failure to Monitor Nutritional Status and Weight
Penalty
Summary
The facility failed to properly monitor the weight and nutritional status of two residents, leading to a deficiency in maintaining acceptable parameters of nutritional status as required by §483.25(g). For Resident R65, the facility did not document any weights for February 2025, despite the policy requiring weights to be obtained routinely. This oversight was confirmed by the Regional Director of Clinical Services during an interview, indicating a lapse in the facility's adherence to its own policy for monitoring nutritional health. For Resident R81, the facility did not obtain the required admission weight and subsequent weekly weights after the resident was readmitted from the hospital. The resident had a feeding tube and a physician's order to obtain weight at admission and weekly for four weeks, which was not followed. The nutritional assessment used a weight from the hospital, but the facility failed to update the assessment with an accurate weight obtained on-site. This lack of documentation and monitoring was evident upon review of the clinical records.
Plan Of Correction
Weights were obtained for R65. R81 no longer resides at the facility, unable to correct. Moving forward, the Director of Nursing (DON)/designee will review new admissions/readmissions to ensure admission weights and four weekly weights are obtained and that the nutrition assessments are able to be updated to include an accurate weight obtained by the facility. Negative findings will be addressed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated dietary tech and nursing staff on the weight policy and updating nutritional assessments with an accurate weight. To monitor and maintain ongoing compliance, the DON/designee will audit new admissions/readmissions for weights as ordered weekly x4 then monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.