Failure to Provide Adequate Nutritional Support and Competency Verification
Penalty
Summary
The facility failed to provide adequate nutritional support and timely identification of severe weight loss for two residents. One resident, admitted with communication and anoxic damage, experienced a 6.7% weight loss over six weeks. Despite observations of the resident struggling to eat due to uncontrollable shaking, no nutritional supplements were ordered, and the resident was left unsupervised during meals. The Registered Dietitian was aware of the weight loss but did not implement weekly weight monitoring or additional nutritional interventions, leading to a severe weight loss of 11.5% in less than two months. Another resident experienced a 9.8% weight loss in one month, with an overall 14% loss over three months. The resident's meal intake was less than 50% over the past 30 days, and although interventions such as fortified food and house shakes were initiated, there was a delay in implementing these measures. The Registered Dietitian failed to place an order for the house shake immediately, resulting in a lack of timely nutritional support. Additionally, the facility did not ensure the competency of a resident performing self-care for a tracheostomy. The resident was observed changing her inner cannula without recent competency verification, as the last documented competency was over a year ago. The facility could not locate the competency checklist, and the resident continued to change her inner cannula more frequently than recommended, without proper oversight or documentation in the electronic health record.
Plan Of Correction
Actions Taken: 1) Resident #52 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #52 on and the resident now attends the dining room for his meals for oversight and assistance as needed. On resident #52 was placed on an appetite stimulant. Resident #52 was placed on weekly and is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. Resident #56 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #56 on the resident was seen by the Speech Pathologist and her diet was downgraded to Puree and on the resident was placed on an appetite stimulant. Resident #56 is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. Others Identified: 2) Full house audit completed between by the Registered Dietitian/Designee to identify residents that may have been affected due to delayed loss intervention or missing a nutritional intervention in the electronic medical record or ticket system recommended by the Registered Dietitian. Additional documentation recommended from the full house audit was completed by facility Registered Dietitian by Regional Dietitian completed a full house audit between to ensure residents have been per protocol and monitored appropriately to identify severe loss. Any concerns identified were immediately addressed. Measures Taken: 3) Regional Dietitian in-serviced the Registered Dietitian on regarding timely nutrition interventions with a focus on residents with loss as well as ensuring nutritional interventions are placed in electronic medical record and ticket system timely as applicable. Nursing staff were re-educated to refer to resident Kardex in reference to the amount of assistance required with meals initiated on by Ellie Schutt, LNHA/Designee. Ongoing Monitoring: 4) The Registered Dietitian/Designee will conduct an audit of 10 residents on each unit weekly to ensure the residents with loss have timely documentation with nutritional interventions and verify that the nutritional interventions are placed in the EMR and the ticketed system timely weekly x 4 weeks, and then every 2 weeks x 2 months. Findings of the audits will be reviewed in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.