Failure to Conduct Nutritional Assessments and Monitor Weight Loss
Penalty
Summary
Maple Ridge Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding nutrition and hydration status maintenance. The facility failed to conduct a comprehensive nutritional assessment and monitor resident weights consistently and accurately, which led to a failure in identifying changes in nutritional status and implementing appropriate interventions for two residents. Resident CR1, admitted with dysphagia and other conditions, experienced significant weight loss shortly after admission. Despite a policy requiring a nutritional assessment within 72 hours, no such assessment was completed, and no interventions were initiated to address the resident's poor intake or weight loss. The resident was later transferred to the hospital in a severely malnourished and dehydrated state. Resident A1, who had a history of Barrett's esophagus and cancer, also experienced significant weight loss over a 30-day period. Although the resident's care plan included periodic weight monitoring and nutritional interventions, the facility failed to identify the weight loss in a timely manner and did not implement additional nutritional strategies. Observations revealed that the resident was not consistently provided with finger foods, an intervention included in the care plan to support the resident's independence and nutritional intake. Interviews with facility staff, including the RD and DON, confirmed the deficiencies in nutritional assessments and interventions. The facility lacked a qualified nutrition professional during a critical period, and the care-planned accommodations for Resident A1 were not consistently implemented. These failures contributed to the residents' deteriorating nutritional status and were not addressed in a timely manner, leading to significant health declines.
Plan Of Correction
Please note that the filing of this Plan of Correction does not constitute any admission to the alleged violations set for in the statement of deficiencies. This Plan of Correction is being filed as evidence of the facility's continued compliance with all applicable laws. 1. Resident CR1 was discharged from facility on 3/25/25. Resident Al therapy screen for eval placed 4/16/25. Resident Al reassessed by RD on 4/16/25, and a revised nutrition plan will be implemented if necessary. 2. A facility-wide audit will be completed on residents with nutritional risks over the past 14 days to determine if Initial Nutritional Assessment was completed within 72 hours and interventions are in place for those at risk. Will review residents over last 2 weeks who trigger for significant weight loss to ensure that proper interventions have been implemented. 3. Education on and review of facility policy provided to RD on timely completion of Initial Nutrition Assessment. Education provided to Nursing staff/RD to ensure that interventions put in place for residents who trigger at risk for weight or have significant weight loss. 4. DON/Designee will audit 10 random resident charts weekly x 4 weeks, then q 2 weeks x 2 months for timely completion of Initial Nutrition Assessment, RD interventions are in place for those at risk, and nutrition care plans are updated. Results of audits will be reviewed at monthly QAPI meeting.