Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
Haven Place was found to be non-compliant with the requirements for maintaining nutritional and hydration status for a resident, identified as Resident 1, during an abbreviated survey following a complaint. The facility failed to adequately monitor and assess the resident's nutritional status, resulting in significant weight loss over several months. Resident 1, who had diagnoses including dysphagia, GERD, vitamin D deficiency, hypokalemia, and dementia with psychotic disturbance, experienced a weight loss of 11.4 pounds, equating to a 10.32% decrease over 4.5 months. The facility's speech therapist, Employee 1, had ordered a full liquid diet with thin liquids and pureed food for pleasure, noting that Resident 1 required specific cues and assistance when drinking. Despite these interventions, dietary notes indicated that Resident 1 was refusing most food and only accepting certain nutritional supplements. The interim registered dietician, Employee 2, documented Resident 1's underweight status and significant weight loss but did not adjust the dietary plan or discuss advanced directives with the interdisciplinary team. There was no evidence of changes to the nutritional supplements to address the weight loss. Concerns were raised by Resident 1's responsible party about the resident not receiving Ensure on their tray, which was addressed by the Director of Nursing. However, there was no documentation of further dietary interventions or assessments by Employee 2 or Employee 3, the newly hired dietician, after March 11, 2025. The Nursing Home Administrator confirmed that Employee 3 had not reviewed Resident 1's clinical record for weight loss concerns, and the dietician worked remotely without a scheduled visit until later in April.
Plan Of Correction
1. Resident # 1 was re-weighed, re-assessed by Dietician for nutritional needs. Diet updated to include Yogurt, Pudding and Jello. Care plan meeting was held with family and discussed progression of resident's Dementia. Per family wishes the resident was assessed and admitted under hospice services. 2. Dietician audited residents with significant weight loss to ensure appropriate interventions are in place. 3. Education will be provided to dietician and IDT on the process for capturing residents that are at risk for significant weight loss. 4. Dietician will provide weekly report to IDT for any resident that is at risk for significant weight loss. IDT will meet weekly to review residents at risk during risk meeting to ensure that the appropriate interventions are in place. 5. Results will be discussed at QAPI.