Nutritional Deficiencies Due to Inadequate Monitoring and Feeding Regimen
Penalty
Summary
The facility failed to provide timely nutritional assessments and interventions, resulting in significant weight loss for a resident. The resident experienced a severe weight loss of 25.2% over eight months, with various dietary orders being inconsistently applied or discontinued without adequate follow-up. The resident's nutritional needs were not met, and there was a lack of consistent monitoring and adjustment of feeding regimens. Observations revealed that the resident's food intake was often inaccurately recorded, and the resident's preferences and dislikes were not adequately addressed, contributing to the nutritional deficiency. Another resident had overlapping orders for enteral feeding, leading to confusion and improper administration of nutritional support. The resident's feeding regimen was not consistently followed, with discrepancies in the amount of formula administered. The facility's staff failed to recognize and correct these issues, resulting in inadequate nutritional support for the resident. A third resident also experienced issues with enteral feeding, with observations showing that the prescribed feeding regimen was not followed. The resident's nutritional assessment indicated a risk for malnutrition, yet the recommended adjustments to the feeding regimen were not implemented. The facility's failure to adhere to physician orders and properly monitor and adjust feeding regimens contributed to the nutritional deficiencies observed in these residents.
Plan Of Correction
Resident #51 was sent to hospital on Resident #51 remains in hospital as of Resident #167 and #169 orders for feeding were clarified and corrected on 100% audit of all feeding residents for orders to meet nutritional needs, one order and RD documentation. Inservice DON and Registered Dietician of documentation and feeding order requirements. DON or designee to audit for feeding orders and RD documentation with feeds weekly times 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.