Failure to Monitor and Intervene for Nutrition and Hydration Needs
Penalty
Summary
The facility failed to adequately assess, monitor, and intervene for the nutritional and hydration needs of two residents. One resident, an 82-year-old with severe cognitive impairment and multiple diagnoses including Alzheimer's Disease and failure to thrive, experienced significant weight loss over a six-month period. Despite a dietitian's recommendation to increase nutritional supplements to four times daily, the facility did not implement this intervention, and records showed inconsistent or missing documentation of supplement administration and food intake. The care plan for this resident was not updated or revised in response to ongoing weight loss, and there was no consistent monitoring of food and supplement intake as required by physician orders and care plan approaches. Another resident, admitted with dementia and other medical conditions, did not have an admission weight recorded, nor was there a baseline or monthly weight documented as required by facility policy. This resident also lacked any documentation of food or fluid intake, and there was no nutrition or weight-related problem addressed in the care plan. During a dining observation, this resident's meal was delivered late, and the DON confirmed that the initial weight assessment was missed. The facility's policy requires admission weights within 24 hours and monthly weights, but these procedures were not followed for this resident. The deficiencies were identified through record review, staff interviews, and direct observation. The DON acknowledged the lack of consistent documentation and monitoring for both residents, including missed weights, unrecorded supplement administration, and incomplete food acceptance records. The facility's failure to follow its own policies and physician or dietitian recommendations contributed to the ongoing nutritional risks for the affected residents.
Plan Of Correction
The facility identifies, assesses, and monitors resident weights and ensures interventions to promote nutrition and prevent weight loss are in place. 1. Resident #19's nutritional status was assessed by the Dietitian on 2/27/25 and again by 4/7/25. His care plan was reviewed and revised, with interventions including acceptance/documentation of supplements reviewed with staff involved with his care. His MD was notified on 3/25/25 of his weight fluctuation. Resident #37 was weighed on 2/28/25; the Dietitian evaluated on 1/13/25 and will evaluate again before 4/7/25. She will be monitored for any weight concerns. 2. All residents are potentially affected. An audit of each resident's weight was reviewed by the Dietitian and Director of Nursing on 3/11/25 to determine any need for increased monitoring/interventions. Residents currently receiving supplements were reviewed for acceptance/tolerance of supplements and documentation of supplement intake. 3. The documentation of meal intake for high-risk residents was reviewed, and a new form was initiated on 3/17/25 after review/in-service by the DON with the nursing staff. Process was reviewed during in-service on 3/26/25. Processing and communication of dietician recommendations were reviewed and discussed with the DON, Dietary Manager, and Dietitian on 3/11/25 to ensure prompt follow-up. A weekly Nutrition At Risk (NAR) meeting will begin on 3/21/25 to review residents, including but not limited to new admissions, with the IDT and Dietary Manager. The DON will lead the meeting. Nursing staff were in-serviced on recording and reporting supplement percentages as well as residents' acceptance of supplements on 3/26/25 by the DON. Admission weight and weekly weights for four weeks were added to the admission standing batch orders on 3/21/25 to ensure communication, completion, and documentation. 4. The DON or designee will conduct weekly audits of Performance Monitoring related to weights, meal intake, and supplement documentation to ensure they are recorded and complete to monitor weight fluctuations. The audit will be completed weekly for four weeks, then monthly. Any identified areas of concern will be addressed and immediately corrected. Results of the audits will be taken to the QAPI Committee for review and recommendation, and for determination of continued monitoring. The DON will be responsible for monitoring sustained compliance.