Failure to Complete Timely Nutritional Assessment on Admission
Penalty
Summary
The facility failed to conduct a nutritional assessment upon admission for one of four sampled residents, as required by its own policy and procedure. The resident in question was originally admitted with multiple diagnoses, including hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. Despite these significant health conditions, there was no documented evidence that a nutritional assessment was completed by the dietitian at the time of admission. Record reviews showed that the resident's weight was documented at various points, both in the hospital and at the facility, but there were inconsistencies and strikethrough entries in the weight records. The resident had been refusing to be weighed since January, and the last recorded weight was from that time. The dietitian only completed the nutritional assessment after the resident returned from a hospital stay in April, well beyond the required timeframe for an initial assessment. Interviews with facility staff confirmed that the initial nutritional assessment was not completed as required. The Director of Staff Development acknowledged the absence of documentation for the assessment at admission, and the Registered Dietitian stated she was unaware that the assessment had not been done, attributing the oversight to a transition between dietitians. The facility's policy clearly states that a nutritional assessment should be conducted upon admission, but this was not followed in this case.