Failure to Complete Required Quarterly Nutrition Assessment
Penalty
Summary
The facility failed to follow its policy to complete quarterly nutritional assessments for a resident with multiple medical conditions, including polyosteoarthritis, legal blindness, vitamin D deficiency, chronic gastritis, and nicotine dependence. The resident was cognitively intact and had a care plan identifying several nutritional risks, with a goal to maintain stable weight. Despite this, the electronic medical record showed that the last nutrition assessment by the Dietary Manager was completed in late October, and no further assessments were documented for nearly six months. The resident's weight steadily declined over this period, with a loss of over 11 pounds. During interviews, the Dietary Manager confirmed that quarterly nutrition assessments are required for residents not seen by the dietitian, and the Director of Nursing stated that the dietitian only evaluates residents with significant weight loss. The resident reported feeling that he was losing weight and was observed eating unassisted, dropping food onto his lap and tray without staff assistance. The facility's policy requires quarterly documentation and assessment in accordance with the MDS schedule, but this was not followed for the resident in question.