Failure to Provide Prescribed Supplements and Document Nutritional Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to provide prescribed nutritional supplements and to document meal intake for residents experiencing weight loss. For one resident with diagnoses including dementia and protein-calorie malnutrition, observations showed that a prescribed Mighty Shake supplement was not provided with lunch, and both a CNA and an LPN confirmed the supplement was not given. The resident had a documented weight loss over several months and required setup assistance for eating. Physician orders and care plans specified the need for the supplement and fluid restrictions, but these were not followed during the observed meal. Another resident, who was severely cognitively impaired, dependent on staff for all activities of daily living, and receiving hospice care, also experienced significant weight loss. The care plan required monitoring and recording of food intake at each meal. However, review of documentation revealed multiple instances where meal intake was not recorded, specifically missing lunch and dinner entries on several dates. The facility's own policy required staff to ensure residents received correct diets and supplements and to monitor and document meal and supplement consumption, but this was not consistently done.