Failure to Implement Dietary Recommendations and Monitor Nutrition
Penalty
Summary
The facility failed to implement dietary recommendations and adequately monitor and document meal intake for two residents with significant nutritional needs. For one resident with end stage renal disease, protein-calorie malnutrition, heart failure, diabetes, and liver disease, the dialysis dietician had recommended high-protein snacks at night to address low albumin levels. Despite this recommendation being faxed to the facility, there was no evidence of a corresponding order, documentation, or provision of a nighttime protein snack. Interviews confirmed that the facility's dietician had misplaced the recommendation, and the resident did not routinely receive a protein snack at night unless specifically requested. For another resident with dementia, anemia, malnutrition, and other chronic conditions, the care plan included multiple interventions to address nutritional risk, such as monitoring meal intake and providing assistance as needed. However, review of documentation revealed several instances where meal intake was not recorded, and analysis of the available records showed variable and often low meal consumption. Staff interviews confirmed that meal intake was expected to be documented for every meal, but gaps in documentation were present. Observations and interviews further supported that the facility did not consistently follow through on dietary recommendations or maintain accurate records of residents' nutritional intake. The lack of implementation of specific dietary orders and incomplete documentation of meal consumption contributed to the deficiency in ensuring adequate food and fluid provision to maintain residents' health.