Failure to Monitor and Address Resident's Nutritional and Hydration Needs
Penalty
Summary
The facility failed to adequately evaluate and monitor the nutritional and hydration needs of a resident with multiple medical conditions, including Parkinson's disease, muscle weakness, and heart failure. The resident was admitted with an indwelling catheter and was dependent on staff for most activities of daily living. A physician's order was in place to monitor the resident's input and output (I&O) for hydration, and the care plan included interventions to observe urine output and encourage fluid intake. However, review of documentation revealed that while fluid intake was recorded, urine output was not consistently documented every shift as required by the physician's order and facility policy. This lack of consistent documentation prevented staff from accurately assessing the resident's hydration status. Additionally, the registered dietitian (RD) initially assessed the resident's nutritional needs and recommended a fortified diet to provide additional calories due to the resident being underweight and at risk for weight loss and dehydration. Despite this recommendation, there was no evidence that the RD continued to evaluate the resident's nutritional needs after the initial assessment, and the resident was not provided with the fortified diet as recommended. The dietary supervisor confirmed that the resident did not receive the fortified diet, which could have contributed to inadequate nutritional intake. Interviews with facility staff, including the registered nurse supervisor and the director of nursing, confirmed that the required monitoring and documentation of I&O were not performed consistently. The RD also acknowledged that there was no follow-up or documentation after the initial assessment. Facility policies and job descriptions reviewed indicated that these actions were required, but they were not carried out, resulting in the facility's failure to meet the resident's hydration and nutritional needs.