Failure to Accurately Assess and Monitor Nutrition and Hydration Needs
Penalty
Summary
The facility failed to ensure comprehensive and accurate nutritional assessment and monitoring for a resident with significant medical needs, including moderate protein-calorie malnutrition, iron deficiency anemia, failure to thrive, and multiple pressure injuries. The Registered Dietitian (RD) did not reassess the resident's daily calorie, protein, and fluid needs after significant changes in condition, such as unplanned weight loss and worsening pressure injuries, despite facility policy and standard practice requiring such reassessment. The RD also did not evaluate whether the resident's food and fluid intake met her nutritional needs, nor did she review or utilize fluid intake logs to identify insufficient hydration, even when the resident had increased fluid needs due to draining wounds. The facility did not effectively monitor or document the consumption of oral nutrition supplements (ONS) provided to the resident. CNAs recorded total fluid intake from meal trays without specifying the type or amount of ONS consumed, making it impossible for the RD or nursing leadership to determine if the supplements were provided and consumed as ordered. Additionally, the facility delayed convening an interdisciplinary team (IDT) weight variance meeting to evaluate the effectiveness of the ONS intervention, during which time the resident continued to experience significant weight loss. The facility also lacked a variety of nutrition supplements to offer residents who required additional calories or protein, and did not offer alternative supplements when the resident refused the standard house nourishment shake. There was a lack of systematic monitoring and evaluation of the resident's hydration status. The RD did not review fluid intake documentation to compare actual intake to assessed needs, nor did she communicate concerns about inadequate fluid intake to the IDT or physician. The facility did not obtain the resident's beverage preferences to help improve fluid intake, and staff did not routinely monitor or discuss fluid intake logs in IDT meetings. As a result, the resident experienced further decline, including continued weight loss, poor wound healing, and a hospitalization for dehydration requiring IV fluids.