Failure to Monitor and Document Nutrition and Fluid Status for Two Residents
Penalty
Summary
The facility failed to adequately monitor and document the nutritional and fluid status of two residents with significant medical conditions. For one resident with diagnoses including heart disease, hypertension, and diabetes, there were multiple dates where daily weights were not recorded as ordered by the physician. Additionally, when the resident experienced weight gains of two pounds or more in a day, the prescribed PRN dose of Lasix was not administered as required. Staff interviews confirmed that weights were to be obtained daily and reported to the nurse, who would then determine if the PRN medication should be given, but this process was not consistently followed. The facility also lacked a policy for following physician orders, relying instead on standard practice. For another resident with severe cognitive impairment and a diagnosis of malnutrition, the clinical record was missing documentation of meal intake for numerous meals across several dates. Facility policy required that meal intake be recorded in the electronic health record, but this was not consistently done. Staff interviews confirmed that meal documentation was expected, but the records showed significant gaps, particularly for a resident at risk due to malnutrition.