Failure to Monitor and Intervene for Resident Hydration and Nutrition
Penalty
Summary
The facility failed to implement and monitor interventions to maintain proper hydration and nutrition for two residents. For one resident with diagnoses including anorexia, diabetes, major depressive disorder, and acute kidney failure, there was a physician's order to monitor intake and output every shift with a minimum daily fluid intake of 1500cc/ml. However, review of documentation over a 30-day period revealed multiple days where nursing staff and CNAs did not document fluid intake every shift as ordered, and several days where the recorded intake did not meet the minimum requirement. The Director of Nursing confirmed these findings, acknowledging that the required monitoring and documentation were not consistently performed. For another resident with acute and chronic respiratory failure, severe protein-calorie malnutrition, and a history of significant weight loss, the facility failed to notify the Registered Dietician (RD) of a substantial change in nutritional status. The resident experienced a 19-pound weight loss in one month following hospitalization and new PEG tube placement. Although the care plan indicated a referral to the RD for evaluation due to the significant weight loss, there was no evidence in the medical record that such a referral or evaluation occurred. The RD confirmed she did not receive any request for evaluation regarding the resident's weight loss, and the DON could not provide documentation of a referral or evaluation being sent. Facility policies required monitoring and documentation of intake and output for residents with physician orders, as well as prompt RD consultation for significant weight changes. In both cases, the facility did not follow its own policies or physician orders, resulting in a failure to ensure adequate hydration and nutrition monitoring and intervention for the affected residents.