Failure to Meet Professional Standards in Nutrition Assessment and Physician Order Compliance
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of quality for two residents. For one resident with quadriplegia and complete dependence on staff, the facility did not accurately assess, document, or update the resident's nutritional status in accordance with healthcare standards. The resident appeared malnourished, and family members reported significant weight loss and missed meals. Review of the electronic medical record showed that the last documented weight was several months old, and meal intake records indicated the resident was consuming only about 50% of meals, despite documentation stating the resident was meeting more than 75% of nutritional needs. The registered dietitian admitted that some assessments were not documented in the EMR and that calculations of intake were based on meal orders rather than actual consumption, with no documentation explaining changes in nutritional supplements. For another resident, staff failed to follow a written physician order for contracture management. The order required the use of a left palm grip, to be removed only during daily hand hygiene. Multiple observations by the surveyor found the resident was not wearing the palm grip, and there was no documentation in the medical record regarding its use, contraindications, or resident refusal. Nursing staff were unable to locate documentation of palm grip usage and only after surveyor inquiry was the device observed in use. No explanation was provided by staff for the lack of compliance with the physician order during previous observations.