Failure to Accurately Monitor Meal Intake and Address Weight Measurement Errors
Penalty
Summary
The facility failed to accurately monitor and document a resident's meal intake and feeding abilities, as well as address suspected errors in weight measurements, in the context of a resident experiencing severe weight loss. Observations showed that the resident, who had recently returned from two hospitalizations and now required supervision or assistance with eating, was left alone in bed with a meal tray placed out of reach and without any setup or assistance. The resident struggled to feed himself and ultimately consumed very little of his meal, despite documentation indicating he had eaten 76-100% of his lunch. This pattern of inaccurate meal intake documentation was noted over several days. Additionally, the resident's weight records over several months showed a significant and steady decline, amounting to an 11.59% loss over three months. Nutrition notes repeatedly identified possible errors in weight measurements and called for reweighs to verify accuracy, but these discrepancies were not resolved over a six-month period. The resident's weight loss was being monitored, and while some weight loss was considered desirable due to the resident's BMI, the facility did not ensure accurate monitoring of food intake or address ongoing concerns about the accuracy of weight measurements.