Failure to Implement Assessed Nutritional Interventions to Prevent Weight Loss
Penalty
Summary
The facility failed to implement and consistently provide assessed nutritional interventions to prevent weight loss for two residents with significant medical conditions. Both residents had documented weight loss and were assessed by the Registered Dietician (RD) to require specific dietary interventions, including fortified foods, nutritional supplements, and planned snacks. Despite these recommendations, documentation and direct observation revealed that the prescribed supplements were frequently not offered, refused, or not consumed, and that fortification of meals was inconsistently applied. For one resident with diagnoses including anemia, end stage renal disease, dementia, and malnutrition, the care plan included fortified foods, protein powder, and clear nutritional supplements at specified meals. However, records showed that the resident did not receive or consume the supplements on numerous occasions over several months. Observations confirmed that the resident did not receive the supplement as recommended during meal service, and the Dietary Manager acknowledged that supplements were not always offered or documented as required. Another resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain dysfunction and malnutrition, was also assessed to need fortified meals, clear nutritional supplements at noon and evening meals, and snacks three times daily. Documentation indicated that the resident frequently did not receive or consume the supplements, and meal observations showed that fortification and prescribed substitutions (such as half and half instead of milk) were not provided. The Dietary Manager confirmed these interventions were not consistently implemented as ordered.