Failure to Provide Prescribed Nutrition and Meal Accuracy for Residents with Weight Loss
Penalty
Summary
Two residents experienced significant unplanned weight loss due to the facility's failure to provide prescribed nutritional interventions and ensure meal accuracy. One resident, with diagnoses including dementia and failure to thrive, had a documented history of severe weight loss and was assessed as severely malnourished. Despite care plans and physician orders specifying double portioned entrees, fortified juices, Magic Cups, and other supplements, these items were frequently missing from meal trays. Observations confirmed that the resident did not consistently receive the required fortified foods or double portions, and staff were unaware of or did not act on the missing items. Additionally, the resident was not always assisted with eating in a dignified manner, as staff were observed standing over the resident and hurrying the feeding process, contrary to facility policy. Another resident, with Alzheimer's disease and a history of mini strokes, also experienced significant weight loss. This resident's care plan included specific food preferences and supplements, such as yogurts, peanut butter and jelly sandwiches, and chocolate milk, to help maintain weight. However, multiple observations revealed that these preferred and prescribed food items were missing from meal trays. The resident reported that, despite frequent discussions with dietary staff about food preferences, the requested items were not provided. Staff interviews confirmed that supplements and preferred foods were not consistently delivered, and there was no evidence of physician intervention for the ongoing weight loss. Facility policies required staff to check meal tickets for accuracy and substitute unavailable supplements as per a documented substitution list. Despite these policies, both dietary and nursing staff failed to ensure that residents received all ordered and preferred nutritional items. Staff interviews revealed a lack of awareness and follow-through regarding missing supplements and meal components, contributing to the residents' continued weight loss. The facility did not document timely weights as ordered for one resident, and there was a lack of communication and coordination among staff to address the deficiencies in nutritional care.