Failure to Monitor and Assist with Nutrition Leading to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a history of diabetes and malnutrition, resulting in significant weight loss. The resident experienced a 20% weight loss since admission, with documented weights showing a rapid decline over several months. Physician orders included a regular, easy-to-chew diet and scheduled nutritional supplements (Boost) three times daily and as needed for malnutrition. The care plan identified impaired physical functioning, the need for supervision at meals, and interventions such as encouraging food and fluid intake, recording meal percentages, and consulting a dietitian for caloric and nutritional needs. Despite these interventions, staff did not accurately monitor or document the resident's food and supplement intake. Multiple observations revealed discrepancies between actual consumption and what was recorded in the medical record and medication administration record (MAR). Staff frequently left supplements and meals unassisted, failed to provide encouragement, and did not offer alternative menu items when the resident refused food. The resident was often left alone during meals, and staff did not consistently provide the 1:1 assistance indicated by the interdisciplinary team (IDT). The MAR also showed that the resident did not receive any as-needed supplements during the survey period. The facility's records lacked a current dietitian evaluation addressing the significant weight loss and did not update the care plan to reflect the need for 1:1 meal assistance. Staff interviews confirmed expectations for accurate documentation and observation of intake were not met. The combination of inadequate monitoring, lack of assistance, and failure to implement care plan changes contributed to the resident's continued weight loss.