Failure to Reassess Nutritional Status After Hospitalization
Penalty
Summary
The facility failed to reassess the nutritional status of a resident following a hospitalization for volume overload. The resident, who had diagnoses including end stage renal disease, congestive heart failure, and diabetes mellitus, was admitted to the hospital where 44 pounds of fluid were removed. Upon return to the facility, there was no documentation of a nutritional assessment being completed, despite significant changes in the resident's weight and clinical status. Interviews with the Dietitian Technician and Registered Dietitian confirmed that neither had updated or completed a nutritional assessment for the resident after readmission. Both staff members were unaware of the resident's recent hospitalization and the substantial fluid loss, and acknowledged that a nutritional assessment should have been performed due to the nutritional significance of the hospitalization.