Failure to Routinely Assess and Monitor Resident Nutrition
Penalty
Summary
The facility failed to ensure that residents were routinely assessed and monitored for nutritional status, resulting in lapses in care for two residents. One resident with multiple complex diagnoses, including hemiplegia, diabetes, heart failure, and chronic kidney disease, was admitted and placed on a regular diet with PEG tube feedings. Despite significant weight fluctuations and a 12% weight gain over five months, there were missing weight records for two months and no nutritional assessment or care plan was completed from admission until nearly seven months later. The registered dietitian supervisor confirmed the absence of prior assessments and identified the resident as high risk for nutritional issues. Another resident with end stage renal disease, diabetes, heart failure, and blindness experienced a 7.5% weight loss over one month and had not received a nutritional assessment or care plan from admission until over five months later. The nutrition note indicated significant weight loss, underweight BMI, and lack of communication with the dialysis dietitian. Both the registered dietitian supervisor and the administrator acknowledged a lapse in dietitian services for several months, and there was no evidence of nutritional oversight or monitoring for these residents during that period.