Failure to Ensure Adequate Nutrition and Hydration Services
Penalty
Summary
The facility failed to ensure residents maintained acceptable nutritional status and did not consistently provide or document hydration services. For one resident with a history of brain injury and diabetes, significant weight fluctuations were observed without timely reweighs or assessments. The resident experienced a rapid weight gain followed by a substantial loss, with gaps in weight documentation and no assessment or intervention for these changes. The care plan lacked specific interventions for when to weigh or reweigh the resident, when to report weight deviations, or what constituted a safe, measurable weight loss goal. Staff interviews confirmed that reweighs and assessments were not performed as expected when significant weight changes occurred. Two other residents were not consistently offered or provided hydration services. One resident, who had no memory impairment or swallowing difficulties, reported that staff did not routinely bring water and that they often had to request a water pitcher, which was not always provided. Observations confirmed that staff did not offer hydration during care, and the resident had to ask for water. Another resident, with severely impaired decision-making ability and a care plan indicating the need for hydration support, was observed without any fluids available in their room. Staff interviews revealed that the expectation was for water pitchers to be provided to all residents every shift and as needed, and that residents should not have to request hydration. However, these expectations were not met, as evidenced by the lack of hydration services observed and reported by the residents. The failure to provide consistent hydration and to monitor and respond to significant weight changes placed residents at risk for dehydration and unaddressed weight loss.