Failure to Complete Timely Nutritional Assessments and Provide Required Supplements
Penalty
Summary
The facility failed to ensure accurate and timely completion of nutritional assessments, weight monitoring, and provision of required nutritional supplements for multiple residents. For one resident, there was a significant delay in obtaining an initial weight after admission, with the first weight recorded seven days post-admission, showing a severe weight loss compared to hospital records. There was no documentation of re-weighing to confirm the loss, no investigation into the cause, and no evidence that the provider or resident representative was notified. The resident also reported not being involved in dietary decisions, and staff interviews revealed uncertainty about the reasons for weight refusals and lack of reconciliation of hospital and facility weights. Another resident with dialysis needs had orders for a specific nutritional supplement (Nepro) prior to dialysis, but documentation was inconsistent regarding administration and consumption. The resident reported disliking the supplement and instead consumed a different product brought from outside the facility. Staff were unaware of the resident's refusal and the substitution, and there was no documentation of the facility addressing the refusals or ensuring the prescribed supplement was provided as ordered. The dietary manager and nursing staff demonstrated a lack of clarity about the supplement's provision and documentation, and the registered dietitian was unaware of the resident's non-compliance with the prescribed supplement. Additional deficiencies included a resident with significant weight loss who did not receive a comprehensive nutritional assessment as required, and another resident with severe cognitive impairment and diagnoses of malnutrition and failure to thrive who experienced frequent meal refusals. The care plan for this resident lacked individualized interventions, and the nutritional assessment was completed late. There was no documentation of alternative interventions or communication with the resident's representative regarding preferences, and the dietary profile was missing from the record. Staff interviews confirmed delays in assessment and a lack of resident-specific interventions.