Failure to Ensure Adequate Nutrition and Hydration for Multiple Residents
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for three residents, resulting in one resident experiencing actual harm and two others being placed at risk for more than minimal harm. For one resident with severe dementia, the facility did not total or assess daily fluid intake, failed to accurately assess and document ongoing signs and symptoms of dehydration, and did not update care plans or nutritional assessments after a significant change in condition that led to hospitalization for severe hypernatremia and dehydration. Despite clear evidence of declining intake and physical changes, there was no documentation of interventions attempted or communication with the registered dietitian prior to the hospitalization. Staff interviews confirmed that the resident required assistance and encouragement to eat and drink, but this was not consistently documented or reflected in updated care plans. Another resident experienced significant weight loss, but the facility did not appropriately notify the physician or nurse practitioner, started a nutritional supplement without a physician's order, and failed to monitor the amount of supplement consumed. The dietary assessment for this resident had not been updated in over a year, and there was no comprehensive documentation of calorie, protein, or hydration needs. Staff interviews revealed confusion about the process for supplement administration and tracking, and the resident reported dissatisfaction with the food and lack of snacks. A third resident's fluid intake was not monitored, and the physician was not notified of a severe weight loss of 10% over two weeks. The resident's favorite beverage was not added to the care plan as required by facility policy, and a complete nutrition assessment by the registered dietitian was not conducted. Documentation of fluid intake was inconsistent, and the resident was not consistently offered snacks. Facility policies required systematic assessment, monitoring, and documentation of hydration and nutrition, but these were not followed for the residents reviewed.