Failure to Communicate and Address Resident Meal Refusals and Low Intake
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who consistently consumed less than 50% of meals on multiple occasions. Despite repeated low meal intakes documented throughout March, there was no evidence that these occurrences were communicated to nursing staff, the physician, or the registered dietitian. The resident, who was alert and able to make decisions, reported dissatisfaction with the food, lack of alternatives, and ongoing weight loss. Observations confirmed that the resident was not offered alternative meals when refusing food, and staff interviews revealed a lack of timely communication and documentation regarding meal refusals. Record reviews showed that the resident had a history of schizophrenia and a moderately impaired cognitive status, but retained the capacity to understand and make decisions. The resident's intake records indicated multiple instances of eating less than 50% of meals, yet there was no documentation that these patterns were reported or addressed by the care team. The facility's own policy required that variations in eating patterns be documented and reported to nursing, the physician, and the dietitian, but this was not followed in the resident's case. Interviews with the DON and RD confirmed they were not made aware of the resident's inadequate intake or meal refusals until after the surveyor's inquiry. There was also no evidence that a care plan was developed to address the resident's meal refusals or to provide interventions to prevent further weight loss. The lack of communication and documentation regarding the resident's nutritional intake represented a failure to follow facility policy and to meet the resident's dietary needs and preferences.