Failure to Address Nutritional Needs and Denture Assistance
Penalty
Summary
A deficiency occurred when the facility failed to recognize, evaluate, and address the nutritional needs of a resident who experienced significant weight loss over a one-year period. Despite system-generated warnings and multiple lab results indicating low albumin levels, which signaled low protein status, there was no documented response or intervention to address the resident's declining weight. The care plan did not reflect the resident's use of dentures, and there was no evidence that the system alert for significant weight loss was addressed in progress notes or during weight meetings. The resident's care plan interventions, such as health shakes and monitoring, were not updated to reflect the ongoing weight loss, and the resident's food preferences and needs were not adequately considered. The resident, who had a history of cerebral aneurysm, vitamin D deficiency, depression, hyperlipidemia, anemia, and hypertension, was cognitively intact and required assistance with oral hygiene and denture care. Observations and interviews revealed that the resident was not wearing her dentures during meals and was not assisted by staff in using them, despite expressing a desire to eat a greater variety of foods. Staff members, including CNAs and dietary staff, were either unaware of the resident's need for dentures or assumed she did not have them. The resident repeatedly stated she wanted to use her dentures to eat different foods but did not receive the necessary assistance, leading her to stop asking for help. The facility's policies required monitoring of undesirable weight changes, individualized care planning, and provision of denture care, but these were not followed in this case. Staff interviews confirmed a lack of awareness regarding the resident's denture needs, and the care plan was not updated to include this information. The resident's meal tickets did not reflect her preferences or needs, and the dietary manager was unaware of her denture status. The failure to provide assistance with dentures and to address the resident's nutritional needs resulted in continued impaired nutritional status and significant weight loss.