Failure to Notify and Document Resident's Refusal of Nutrition and Hydration
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including a recent stroke, heart disease, and ataxia, was admitted to the facility and subsequently refused all meals and hydration from dinner on the day of admission through breakfast two days later. Despite this refusal, there was no documentation in the resident's progress notes regarding the lack of nutrition or hydration, nor was there evidence that the practitioner or responsible party (RP) was notified of the resident's ongoing refusal. The care plan was updated only after the resident was sent to the emergency room, and meal intake documentation was limited to entries indicating 0-25% consumption, with no option to record 0% intake. Interviews with staff revealed that the certified nursing assistant (CNA) informed the charge nurse of the resident's refusal to eat or drink, but the charge nurse did not document these refusals or notify the practitioner or RP. The nurse stated she became busy and did not complete the required documentation or notifications. Nurse practitioners who saw the resident during this period were not informed of the missed meals and were unaware of the resident's poor intake until after the resident was found to be lethargic and was sent to the hospital. The responsible party was only notified when the resident was being transferred to the emergency room, and expressed that earlier notification could have allowed them to intervene. Upon arrival at the hospital, the resident was diagnosed with acute encephalopathy, acute renal failure, and profound dehydration, requiring admission for further treatment. The facility's own policy required notification of the physician and RP in cases of significant changes in intake or nutritional status, but this was not followed. Multiple staff, including the director of nursing, administrator, and medical director, confirmed that the expected protocol was not adhered to, and that the lack of communication and documentation contributed to the resident's decline.
Removal Plan
- Resident #1 no longer resides in the facility.
- DON/Designee initiated a full audit of all residents to identify any with poor intake or refusal trends.
- Residents identified with low or declining intake (25% or less) were immediately evaluated by nursing. NP/MD and RP notifications initiated.
- Care plans updated accordingly by DON/Designee.
- DON/Designee will in-service Licensed nursing/licensed agency staff re-educated and directed to notify Practitioner and RP for 2 consecutive days of missed meals or poor intake (<25%), accurate documentation in nurses note and communication expectations. This will be added to licensed nurses' general orientation for new hires.
- DON/Designee will in-service CNAs/Agency CNA re-educated and directed to notify charge nurse of missed meals or poor intake (<25%), accurate documentation and communication expectations. This will be added to CNAs general orientation for new hires.
- Mandatory in-services will be completed with all current and oncoming nursing staff prior to start of shift worked.
- Competency for License staff and CNAs/Agency CNAs validation conducted on meal percentages documentation and training above per visual aides and return demonstration. This will be added to licensed nurses/CNAs general orientation for new hires.
- Administrator was in-serviced on department head meal manager schedule and details by Texas Area President.
- Department Heads will be in-serviced by administrator on meal manager requirements.
- DON/designee will monitor for residents with poor intake on PCC dashboard in the morning meeting or remotely daily for a period to ensure that interventions are initiated, and Practitioner and RP are notified immediately but not later than 24 hours from identification of nutritional change. This will be documented on a monitoring tool.
- Any issues will be reported to the QAPI Committee meeting.
- Ad hoc QAPI to review the deficiency and the process for POR will be completed.