Failure to Monitor and Address Resident's Nutritional Status and Dietary Needs
Penalty
Summary
A deficiency occurred when the facility failed to accurately and consistently assess and monitor the nutritional status of a resident who was at risk for malnutrition. The resident, who had a history of tongue cancer, surgical aftercare, and gastro-esophageal disease, was admitted with difficulty swallowing and a poor appetite. Despite physician orders for regular weight monitoring and a speech therapy (ST) evaluation, the facility did not ensure these orders were carried out. The resident's weights were not properly obtained or documented, with staff entering a weight value even when the resident refused to be weighed, resulting in inaccurate records. Additionally, the resident's declining food and supplement intake was not communicated to the Registered Dietician (RD) or physician as required. The resident's care plan identified her as being at nutritional risk and included interventions such as monitoring intake, offering alternate food choices, and alerting the RD and physician to any decline in intake. However, these interventions were not effectively implemented. The resident and her responsible party repeatedly requested a different diet due to her difficulty chewing and swallowing, but these requests were not addressed, and the resident was not evaluated for an appropriate diet. The RD was not notified of the resident's poor intake or refusal to be weighed, and the ST evaluation was never completed. There was also no evidence of an interdisciplinary team (IDT) meeting to address the resident's nutritional risk, despite facility policy requiring such collaboration. Interviews with facility staff, including the RD, DON, and Director of Rehabilitation, confirmed that there was a lack of communication and follow-through regarding the resident's nutritional needs. The resident reported feeling weak and unhealthy due to inadequate nutrition and an inappropriate diet. Facility policies required weekly weights after admission, comprehensive care planning, and IDT involvement when care was refused or requested, but these were not followed. The failure to monitor, document, and communicate the resident's nutritional status and to implement physician orders led to a delay in evaluation and care, placing the resident at risk for malnutrition and weight loss.