Unqualified Staff Conducted Nutrition Assessments Without Proper Oversight
Penalty
Summary
The facility failed to ensure that staff with the appropriate competencies and skill sets completed residents' Quarterly Nutrition Assessments. Specifically, the Dietary Service Supervisors (DSS 1 and DSS 2), who were not qualified to perform such assessments, completed and signed off on these evaluations for multiple residents over several months. Record reviews confirmed that these assessments were not verified by any other qualified personnel, such as a Registered Dietitian (RD). During interviews, both the RD and the Interim Director of Nursing (IDON) confirmed that the DSS did not have the scope of practice or qualifications to conduct these assessments, and that the process lacked oversight from appropriately credentialed staff. One resident's assessment included an incorrect Ideal Body Weight Range (IBWR), which the RD could not verify and stated was not accurate. The lack of qualified staff conducting and verifying these nutrition assessments affected a group of 52 highly vulnerable residents, as the assessments are intended to identify nutritional deficiencies or risks and guide personalized interventions. The deficiency was identified through interviews and record reviews, which revealed that the assessments were being completed solely by unqualified staff without proper verification.