Failure to Provide Adequate Nutrition and Diet Consistency
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with significant medical needs, including malignant neoplasm of the larynx, severe protein-calorie malnutrition, muscle wasting, and multiple pressure ulcers. The resident expressed concern about ongoing weight loss, reporting a decrease from 180 pounds to approximately 130 pounds, and was observed to have severe muscle wasting. Despite a diet order specifying a mechanical soft diet with pureed meat, whole milk, and soft sandwiches, the resident was repeatedly served food items that did not comply with these requirements, such as ground meat instead of pureed, well-done toast instead of soft bread, and 2% milk instead of whole milk. The resident also reported receiving the same type of sandwich (PB&J) multiple times daily, which he did not want, and requests for alternative options like a tuna sandwich were not fulfilled. Observations revealed that the resident frequently did not eat the meals provided, with uneaten food and sandwiches remaining on the tray for extended periods, sometimes attracting insects. The dietary staff acknowledged that the meals served did not match the prescribed diet order. Additionally, the resident's weight was not monitored according to professional standards or the facility's own policy, which required weekly weights for the first four weeks after admission. Only one weight was recorded at admission, and a significant weight loss of 7.8 lbs (6.1%) over 20 days was identified only after the surveyor requested a current weight. The nutrition assessment for the resident was not completed within the expected timeframe, being signed 19 days after admission, and there was no documented nutrition care plan in the medical record. The dietary team was unaware of the lack of weekly weights and could not explain why they were not performed. Interventions to address the resident's weight loss were delayed due to the absence of timely monitoring and assessment, despite the resident's high risk status and ongoing nutritional decline.