Failure to Provide Ordered Nutritional Support and Monitoring
Penalty
Summary
The facility failed to ensure that two residents received appropriate nutritional care as ordered. One resident with diagnoses including hemiplegia, hemiparesis, and malnutrition was observed during a meal without the prescribed adaptive drinking device (nosey cup). Instead, the resident was provided a regular cup, resulting in difficulty drinking, with most of the liquid spilling onto the resident's chin and napkin. The LPN confirmed that the nosey cup was not provided and was not listed on the meal ticket, despite a physician's order and facility policy requiring adaptive devices to be supplied as ordered. Another resident with Alzheimer's disease and a history of significant weight loss was not weighed bi-weekly as ordered by the physician. The clinical record showed missing weight documentation for an entire month, and there was no record of refusals or attempts to obtain the weight. The resident's care plan identified them as being at nutritional risk and required weight monitoring, but this intervention was not consistently implemented. The DON acknowledged that nursing staff were responsible for obtaining and documenting weights and refusals, but could not explain the lack of documentation.