Failure to Monitor and Document Nutritional Intake for At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and document the nutritional intake of a resident with a history of significant weight loss. The resident, who was severely cognitively impaired and required supervision for eating, experienced a weight loss of over 12% in six months. The care plan indicated the need for monitoring and recording intake, serving and encouraging supplements, and following prescribed diets. Despite these interventions, there were multiple instances where meal consumption amounts were not documented for breakfast, lunch, and dinner over a period of several months. The resident's records showed that she was at nutritional risk and had been placed on a mechanical soft diet due to dental issues. A dietician's review noted that her weight had stabilized for a period, but significant gaps in intake documentation persisted. The facility's policy required nursing personnel to evaluate and document food and fluid intake for residents at risk for nutritional problems, but this was not consistently done for this resident. The DON confirmed there was no additional information to explain the missing documentation.