Failure to Maintain Nutrition and Hydration Status Due to Incomplete Assessments and Unimplemented Dietary Orders
Penalty
Summary
The facility failed to maintain adequate nutrition and hydration for several residents, as evidenced by multiple instances of unaddressed weight loss, incomplete nutritional assessments, and failure to follow physician and dietary orders. One resident with Alzheimer's disease and severe cognitive impairment experienced significant and ongoing weight loss after admission. Despite documented weight loss and poor oral intake, the resident's nutritional supplement was reduced from three times daily to once daily without documented rationale, and the dietitian did not complete the required quarterly assessment. The dietitian was unaware of the most recent weight loss and could not explain the reduction in supplement calories, while the MAR did not indicate any refusal of supplements by the resident. Another resident with a history of diabetes and cognitive impairment did not consistently receive double portions or fortified foods as ordered, and weights were not obtained weekly as prescribed. Observations showed that the resident's meal portions were not increased as required, and fortified foods were not prepared according to the facility's standards. The dietitian and food service director were unclear about the implementation of dietary interventions, and the dietitian had not evaluated the resident following a significant weight loss after hospitalization, despite a physician's order for a nutritional consult. A third resident with a feeding tube and severe cognitive impairment did not have quarterly nutrition assessments completed for over eight months, contrary to facility policy and the dietitian's stated practice for high-risk residents. Additionally, another resident with multiple chronic conditions had a physician's order for weights every three weeks, but weights were not consistently obtained or documented, and the MAR indicated weights were signed off without corresponding records. Staff interviews confirmed a lack of awareness and adherence to these orders, and the DON stated that such orders should be followed and the physician notified if weights are not obtained.