Failure to Provide Adequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to ensure that a resident identified as being at risk for nutritional problems and malnutrition maintained acceptable parameters of nutritional status. The resident, who had multiple diagnoses including respiratory failure, dysphagia, diabetes, muscle weakness, and significant cognitive impairment, experienced severe and ongoing weight loss over several months. There was no documented evidence of an admission nutritional assessment or risk assessment, and the resident's care plan was not updated in response to significant changes in her condition, including weight loss, diet order changes, or hospitalization. Orders for weekly weights and meal assistance were not consistently followed, and documentation of weights was incomplete or missing, with staff signing off on tasks that were not performed. Observations and interviews revealed that the resident was not consistently assisted with meals as ordered, despite having documented needs for supervision and assistance due to pocketing food and cognitive impairment. On multiple occasions, the resident was left with meal trays without being assisted to a sitting position or being supervised, and alternatives were not offered when meals were refused or only partially consumed. Staff were often unaware of the resident's assistance needs or the meaning of physician orders for meal assistance, and there was confusion among staff and management regarding the implementation of these orders. The facility's own policies required individualized assistance with meals and routine weight monitoring, but these were not adhered to in practice. The facility also experienced issues with record-keeping and continuity of care following a change in ownership and electronic medical record systems, resulting in missing documentation related to the resident's nutrition. The dietitian and other staff confirmed that weekly weights were not obtained as ordered and that it was difficult to get staff to complete these tasks. The resident's intake remained poor, and despite recommendations and orders for supplements and appetite stimulants, these interventions were inconsistently effective due to frequent refusals and lack of proper assistance. The cumulative effect of these failures was a significant and unaddressed decline in the resident's nutritional status.