Failure to Monitor and Document Resident's Nutrition and Hydration Status
Penalty
Summary
A resident with diagnoses including chronic pain and muscle weakness experienced a significant weight loss of 9.52% over approximately one month. The dietician acknowledged this weight loss and implemented a plan to monitor the resident's weight weekly for one month, with corresponding physician orders to weigh the resident weekly on Tuesdays. However, there was no documentation of the resident's weight being recorded on one of the scheduled dates. Additionally, the resident had a physician's order for an enhanced shake to be provided three times daily to support nutritional intake. Review of the Treatment Administration Record (TAR) revealed that the enhanced shake was not documented as given at several scheduled times. During interviews, the Nursing Home Administrator was unable to provide explanations for the missing weight and shake documentation, though she confirmed that these actions were expected to have been completed and recorded.