Failure to Monitor and Assess Nutritional Status of At-Risk Residents
Penalty
Summary
The facility failed to adequately monitor and assess the nutritional status of six residents identified as being at nutritional risk. Facility policy required reweighs within 72 hours for weight changes of 3% or greater in one month, and for all weights, including reweighs, to be documented in the electronic medical record. Additionally, the policy identified muscle wasting, depression, dementia, and the need for therapeutic or mechanically altered diets as risk factors for malnutrition. Despite these policies, there was no evidence that reweighs were performed or that residents experiencing significant weight changes were evaluated by a dietitian or qualified nutrition professional. In some cases, required monthly weights were missed without documented refusals. The residents involved had complex medical histories, including muscle weakness, dementia, dysphagia, polyneuropathy, congestive heart failure, cirrhosis, pressure ulcers, diabetes, edema, metabolic encephalopathy, anemia, and end stage renal disease. Several residents experienced significant weight loss or gain over a one-month period, yet there was no documentation of follow-up assessments or interventions by nutrition professionals as required by facility policy. These deficiencies were identified through facility policy review, clinical record review, and staff interviews.