Failure to Monitor and Assess Nutritional Status for Residents at Risk
Penalty
Summary
The facility failed to adequately monitor and assess the nutritional status of seven residents identified as being at nutritional risk. Facility policy required that indicators such as bilateral edema, muscle wasting, depression, dementia, and specialized diets be considered as risk factors for malnutrition. Despite this, clinical record reviews showed that multiple residents with significant medical histories, including diabetes, feeding difficulties, muscle weakness, dysphagia, pressure ulcers, end stage renal disease, and metabolic encephalopathy, did not receive required nutritional assessments or regular weight monitoring as ordered by physicians. In several cases, there was no documentation that residents were weighed according to physician orders, and no evidence that a registered dietitian or qualified nutrition professional evaluated their nutritional status within the required timeframes. For example, one resident with diabetes and feeding difficulties was not weighed for several months and had no documented dietitian evaluation. Another resident with muscle weakness, dysphagia, and pressure ulcers was not weighed as ordered and had not been assessed by a dietitian since the previous year. Additional residents with complex conditions such as end stage renal disease, major depressive disorder, and dependence on dialysis also lacked evidence of timely nutritional assessments and weight monitoring. The facility administrator confirmed that these assessments and reviews should have occurred monthly but were not completed as required.