Failure to Maintain Nutritional Status and Provide Adequate Mealtime Assistance
Penalty
Summary
Two residents experienced significant weight loss due to the facility's failure to maintain acceptable nutritional parameters and provide necessary assistance during meals. One resident, with severe cognitive impairment and multiple comorbidities including Parkinson's disease and dementia, lost 14.4 pounds over six months without new interventions being implemented. Despite care plan interventions such as monitoring for malnutrition and providing adaptive equipment, the resident was not observed using specialized dinnerware and continued to lose weight even while documented as consuming 76-100% of meals on most days. Staff interviews revealed inconsistent understanding of the resident's needs, and the resident was not always cued to eat as required. Another resident, with diagnoses including Alzheimer's disease, diabetes, and recent fractures, also experienced ongoing weight loss. Observations showed the resident frequently left the dining room without eating, required cueing to eat, and sometimes attempted to eat with inappropriate utensils. Although the care plan indicated the need for setup assistance and cueing, staff did not consistently provide this support, and meal intake documentation showed frequent low consumption or refusal of meals. Supplement and snack intake were also low, and there was confusion among staff regarding documentation and provision of snacks. Interviews with dietary and nursing staff highlighted gaps in communication and documentation regarding residents' nutritional intake, especially for snacks and supplemental feedings. The registered dietician acknowledged concerns about weight loss and was unsure where snack intakes were documented. The dietary manager and CNAs were unclear about procedures for residents who missed snacks or required additional assistance, contributing to the facility's failure to ensure adequate food and fluid intake to maintain residents' health.