Failure to Ensure Adequate Nutrition and Timely Dietary Intervention
Penalty
Summary
Facility staff failed to ensure adequate nutrition for a resident with severe cognitive impairment and multiple comorbidities, including dementia, severe protein calorie malnutrition, and dysphagia. The resident experienced a significant weight loss of 29 pounds over a period of approximately six weeks. Despite documented evidence of underweight status and ongoing weight loss, staff did not consistently recognize or respond to signs of malnutrition, nor did they consult with the registered dietician for recommendations as ordered by the physician on several occasions. Medical records and provider notes indicated repeated concerns about the resident's low BMI, declining oral intake, and the need for close monitoring and dietary consultation. The registered dietician's evaluation lacked current weight data and did not recommend changes, stating that intake met or exceeded estimated needs, despite evidence to the contrary. The resident's care plan included goals for gradual weight gain and interventions for monitoring and reporting signs of malnutrition, but these were not effectively implemented, as weights were not regularly checked and dietary consults were not consistently obtained. Documentation also revealed confusion regarding the resident's hospice status, which impacted the monitoring of weights and implementation of care plan interventions. The resident was not on hospice for a period when the care plan indicated otherwise, and routine weights were not obtained during this time. Supplements and dietary changes were not initiated in a timely manner, with house shakes only ordered on the day of the resident's death, despite ongoing weight loss and nutritional risk.