Failure to Provide Adequate Nutrition and Accurate Documentation
Penalty
Summary
The facility failed to implement effective interventions to maintain adequate nutrition for a resident identified as being at risk for nutritional problems and diagnosed with malnutrition. Despite the facility's policy requiring meal substitutes to be offered when a resident consumes less than 50% of a meal, observations showed that staff did not encourage the resident to eat or offer substitutes when intake was low. The resident consistently consumed less than half of their meals, expressed dissatisfaction with the food, and reported a lack of appetite due to loss of taste and smell. Collateral contacts confirmed the resident's poor intake and noted that staff did not offer meal substitutes or protein drinks as recommended. Documentation in the resident's records was found to be inaccurate, with staff recording higher meal consumption than what was observed. The care plan and provider notes indicated the need for meal substitutes and supplements, but these interventions were not provided. The registered dietician relied on inaccurate aide documentation and did not interview the resident or family regarding meal intake history. There was also no documentation of the resident's food preferences in the electronic health record until prompted by the surveyor, and recommendations from a hospital dietitian for protein shakes were not followed.