Failure to Ensure Adequate Nutrition and Accurate Meal Documentation
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including body weight and meal intake, as required. For four residents reviewed, there were significant lapses in tracking meal consumption, providing necessary assistance during mealtimes, and implementing dietary recommendations. One resident experienced severe weight loss since admission, with documented weights showing a decline from 117.8 lbs to 102 lbs over a period of less than two months. Despite orders for weekly weights and house supplements, the facility did not ensure these interventions were carried out, and documentation was inconsistent or inaccurate. Observations revealed that the resident who suffered severe weight loss did not consistently receive assistance with meals, despite being blind and deaf and requiring such support. Staff failed to provide ordered supplements, yet documented in the medication administration record that the supplements were given and fully consumed. Meal intake documentation was incomplete, with only 76 out of 147 meals tracked over a 49-day period. During direct observation, the resident was left waiting for her meal, did not receive timely assistance, and staff inaccurately recorded that she consumed 100% of her meal when she did not. For three additional residents, meal intake documentation was also incomplete, with many meals missing from the records. This lack of documentation prevented accurate nutritional assessments and timely identification of potential nutrition problems. Staff and management interviews confirmed that all meals should be documented, and that the lack of accurate records hindered the ability of the dietician and physician to evaluate and address residents' nutritional needs.