Failure to Provide Adequate Nutrition and Supervision During Meals
Penalty
Summary
Two residents did not receive the necessary services to maintain acceptable nutrition and hydration. One resident with multiple diagnoses, including multiple sclerosis, atrial fibrillation, and dementia, experienced a 7.65% weight loss over approximately one month. This significant weight loss was not communicated to the physician or dietician, and there was no evidence of a comprehensive assessment or updated care plan to address the weight loss. The facility's policy required notification of the physician and dietician for significant weight changes, but this was not followed. Additionally, the resident was served food items not appropriate for their prescribed mechanical soft diet, and the correct dessert was not provided as indicated on the meal ticket. The dietary manager reported that weight monitoring was conducted monthly, and significant weight loss would be addressed at the next scheduled meeting. However, there was no documentation that the recent weight loss was addressed promptly or that interventions were implemented based on a comprehensive nutritional assessment. The facility's process for monitoring and responding to weight changes did not ensure timely communication or intervention for the resident's nutritional needs. Another resident with severe cognitive impairment and a care plan requiring supervision or touching assistance with eating was observed on two occasions eating unsupervised in their room. The resident's care plan and facility records indicated the need for supervision during meals, but staff did not provide the required assistance. The resident was left alone with their meal tray, and staff only entered the room briefly to assist with removing lids or to help with toileting, leaving the resident unsupervised for the majority of the meal.