Failure to Ensure Food Was Accessible to Resident with Nutritional Risk
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with multiple medical conditions, including malnutrition, dementia, hemiplegia, and a history of weight loss. The resident was on a large portion, regular texture diet with specific interventions outlined in the care plan, such as providing fortified cereal, monitoring intake, and offering snacks. Despite these interventions, the resident's weight remained below the recommended Body Mass Index, and a slight weight loss was documented over a two-month period. During a lunch meal observation, the resident was placed in a geri-chair with his functional side against the table, but his main plate was positioned out of reach. The resident was only able to access a salad and not the main components of his meal. Staff, including the DON, did not notice that the plate was out of reach, and the resident verbally expressed hunger and his inability to reach the food. Only after the surveyor moved the plate did the resident begin eating the rest of his meal. The DON later assisted with eating, but the initial lack of access to food was not addressed by staff. Interviews with facility staff revealed there was no policy in place to ensure food was placed within reach of residents. The MDS Coordinator and Regional RN acknowledged the issue, and the VP of Regional Operations stated it was common sense for aides to leave food within reach. The deficiency was further highlighted by the lack of staff awareness and the absence of a formal policy to address the placement of food for residents who require assistance or supervision during meals.