Failure to Maintain Accurate Nutritional Status and Documentation
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including usual or desirable body weight, for all residents reviewed for nutrition status. Specifically, there was a lack of documented heights for all 58 residents, which prevented accurate calculation of BMI and assessment of nutritional needs. Multiple dietary consultant reports noted missing heights and recommended obtaining them, but these were not entered into the current electronic medical record system due to data transfer issues from the previous system. The registered dietitian confirmed that the absence of height data hindered his ability to track low BMIs and provide appropriate interventions. The facility also failed to maintain proper calibration and inspection of the scale used for weighing residents. The last inspection was overdue, and the scale had not been calibrated as required by the manufacturer's maintenance schedule. Staff interviews revealed that the scale's calibration was not up to date, and there was confusion about the accuracy of weights being recorded. Additionally, meal intake percentages were inaccurately documented in advance in the electronic medical record for several residents, with some meals being charted before they were actually consumed. Observations showed discrepancies between the documented intake and what residents actually ate, and staff interviews confirmed that some CNAs were entering meal percentages prematurely or inaccurately. Furthermore, the facility did not notify the registered dietitian or physician when significant weight loss occurred in two residents. There was also a failure to complete a Mini Nutritional Evaluation for a resident as required by her care plan. These actions and inactions, including inaccurate weight and intake documentation, lack of timely communication with clinical staff, and missing nutritional assessments, contributed to the deficiency in maintaining residents' nutritional status.