Failure to Monitor and Manage Nutritional Status and Weight Changes
Penalty
Summary
The facility failed to ensure adequate nutritional management for two residents identified as nutritionally high-risk. One resident with a diagnosis of protein-calorie malnutrition experienced significant weight loss over a six-week period, with documentation showing a 5.8% decrease in body weight. Despite physician orders for weekly weights, fortified ice cream, and nutritional shakes three times daily, the resident's records lacked documentation of weekly weights on two occasions, and meal intake records showed poor consumption on 22 occasions. Observations revealed that nutritional supplements were not consistently provided with meals, and when they were, staff did not encourage consumption or inform the resident about the supplement. Additionally, there was no documentation that the dietitian was alerted to the resident's poor intake, as required by the care plan. Another resident, who was on hospice care and had a history of significant weight loss, was not reweighed after a documented significant weight gain, as required by facility policy. The resident's weight increased dramatically between two recorded dates, but there was no evidence of weekly weights or follow-up actions in the medical record. Staff interviews confirmed awareness of the policy to reweigh residents in case of discrepancies, but this was not carried out or documented. The facility's policies on significant weight changes and obtaining accurate weights were not followed for these residents.