Failure to Monitor Nutritional Status and Obtain Required Weights
Penalty
Summary
A deficiency occurred when staff failed to monitor a resident's nutritional status and the effectiveness of interventions by not obtaining admission and weekly weights as ordered for a resident diagnosed with severe protein-calorie malnutrition. The facility's policy required a comprehensive nutritional assessment upon admission, including obtaining a weight within the first 24 hours and weekly weights for four weeks, but these were not consistently completed. Documentation repeatedly showed weights were not obtained, with no explanation or evidence of further attempts to secure the required measurements, despite clear orders and the resident's high risk status. The resident in question had a history of vascular dementia with behavioral disturbance and was admitted with severe chronic malnutrition, as evidenced by severe fat and muscle loss and intake of less than 75% of estimated needs. Hospital records and facility documentation indicated variable oral intake, with the resident consuming most of the prescribed nutritional supplement but less than 50% of meals. Despite these concerns, the facility failed to document weights at admission and on a weekly basis, and there was no documentation of why weights could not be obtained or of any follow-up actions to address the missed weights. Interviews with facility staff, including the registered dietician, LPNs, nurse practitioner, and regional nurse consultant, confirmed expectations that weights should be obtained upon admission and weekly thereafter for new admissions, especially for residents at nutritional risk. However, the records showed ongoing failures to obtain and document weights, and staff were not notified of significant weight changes. The lack of consistent weight monitoring and documentation for this resident with severe malnutrition constituted a failure to follow facility policy and ensure adequate monitoring of nutritional status.