Failure to Monitor and Document Nutrition and Hydration Status
Penalty
Summary
Facility nursing staff failed to obtain weekly weights and did not recognize severe weight loss in one resident, despite physician orders to monitor weight weekly and reweigh if there was a significant change. The resident experienced a 14-pound weight loss over a short period, with no weight documented for three weeks. Staff interviews revealed that the resident often refused weights, and when finally weighed, a significant decline was noted. The resident also had poor dentition, a dental infection, and was experiencing decreased appetite, nausea, and loose stools, all of which contributed to poor intake. Staff were not consistently monitoring or documenting food and fluid intake, and there was confusion about responsibilities for monitoring hydration and nutrition. Additionally, the facility failed to ensure that residents were monitored and tracked for maintenance of proper hydration status. Multiple residents were hospitalized with conditions related to dehydration, including acute renal failure, hyponatremia, and hypovolemia. Staff interviews indicated that hydration status was not routinely tracked or monitored unless residents showed overt signs of dehydration. Documentation of fluid intake was inconsistent or missing, and some staff were unaware of the need to monitor for the effects of diuretic use beyond checking for edema. The facility's own policy required systematic assessment and monitoring of hydration status, but this was not consistently implemented. Staff reported that hydration tracking had been removed from the charting system for most residents, and only a few had active hydration monitoring. There was a lack of clear communication and accountability regarding who was responsible for monitoring and documenting hydration and nutritional intake, leading to missed signs of decline and delayed interventions for residents at risk.