Failure to Maintain Nutritional Status and Supervise Tube Feeding Administration
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, as evidenced by deficiencies in the care of two residents. One resident experienced significant, unaddressed weight loss over several months, with documented weights showing a 12.6% loss in one month and a 9.5% loss over five months. Despite multiple progress notes from medical staff and recommendations for increased fluid intake and nutritional supplements, there was no documented evidence that these interventions were implemented. The resident's poor intake and weight loss were not timely reported to the physician or dietitian, and there was no documentation of a dietitian consultation or new nutritional interventions on the care plan. Staff interviews revealed gaps in communication and monitoring, with nursing and dietary staff each assuming the other was responsible for follow-up and documentation. Another resident, who was dependent on tube feeding for nutrition, was observed self-administering their feedings and water flushes without direct supervision or a physician order authorizing self-administration. The resident was seen administering incorrect amounts of formula and water, and the care plan did not reflect that the resident was permitted to self-administer. Nursing staff signed off on medication administration records as if the correct procedures were followed, but direct observation showed that the resident was not receiving the prescribed amounts. Staff interviews confirmed that supervision was inconsistent and that required documentation and orders for self-administration were missing. Facility policies required that significant weight loss be reported and addressed by the interdisciplinary team, and that tube feedings and medication administration be performed according to physician orders, with proper documentation and supervision. In both cases, these policies were not followed, resulting in unaddressed nutritional risks and deviations from prescribed care. The deficiencies were identified through record review, staff and resident interviews, and direct observation during the survey.