Failure to Provide Adequate Hydration and Nutritional Supplements
Penalty
Summary
The facility failed to ensure that residents received adequate hydration and nutritional supplements as ordered. Observations and interviews revealed that multiple residents did not have fresh water provided throughout the day. Specifically, four residents were found with either empty or outdated water cups in their rooms, and staff confirmed that water was only provided upon resident request rather than routinely. Residents reported that their water cups had not been refilled daily, and staff interviews corroborated that water was not consistently passed out unless specifically asked for by the resident. Additionally, the facility failed to provide a prescribed nutritional supplement to a resident with significant weight loss. The resident, who was severely cognitively impaired and dependent for eating, had a physician's order for a magic cup supplement to be given at lunch. Observations during a lunch meal showed that the supplement was not present on the resident's tray, and both the assigned CNA and the Dietary Manager were unaware of the order to provide the supplement at lunch. This oversight was confirmed through staff interviews and review of the resident's care plan and dietary orders. The deficiencies were identified through medical record reviews, resident and staff interviews, direct observations, and policy review. The facility's own policies required hydration support and implementation of interventions for weight loss, but these were not followed for the affected residents. The findings were documented under a specific complaint investigation, and the facility census at the time was 34.