Failure to Properly Assess, Document, and Communicate Nutrition and Weight Management Needs
Penalty
Summary
The facility failed to properly assess and manage the nutritional needs and dietary orders for multiple residents, resulting in deficiencies related to food and fluid provision. For one resident with complex medical conditions including ALS, heart failure, diabetes, and dysphagia, the facility changed his diet order from regular to pureed texture without documented evidence of a swallow study or a medical assessment confirming the necessity of this change. Despite the resident's repeated refusals of the pureed diet and his requests for a risk agreement to acknowledge his preference for a regular diet, the facility did not provide such documentation or allow him to sign a risk agreement. The resident continued to refuse facility meals and medications, and there was no evidence that his medications were modified to accommodate his dietary order, as they were administered whole with thin liquids, contrary to typical practice for a pureed diet order. Another resident was admitted with multiple chronic conditions and had discrepancies in her initial weight documentation. The initial weight recorded was later deemed inaccurate, but a re-weight was not obtained until 11 days later, despite the facility's policy and the dietitian's expectation that re-weights should be completed within 72 hours of a request. This delay in obtaining an accurate weight hindered the dietitian's ability to perform an accurate nutritional assessment and monitor the resident's nutritional status as intended. A third resident, also with significant medical issues, had physician orders for daily weights and for the physician to be notified of weight gains exceeding three pounds over two days. The facility failed to document weights on several required days and did not notify the physician of multiple instances where the resident's weight increased by more than three pounds in the specified timeframe. These failures were confirmed by facility staff interviews and were not in accordance with the facility's own weight management policy, which required regular monitoring and timely notification of significant weight changes.