Failure to Implement Effective Nutrition and Hydration Plan Resulting in Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized, and effective nutrition and hydration plan for a resident with moderate cognitive impairment, resulting in significant weight loss and dehydration. The resident, who had diagnoses including dementia, hemiplegia, diabetes, and other chronic conditions, was at moderate risk for malnutrition and required cues and assistance with eating. Despite care plan interventions to monitor and provide hydration, the facility did not ensure ongoing weight monitoring or implement adequate interventions in response to the resident's decreased meal intake. The resident experienced a severe weight loss of 17.3 pounds (8.3%) in two weeks and was subsequently hospitalized for altered mental status secondary to dehydration, requiring intravenous fluids. Medical record review revealed that the facility did not obtain an admission weight for the resident upon readmission and failed to record fluid intake amounts for the entire month of September. There was no evidence that the diet technician was notified of the resident's decreased meal intake, and no updates or new interventions were made to the care plan during the period of declining intake. Observations showed that fluids were not consistently within the resident's reach, and interviews with staff and family members indicated that the resident's meals were often left on the bedside table without adequate assistance, despite the resident's need for help with feeding. The facility's own weight monitoring policy required weekly weights for four weeks after admission and prompt reporting of significant weight changes, but these protocols were not followed. The resident's significant weight loss and decreased intake were not addressed in a timely manner, and the lack of proper monitoring and intervention led to actual harm, as evidenced by the resident's hospitalization for dehydration. Interviews confirmed that staff were aware of the resident's declining intake but did not take appropriate action to notify the diet technician or update the care plan.