Failure to Monitor and Maintain Nutrition and Hydration for Two Residents
Penalty
Summary
Two residents were identified as not having their nutritional and hydration needs adequately monitored and maintained, resulting in deficiencies related to weight monitoring, dietary orders, and fluid intake documentation. One resident, with a history of chronic wounds, diabetes, dementia, acute kidney injury, and moderate protein calorie malnutrition, was dependent on staff for eating and required a mechanically altered diabetic diet. Despite facility policy requiring regular weight monitoring, there was a lack of weight documentation for this resident during critical periods, including after a significant weight loss of 23.3% over 57 days. Staff interviews confirmed that weights were not obtained as required, and the most recent weights used in assessments were outdated. Additionally, there was confusion and inconsistency regarding the resident's dietary orders, including portion sizes and vegetarian status, which were not clearly communicated or implemented by kitchen staff. Another resident, who was severely cognitively impaired and dependent for eating, had care plans in place to address risks of dehydration, constipation, and weight changes. However, review of CNA documentation revealed multiple shifts across several months where there was no evidence that fluids were offered or consumed, despite care plan interventions requiring encouragement and assistance with fluid intake. Interviews with CNAs and nursing staff confirmed that fluids should be offered and documented at least once or twice per shift, but the documentation did not reflect this practice for numerous shifts. The deficiencies were confirmed through record review, staff interviews, and direct observation. The facility failed to adhere to its own policies and care plans regarding weight monitoring, dietary order implementation, and hydration support, resulting in inadequate monitoring and provision of nutrition and fluids for the affected residents.