Failure to Monitor and Document Nutritional Status and Supplement Intake
Penalty
Summary
The facility failed to recognize, evaluate, and address the nutritional needs of residents at risk for or experiencing impaired nutrition, as evidenced by the lack of consistent weight monitoring and documentation for three residents with diagnoses including severe protein-calorie malnutrition. For one resident, there was only a single weight recorded after admission, with no subsequent weights documented, despite care plans and facility policy requiring regular weight monitoring. The resident was on enteral feedings due to dysphagia and esophageal cancer, and the Registered Dietitian (RD) acknowledged not bringing the missing admission weight to anyone's attention. Interviews revealed inconsistent practices and a lack of a set frequency for obtaining weights, with staff relying on ad hoc communication rather than systematic monitoring. Another resident experienced a significant weight loss of 15% over three months, with no weights documented for two consecutive months. The resident was at risk for malnutrition, had a therapeutic diet, and was prescribed a house nutritional supplement, but there was no documentation of the percentage of supplement consumed. The RD and nursing staff described a process where weights and supplement intake were to be monitored and communicated, but gaps in documentation and follow-through were evident. The resident reported dissatisfaction with the food and was unaware of the extent of their weight loss. A third resident, also diagnosed with protein-calorie malnutrition, had no documented weights for two months and no records of supplement intake, despite orders and care plans specifying these interventions. Staff interviews confirmed that weights should be obtained upon admission, monthly, and as needed, but acknowledged communication breakdowns and missing documentation. The facility's own policy required weights to be recorded upon admission and monthly, with the RD reviewing all admission weights for possible intervention, but these procedures were not consistently followed for the residents reviewed.