Failure to Provide Adequate Nutrition and Monitor Intake
Penalty
Summary
The facility failed to ensure adequate nutrition care and services for two residents, resulting in significant unplanned weight loss and insufficient monitoring of nutritional intake. One resident experienced a 12% weight loss over five months and had a Stage 3 pressure ulcer, yet their care plan lacked documentation of food preferences and did not include any nutritional interventions. Despite a history of poor appetite and refusal of supplements, meal intake was not consistently documented, with 13 out of 24 meals left unrecorded during the survey period. The resident frequently ordered take-out food due to dissatisfaction with facility meals, and there was no evidence of supplemental protein being provided to support wound healing, as would be expected for a non-healing wound. Another resident experienced a 9.8% weight loss in six weeks and consistently consumed less than 50% of meals during the survey period. The care plan for this resident included general interventions such as offering food preferences and between-meal nourishment, but did not specify a particular nutrition supplement. Although a dietary supplement (Magic Cup) was recommended and ordered by the dietitian, there was a delay of several days before the supplement was actually started. Intake documentation showed that the resident continued to eat poorly, and observations revealed difficulty with meal consumption, including spitting out food despite being served a preferred diet texture. Interviews with staff, including the registered dietitian, speech therapist, and LPN, confirmed gaps in documentation of food preferences and inconsistent implementation of dietary interventions. The facility's policies required daily intake monitoring and immediate care plan updates for weight changes, but these procedures were not consistently followed for the affected residents. The lack of timely and individualized nutritional interventions contributed to ongoing weight loss and inadequate support for residents with complex medical needs.