Failure to Monitor and Document Resident Weights and Nutritional Interventions
Penalty
Summary
The facility failed to obtain and document a resident's weight upon admission as required by physician orders and facility policy. The resident, who had multiple diagnoses including severe protein calorie malnutrition, dysphagia, and acute respiratory failure, had a history of significant weight loss prior to admission. Despite a physician order for weekly weights for four weeks followed by monthly weights, there was no admission weight recorded, and weights were not documented from a certain date through discharge. This lack of documentation prevented proper monitoring of the resident's nutritional status. Additionally, the facility did not ensure that all recommended nutritional interventions were implemented and monitored. Although the dietician recommended a health shake and a frozen nutritional supplement to address the resident's protein and calorie needs, only the health shake and protein supplement were ordered and documented as administered. There was no physician order or documentation for the frozen nutritional supplement, and staff interviews confirmed it was not received. Facility policies required monitoring and documentation of weights and dietary intake, but these were not consistently followed for this resident.