Failure to Consistently Monitor and Document Nutritional Status and Weights
Penalty
Summary
The deficiency involves the facility’s failure to consistently and comprehensively manage nutritional services for a resident identified as being at risk for significant weight loss. The resident was admitted with dementia, chronic and acute kidney disease, and cellulitis of the left lower limb, and had a BIMS score indicating severe cognitive impairment. The admission MDS showed no significant weight loss prior to admission. Physician’s orders directed that the resident receive a regular chopped diet with thin liquids, be weighed weekly on shower days, be offered a bedtime snack each evening, and receive ProStat 30 mL twice daily to support wound healing. The care plan, revised shortly after admission, identified the resident as at risk for significant weight loss and directed that all foods be served as a regular diet cut into bite-sized pieces, that intake be monitored, and that the resident receive diet as ordered. The diet/tray card used by staff showed a soft and bite-sized regular diet and no recorded food or fluid dislikes. Review of the weight record showed weights of 118 lbs, 113.8 lbs, 114.0 lbs, and 110.0 lbs over several days, with no recorded weights after the last entry despite orders for weekly weights. The vitals report showed that meal intake was not documented for 10 of 46 meals since admission, contrary to the care plan and the facility’s Monitoring Nutrient Intake Policy, which required nursing to document percentage of each meal consumed and substitutions. The initial nutritional assessment documented that the resident was underweight and at risk for significant weight loss, with a plan to monitor for need of additional high-calorie supplements based on intake, skin, and weight trends, and for the RD to update the plan of care as needed. There was no documentation of facility follow-up related to the resident’s weight loss since admission, no evidence of efforts to ensure accurate meal intake documentation, and no evidence that weights were obtained as ordered. The DON and Administrator confirmed that no weights were documented after the last recorded date and that meal intake had not been consistently documented, despite the facility’s policies requiring monthly weights or more frequent monitoring as ordered, and recording of all obtained weights in the EMR.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.