Failure to Monitor and Document Nutrition and Hydration Needs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to effectively monitor and evaluate nutrition and hydration needs for two residents. One resident with hemiplegia, aphasia, dysphagia, and severe cognitive impairment was dependent on staff for all ADLs. Although the MDS indicated no swallowing disorders, a CNA later reported that toward the end of the resident’s stay he was not interested in food, was congested, choked sometimes while eating, and began pocketing food and coughing. The RD confirmed that on a specific date the resident had a change in condition and was noted to be pocketing food during meals, which the RD stated placed the resident at risk for not meeting food and fluid intake and for aspiration. Despite this documented change in condition, the RD stated there was no evidence that the IDT met to discuss the resident’s change in dietary needs, and no new nutritional assessment was completed. The resident’s care plan did not reflect the pocketing of food, and no new interventions were implemented to address this change. This inaction occurred despite the facility’s written policy on Resident Hydration and Prevention of Dehydration, which required the dietitian to assess residents more often as necessary per resident need, initiate intake and output monitoring when potential inadequate intake or signs of dehydration were observed, and update the care plan with documented resident response to interventions. The second resident had diagnoses including severe protein-calorie malnutrition and dysphagia and was cognitively intact, requiring supervision for eating. A restorative nursing assistant observed that this resident received a thickened liquid nourishment as part of a scheduled nourishment pass but appeared to consume less than half. The RD stated that speech therapy had determined the resident could only consume liquids with a spoon, placing the resident at higher risk for dehydration, and that the resident required a specific daily fluid range to be adequately hydrated. Record review showed the resident’s documented fluid intake on one day was 236 ml, with no documented fluid intake for the following two days, and the RD stated the resident did not meet minimum fluid intake requirements during that period. The DON acknowledged that CNAs were only documenting fluid intake during meals and not during med passes or nourishments, despite facility policy requiring aides to provide, encourage, and document intake of bedside, snack, and meal fluids and to report intake of less than 1200 ml/day to nursing staff.
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