Failure to Provide Meal Supervision, Nutritional Assessments, and Ordered Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance and supervision with meals and to follow its own policies for nutritional assessment and interventions. One resident with a history of CVA, right-sided hemiplegia, dysphagia, and documented history of pocketing food was care planned and listed on the Kardex as needing supervision with eating. Despite this, surveyor observations during a lunch meal showed the resident eating without any staff present to supervise or assist. The speech therapist confirmed that the resident required staff supervision during meals due to dysphagia and pocketing of food and that staff should have been present during the observed lunch. The facility also failed to complete required nutritional assessments for multiple residents who experienced significant weight changes. The facility’s policy required baseline weights on admission, routine weight monitoring, and comprehensive nutritional assessments by the RD within 14 days of admission and periodically thereafter, with additional monthly reviews for high-risk residents. However, several residents with diagnoses such as muscle wasting, morbid obesity, diabetes, heart failure, respiratory failure, and muscle weakness had documented weight losses over time without corresponding nutritional assessments. Specifically, residents admitted in 2021, 2024, and 2025 had weight records showing notable decreases, yet their clinical records lacked evidence of comprehensive nutritional assessments after earlier dates, including after admission for one resident. Additionally, the facility did not implement or follow through on nutritional interventions identified in RD assessments. One resident’s nutritional assessment noted a 20-pound decrease in the past month and questioned whether the most recent weight might be an error, recommending a reweigh; the record contained no evidence that a reweigh was completed. Another resident’s nutritional assessment documented an unplanned significant weight loss over 30 days and recommended adding a House Shake at dinner, with notification to Dietary the same day; the facility’s records lacked evidence that the House Shake was added to the resident’s meal plan or orders. During an interview, the Nursing Home Administrator confirmed the absence of required nutritional assessments, the lack of meal supervision for the resident requiring it, and the failure to complete recommended nutritional interventions.
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