State Findings:
Based on interview, record review and policy review it was determined the facility failed to ensure residents with an identified weight loss were monitored for further weight loss and that supplements were provided as recommended for one (1) of thirty-two (32) sampled residents (Resident #107).
Review of the Nutrition/Dietary Note made on 12/05/2019, revealed Resident #107 weighed 103.2 pounds and the resident had a significant weight loss of 11.8 percent in the last three months and 11.3 percent in the last six months. The resident’s diet was a mechanical soft modified diabetic diet with thin liquids. The Dietitian recommended eight ounces of Glucerna two times a day. Review of the Medication Administration Record [REDACTED].
Interview, on 01/11/2020 at 10:38 AM and 1:03 PM, with Licensed Practical Nurse (LPN) #15, revealed Resident #107 was diabetic, small in stature and sat in a wheelchair. However, due to her being agency staff, she could not remember much more about the resident. She stated the facility did not bring it to her attention the resident had a significant weight loss or that the resident was not being weighed as ordered. LPN #15 stated nothing was on the MAR indicated [REDACTED]. LPN #15 stated she also did not review the plan of care, she just depended on the MAR indicated [REDACTED]. She stated if staff did not weigh the resident or provide supplements as ordered they could contribute to a decline.
Interview with the Director of Nursing (DON), on 01/11/2020 at 12:55 PM, revealed she had identified staff were not routinely obtaining weights as ordered. The DON stated she recently assumed her role and had not yet fixed the system issues related to monitoring residents with identified weight loss. She stated the facility tried to pull staff aside at the time they identified non-compliance with physician orders [REDACTED]. The DON stated she had not identified Resident #107’s weight loss, nor did she remember a discussion in the morning meeting about the staff not weighing the resident or providing the supplements as ordered. She stated if the facility did not assess or monitor residents for weight loss, residents could experience a decline.
Interview with the Administrator, on 01/11/2020 at 2:03 PM, revealed he expected staff to follow facility policy and physician orders [REDACTED].
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