Failure to Implement Nutritional Interventions for Resident at Risk
Penalty
Summary
The facility failed to implement nutritional interventions for a resident identified as being at nutritional risk, which contributed to the development and deterioration of pressure sores. The resident, who was cognitively impaired and had diagnoses including dementia, anemia, malnutrition, and a swallowing disorder, was assessed to be at high risk for pressure ulcer development. Despite being prescribed a mechanically altered diet and a nutritional supplement to promote weight gain and skin healing, the facility did not ensure these interventions were consistently administered. Clinical records indicated a significant weight loss for the resident over a short period, dropping from 172 pounds to 162 pounds, which was a 5% weight loss in one month. The facility's policies required notification of the dietitian and physician for unplanned weight changes, but there was no documentation that this occurred. Additionally, there was no evidence of a nutritional assessment being completed after the weight loss was identified, nor was there documentation of the administration of the prescribed nutritional supplement during March and April. Interviews with staff confirmed the lack of administration of the nutritional supplement and the absence of necessary documentation related to nutritional assessments and care planning. The resident's condition worsened, with the development of Stage III pressure ulcers, which were attributed to poor nutritional status and protein-calorie malnutrition. The facility's failure to adhere to its policies and ensure proper nutritional interventions contributed to the resident's declining health status.
Plan Of Correction
A - Resident R82 is receiving prosource and house supplement shakes with nursing documentation of percent consumed as nutritional interventions to assist with wound healing. B - All residents at nutritional risk with wounds audited to ensure nutritional interventions are in place. C - Educated dietitian on nutritional interventions for at risk residents and nutritional assessments. D - Weekly x 4 then monthly x 2 audit by DON or designee of newly at risk residents for nutritional interventions in place. Results discussed during QAPI meetings.