Failure to Implement Recommended Nutritional Interventions
Penalty
Summary
The facility failed to implement recommended nutritional interventions for a resident identified as being at nutritional risk. The dietician had recommended that the resident, who had cognitive impairment and unplanned weight loss, be provided with ice cream twice a day to address her weight loss and decreased food intake. However, there was no documented evidence that the ice cream was provided as recommended. The resident's weight decreased from 130.7 pounds to 125.5 pounds over a period of approximately one month. Interviews with the dietician and dietary manager revealed that the ice cream was not included in the resident's meal ticket, and there was no order in the clinical record for the ice cream to be provided twice a day. The dietician believed the resident was receiving the ice cream or an equivalent supplement, but this was not the case. The dietary manager confirmed that the usual process of adding nutritional support items to a resident's diet was not followed, resulting in the resident not receiving the recommended nutritional intervention.
Plan Of Correction
(Magic Cup) Immediately for Resident 12, Order was obtained for Magic Cup and added to resident tray ticket. An audit/review of all other current residents in the facility ordered supplements/interventions were reviewed for accuracy and appropriateness. Policy was Reviewed by Dietary Management, Medical Director, Nursing Administration and Dietician for accuracy. This Policy will be educated and reviewed with All current Registered Nurses and Dieticians; acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated, as necessary. Dietary Management or Designee will inspect the supplements provided at meal service. Audits will be completed with one meal per day x 7 days for two weeks. Then one meal per day x 3 days for two weeks. Finally, one meal a day x 1 day for one week and/or as needed. Dietitian or Designee will Audits items ordered in Care plans, physician orders and tickets/labeled snacks as appropriate. The Dietician is the responsible Dietary staff member who reviews and accepts orders in Electronic Medical Record (EMR) to know if supplements are being consumed. Dietician Audits for Care plans, physician orders and tickets/labeled snacks as appropriate Audits need to be completed once weekly x 5 weeks and/or with changes to supplement orders. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.