Failure to Complete Quarterly Nutritional Assessment and Update Care Plan
Penalty
Summary
The facility failed to complete a required Quarterly Nutritional Assessment for one resident who was readmitted with multiple diagnoses, including legal blindness, dementia, and psychosis. The resident had a moderate to severe cognitive impairment and required set-up or clean-up assistance for eating. Observations showed that the resident was routinely provided with the same limited food choices and expressed dissatisfaction with the lack of variety. The care plan identified the resident as being at risk for altered nutrition due to end-stage cerebral atherosclerosis, underweight status, and legal blindness, and noted inadequate oral intake with 25% or more of most meals uneaten. Despite these risks, there was no evidence that the Clinical Dietitian completed or updated the Quarterly Nutrition Assessment or revised the care plan after a specified date. Interviews with facility staff confirmed that the Clinical Dietitian was responsible for updating nutrition care plans and completing Quarterly Nutrition Assessments, but the assessment was not completed for this resident. The Dietary Manager and Registered Dietitian both acknowledged the lapse, with the Registered Dietitian unable to explain why the assessment was missed. Additionally, the most recent assessment did not document any direct interaction with the resident to determine food preferences, likes, or dislikes, and there was no documentation of the resident's refusal of supplements prior to the assessment.