Failure to Consistently Provide Adaptive Equipment for Nutrition Support
Penalty
Summary
A resident with diagnoses including moderate protein calorie malnutrition, dementia, osteoarthritis, and multiple rib fractures was admitted and identified as being at risk for altered nutritional status. The resident required partial to moderate assistance with eating and had documented hand deformity and tremors, necessitating the use of adaptive equipment such as weighted utensils and a plate guard. The care plan included these interventions, but did not specifically address the resident's risk for weight loss or nutrition concerns. Despite the care plan and occupational therapy recommendations, observations revealed that the resident was inconsistently provided with the necessary adaptive equipment during meals. On multiple occasions, the resident was served meals without the required weighted utensils or plate guard, resulting in visible difficulty eating, dropping food, and reduced intake. Staff interviews confirmed that the provision of adaptive equipment was inconsistent and dependent on the meal, and the facility lacked a policy to ensure these devices were always provided as ordered. The resident experienced a significant weight loss over several weeks, with documented losses exceeding 5% in a short period. Although the facility's weight monitoring policy required physician notification and intervention for significant weight changes, there was no evidence that the resident's nutritional risk was adequately addressed in the care plan or that consistent interventions were implemented to prevent further decline.