Failure to Develop and Implement Nutrition Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan to address the nutritional and hydration needs of a resident who was admitted with diagnoses including Parkinson's disease, muscle weakness, and heart failure. The resident was assessed as having mild cognitive impairment, was dependent on assistance for multiple activities of daily living, and had an indwelling catheter. The nutritional assessment indicated the resident had variable oral intake, was underweight, and required additional calories. Despite these findings, no care plan was created to address the resident's nutritional needs. During interviews and record reviews, the DON confirmed that although the resident was receiving high protein supplements three times a day due to malnutrition, there was no care plan in place to monitor or evaluate the effectiveness of these interventions. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables for all residents, including those at risk for nutritional complications. The absence of a care plan meant the facility did not address or monitor the resident's nutritional and hydration needs as required.