Failure to Provide Dietician-Recommended Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
A resident with severe cognitive impairment and a history of significant weight loss was not provided with the dietician-recommended nutritional interventions during a lunch observation. The resident, who had lost 14.5% of body weight over six months and had a pressure ulcer, was supposed to receive large portions, fortified pudding at lunch, and fortified ice cream with lunch and dinner, as documented by the dietician. However, during the observed lunch, the resident received regular-sized portions and did not receive the fortified pudding or fortified ice cream. No staff were seen monitoring the resident's food intake or encouraging eating during the meal. The resident's care plan and facility policies required the provision of supplements as ordered, monitoring and documentation of food intake, and communication of significant weight changes. Despite these requirements, the dietary interventions were not implemented as recommended. The Food Service Director confirmed that the meal ticket indicated the need for large portions and fortified pudding, but these were not provided, and there was confusion regarding the inclusion of fortified ice cream. Both the Director of Nursing and Food Service Director acknowledged the failure to provide the recommended supplements and recognized the importance of weight maintenance for the resident's health.