Failure to Develop Comprehensive Nutritional Care Plan
Penalty
Summary
Facility staff failed to develop a comprehensive, resident-centered care plan addressing the nutritional needs of a resident who experienced significant weight loss. Medical record review showed that the resident's weight dropped from 183.8 lbs. to 166.6 lbs., a loss of 17.2 lbs. or 9.4% over a short period. Despite this notable weight loss and the resident being on a specialized diet, there was no nutritional care plan documented in the resident's medical record. During interviews, the facility's dietician acknowledged responsibility for creating nutritional care plans but admitted that due to limited contracted hours, she prioritized high-risk cases and was unable to address all needs. The dietician could not provide an explanation for the absence of a nutritional care plan for this resident. The Medical Director confirmed the lack of a nutritional care plan after reviewing the medical record.