Failure to Develop and Implement Person-Centered Nutritional Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered nutritional care plan for a resident who was admitted with multiple complex medical conditions, including diabetes mellitus (insulin dependent), status-post left below the knee amputation, peripheral vascular disease, urinary retention with an indwelling catheter, and depression. Upon admission, the resident required a therapeutic diet as indicated by both the hospital discharge summary and the facility's own nutritional evaluation, which specified dietary needs such as an IDDSI Level 6 dysphagia diet, low calorie sweetener, 2g sodium, pureed textures, nectar thick liquids, and a PM diabetic snack. Despite these documented needs, a review of the resident's medical record revealed that no nutritional care plan was developed or implemented from admission through the end of the review period. Interviews with the Registered Dietician (RD) and the Director of Nurses (DON) confirmed that neither was aware of the absence of a nutritional care plan for the resident. The RD acknowledged responsibility for developing such plans as part of the interdisciplinary team but admitted that not all residents had care plans in place. The facility's policy requires individualized, measurable care plans to be developed within seven days of the comprehensive assessment, but this was not done for the resident in question.