Failure to Revise Care Plans and Follow Dietary Orders for Nutrition and Hydration
Penalty
Summary
The facility failed to ensure that dietary care plans were revised for actual weight loss and did not follow dietary orders for two residents, resulting in the potential for continued weight loss. One resident, a 91-year-old with multiple diagnoses including major depressive disorder, congestive heart failure, and anxiety, experienced a 10.1% weight loss over six months. Despite a significant weight loss being identified, there was no care plan addressing actual weight loss, only a care plan for potential alterations in nutritional status, which had not been updated. The Registered Dietitian confirmed that a care plan for actual weight loss should have been in place and acknowledged that no additional interventions were implemented beyond updating preferences and adding the resident to weekly weights. Another resident, admitted with diagnoses including heart failure, COPD, and mild protein-calorie malnutrition, had physician orders for a regular diet with large or double protein portions. The resident reported not consistently receiving the ordered double portions of protein and expressed concern about the lack of protein options and the quality of alternatives provided. The care plan did not mention the need for additional protein, and the nutritional evaluation failed to address the extra protein requirement. The resident's albumin levels were low and declining, and there was a lack of documentation and follow-up regarding the resident's dietary concerns and lab results. Both cases demonstrate failures in care planning and implementation of dietary orders. The facility did not update care plans to reflect actual weight loss or ensure that dietary interventions matched physician orders and resident needs. There was also insufficient monitoring and documentation of residents' nutritional status and preferences, as well as a lack of communication between dietary staff and other care team members regarding residents' changing conditions and concerns.