Failure to Provide Prescribed Diet and Address Chewing Difficulties
Penalty
Summary
A resident with multiple diagnoses, including Parkinson's disease, anemia, protein calorie malnutrition, and muscle weakness, was admitted and identified as being at risk for malnutrition and weight loss. The care plan specified the need to provide the prescribed diet, encourage adequate intake, and observe for difficulty chewing, with modifications to diet consistency as needed. Despite these interventions, the resident experienced a significant weight loss over several months, as documented in the weight records. During meal observations, the resident did not receive the prescribed fortified oatmeal at breakfast and was not provided with the ordered ice cream at dinner. The resident was observed having difficulty eating, with no staff assistance provided during breakfast and only partial assistance at dinner. The CNA assisting at dinner noted the resident's inability to chew and had to moisten the sandwich to facilitate eating, but did not report this difficulty to other staff members. Documentation and communication lapses were also identified. The Unavoidable Weight Loss form did not contain information related to the resident's weight loss, focusing instead on pressure ulcers. The Registered Dietitian was unaware of the resident's chewing difficulties until informed by surveyors, and only then was a Speech Therapy evaluation initiated. The lack of timely coordination and accurate documentation contributed to the resident not receiving appropriate interventions for nutrition and swallowing difficulties.