Failure to Implement Nutrition Interventions for At-Risk Resident
Penalty
Summary
The facility failed to implement identified interventions to promote adequate meal consumption for a resident with significant nutritional risk. The resident had diagnoses including cerebral infarction, dysphagia, and left-sided hemiplegia, and was assessed as having severe cognitive impairment and requiring mechanically altered foods. Over several months, the resident experienced notable weight loss, with a 6.55% loss in one month, 13.42% in three months, and 15.31% over several months. The care plan specified interventions such as serving half portions of one food in a bowl at a time, providing encouragement and assistance during meals, and avoiding overwhelming the resident with large plates of food. A nursing note also documented that the resident appeared overwhelmed by plates of food and recommended serving one item at a time in a bowl. Despite these documented interventions, multiple observations showed the resident being served full plates of food with multiple items at once, both in the dining room and in her room. Staff interviews confirmed awareness that the resident should receive small portions in individual bowls, but this was not consistently practiced. The facility's policy required that weight loss interventions be addressed in the care plan and implemented, but the interventions were not followed as outlined, contributing to the resident's continued weight loss.