Failure to Implement Fortified Diet and Nutritional Interventions for Resident with Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to implement and provide necessary nutritional interventions for a resident with a history of significant weight loss and severely impaired cognition. The resident had diagnoses including unspecified psychosis, depression, and anxiety, and was identified as being at risk for weight instability, impaired fluid balance, abnormal lab values, and impaired skin integrity. Despite a physician's order for a fortified foods diet and recommendations from the registered dietician to add fortified foods due to ongoing weight loss, the resident's care plan did not reflect these interventions, and staff did not consistently provide fortified foods or health shakes as ordered. Observations revealed that staff did not offer drinks to the resident during meals and did not use built-up utensils as specified in the care plan. Staff interviews confirmed that the resident was dependent on staff for meal assistance, often refused supplements, and did not receive fortified foods at meals. Dietary staff were unaware of the fortified diet order, and the resident's meal did not include any fortified items. Documentation showed that the resident continued to lose weight, with a significant 10% loss over several months, and frequently refused the prescribed nutritional supplements. The facility's policy required individualized interventions and care plan updates in response to significant weight loss, but these were not implemented for the resident. Communication lapses between nursing and dietary staff resulted in the failure to provide the ordered fortified diet, and staff did not consistently follow the care plan interventions designed to address the resident's nutritional needs.