Failure to Provide Ordered Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, type one diabetes mellitus, and dysphagia experienced a significant weight loss of 6.72% over a three-month period. The resident was assessed as severely cognitively impaired and required set up or clean up assistance with meals. The care plan and physician orders specified that the resident should receive a regular diet with thin liquids and soup provided with lunch and dinner as a nutritional intervention to address weight loss. Despite these orders, observations revealed that the resident was not served soup with either lunch or dinner, and staff confirmed that soup was not routinely provided. Additionally, staff did not encourage the resident to eat or offer alternatives when the resident did not consume the meal provided. Interviews with staff indicated a lack of awareness regarding the resident's dietary orders, with one CNA stating she did not read the meal tickets and an LPN expressing uncertainty about the resident's dietary requirements. The registered dietitian confirmed that soup was added to the resident's meals as an intervention for weight loss and expected staff to encourage meal consumption and offer alternatives as needed. The facility's policy required individualized nutritional interventions and monitoring, but these were not consistently implemented for this resident.