Failure to Individualize Nutritional Care Plans and Communicate Fluid Restrictions
Penalty
Summary
The facility failed to individualize care plans to address specific nutritional concerns for two residents and did not ensure staff awareness of fluid restriction orders for another resident. For one resident with Alzheimer's disease, osteoporosis, and swallowing difficulties, the care plan did not include resident-specific interventions for the prescribed pureed diet, thickened liquids, and nutritional supplements, despite physician orders for these items. The care plan only listed general interventions such as providing the ordered diet and supplements, without detailing how these should be implemented for the resident's unique needs. Another resident with cancer, malnutrition, and depression experienced significant weight loss and received more than half of their calories through tube feeding. The care plan for this resident failed to document the ongoing weight loss, the resident's tendency to pull out or refuse the feeding tube, or specific interventions related to the prescribed tube feeding formula. Staff interviews confirmed that these individualized concerns and interventions were not reflected in the care plan. Additionally, a resident with high blood pressure, end stage renal disease, and a history of heart transplant had a physician order for a fluid restriction of 1800 mL per 24 hours. However, the order did not specify how the fluid allowance should be divided between nursing and dietary departments, and direct care staff were not made aware of the fluid restriction details. Facility staff acknowledged that the lack of clear breakdown and communication failed to ensure that acceptable nutritional parameters were maintained for this resident.