Failure to Provide Timely Nutritional Support and Assessment
Penalty
Summary
A resident with multiple sclerosis and dysphagia was admitted with a care plan identifying them as at risk for nutritional and hydration imbalances due to a history of significant weight loss. Physician orders specified a pureed diet with thickened liquids, fortified foods, and a frozen nutritional treat twice daily, with intake percentages to be recorded. Facility policy required significant weight changes to be reported to the physician and responsible party, and for the interdisciplinary team to assess and document interventions. The resident experienced a significant weight loss over several weeks, as documented in weight records and meal intake logs. Despite the documented weight loss meeting the facility's definition of significant loss, there was no evidence that the physician or responsible party were notified, nor was there documentation of a timely nutritional assessment, new interventions, or care plan revisions in response to the decline. The registered dietitian confirmed that she had not evaluated the resident following the weight loss and that the nutritional regimen was not reviewed or revised until several weeks after the initial decline. There was no documented evidence of timely interdisciplinary reassessment or intervention to address the resident's nutritional status during the period of weight loss.