Failure to Adjust Protein Intake for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to modify and implement appropriate protein interventions for a resident who was at risk for developing pressure ulcers. According to the facility's policy, residents at risk for pressure ulcers should receive 1.2g/kg of protein. However, the nutrition assessment for the resident prescribed only 1.0g/kg, and the dietitian documented a daily protein prescription of 86 grams based on this lower factor. The resident's Braden Scale assessment indicated a risk for pressure ulcers, but there was no documented evidence that the resident's protein needs were re-assessed after this risk was identified. The resident involved had multiple medical conditions, including aphasia, obesity, dysphasia, multiple sclerosis, and hemiplegia. Despite these complex needs and the identified risk for pressure ulcers, the facility did not update the resident's nutritional plan to align with current professional standards and the facility's own policy. The registered dietitian confirmed that the resident should have received at least 1.2g/kg of protein, but this adjustment was not made or documented.