Failure to Individualize Care Plans and Monitor Nutrition Status
Penalty
Summary
The facility failed to individualize care plans and properly monitor the nutritional status of two residents. For one resident with diagnoses including anemia, dementia, and dysphagia, the care plan did not include goals or interventions related to dysphagia, despite documented symptoms such as loss of liquids/solids from the mouth, holding food in the mouth, coughing or choking during meals, and significant weight loss over several months. Additionally, the facility did not obtain or document the resident's weight in several months as required by policy, which mandates routine weight monitoring upon admission, weekly for the first four weeks, and monthly thereafter or as indicated by risk. Another resident, admitted with traumatic brain injury, hemiplegia, and anxiety, had a physician order for specific amounts of free water to be administered daily. However, the resident's care plan was not updated or individualized to reflect these specific nutritional and hydration needs, as the interventions listed did not match the physician's order. These deficiencies were confirmed through review of clinical records, facility policies, and staff interviews.