Failure to Develop Person-Centered Nutrition Care Plan for Resident with Weight Loss
Penalty
Summary
A deficiency was identified when the facility failed to develop a person-centered, comprehensive care plan addressing the nutritional needs of a resident who experienced significant weight loss. The resident, admitted with diagnoses including end stage renal disease and dysphagia, had a physician's order for a mechanical soft, ground texture diet with nectar thick liquids. Documentation showed that a Care Area Assessment (CAA) was completed, indicating the need for a therapeutic and mechanically altered diet, and that this concern was triggered for care planning. However, review of the resident's care plan revealed no focused CAA for nutrition, nor any individualized, person-centered interventions or approaches to address the resident's specific needs and required level of assistance. Interviews with facility staff confirmed the deficiency. The Speech Pathologist reported that the resident was receiving speech therapy for dysphagia and was scheduled for a Modified Barium Swallow test due to frequent refusal of the prescribed diet. The DON acknowledged the absence of a Registered Dietitian since March and reliance on a Corporate Dietician as needed. Both the Assistant DON and the Administrator confirmed that the care plan lacked a focused nutrition section with specific, individualized interventions for the resident.