Failure to Complete Nutritional Assessment per Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident with multiple diagnoses, including muscle weakness, atrophy, lack of coordination, and cognitive communication deficit. The resident's care plan identified a risk for malnutrition and included specific interventions such as completing a Mini Nutritional Evaluation and consulting a dietician based on the results. However, the Mini Nutritional Assessment for the resident was started but not completed, and the Registered Dietician (RD) was unaware that the evaluation was required. The care plan interventions were not fully carried out as intended. Interviews revealed a lack of communication and follow-through regarding the nutritional assessment. The RD stated he was not informed that a Mini Nutrition Evaluation was needed, and the Regional Nurse Consultant indicated that care plans should trigger the RD to complete necessary assessments. Facility policy required the care plan to describe services to maintain the resident's well-being, but this was not achieved due to the incomplete assessment and lack of coordination among staff.