Failure to Individualize Nutrition Care Plan for Resident Food Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with multiple diagnoses, including type 2 diabetes mellitus, depression, and epilepsy. Upon admission, the resident's physician order specified a controlled carbohydrate, no added salt, regular texture diet with no fish. However, the facility's menu included fish for lunch, and the resident was served a meal containing fish. The resident's food preference for no fish was not documented on the meal ticket, and the Certified Nursing Assistant (CNA) was unaware of this preference until informed by a family member. The CNA then returned the tray to the kitchen for replacement. Further review revealed that the resident's care plan did not address the food preference for no fish, and the care plan on nutrition was not individualized. Both the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the resident's food preference should have been identified and documented during the admission process, and that the care plan should have been updated to reflect this preference. The facility's policy required comprehensive, person-centered care plans based on thorough assessments, but this was not followed in the resident's case.