Failure to Individualize and Implement Nutritional Care Plan
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including dementia, diabetes, congestive heart failure, and a history of pulmonary embolism, did not receive individualized and consistent nutritional care. The resident was assessed as being dependent for eating and required a mechanically altered diet due to swallowing difficulties. However, the care plan only indicated assistance with meals as needed, which was inconsistent with the comprehensive assessment. Documentation by CNAs showed that the resident was frequently recorded as independent or only receiving minimal assistance during meals, despite being assessed as fully dependent. Further review revealed that the resident's nutritional status was not adequately monitored. The care plan included an intervention to monitor, record, and report significant weight loss, specifically a loss of more than three pounds per week, but only one weight measurement was documented in the medical record. The facility's point-of-care system also failed to consistently document the required level of assistance provided during meals, and the intervention for weekly weight monitoring was not followed. Additionally, when the resident's nutritional supplement was increased in response to family concerns and poor intake, there was no documented method to measure the effectiveness of this intervention. The registered dietician acknowledged that the care plan was generic and not individualized, and that the required weekly weight monitoring was not performed. Facility policies required integration of assessment findings into care planning and regular weight monitoring, but these were not implemented for this resident.