Failure to Implement Care Planned Nutritional Supplementation for Wound Healing
Penalty
Summary
The facility failed to implement care planned interventions for nutritional supplements for a resident with multiple stage 4 pressure ulcers and significant comorbidities, including hemiplegia, chronic kidney disease, and obesity. Upon admission, the resident was identified as being at high risk for skin breakdown and poor nutritional intake, and the care plan included recommendations for nutritional assessment and supplementation to support wound healing. The dietician specifically recommended a protein supplement (prosource) to aid in wound healing, and this intervention was documented in the care plan. Despite the dietician's recommendation and the care plan update, there were no physician orders for the recommended supplement, and the intervention was not implemented. The dietician's recommendation was communicated via email to the Administrator, DON, and ADON, but the message was not relayed to the resident's physician. As a result, the physician was unaware of the recommendation and did not order the supplement. The resident experienced significant weight loss over a short period, and both the resident and her spouse expressed concern that the weight loss was contributing to poor wound healing. The wound physician also identified nutrition as the primary barrier to wound healing for this resident. Interviews with facility staff confirmed that the breakdown in communication led to the failure to implement the recommended nutritional intervention. The facility's policy required that dietician referrals and recommendations for supplements be administered in accordance with physician orders, but this process was not followed. The deficiency was identified through observation, interviews, and record review, and it affected one resident reviewed for wounds.