Failure to Provide Therapeutic Diet and Timely Interventions for Resident with Nutritional Decline
Penalty
Summary
A deficiency occurred when the facility failed to ensure a therapeutic diet was offered and appropriate interventions were implemented for a resident experiencing nutritional problems, including poor intake related to swallowing difficulties and physical decline. The resident, an older female with a history of abnormal weight loss, was admitted with a left ankle fracture and subsequently developed a wound after cast removal. Despite documented weight loss, low prealbumin levels, and decreased oral intake, the care plan was not updated in a timely manner to reflect these changes, and no dietician consult was initiated as recommended by the wound care physician. Staff interviews and record reviews revealed that the resident's care plan had not been revised to address her weight loss, swallowing issues, or wound care needs since several months prior. The resident's diet remained unchanged, and although staff observed her difficulty swallowing and poor appetite, no formal order was placed to modify her diet consistency. The dietary manager and aides noted the resident's decreased intake and attempts to provide softer foods, but these actions were not supported by updated physician orders or care plan interventions. The speech therapist was only informally consulted and did not complete a formal assessment until much later. Multiple staff members, including nurses, aides, and dietary staff, reported the resident's declining intake and difficulty swallowing over a period of weeks. Despite these observations and the resident's significant weight loss, there was a lack of communication and follow-through to ensure appropriate dietary and therapeutic interventions were implemented. The facility's own policies required notification of the physician and dietitian for significant weight changes, but these steps were not taken in a timely manner, resulting in the resident not receiving the necessary nutritional support.