Failure to Assess and Update Nutritional Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess the nutritional status and update the individualized care plan for a resident with significant health concerns. According to the facility's own policy, a comprehensive nutritional assessment by a dietitian is required within 72 hours of admission, annually, and upon a significant change in condition. However, for a resident admitted with chronic obstructive pulmonary disease, diabetes mellitus, and bipolar disorder, and who developed a Stage 3 pressure ulcer, the required comprehensive nutritional assessment was not completed following a significant change in condition as documented in the Minimum Data Set (MDS) assessment. The clinical record review did not show evidence that the dietitian completed the necessary assessment to address the resident's current nutritional status in relation to the Stage 3 pressure ulcer. Specifically, there was no documentation of updated nutrient needs, evaluation of laboratory or diagnostic values, or assessment of the need for additional nutritional interventions to support pressure ulcer repair. The absence of this assessment was confirmed by the registered dietitian during an interview. Additionally, the resident's nutritional care plan, which was last updated after the significant change in condition, did not include any focus, goals, or interventions related to the newly identified Stage 3 pressure ulcer. This lack of care plan update was acknowledged by both the registered dietitian and facility leadership, confirming that the resident's specific nutritional concerns were not addressed as required.
Plan Of Correction
Resident 8 received an updated nutritional assessment and updated care plan. All residents in the last 30 days that have a nutritional concern will be reviewed for having a nutritional assessment and updated care plan based on their needs. Administrator or designee will educate the Registered Dietician and Certified Dietary Manager on the need to do accurate nutrition assessment and updating the care plans based on their nutritional needs. Registered Dietician or designee will audit 3 resident nutrition assessments and care plans weekly times 3 and monthly times 2. Results will be turned into monthly Quality Assurance meeting.