Failure to Maintain Nutritional Risk Care Plans for Two Residents
Penalty
Summary
Surveyors identified a failure to develop and maintain comprehensive, accurate care plans addressing nutritional risk for two residents. One resident was admitted with diagnoses including abscess of lung without pneumonia, acute respiratory failure with hypoxia, and unspecified severe protein-calorie malnutrition. The admission MDS showed the resident was cognitively intact, independent with eating, and had experienced more than 5% weight loss in the last month and 10% in the last six months without being on a prescribed weight loss regimen, with no nutritional approaches documented. Physician orders specified a regular diet with regular texture and thin consistency. Weight records showed the resident’s weight remained at 109.4 lbs shortly after admission but decreased to 96.0 lbs by the end of the month, and a subsequent weight change progress note documented a continued downward trend. An RN confirmed the resident had been assessed as at risk for nutrition but did not have a corresponding care plan, and review of active care plans confirmed there was no documented care plan addressing nutritional risk. For the second resident, the medical record showed an admission with diagnoses including traumatic brain injury (TBI), dysphagia, and unspecified severe protein-calorie malnutrition. A quarterly MDS indicated moderate cognitive impairment, a need for set-up assistance with eating, no documented swallowing disorder or weight loss, and use of a mechanically altered diet. An RN confirmed this resident was also assessed as a nutritional risk. The RN reported that the resident’s dietary care plan had been discontinued during a system changeover and that a new dietary care plan was never implemented, despite the resident’s nutritional risk status. Review of active care plans showed there was no documented care plan for nutritional risk for this resident. The Regional Director of Clinical Operations stated the facility did not have a policy on care plans. This deficiency was investigated under Complaint Number 2708144.
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