Failure to Develop and Implement Comprehensive Nutrition Care Plan for Malnourished Resident
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively develop and implement a care plan for a resident with a diagnosis of malnutrition and poor nutritional intake. The resident’s admission MDS showed intact cognition, a need for set-up assistance with meals, and diagnoses including pneumonia and malnutrition. The care plan dated 2/2/26 identified a potential nutritional problem related to moderate malnutrition and included interventions such as assisting with meal set-up, recording nutritional intakes, taking orders at meals, and offering alternatives. However, the care plan did not include specific interventions for when the resident did not eat meals, nor did it provide direction on when to offer the ordered nutritional supplement. The care plan also lacked documentation of the resident’s food preferences. On observation, the resident was seen eating only a small portion of a noon meal, using fingers to eat a few bites of fish, drinking fluids, and not consuming the pasta and vegetables, stating she did not like the meal. One staff member removed the tray after confirming the resident was done, estimated intake at about 10%, and acknowledged knowing the resident disliked the facility food but did not offer an alternative or assistance, and had not reviewed the care plan. Another staff member charted that the resident ate 50% of the meal without having seen the resident eat or removed the tray, later admitting this was inaccurate and that actual intake was about 25%. This staff member also acknowledged not offering assistance or an alternative food choice despite typical practice to do so. Review of the care plan days later confirmed it had not been updated with interventions for poor intake or food preferences, and the resident reported staff had not asked about her food preferences. The DON stated that documentation showed 50–75% intake for that meal and described expectations that staff offer alternatives, notify appropriate clinical staff, and increase monitoring when a resident does not eat well, but acknowledged this was not done and that such interventions were expected to be in the care plan.
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