Failure to Implement and Document Nutritional Interventions for Weight Loss
Penalty
Summary
The facility failed to consistently implement and document interventions for significant weight loss for a resident, identified as Resident 67, who was at nutritional risk. The resident, diagnosed with diabetes and congestive heart failure, experienced a significant weight loss of 5.5% within one month, which was attributed to fluid loss from IV Lasix therapy. Despite the Registered Dietitian (RD) adjusting the resident's dietary preferences and planning for additional nutritional supplements, there was no documented evidence that these interventions were consistently implemented or communicated to the physician or responsible party in a timely manner. Further weight loss was noted, reaching an 8% loss within one month, prompting the RD to discuss and plan for the administration of Ensure pudding and ProStat as nutritional supplements. However, the Medication Administration Record (MAR) lacked documentation of the administration or consumption of these supplements. The RD confirmed that the facility failed to implement the planned nutritional interventions and did not document the physician-ordered nutritional interventions, which were crucial to maintaining the resident's nutritional parameters and preventing further weight loss.
Plan Of Correction
1. Resident # 67 has Ensure Pudding once daily and ProStat twice daily added to his EMAR to now collect supplement administration and consumption to deter weight loss. 2. The Registered Dietitian completed an audit of current in-house resident supplements ordered to ensure that both supplement administration and consumption are being captured in the medical record. 3. The Clinical Coordinator or designee will re-educate licensed nursing staff and the Registered Dietitian regarding the facility's current Weighing of Residents Policy and the order entry process for supplements to ensure consistent implementation and documentation of physician-ordered nutritional interventions to maintain nutritional parameters and deter weight loss of a resident. 4. The Registered Dietitian or designee will review current in-house and new resident orders for supplementation weekly for three months to ensure consistent implementation and documentation of physician-ordered nutritional interventions to maintain nutritional parameters and deter weight loss of a resident. Audit results will be reported to the Quality Assurance Performance Improvement committee to determine compliance.