Failure to Address Significant Weight Loss in Residents with Feeding Tubes
Penalty
Summary
The facility failed to ensure timely physician notification and intervention for significant weight loss in two residents with feeding tubes. Resident 66, who is severely cognitively impaired and requires extensive assistance for daily care, experienced a 14-pound weight loss over 15 days. Despite this significant change, there was no documented evidence of interventions to prevent further weight loss or notification to the physician. The Director of Nursing confirmed that as of December 12, 2024, the weight loss had not been addressed by the dietician or physician. Similarly, Resident 78, who is cognitively intact and also requires assistance for daily care, experienced a 13-pound weight loss over 17 days. Like Resident 66, there was no documented evidence of any interventions or physician notification regarding the weight loss. The Director of Nursing confirmed that the weight loss for Resident 78 had not been addressed by the dietician or physician as of December 12, 2024. These deficiencies indicate a failure to adhere to the facility's policy on maintaining acceptable nutritional status and timely physician involvement.
Plan Of Correction
1. The facility cannot retroactively address the findings. 2. Weights completed. Those with significant changes to have completion of nutrition assessment with MD and responsible party notification. 3. Director of Nursing or Designee to educate nursing staff regarding weights and implementation of follow through documentation and notification. 4. Director of Nursing or Designee to complete weekly weight audits to ensure follow through of significant weight changes as well as the completion of interventions or re-evaluation of weights. Audits to be completed weekly for 4 weeks then monthly for 2 months. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.