Failure to Address Weight Loss and Conduct Nutritional Assessments
Penalty
Summary
The facility failed to address significant weight loss in a timely manner for a resident, identified as Resident R36. The resident, who had diagnoses including anemia, Alzheimer's Disease, and hyperlipidemia, experienced a significant weight loss of 9.12% in one month and 15% over three months. Despite these changes, there was no documentation of an assessment by the Registered Dietitian (RD) during the critical months of September, October, November, and December 2024. Additionally, there was a change in the tube feeding order that decreased the amount of formula administered, but no documentation supported this change or any nutritional recommendations. The report also highlights the facility's failure to complete initial nutrition assessments for two other residents, identified as Resident R29 and Resident R49. Resident R29, admitted with conditions such as a fracture of the right femur and atrial fibrillation, did not have documented assessments by the RD in the months following admission. Similarly, Resident R49, with diagnoses including asthma and aortic stenosis, also lacked documented nutritional assessments in the months after admission. Interviews with RD Employee El revealed that the RD was not employed at the facility during a critical period and was only notified of Resident R36's weight loss in November. The RD recommended increasing the tube feeding rate, but the resident's husband, who dictated most of her care, refused this change. This refusal was not documented in the resident's clinical record, indicating a lack of proper documentation and communication regarding the resident's care and nutritional needs.
Plan Of Correction
Resident 36 MD aware of the weight loss. Dietician restarted on 11-6-2024. Dietician reviewing all weights and notifying physician timely. All residents reviewed for weight loss and MD updated as indicated. Resident 29 and Resident 49 nutritional assessments completed. All residents verified for having a current nutritional assessment. Dietician will monitor all current residents and any new admissions to ensure they have an assessment. Dietician educating nursing on need for nutritional assessments and addressing weight loss timely. QAPI will be initiated on timely notification of physician on weight loss and nutritional assessments completed on new admissions, weekly for one month, bi-weekly for one month and monthly thereafter. All results for QAPI will be reported to the QA committee.