Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to identify and address severe weight loss in a timely manner for two residents, leading to significant nutritional deficiencies. Resident #52, who was admitted with cognitive and physical impairments, experienced a 10.8% weight loss over less than two months. Despite observations of the resident's inability to eat independently due to uncontrollable hand tremors, the facility did not provide adequate assistance during meals or implement nutritional supplements. The Registered Dietitian was not informed of the resident's severe weight loss and did not take timely action to address the nutritional needs. Resident #56 also experienced a severe weight loss of 9.8% in one month and an overall 12% weight loss over six months. The facility's interventions were delayed, with nutritional supplements not being ordered until over a month after the significant weight loss was identified. The resident's meal intake was consistently below 50%, yet the facility failed to ensure the prescribed fortified foods and supplements were consistently provided. The facility's policies on weight monitoring and nutritional assessment were not effectively implemented, leading to a lack of timely interventions for residents experiencing significant weight loss. The Registered Dietitian and staff failed to communicate and document weight changes and nutritional needs adequately, resulting in continued weight loss and potential malnutrition for the residents involved.
Plan Of Correction
Boca Circle Rehabilitation Center failed to identify a severe loss in a timely manner and failed to provide adequate nutritional supplements to prevent further severe loss. **Actions Taken:** 1) Resident #52 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #52 on and the resident now attends the dining room for his meals for oversight and assistance as needed. On resident #52 was placed on an appetite stimulant. Resident #52 was placed on weekly and is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. Resident #56 was evaluated by the Registered Dietitian on and additional nutritional interventions were implemented. A comprehensive nutritional assessment was completed for Resident #56 on the resident was seen by the Speech Pathologist and her diet was downgraded to Puree and on the resident was placed on an appetite stimulant. Resident #56 is currently receiving Occupational and Speech therapies. The Resident's responsible party has been updated. **Others Identified:** 2) Full house audit completed between by the Registered Dietitian/Designee to identify residents that may have been affected due to delayed loss intervention or missing a nutritional intervention in the electronic medical record or ticket system recommended by the Registered Dietitian. Additional documentation recommended from the full house audit was completed by facility Registered Dietitian by Regional Dietitian completed a full house audit between to ensure residents have been per protocol and monitored appropriately to identify severe loss. Any concerns identified were immediately addressed. **Measures Taken:** 3) Regional Dietitian in-serviced the Registered Dietitian on regarding timely nutrition interventions with a focus on residents with loss as well as ensuring nutritional interventions are placed in electronic medical record and ticket system timely as applicable. Nursing staff were re-educated to refer to resident Kardex in reference to amount of assistance required with meals initiated on by Ellie Schutt, LNHA/Designee. **Ongoing Monitoring:** 4) The Registered Dietitian/Designee will conduct an audit of 10 residents on each unit weekly to ensure the residents with loss have timely documentation with nutritional interventions and verify that the nutritional interventions are placed in the EMR and the ticketed system timely weekly x 4 weeks, and then every 2 weeks x 2 months. Findings of the audits will be reviewed in the QAPI Meetings to ensure substantial compliance. The QAPI committee is responsible for the ongoing compliance.