Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and provide timely nutritional interventions for a resident, identified as Resident #23. The resident was admitted with several diagnoses and was dependent on staff assistance for eating and all activities of daily living. Despite having a care plan that required a pureed diet with double portions, the resident was initially served an incorrect meal consistency. Observations showed that the resident had a good appetite and consumed 100% of meals when provided correctly. The resident experienced a significant weight loss of 10.30% from admission to a later date, which was not addressed in a timely manner. The facility's policy required weight monitoring and intervention for significant changes, but the dietitian failed to identify the weight loss as significant during assessments. The dietitian only reviewed recent weight changes and did not consider the complete history, missing the overall trend of weight loss. No additional nutritional interventions or supplements were ordered despite the resident's risk for further weight loss and overall decline. Interviews with staff revealed communication gaps and procedural lapses. The dietitian was not aware of the resident's double portion preference and did not attend high-risk rounds, relying on email updates. The Assistant Director of Nursing (ADON) identified the weight loss and notified the dietitian, but the dietitian did not provide recommendations to update the nutrition care plan. The interdisciplinary team acknowledged the findings, indicating a lack of coordinated response to the resident's nutritional needs.
Plan Of Correction
POC for Citation F692 This plan of correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan does not constitute admission nor agreement by the provider of the truth and facts alleged nor conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by provisions of federal and state law. Resident #23 had a loss which was reviewed by the Registered Dietician. Both resident's son and PCP were aware of his stated loss. Care plan was updated by Clinical Team to include the following new interventions: - Daily per Registered Dietician - Continue double portion meals - Ensure Shakes increased from daily to twice a day - Lab work (CMP, Pre-) Resident was daily until with fluctuations between 118- consistently, and consuming 100% of meals. Per dietician, despite consuming 100% of meals (double portions) and Ensure supplement, the resident continues to experience unintentional loss ( ). Order was received to discontinue daily and new order was given for weekly. During conversation with Resident #23's son on to give an additional follow-up regarding his current status, he requested a hospice consult and was signed onto hospice effective. The Registered Dietician, ADON, or designee will conduct an audit of current Skilled Nursing residents to identify loss, and ensure proper nutritional interventions are in place. Any discrepancies will be addressed promptly. The Staff Development Coordinator or designee will educate the Registered Dietician and Nursing staff on the facility policy for management. The ADON or designee will review the report and clinical notes during morning clinical meeting to identify a loss or change in condition to ensure proper nutritional interventions are in place promptly. The Registered Dietician will attend weekly high-risk rounds meeting to review any residents with loss and/or change in condition. The Registered Dietician or designee will conduct an audit of current residents on a weekly basis for one month, and then monthly for two months thereafter to identify loss and ensure proper nutritional interventions are in place. Discrepancies will be addressed promptly. Audit findings will be reported to the Quality Assurance Performance Improvement (QAPI) committee for monthly review. Additional audits and education may be determined based on audit findings.