Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident #97, who was under review for nutrition. The resident, who had a diagnosis of malnutrition and dementia, experienced significant weight loss without the required weekly weight monitoring as ordered by the dietician. The facility's policy mandated weekly weight checks for four weeks following admission and more frequently if clinically indicated, but this was not adhered to for the weeks of 11/25/2024 and 12/09/2024. Resident #97 was admitted with a history of malnutrition and had a care plan focused on addressing nutritional problems, including unintentional weight loss. Despite the care plan's goal to maintain stable weight, the resident's weight dropped from 119 pounds in August to 107 pounds by December, indicating a significant weight loss of over 10 percent. The resident expressed dissatisfaction with the facility's food, describing it as cold and unappealing, which contributed to their reduced intake and subsequent weight loss. Interviews and record reviews revealed that the dietician had ordered weekly weights due to the resident's significant weight loss, but these orders were not consistently followed. The registered nurse responsible for monitoring weights did not receive the necessary communication from the dietician, resulting in missed weight checks. This oversight was compounded by the absence of active orders for weekly weights in the resident's records, highlighting a breakdown in communication and adherence to the facility's weight management policy.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action taken: the weekly weight order was obtained and entered for resident #97. The resident’s weight was obtained and the facility provider notified. The Registered Dietitian met with resident #97 regarding food preferences and dietary supplements. 2. All residents have the potential to be affected by the deficient practice. Plan to prevent reoccurrence: Registered Dietitian completed a full house of those residents who were recommended to have weekly weights. Those residents found to have weight omissions will have weights obtained and evaluated by the Registered Dietitian and nursing. 3. The facility systemic changes: The policy titled Weight Management was reviewed with no revisions necessary. The Director of Nursing re-educated the Registered Dietitian on 1/13/2025 on facility policy titled Weight Management with the focus on ensuring the recommended weight order is in place. 4. The Registered Dietitian will conduct an audit on all residents with weekly weights to ensure physician order [REDACTED]. Results of the reviews will be reviewed by the DON and Registered Dietitian weekly. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible party: Registered Dietitian