Failure to Timely Monitor Weights for Resident on Enteral Nutrition
Penalty
Summary
A deficiency occurred when the facility failed to monitor weights in a timely manner for a resident who was readmitted after hospitalization with a significant change in nutritional status, specifically the initiation of a PEG tube for enteral feeding. The resident had a complex medical history, including intracerebral hemorrhage, gastrostomy, abdominal aortic aneurysm, dysarthria, aphasia, hemiplegia, Alzheimer's disease, and muscle wasting. Upon readmission, the resident had experienced a notable weight loss, dropping from 131.6 lbs prior to hospitalization to 118.4 lbs at readmission, and further to 114.2 lbs over the following 18 days. The resident's nutritional assessments indicated ongoing weight loss and recommended weekly weight monitoring for the first four weeks post-readmission, in accordance with facility policy and the dietitian's assessment. Despite these recommendations and the resident's continued weight loss, weekly weights were not consistently obtained after the increase in enteral feeding from four to five cartons daily. The dietitian and DON both acknowledged that the required weekly weights were missed during this critical period. Facility policy required weekly weights for residents within the first four weeks of admission or as determined by the interdisciplinary team, especially for those with significant nutritional changes. The failure to adhere to this policy resulted in a lack of timely monitoring of the resident's weight status, despite clear evidence of ongoing weight loss and changes in nutritional interventions.
Plan Of Correction
Element 1 Resident #62's weight was obtained. Physician was notified. She was assessed by Dietitian for nutritional needs and nutrition plan of care was reviewed. Weight obtained showed weight gain and that interventions were successful. Resident will continue to be followed by Dietitian. Element 2 An audit was completed for Residents who returned from the hospital to ensure weekly weights were completed x4 weeks and all Residents with significant weight loss had interventions in place. An audit was completed for Resident on enteral feeding to ensure any weight loss or changes in orders were addressed with weekly weight monitoring in place. Any concerns identified were corrected. Element 3 Director of Nurses/Designee completed re-education to Nursing staff in obtaining weekly weights x4 weeks for any new admits or any Residents who were recently admitted to the hospital and re-admitted to the facility. Director of Nursing/Designee completed education to Registered Dietitian on tracking and requesting weekly weights for new admits as well as for any Resident showing weight loss or had changes in enteral feeding. Any staff members not educated by May 20, 2025 will be educated on their next scheduled shift. Unit Managers/Designee will verify that there are no missing weekly weights for new admits x4 weeks. Registered Dietician will provide a list to nursing for Residents with weight changes or enteral feeding changes. Nurse Managers will review medical record for new admits as well as re-admits during morning meeting to ensure all weights are obtained. Nurse Managers will review medical record for Residents with weight changes or enteral feeding changes during morning meeting to ensure all weights are obtained. Element 4 Unit Manager/Designee will complete random weekly audits X4 weeks of weights to ensure no weekly weights are missed with results of findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5 Director of Nursing is responsible for maintaining compliance.