Failure to Timely Assess, Monitor, and Intervene for Severe Weight Loss and Malnutrition
Penalty
Summary
A resident with a history of severe protein-calorie malnutrition, dysphagia, and abnormal weight loss was admitted to the facility following a hospital stay. Upon admission, the resident's weight was recorded as the same as the hospital discharge weight, and the initial nutrition assessment noted a significant weight loss of 30 pounds over the prior three months. Despite this, the facility failed to identify or address a further weight loss of 4.29 pounds within the first week of admission, and no interventions were implemented to prevent additional weight loss for more than two weeks. The resident continued to experience poor appetite, nausea, and difficulty tolerating the prescribed diet, but interventions such as medication adjustments and dietary supplements were delayed or not implemented in a timely manner. Communication and coordination among the facility's interdisciplinary team were lacking. Requests for a gastroenterology (GI) referral for possible PEG tube placement were not followed up promptly, and there was no documentation of timely notification to the physician or action taken regarding the resident's and family's expressed wishes for a feeding tube. The registered dieticians were unaware of the resident's request for a PEG tube and did not document or address the ongoing nutritional concerns. Additionally, the facility failed to consistently monitor the resident's intake, did not obtain a new weight upon readmission from the hospital, and did not ensure that ordered dietary supplements were administered as documented in the medical record. Throughout the resident's stay, there was a breakdown in communication and oversight, with the registered dieticians and nursing staff failing to collaborate effectively or escalate concerns to administration. The resident experienced a severe weight loss of 13.27% within two months, was hospitalized twice for acute changes in condition related to poor intake and dehydration, and ultimately died with severe calorie malnutrition listed as a cause of death. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's nutritional status, interventions, and care planning, as well as failures to follow facility policy on monitoring and addressing nutritional risk.
Plan Of Correction
F692 Nutrition/Hydration Status Maintenance It is the practice of the facility to ensure that resident maintains acceptable parameters of nutritional status such as usual body weight or desirable body weight range and electrolyte balance, unless the residents' clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Element 1: Resident 402 no longer resides in the facility. Element 2: Residents who live in the facility can be affected by the deficient practice. An audit was conducted for residents with recommendations for Gastrointestinal referrals to ensure that they have a physician order for the consult and documentation that an appointment for the consult was scheduled with the Gastrointestinal specialist. Current residents in the facility had their weights reviewed to be sure that the most recent and accurate weights were reported to the Dietitian. An audit was completed by the Dietitian of residents with significant weight loss to ensure physician notification was documented and interventions are in place to address weight loss. Current residents admitted within the last 30 days will be reviewed to ensure admission weights were obtained and recorded in their medical records. Any resident admitted within the last 30 days who does not have a weight recorded in the medical record will be weighed and documented in the medical record. Newly admitted residents will be reviewed by the dietitian to ensure weekly weights are completed and documented for 4 weeks and then as directed by the dietician. The IDT Team will have a nutritional at-risk meeting weekly to review residents at nutritional risk, residents with significant weight loss, and residents with gastrointestinal referrals, to ensure physician notification has been completed and documented, and appropriate nutritional interventions are in place. Element 3: The interdisciplinary team reviewed the Consultations policy and deemed it appropriate. The facility unit clerks and nurse managers were educated on the Consultations policy. The interdisciplinary team reviewed the weight policy and deemed it appropriate for use. The nursing staff and Dieticians were educated on the policy. The interdisciplinary team reviewed the Monitoring Adequate Nutrition and Hydration Status policy and deemed it appropriate for use. The dietitians were educated on the policy. Element 4: The director of nursing/designee will audit residents with recommendations for gastrointestinal referrals to ensure physician orders and appointments are in place weekly for 4 weeks and then monthly for 3 months. The dietitian will audit newly admitted residents to ensure weights are obtained upon admission and weekly for 3 additional weeks and that current residents' ordered weights/reweights are completed and documented. The administrator/designee will audit residents with significant weight loss to ensure physician notification and nutritional interventions were implemented weekly for 4 weeks then monthly for 3 months. The results will be reviewed monthly in QAPI for 3 months and then PRN if no trends are noted. Element 5: The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.