Failure to Timely Notify Dietitian and Implement Nutritional Interventions for Resident with Weight Loss and Pressure Injury
Penalty
Summary
A resident with diagnoses including Parkinson's disease and bacteremia was admitted to the facility and assessed by the Registered Dietitian (RD) as being at risk for malnutrition. Despite this, the resident developed a pressure injury and experienced a significant, unplanned weight loss over a short period. The facility's policies required prompt notification of the RD and initiation of nutritional interventions for residents at risk of skin breakdown or with significant weight changes, but these steps were not taken in a timely manner. Family members reported that the resident did not receive adequate assistance with eating, leading to further weight loss. Documentation showed that the resident's weight dropped from 168 lbs. to 145.6 lbs. in just over a month, representing a 13.3% loss. Although the resident's diet was modified by therapy staff and the resident was able to eat independently, there was no evidence that the RD was notified of the severe weight loss or the development of the pressure injury until several weeks after these issues were identified. Nursing staff and unit managers confirmed that weight monitoring and reporting processes were not consistently followed, and the RD relied on nursing staff for notifications rather than proactively reviewing weight reports. Interviews with facility staff revealed that significant weight changes were not promptly communicated to the RD, and the required progress notes and notifications were not completed. The RD only became aware of the resident's condition and initiated appropriate nutritional interventions weeks after the onset of the pressure injury and significant weight loss. This delay in notification and intervention contributed to the resident not receiving timely nutritional support to address their health needs.