Failure to Provide Prescribed Nutritional Supplements and Weight Monitoring
Penalty
Summary
A resident with multiple complex medical conditions, including pneumonia, respiratory failure, sepsis, pressure ulcers, dysphagia, chronic kidney disease, metabolic encephalopathy, and iron deficiency anemia, experienced significant weight loss after re-entry to the facility. The resident was on a physician-ordered weight gain plan, a therapeutic diet, and prescribed several nutritional supplements, including Ensure Clear, Magic Cups, and LiquaCel. Despite these orders, the resident's weight dropped from 132.9 lbs to 123 lbs within 30 days, a 7.4% loss. The facility failed to obtain a valid follow-up weight promptly after an invalid result and did not record the required monthly weight for April as ordered by the physician. Observations and interviews revealed that the resident did not receive the Magic Cup supplement with lunch as ordered, and was unaware of what it was, despite it being listed on her meal ticket. Staff confirmed the supplement was available in the facility but was not provided to the resident. The Registered Dietitian acknowledged that after a slight weight increase, no further monitoring was conducted, and the required monthly weight was not obtained. The facility's policy required daily and monthly weight reviews and referral to a dietitian for significant weight changes, but these procedures were not followed for this resident.