Failure to Implement Dietary Recommendations for Resident with Weight Loss
Penalty
Summary
The facility failed to implement a dietary recommendation for a resident with significant medical conditions, including metabolic encephalopathy, atherosclerotic heart disease, multiple sclerosis, and type 2 diabetes mellitus. The resident, who had severe cognitive impairment and required assistance with eating, experienced documented weight loss of 5% or more in the last month or 10% or more in the last six months. A dietary recommendation was made by the Registered Dietician (RD) for high calorie snacks between meals due to the resident's oral intake being less than 25% and a 17% weight loss over three months. Despite this recommendation, staff interviews revealed that no morning or afternoon snacks were routinely provided, and the resident confirmed not receiving in-between meal snacks. The Certified Dietary Manager (CDM) stated that the kitchen did not send out snacks between meals and was unaware of the RD's recommendation, possibly due to email communication issues. The RD reported that dietary recommendations were typically communicated via email to the CDM, but could not specifically recall the recommendation for this resident without reviewing the chart. Other dietary recommendations from the same date were being followed, indicating a lapse in communication or implementation for this particular resident.