Failure to Monitor and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to monitor and implement effective interventions for a resident at high risk for malnutrition, resulting in a 34.8% unplanned weight loss over less than six months. The resident had multiple diagnoses, including diabetes, muscle wasting, dysphagia, seizures, and gastrostomy status, and required substantial to maximal assistance with eating. Despite being on continuous enteral feeding with nothing by mouth status, the feeding order was changed in January to a twice-daily bolus, which provided only about half of the estimated caloric needs. Dietary notes repeatedly documented the resident's high risk for malnutrition, significant weight loss, and questioned the accuracy of some weight measurements, but no new interventions or adjustments to the feeding regimen were documented in response to the ongoing weight loss. Staff interviews revealed uncertainty regarding the accuracy of the resident's weight history and a lack of clear interventions or monitoring in response to the significant weight loss. The dietician acknowledged the weight loss and questioned the validity of previous weights but did not implement additional interventions, stating the resident's weight was stable at a lower level. The nurse practitioner was unaware of any concerns or interventions related to the weight loss. The facility's weight management policy required weekly weights and timely follow-up with dietary recommendations in cases of significant change, but there was no evidence these procedures were followed for this resident.