Failure to Monitor and Document Nutrition for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and document the weights and meal intakes for a resident with significant weight loss. The resident, who had diagnoses including early onset Alzheimer's Disease and osteoarthritis, was identified as being at risk for altered nutrition and required at least partial or moderate assistance with eating. Despite physician orders for a regular diet with puree texture, thin liquids, and weekly weights, there were multiple instances in April and May where meal intake documentation was missing, with no indication if meals were refused. The resident's weight showed a significant downward trend, with a loss of over 12% in three months, triggering concern for malnutrition. The registered dietician noted the resident averaged 25-75% meal intake and was refusing some meals, and recommended nutritional supplements and fortified foods to address the weight loss. Observations confirmed the resident required full staff assistance for eating and had severe cognitive deficits. Interviews revealed that the registered dietician was not responsible for ordering weekly weights and assumed the primary care physician had done so. The facility's policy required the multidisciplinary team to monitor and intervene for undesirable weight loss, with specific thresholds for significant and severe weight loss. However, the lack of consistent documentation of meal intake and adherence to weight monitoring orders contributed to the failure to properly assess and address the resident's nutritional status.