Failure to Implement Nutritional Interventions and Timely Reporting of Weight Loss
Penalty
Summary
The facility failed to implement care plan interventions and address significant weight loss for a resident with multiple risk factors, including dementia, protein-calorie malnutrition, and dysphagia. Despite care plans indicating the need for eating assistance and prompt notification of significant weight changes to the physician, the resident experienced a 6.6% weight loss over 30 days. Documentation showed repeated low meal intake, frequent meal refusals, and missing records for several meals. There was no evidence that meal replacements or supplements were offered or recorded, and no additional weights or reweights were documented as required by facility policy. Interviews with staff revealed that the resident did not receive eating assistance as outlined in the care plan, and that significant weight changes were not reported to the physician or family in a timely manner. The facility's policy required weekly weights for new admissions, reweights for variances of three pounds or more, and physician notification for weight losses of 5% or more in 30 days. These procedures were not followed, and progress notes lacked documentation of reweights or reporting of the weight loss. The deficiency was identified for one resident out of three reviewed.