Failure to Notify Physician and Implement Dietitian Recommendations for Significant Weight Loss
Penalty
Summary
The facility failed to follow Registered Dietitian recommendations and notify the physician regarding a resident who experienced significant weight loss. The resident, who had diagnoses including essential hypertension, morbid obesity, and type 2 diabetes, was on a carbohydrate-controlled diet and had a documented 7% weight loss in 30 days. Despite multiple Interdisciplinary Team (IDT) Nutrition At Risk (NAR) notes recommending discontinuation of the carbohydrate control portion of the diet to improve intake, there was no documentation that the physician was notified of the significant weight loss or that the diet was changed as recommended. The resident's weight continued to decline over several months, and the care plan and orders were not updated to reflect the recommendations. Interviews with staff revealed that the Director of Nursing (DON) was unaware of the IDT NAR notes in the electronic medical record and relied solely on emailed reports from the Registered Dietitian, which did not include this resident. The DON acknowledged that physician notification should have occurred and that the NAR program was ineffective if recommendations were not communicated. The facility's policy required physician notification for significant changes in weight or nutritional status, but this was not documented in the resident's clinical record.