Failure to Complete Nutritional Assessments and Address Significant Weight Loss
Penalty
Summary
Facility staff failed to complete required quarterly nutritional assessments for multiple residents and did not recognize or respond appropriately to significant weight loss. For one resident with a diagnosis of malnutrition, the last nutritional assessment was completed over a year before discharge, with no subsequent dietitian notes or follow-up. The dietitian confirmed the lack of documentation and attributed it to limited contracted hours, stating she could not complete all necessary assessments within her allotted time. Another resident experienced a 9.4% weight loss over several months, but there was no evidence in the medical record that the dietitian, physician, or responsible party were notified. The resident's care plan lacked a nutritional component, and staff interviews revealed confusion about who was responsible for notifying the dietitian. The medical director and DON acknowledged that the weight loss should have been addressed and that dietary assessments were missing from the record. A third resident had a documented 7.1% weight loss in one month, with no documentation that the dietitian or physician were notified. Subsequent medical notes referenced the resident's weight but did not address the loss or initiate a nutritional consult. The DON confirmed that no notifications were made regarding the weight losses, and the medical director concurred with the findings.