Failure to Maintain Nutritional Status After Feeding Tube Placement
Penalty
Summary
A deficiency was identified when the facility failed to maintain or improve a resident's nutritional status following the placement of a gastrostomy tube. The resident, who had diagnoses including quadriplegia, malnutrition, a sacral pressure ulcer, and contractures, was admitted with a care plan to address nutritional risk and weight gain. The care plan included interventions such as administering the prescribed diet, providing tube feeding if meal intake was less than 50%, monitoring weights and labs, notifying the physician and dietician of significant weight loss, and administering supplements as ordered. Despite these interventions, the resident experienced a significant weight loss over a three-week period, dropping from 113.8 pounds to 112.8 pounds, with a mistaken entry of 119.4 pounds later corrected by the DON. The DON acknowledged that the incorrect weight entry was not communicated to the resident's physician at the time it was discovered. The resident's weights were inconsistently documented, and the significant weight loss was not promptly addressed according to the care plan's requirements. The failure to notify the physician and dietician of the weight loss and to ensure accurate and timely documentation contributed to the deficiency in maintaining the resident's nutritional status.