Failure to Monitor and Address Severe Weight Loss in Resident with Malnutrition
Penalty
Summary
Facility staff failed to consistently assess, monitor, and review the nutritional needs of a resident with severe protein-calorie malnutrition, dysphagia, and recent surgical amputation. Upon admission, the resident had a documented history of inadequate energy intake, significant weight loss, and was identified as needing a regular diet with specific supplements and feeding assistance. Despite physician orders for weekly weights, the facility missed obtaining a required weight during the first week, and subsequent weights showed a rapid and significant decline in body weight. Throughout the resident's stay, food intake records indicated that the resident was consuming only 0% to 25% of meals, and multiple notes documented ongoing poor intake, difficulty swallowing, and a preference for fluids over solid foods. Although interventions such as supplements and a modified diet were ordered, the facility did not consistently implement or adjust these interventions in response to the resident's continued weight loss and declining intake. The care plan noted the need for feeding assistance and monitoring for signs of dysphagia, but documentation showed that these needs were not adequately addressed or modified as the resident's condition worsened. The facility's Registered Dietician did not identify or address the resident's significant weight loss until after the resident was transferred to the hospital for extreme weakness, lethargy, and refusal of food and fluids. Additionally, a dietary evaluation following the weight loss was incomplete and lacked documentation of interventions to prevent further decline. The facility's own policy required ongoing evaluation and modification of interventions for significant weight loss, but this was not followed, resulting in a severe weight loss of over 15 pounds within four weeks of admission.
Plan Of Correction
Element I- Resident #305 was identified and no longer resides at the center. All residents who reside at the center have the potential to be affected by the deficient practice. Element II- The facility completed an initial audit that consisted of pulling a PCC report for all residents who triggered for significant weight loss in the past 90 days. The facility reviewed the residents on report to ensure adequate interventions are in place to further weight loss. Element III- During morning clinical meetings, the facility IDT will review the EMR clinical dashboard for any resident who triggers for less than 50% of meal consumption and/or significant weight loss. The IDT will immediately assess the nutritional needs of those residents to ensure adequate interventions are consistently implemented and/or modified to prevent further weight loss. The facility will conduct weekly risk management meetings to complete follow-up on all residents who are identified as having weight loss and/or poor appetite. The facility will educate the RD/Designee, and members of the IDT which includes the DON, MDS, Unit Managers, and the Certified Dietary Manager on the Nutrition Monitoring and Management policy to promptly identify risk and address any concerns regarding weight loss or poor appetite. Element IV- The Registered Dietician/Designee will audit the medical records of 5 residents with triggered weight loss, four times over four weeks, then monthly for three months to ensure the facility is assessing, monitoring, and reviewing nutritional needs and intervention to prevent further weight loss of its residents. The audit results will be given to the administrator who will provide them to the QAPI committee for review and recommendations. Element V- The Administrator is responsible for achieving and maintaining compliance, the compliance date is 6/2/2025.