Failure to Implement and Monitor Individualized Nutrition Interventions After Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive and individualized interventions to prevent significant weight loss for two residents. For one resident with multiple complex medical conditions, including cerebrovascular disease, dysphagia, and dementia, there was a lack of documented evidence that swallowing strategies recommended by speech therapy were incorporated into the care plan. The resident experienced significant weight loss over several months, but weekly weights were not consistently obtained following these losses, and there was no documentation of individualized interventions after further weight decline. Additionally, the intake of nutritional supplements, such as Thrive Gelato, was not monitored, as the facility considered it part of fortified foods rather than a supplement, resulting in a lack of documentation regarding the resident's actual consumption. For another resident with diagnoses including moderate protein-calorie malnutrition and diabetes, there was a documented significant weight loss exceeding 11% in one month. Although the care plan called for weekly weights following significant weight changes, these were not consistently obtained. The dietitian recommended a reweight and an appetite stimulant, but the reweights were not completed, and weekly weights were not continued as required by facility policy. The resident's intake of nutritional supplements was also inconsistent, with documentation showing refusals and varied acceptance, but no further individualized interventions were implemented at the time of the deficiency. Interviews with facility staff, including the RD, DON, and nursing staff, confirmed that the required monitoring and documentation were not performed according to policy. Staff also indicated a lack of awareness or implementation of specific swallowing strategies for the resident with dysphagia, and there was confusion regarding the classification and monitoring of nutritional supplements. The facility's own policy required weekly weights and close monitoring after significant weight loss, but these procedures were not followed for the affected residents.