Failure to Prevent Significant Weight Loss in Resident with Complex Medical Needs
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a 25.96% weight loss over four months. The resident, who had multiple complex medical diagnoses including protein-calorie malnutrition, diabetes mellitus, end stage renal disease requiring dialysis, and Parkinson's Disease, was admitted on a mechanically altered diet and required setup or clean-up assistance with eating. Despite being identified as at risk for unplanned weight loss on her care plan, interventions such as monitoring weight, encouraging meal completion, and offering supplements or alternatives were not effectively implemented or documented. The resident's weight declined from 195.00 pounds to 169.40 pounds over the review period. Nutrition assessments noted significant weight loss, but the only dietary change recommended was a modification in diet texture. The resident refused several meal trays, citing dislike for the food options, particularly ground meats and salty alternatives, and expressed a preference for specific meals like chicken pot pie. The facility's red cup program, designed to alert staff to residents at risk for malnutrition, did not include this resident, and there was confusion among staff regarding responsibility for monitoring and implementing this program. Interviews with staff revealed gaps in communication and follow-through regarding the resident's nutritional needs. The dietitian was aware of the weight loss but questioned the accuracy of weights and did not consistently review dialysis weights or logs. The DON acknowledged awareness of the weight loss but did not recognize its severity until recent training and had left intervention planning to the dietitian. The CNA and LVN assigned to the resident were either unaware of the weight loss or not involved in monitoring intake. The facility's policies required more frequent weights and interventions for significant weight loss, but these were not consistently followed for this resident.