Failure to Prevent Significant Weight Loss Due to Inadequate Nutrition Management
Penalty
Summary
Facility staff failed to ensure adequate nutrition for a resident with multiple medical conditions, including dementia, depression, muscle weakness, and cognitive and communication deficits. The resident was severely cognitively impaired, unable to follow instructions, feed herself, or engage in meaningful conversation. Despite being admitted with a weight of 184.4 pounds, the resident experienced a significant weight loss of over 17% within five months, dropping to 151 pounds. The clinical record showed that while dietary interventions such as large protein portions and liquid protein supplements were ordered, these were not consistently reflected in the resident's meal tickets or diet orders, and some supplements were not added until months after significant weight loss had occurred. Dietician notes indicated ongoing concerns about the resident's weight, with repeated documentation of significant weight loss triggers and adjustments to dietary interventions. However, there was a lack of timely and coordinated implementation of these interventions, and communication with the dietician was unsuccessful during the survey. The resident's weight continued to decline despite these measures, and the facility did not provide further information when the deficiency was brought to the administrator's attention.