Failure to Monitor and Address Significant Weight Loss in Resident at Nutritional Risk
Penalty
Summary
The facility failed to ensure that a resident at risk for weight loss received appropriate nutritional review and intervention. The resident, who had a history of skin breakdown, protein-calorie malnutrition, post-surgical recovery from a fractured thigh, rheumatoid arthritis, and urinary tract infections, experienced a significant unplanned weight loss of 18.67% over 40 days. Despite facility policies requiring regular nutritional assessments and weight monitoring, there was only one documented nutrition assessment shortly after admission, with no follow-up assessments or progress notes for nearly two months. Observations and interviews revealed that the resident consistently consumed less than the targeted amount of food, with meal intake ranging from 25% to 75%. Staff did not routinely offer alternative food options when the resident refused meals, and there was a lack of documentation regarding reasons for meal refusals or what alternatives were provided. The resident's care plan identified them as being at nutritional risk, but interventions were not effectively implemented or monitored, and significant weight changes were not communicated to the interdisciplinary team, physician, or dietitian as required by facility policy. Further, key staff members, including the ARNP, case manager, and registered dietitian, were unaware of the resident's significant weight loss and nutritional decline. The dietitian noted discrepancies in weight documentation and gaps in communication about the resident's condition. The resident was eventually hospitalized with low protein levels, electrolyte imbalance, and aspiration pneumonia, highlighting the lack of coordinated care and timely response to the resident's nutritional needs.