Failure to Address Severe Weight Loss and Poor Nutritional Intake
Penalty
Summary
The facility failed to implement interventions to promote acceptable parameters of nutritional status for a resident with severe protein-calorie malnutrition. The resident was admitted with this diagnosis and had documented low meal and supplement intake over several months. Staff recorded that the resident consumed zero to 25 percent of meals and less than 25 percent of prescribed nutritional supplements on numerous occasions. Despite these findings, there was no evidence that the facility took timely action to address the resident's poor intake or significant weight loss. Weight assessments for the resident showed a marked decline, with a loss of 28 pounds (over 24 percent of body weight) in two months. The facility's policy required reweighing residents after significant weight changes and evaluating undesirable weight changes, but there were gaps in weight documentation and no evidence of reweighing as required. Some weights were crossed out by the registered dietitian, who believed them to be inaccurate, but no reweighs or further assessments were documented for an extended period. There was also no documentation that the resident refused weights during this time. Additionally, the resident's physician did not assess the severe weight loss until much later, and there was no update to the nutrition plan of care or implementation of new interventions in response to the ongoing weight loss and poor intake. Staff interviews confirmed these findings, and the lack of timely intervention and documentation was acknowledged by the registered dietitian.
Plan Of Correction
Upon identification of noted issue re: resident #28, IDT members, including the PA were notified of weight loss. Facility Physician Assistant assessed resident noting dx of Adult FTT and Severe Protein-Calorie Malnutrition. The provider discussed potential use of enteral/tube feedings to support resident nutrition status. Resident declined tube feeding/nutritional enteral support. Continue to assist resident #28 with feeding, continue to encourage meal, fluid, and supplement intake, and encourage oral fluids q 1hours. Comfort measures were orders by provider on July 17, 2025. Residents are weighed upon admission and at intervals determined by the IDT. Any weight change of 5# or more since the last assessed weight is retaken the next day for confirmation. The facility EMR notifies staff of significant changes in weight status as well. The weight alerts are reviewed and assessed by the facility Registered Dietitian along with other members of the IDT. If a significant change in weight is confirmed, the IDT including the resident physician and/or physician assistant will be notified. The current nutrition plan of care will be reviewed and adjusted as necessary. The facility Registered Nurse Assessment Coordinator will determine if resident qualifies for a significant change assessment and notify IDT members. Education and training was provided to clinical staff regarding the facility's weight program, and the need for timely resident reweighs was emphasized as part of this training. Weight reviews and trends will continue to be a part of the facility's Quality Assurance and Performance Improvement program. Audits will be completed on 5 charts weekly for one month and biweekly for 3 months in regard to the appropriate weights for monitoring and reporting purposes. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions.