Failure to Notify Physician and Dietician of Resident's Poor Intake and Refusal to be Weighed
Penalty
Summary
The facility failed to notify a resident's physician and registered dietician (RD) when the resident exhibited poor food intake and refused to be weighed, as required by facility policy and the resident's care plan. The resident, who had a history of surgical aftercare, malignant neoplasm of the tongue, and gastro-esophageal disease, was identified as being at risk for malnutrition. Documentation showed that the resident was not meeting nutritional needs, consuming only about 53% of meals, and had a poor appetite. The care plan specifically instructed staff to monitor intake, weigh the resident as ordered, and alert the physician and RD to any decline in intake. Despite these instructions, the resident refused to be weighed on multiple occasions, but staff documented the same weight as previous entries, which did not accurately reflect the resident's status. Additionally, the resident's poor meal consumption was not communicated to the RD or physician. The RD confirmed that she was not notified of the resident's refusal to be weighed or the ongoing poor intake, and stated that this lack of communication delayed her ability to reassess and revise the nutritional care plan. The DON also acknowledged that the nursing staff should have notified the RD and physician of these changes, and that the failure to do so resulted in a delay in evaluation and care for the resident. Facility policy required immediate notification of the resident, physician, and representative in the event of significant changes in the resident's condition, including nutritional status. The failure to follow these policies and care plan interventions led to a delay in the resident's evaluation and care, with the potential for the resident to become malnourished and lose weight, as directly stated in the report.