Failure to Address Significant Weight Loss and Follow Dietician Recommendations
Penalty
Summary
The facility failed to provide appropriate nutritional care and services for one resident who experienced significant weight loss. Despite documented weight loss of 8.59% in one month and 19% over six months, the facility did not complete a Change of Condition (COC) or follow the Registered Dietician's (RD) recommendations. The RD had advised a referral to the physician for blood sugar monitoring, the addition of sugar-free home parenteral nutrition and Boost Glucose Control, and lab orders. However, there was no evidence in the medical records that these recommendations were implemented, nor was there documentation of physician notification or follow-up actions. Interviews with facility staff, including the RD, MDS nurse, and Director of Nursing, confirmed that the expected protocol was not followed. The facility's policy required notification of the attending physician and completion of a COC for significant weight changes, but these steps were not taken. The resident involved had multiple diagnoses, including Parkinson's disease, dementia, type 2 diabetes, and dysphagia, and required substantial assistance with daily activities. The failure to act on the RD's recommendations and to complete required documentation constituted a deficiency in the facility's nutritional care practices.