Failure to Address Progressive Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to recognize, evaluate, and address the nutritional needs of two residents who experienced significant and progressive weight loss. One resident, recently admitted after hospitalization for a lung infection and with diagnoses including muscle weakness and unsteadiness, had a care plan that did not include food preferences, weight monitoring, or updated interventions for weight loss. The resident reported dissatisfaction with the food, lack of menu choices, and stated that no one from dietary had discussed her weight loss or food preferences with her. Clinical records showed a 7-pound weight loss in 17 days, with no documentation that the weight loss was addressed or communicated to the registered dietitian (RD) or physician. The RD confirmed being unaware of the weight loss and acknowledged that the resident's food preferences were not documented, and the issue was not discussed in interdisciplinary team (IDT) meetings. Another resident, admitted with diagnoses of spinal fusion, protein-calorie malnutrition, and anemia, experienced a 17-pound weight loss since admission, including a 14-pound loss in one month. The resident appeared emaciated and expressed concern about the weight loss. Medical records lacked documentation of weights after a certain date, and there was no evidence of a nurse's assessment or physician notification regarding the significant weight loss. The RD acknowledged that the resident should have been placed on weekly weights and that this was not done, with no dietary interventions implemented despite the significant weight loss. Facility policy required the multidisciplinary team to monitor and intervene for undesirable weight loss, considering resident preferences and rights. However, in both cases, the facility did not follow its own policy, as there was a lack of timely assessment, communication, and intervention for the residents' nutritional needs and weight loss. The failures were confirmed by staff interviews and record reviews, with both the DON and RD acknowledging the deficiencies in monitoring, documentation, and care planning.