Failure to Implement Timely Nutritional Interventions for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of protein-calorie malnutrition, dysphagia, pneumonitis due to inhalation, and diabetes mellitus experienced significant unplanned weight loss after readmission to the facility. The facility failed to follow the Registered Dietitian's (RD) interventions, including obtaining a dental evaluation, implementing a revised nutritional plan of care, and notifying the attending physician about the resident's significant weight loss. The RD's recommendations for a change in diet, double protein with meals, and daily multivitamins were not communicated or implemented. Additionally, the Dietary Manager did not obtain the resident's most current weight upon readmission, instead copying the previous admission weight, which led to missing the significant weight loss of 7.2 pounds in 14 days. The interdisciplinary team (IDT) did not convene to address, monitor, or intervene regarding the resident's undesirable weight loss as required by the facility's policy on unplanned weight loss. The resident was not accurately reassessed by the Dietary Manager, and the plan of care was not revised despite the documented weight loss. These actions and inactions resulted in the resident not receiving timely and appropriate nutritional interventions, as outlined in the facility's clinical protocol.